The limitations of patient-centered infection control
"You can't just ask customers what they want and then try to give that to them. By the time you get it built, they'll want something new." - Steve Jobs
I woke up to Vineet Chopra and Sanjay Saint's editorial advocating for a patient-centered approach to selecting clinician attire. In the editorial they point out that in the 21 of 30 papers they reviewed "patients had strong preferences about what physicians wore. And it looks like patients more often prefer for their doctors to wear formal clothing and white lab coats than not." They also reference the SHEA guidance document on healthcare attire and state there is little evidence "that germs on male doctors’ neckties, long sleeves, or white coats actually spread infections in a nonsurgical setting. So bans on such garments, such as those in place in some countries, may go too far."
So how can we decide what the safest attire is for our patients? I would recommend epidemiological studies that track bacteria spreading in hospitals and attempt to determine if those same strains are contaminating clinician attire using whole genome sequencing. In fact, CDC released a SHEPheRD Task Order 2015-006 last month that seeks to do just that and more. I very much look forward to the results.
Drs. Chopra and Saint recommend a different patient-centered approach as they "plan to survey thousands of patients from the US, Italy, Switzerland and Japan" and "will specifically assess how factors such as age or how often a person interacts with the health system shape patient opinions." Is this a rigorous or unbiased method? Will the surveyed patients know that a quarter of white coats are coated with invisible S. aureus or MRSA and that they are rarely washed? Will they understand that a lack of data supporting transmission from white coat or long sleeve or neck tie is because no one has ever funded such studies? Will they understand that the circumstantial evidence supporting bare below the elbows is as strong as that supporting a clean environment in hospitals? Will their next editorial say that bleach is stinky and irritating to patients, so we shouldn't use it in hospitals unless supported by a patient-centered survey?
Thus, there are several potential limitations to patient-centered infection control and the planned physician attire survey, which I hope they will consider before collecting data and selling the findings. I'm all for patient-centered healthcare where applicable and data are fairly presented to patients and I support evidence-based medicine when we fairly rate the science based on what studies have been funded or will ever be funded. I'm not sure any patients "feelings" about the dirty white coat are worth the increased risk of MRSA or Acinetobacter infection, but we can disagree. All I would ask is that if we do patient-centered research, it's with properly informed patients.
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Oh, and if we're going to require evidence before making physician attire recommendations, how can the authors write that "scrubs do not belong outside the hospital environment. Especially not in the grocery store." Where is the study that scrubs spread bacteria outside of hospitals and that there is any risk to population health in grocery stores? Clearly the bacteria on cantaloupes are riskier than those on scrubs! And surely the immobile ICU patient with central venous and urinary catheters is at greater infection risk when you wipe your MRSA-contaminated white coat on their catheter than when you brush up against a healthy grocery store patron with your scrubs? Scrubs are at least washed daily - white coat laundering occurs somewhere between every two weeks and... never.
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Additional thought, I am not aware that the US, Italy, Switzerland and Japan have mandatory bare-below elbows policies. It might be important to add Scotland or England to the survey since they have had BBE policies for some time and patients may have adjusted their preferences for physician attire.
Eli Perencevich blog post has stimulated quite the debate in the Twitterverse where a veritable battle of opinions regarding what physicians should wear wages. But while eloquently written, I'd like to push back as follows:
ReplyDelete1/ There is not a single study that has shown that clothing is responsible for transmitting infections between patients. This is not because of lack of funding. Indeed, many of the studies that examined contamination on clothes also looked for evidence of infection transmission. They found none. We can wax academic all day about whether they were powered to find such a trend or whether they looked in the right places or had the right patients. But the SHEA Guidelines concede this point in a single sentence: "Although studies have demonstrated contamination of HCP apparel with potential pathogens, the role of clothing in transmission of these microorganisms to patients has not been established."
2/ Why is it that we make the white coat the focus of infection transmission? What about hands or stethoscopes? Should we give up all of these tools because they are "coated with invisible bacteria?" I, for one, am not ready for that. Nor am I ready to go naked to the hospital, as this op-ed suggests: http://www.theatlantic.com/health/archive/2011/11/what-should-doctors-wear-even-lab-coats-could-spread-disease/247987/
3/ Speaking of coating with invisible bacteria, HCWs are often carriers of such pathogens. There's a fairly robust literature on this -- take a look at this systematic review: http://www.biomedcentral.com/1471-2334/14/363 Its not surprising that some hospitals are in fact doing away with contact precautions for patients with certain bacteria --- the evidence to suggest this works isn't great whereas the evidence that patients may get neglected is pretty solid. Take a look here: http://www.ncbi.nlm.nih.gov/pubmed/24097234
4/ Lets be clear -- our op-ed is meant to be just that: an opinion across an editorial page. We believe what patients expect matters. We think it is important to portray a professional image, esp. for those beginning their residency and training who subconsciously ingest many a facet of their senior resident/attendings. We think that patients care and often write negatively about the doctor that looks like the Abercrombie model. Take a look at this article: http://www.allure.com/beauty-trends/blogs/daily-beauty-reporter/2015/02/doctor-outfit-effectiveness.html
5/ The bigger problem here is that healthcare professionals are lazy about personal hygiene. We aren't good about washing hands or changing coats. The scruffy physician may anchor patients views in this regard. Eli argues for technical solutions such as antiseptic impregnated clothing. We argue for social solutions because not just about the coat, shirt or tie. Personally, my lab coats are changed every 3 days when I am on wards, my ties are never worn twice and I always wear long sleeved shirts. Is that too much or too little? These are the questions we should be asking.
6/ Wearing formal attire and a white coat isn't going to win over a patients trust. But we argue it's a good first step in the right direction. Our survey seeks to validate whether and how much this matters to patients. We don't know if it will -- but if so, the hard work to discuss the implications of what this means for IC/IP must begin. The jury regarding infection is still out. But that for what patients want should be back soon.
7/ One final thought re the srubs in the grocery store. Are such thoughts are evidence-based? No - of course not. But have I seen the spectacle? Absolutely. Has it been talked about within our circles? Take a look: http://www.medscape.com/viewarticle/748401
Does it make me cringe - without a doubt.
Absence of evidence isn't an excuse to relinquish common sense. My common sense tells me that scrubs simply don't belong in the produce section. Period.
Thanks for your comments. We read the literature differently. I'm concerned that patients and our non-ID trained colleagues take that SHEA document at face value, when in fact no high quality studies have properly ruled out transmission from long-sleeves or white coats. Since MDRO research isn't funded to the degree necessary to answer these questions, we need to rely on the overwhelming circumstantial evidences that points to clothing, hands, and environment as being important modes of MDRO transmission in hospitals.
DeleteI'll take your final quote and turn it around:
"Absence of evidence isn't an excuse to relinquish common sense. My common sense tells me that white coats simply don't belong in patient care. Period."
Are you bothered by people in scrubs at your hospital's salad bar? Is that any different than the grocery store produce section?
ReplyDeleteI am a bit bothered by people wearing scrubs at the hospital's salad bar, but only if they're also wearing a white coat. Neither bother me at a grocery store since there are no sick, immunocompromised patients with central-venous catheters at most grocery stores. ;)
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