SHEA: Obsessed, and proudly so

The SHEA guidance on healthcare personnel (HCP) attire is now available (free!), and is already drawing media attention. I particularly enjoyed the NBC News description of SHEA as “the group obsessed with stopping infections in hospitals and health care settings”. Obsessed? Miriam-Webster describes obsession as “a state in which someone thinks about something constantly or frequently, especially in a way that is not normal”*. And it got me thinking that this may be behind some of the general resistance to any guidance about HCP attire. What is this group doing, suggesting what I should wear (or not wear) in the hospital, and how often I should wash my garments? They must be obsessed or something. Show me the data, weirdos!

Therein lies the rub with HCP attire, as with so many other infection prevention practices. There may be biological plausibility that clothing plays a role in pathogen transmission, there may be evidence for pathogen contamination of HCP attire, and there may be a favorable balance of benefit versus harm in implementing changes in practice (such as a bare-below-the-elbows (BBE) approach). But we still lack that direct link between HCP attire and HAI risk. Thus the SHEA guidance ends with a laundry list (pun intended) of research priorities for HCP attire:
· Determine the role played by healthcare personnel (HCP) attire in the horizontal transmission of nosocomial pathogens and its impact on the burden of HAIs.
· Evaluate the impact of antimicrobial fabrics on the bacterial burden of HCP attire, horizontal transmission of pathogens, and HAIs. Concomitantly, a cost-benefit analysis should be conducted to determine the financial merit of this approach.
· Establish the effect of a bare-below-the-elbows (BBE) policy on both the horizontal transmission of nosocomial pathogens and the incidence of HAIs.
· Explore the behavioral determinants of laundering practices among HCP regarding different apparel and examine potential interventions to decrease barriers and improve compliance with laundering.
· Examine the impact of not wearing white coats on patients’ and colleagues’ perceptions of professionalism on the basis of HCP variables (e.g., gender, age).
· Evaluate the impact of compliance with hand hygiene and standard precautions on contamination of HCP apparel.
Now try to imagine the logistics, and costs, associated with a study large enough to demonstrate the incremental contribution of HCP attire to HAI infection risk, or the impact of BBE on HAI incidence. Knowing how long we will be waiting for such evidence, what do you plan to do in your hospital?

* I prefer the Urban Dictionary definition of obsessed: “just a word the lazy use to describe the dedicated”

Graphic credit to Ben Tremblay.


  1. Great post Dan. I wonder if we applied the same standards used in this Attire Guidance to use of certain expensive environmental cleaning technologies. What could we recommend? What is interesting is that there is no money to be made by the BBE policy, so no one will push the policy and certainly there will be little $$ made available to study it. Thus, again we see the bias against basic rational infection control in favor of expensive and equally evidence challenged interventions. I'll stop now lest people think I'm any more than passionate about these here topics.

    Oh, just a question, why do people like long sleeves anyway? Must be some fear of showing our wrists to strangers or something.

  2. Only biological approaches such as competitive exclusion of pathogens by probiotics and targeted killing of pathogens by bacteriophages - could counter, control and contain super bugs in hospitals. Over cleanliness and sanitation disrupt the microbial environment and generate selective pressures which play in favor of a handful of pathogens responsible for most of nonsocial infections.


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