Healthcare Personnel Attire in Non-operating-room Settings

Gonzalo Bearman, MD, MPH; Kristina Bryant, MD; Surbhi Leekha, MBBS, MPH; Jeanmarie Mayer, MD; L. Silvia Munoz-Price, MD; Rekha Murthy, MD; Tara Palmore, MD; Mark E. Rupp, MD; Joshua White, MD


Infect Control Hosp Epidemiol. 2014;35(2):107-121. 

In This Article

Guidance Statement

There is a paucity of data on the optimal approach to HCP attire in clinical, nonsurgical areas. Attire choices should attempt to balance professional appearance, comfort, and practicality with the potential role of apparel in the cross-transmission of pathogens resulting in healthcare-associated infections (HAIs).

As the SHEA workgroup on HCP attire, we recommend the following:

  1. Appropriately designed studies should be funded and performed to better define the relationship between HCP attire and HAIs.

  2. Until such studies are reported, priority should be placed on evidence-based measures to prevent HAIs (eg, hand hygiene, appropriate device insertion and care, isolation of patients with communicable diseases, environmental disinfection).

  3. The following specific approaches to practice related to HCP attire may be considered by individual facilities; however, in institutions that wish to pursue these practices, measures should be voluntary and accompanied by a well-organized communication and education effort directed at both HCP and patients.

A. "Bare below the elbows" (BBE): This article defines BBE as HCP's wearing of short sleeves, no wristwatch, no jewelry, and no ties during clinical practice. Facilities may consider adoption of a BBE approach to inpatient care as an infection prevention adjunct, although the optimal choice of alternate attire, such as scrub uniforms or other short-sleeved personal attire, remains undefined.

1. Rationale: While the incremental infection prevention impact of a BBE approach to inpatient care is unknown, this practice is supported by biological plausibility and studies in laboratory and clinical settings and is unlikely to cause harm.

B. White coats: Facilities that mandate or strongly recommend use of a white coat for professional appearance should institute one or more of the following measures:

1. HCP engaged in direct patient care (including house staff and students) should possess 2 or more white coats and have access to a convenient and economical means to launder white coats (eg, institution-provided on-site laundering at no cost or low cost).

i. Rationale: These practical considerations may help achieve the desired professional appearance yet allow for HCP to maintain a higher frequency of laundering of white coats.

2. Institutions should provide coat hooks that would allow HCP to remove their white coat (or other long-sleeved outerwear) prior to contact with patients or the patient's immediate environment.

i. Rationale: This practical consideration may help achieve the desired professional appearance yet limit patients' direct contact with potentially contaminated attire and avoid potential contamination of white coats that may otherwise be hung on inappropriate objects in the hospital environment.

C. Other HCP apparel: On the basis of the current evidence, we cannot recommend limiting the use of other specific items of HCP apparel (such as neckties).

1. Rationale: The role played by neckties and other specific items of HCP apparel in the horizontal transmission of pathogens remains undetermined. 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.

D. Laundering:

1. Frequency: Optimally, any apparel worn at the bedside that comes into contact with the patient or patient environment should be laundered after daily use. In our opinion, white coats worn during patient care should be laundered no less frequently than once a week and when visibly soiled.

i. Rationale: White coats worn by HCP who care for very few patients or by HCP who are infrequently involved in direct patient care activities may need to be laundered less frequently than white coats worn by HCP involved with more frequent patient care. At least weekly laundering may help achieve a balance between microbial burden, visible cleanliness, professional appearance, and resource utilization.

2. Home laundering: Whether HCP attire for nonsurgical settings should be laundered at home or professionally remains unclear. If laundered at home, a hot-water wash cycle (ideally with bleach) followed by a cycle in the dryer is preferable.

i. Rationale: A combination of washing at higher temperatures and tumble drying or ironing has been associated with elimination of both pathogenic gram-positive and gram-negative bacteria.

E. HCP footwear: All footwear should have closed toes, low heels, and nonskid soles.

1. Rationale: The choice of HCP footwear should be driven by a concern for HCP safety and should decrease the risk of exposure to blood or other potentially infectious material, sharps injuries, and slipping.

F. Identification: Name tags or identification badges should be clearly visible on all HCP attire for identification purposes.

1. Rationale: Name tags have consistently been identified as a preferred component of HCP attire by patients in several studies, are associated with professional appearance, and are an important component of a hospital's security system.

IV. Shared equipment, including stethoscopes, should be cleaned between patients.

V. No guidance can be offered in general regarding prohibiting items like lanyards, identification tags and sleeves, cell phones, pagers, and jewelry, but those items that come into direct contact with the patient or environment should be disinfected, replaced, or eliminated.