Friday, September 22, 2023
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The clothing of healthcare personnel (HCP) may become contaminated during patient care, but the role of clothing in transmitting infectious pathogens to patients has not yet been well established. Following a review of the available research on HCP attire, the Society for Healthcare Epidemiology of America (SHEA) provided recommendations[1] to guide facilities when considering policies regarding HCP attire in non-operating-room settings. According to Gonzalo Bearman, MD, MPH, from Virginia Commonwealth University and first author of the SHEA guidance statement, "All changes in practice with respect to HCP attire and infection control should be voluntary and accompanied by a well-organized communication and education effort directed at both HCPs and patients."
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Is a traditional white coat necessary to inspire patient trust in a healthcare provider? Some evidence suggests that physicians and nurses place more importance on formal attire than patients do.[2] From an extensive review of the research on patient perceptions of HCP attire, SHEA found that when asked, most patients will say that they prefer to see formal attire, including a white coat, but these preferences have little impact on patient satisfaction and confidence in their healthcare providers. Most patients don't think about the infection risks posed by white coats or other clothing; however, when made aware of these risks, patients seem willing to change their preferences for HCP attire.
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SHEA defines "BBE" as wearing short sleeves, no wristwatch, and no jewelry during clinical practice. In 2007, the United Kingdom began requiring physicians to practice BBE,[3] effectively banning the wearing of long sleeves (including scrub jackets and white coats) and watches, wristbands, bracelets, and rings on the hand, wrist, or lower arms. The aim of this mandate was to enable better hand and wrist hygiene, and to minimize the transfer of bacteria that might be contaminating the cuffs or sleeves of HCPs' attire.
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The evidence supporting better handwashing resulting from BBE or a link between BBE practices and reduced transmission of infection has been challenged.[4-6] Still, although not proven as an infection control measure, the benefit of BBE is worthy of consideration in an overall approach to infection prevention.
"We want to emphasize that priority should first be placed on proven strategies to prevent healthcare-associated infections, such as hand hygiene; effective cleaning of the environment; and appropriate insertion and care of invasive devices, such as urinary catheters and intravascular lines. After these types of preventive measures are in place, a BBE program makes sense and can be considered as an adjunctive practice," related Mark E. Rupp, MD, from the University of Nebraska and one of the authors of the SHEA HCP attire guidance statement.
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White coats are frequently contaminated with potentially harmful bacteria, such as Staphylococcus aureus, coagulase-negative staphylococci, and others, including many drug-resistant pathogens,[7,8] and a relationship has been found between contamination of hands and that of white coats.[9]
The wearing of white lab coats, which symbolize cleanliness, has a long tradition in medicine. Many believe that it enhances professional appearance, and in some institutions, white coats are mandatory. In such places, if white coats are worn by those engaged in direct patient care, the wearer should possess 2 or more white coats and have access to a convenient and economical means to launder them (eg, institution-provided on-site laundering at no or low cost). Furthermore, coat hooks should be readily available to encourage wearers to remove and hang up their lab coats or long-sleeved jackets before entering the patient's immediate environment.
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Healthcare professionals who are used to wearing white coats when interacting with patients might wonder what the HCP should wear in the room if the white coat is placed on a hook outside the room.
Dr. Rupp responds, "Standard precautions should be maintained. If the HCP anticipates contact with blood or body fluids, a protective gown or apron should be worn. Similarly, gloves should be used to protect the hands from soiling. The real key is good hand hygiene directly before and after patient contact."
Adds Dr. Bearman, "Although some of these recommendations may seem like a radical departure from common practice for some physicians, we believe that the voluntary attire changes are reasonable; supported by biological plausibility; and unlikely to cause harm, provided that they are used as adjuncts to evidence-based infection prevention practice."
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A popular "professional look" for men in the healthcare professions, when scrubs aren't worn, is a shirt and tie under a white lab coat. When the white coat is removed for patient contact, however, does the tie (or a scarf worn by a woman) pose a threat of transmission of disease?
The role played by neckties and other items of HCP apparel in the horizontal transmission of pathogens remains unknown. If neckties are worn, they should be secured by a white coat or other means to prevent them from coming into direct contact with the patient or near-patient environment. Neckties should be secured by a tie-tack or tucked into the shirt between buttons so that they do not hang down and contact the patient or the near-patient environment. On the basis of the current evidence, SHEA cannot recommend limiting the use of other specific items of HCP apparel.
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This is the variable that separates bacteria-laden scrubs or white coats from clean ones. How often are these items laundered?
According to a recent survey[10] of physicians, white coats are washed every 12.4 ± 1.1 days (P < .001). SHEA says that the frequency of laundering should be determined by how often the wearer is engaged in direct patient care activities.
As Dr. Rupp explains, "We recognize that many clinicians will continue to wear a white coat at the bedside, and that is okay if the coat is laundered appropriately. The data are not available to prohibit bedside use of white coats and our guidance statement does not recommend banning white coats. Ideally, for practicing clinicians, white coats should be laundered frequently, at least weekly and whenever visibly soiled. For a busy clinician seeing many patients, daily laundering would be appropriate. For a physician staffing an outpatient clinic for a half-day once or twice per week, less frequent laundering makes sense."
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Should home laundering of white coats be permitted?
The jury is still out on home laundering. Studies indicate that washing in hot water eradicates certain bacteria, but the wash cycle can introduce other bacteria as well.[11,12] The wash-cycle-acquired bacteria can then be destroyed by tumble drying or ironing.
Industrial laundering doesn't decontaminate clothing more effectively than home laundering,[13] so the only firm recommendation is that if attire for nonsurgical settings is laundered at home, a hot-water wash cycle (ideally with bleach) should be used, followed by a cycle in the dryer. This combination (washing at higher temperatures and tumble drying or ironing) has been associated with elimination of both pathogenic gram-positive and gram-negative bacteria.
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Running shoes and clogs are the most popular types of footwear among hospital-based healthcare professionals. Comfort and support during long hours of standing and walking are the uppermost considerations. No one wants their toes run over by a piece of heavy equipment, to drop a scalpel on their foot, or trip and fall when running to the delivery room. For reasons of safety, SHEA recommends that all footwear worn by healthcare professionals have closed toes, low heels, and nonskid soles.
In the past, it was frowned upon to wear "outdoor shoes" into the patient care environment, a factor not mentioned in the new guidance. Dr. Rupp explains, "There is less concern about shoes, because shoes don't come into direct contact with patients or environmental surfaces that contact patients. Dirty or clearly soiled shoes should not be worn in patient care areas."
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Lanyard or clip-on? Although a piece of adhesive tape with one's name written on it might pose fewer safety risks, it appears unprofessional and is useless for getting through locked doors. Name tags or identification badges must always be clearly visible on all HCP attire for identification purposes, and need to be handy for other uses (eg, security, access, and purchases).
In the absence of evidence, this is another area where common sense must dictate practice. SHEA does not prohibit the wearing of lanyards or identification tags and sleeves, nor the carrying and use of cell phones, pagers, and jewelry, but any item that comes into direct contact with the patient or environment should be disinfected regularly, replaced, or eliminated.
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It doesn't make much sense to worry about white coats, ties, and long sleeves if you use the same stethoscope on patient after patient without decontaminating it between patients. A recent study[14] found that after a single physical examination, stethoscope diaphragms are contaminated as much as (or even more than) the physician's hands, and a direct relationship exists between hand and stethoscope contamination. This suggests that the patient's skin and immediate surroundings are the common denominators and determinants of both physicians' hands and stethoscope contamination. SHEA recommends that all shared equipment, including stethoscopes, should be cleaned between patients.
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Tell us what you think: Do we know enough about the risk for infection to consider making changes in what healthcare professionals wear while at work? Do you believe that short sleeves are important when providing clinical care? What about scarves and ties -- do they need special attention? Jewelry -- do you leave it at home? Do you disinfect your stethoscope between patients? And what about the iconic white lab coat? Would you consider hanging it up before you go into hospitalized patients' rooms?
Please add your comments at Voice Your Opinion: Is It Time to Hang Up Your Lab Coat?
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