Yes we can!

In early 2009, I bought three North Face black vests for myself and my colleagues Gonzalo Bearman and Mike Stevens at VCU Medical Center. Our Infection Control Committee had recently recommended that all healthcare workers adopt a bare below the elbows approach when providing care in the inpatient setting. The vests were good at providing some additional warmth on winter days. We avoided fleece and opted for vests that were nylon on the external surface so that they could be easily cleaned with a disinfectant wipe. We started bare below the elbows with just three people in a hospital with a workforce of 10,000.

We didn’t mandate bare below the elbows and we didn’t aggressively push it. We rolled out an educational campaign with a personal infection prevention bundle that had three components: bare below the elbows, hand hygiene before and after patient contact, and stethoscope wipe down after every patient exam. We talked about it in new employee and new housestaff orientation sessions, always noting that this was a recommendation. We had no support from hospital administration, though no one tried to obstruct us. Importantly, we gave doctors permission to not wear white coats and neckties, and continued to role model the approach as we saw patients. Given how attached some physicians are to their white coats, we knew that a mandate would produce a backlash and doom our plans. Still we got some pushback, but our response to the naysayers was consistent, “You’re not required to do this. It’s just a recommendation.” It's hard for anyone to argue with that.

Here we are a decade later, and this week saw the publication of our results with this experiment in the American Journal of Infection Control. Across 40,000 observed encounters in calendar year 2017, overall compliance with bare below the elbows was 84%. Probably not too surprising, physicians were the laggards at 67%, with most other groups in the high 80s or even 90s. But having two-thirds of doctor-patient encounters occur without the 20-square-foot microbiological zoo (AKA white coat), is pretty damn astounding.

What’s also interesting is that in the prior year, overall compliance was only 40%. In hindsight, we can see that 2016 appears to have been the tipping point as compliance doubled in the ensuing year. Now, bare below the elbows is part of the institutional culture. I have given many talks in the past decade on this topic where I’ve been told repeatedly that doctors will never give up their white coats, but Gonzalo tells me that it is now unusual to see a doctor in a white coat on the wards.

There are a couple of lessons here. We’ve again confirmed that changing behavior in health-related interventions is a slow process (probably even slower when the person whose health is impacted isn’t the person whose behavior must be changed). But more importantly, you don’t have to beat people over the head to make it happen. Provide encouraging messaging, role model the behavior, and let uptake diffuse. Patience is key.

Kudos to Gonzalo and Mike for persisting, and to everyone at VCU in the 84% who stepped forward. When I start service tomorrow it will be 10°F here in Iowa, and though this poikilotherm would like to be bundled in 20 layers, you can bet your bottom dollar that I’ll be bare below the elbows.

Debating Bare Below the Elbows

At IDWeek in San Diego this past Saturday, I debated Neil Fishman on bare below the elbows, a topic that regular readers of this blog know is one of my favorites. I had 10 minutes to deliver the pro argument and Neil had the same for the con. You can read an unbiased account of the debate here.

So in my 10 minutes, here's what I argued:

• We have conclusive evidence that healthcare workers' clothing becomes contaminated with pathogens during the care of patients.
• There is some in vitro evidence that pathogens can be transmitted from clothing to patients.
• There is no evidence that intervening (removing white coats and neckties and having HCWs go bare below the elbows) reduces healthcare associated infections, though of course, absence of evidence is not necessarily absence of effect.
• The literature on patient preference for physician attire shows mixed results in weak studies where patients look at pictures of doctors in different attire, while studies that randomized attire show no difference in patient satisfaction, and others that add context show that attire is one of the least important characteristics that patients consider in evaluating their physician.
• On the basis of biologic plausibility, I argued that we should recommend (but not mandate) bare below the elbows.

Neil argued the following (and I've added my comments in italics):

•  We already have too many metrics to follow and we shouldn't add one more. We can't be the "fashion police." (There's no added work to implement bare below the elbows. Give HCWs permission to do it and provide some encouragement).
• Bare below the elbows is not enforceable (With no mandate there is nothing to enforce).
• Arms are just as likely to be contaminated as the sleeves of the white coat (True, but you can wash your arms between patients; in a survey of physicians that we published, nearly 20% reported that they had NEVER washed their white coats).
• 5% of the population has eczema or psoriasis, and these individuals have higher rates of staphylococcal colonization (True, but we usually don't formulate policy on the 5% exception). 
• If the white coat goes, all measures of hygiene will decline. (This is a borderline insane argument borrowed from Stephanie Dancer, that I previously blogged about here).

So what was the verdict? Before the debate, 37% of the audience supported bare below the elbows, and after the debate 42% were in support. So in 10 minutes I moved the needle 5 percentage points. Not dramatic, but I'll take it. But just imagine having this debate 10 years ago, or even 5 years ago; I suspect supporters would account for <10%.

Any intervention that involves changing behavior produces incremental results. But from firsthand experience, I know it can be done. At VCU, we recommended a bare below the elbows approach to inpatient care in 2009. It was a very soft rollout--no mandate, just a recommendation. Gonzalo Bearman, Mike Stevens and I consistently wore scrubs and others slowly joined in. It started with just three people. Last year before I left VCU, we did a 12-week prevalence survey and we were pleasantly surprised to see that 69% of inpatient encounters were via HCWs bare below the elbows. This year, it has increased to 80%. Compliance was boosted when the medical school bought their students scrubs and nylon vests (see the photo of Gonzalo with some VCU medical students). I think this is an amazing accomplishment, and I will venture a guess that 10 years from now, the vast majority of doctors in the US will look just like those in that picture.

Better than germ-zapping robots...

Joe Schlesinger, an anesthesiologist and critical care medicine colleague from Vanderbilt University, sent me this photo he took a few days ago at a hospital in Kenya. If only US hospitals were so forward thinking...

Bare below the elbows: Making progress

We have had a recommendation for bare below the elbows (BBE) in the inpatient setting for 5 years at my hospital. No mandate, just a recommendation. And it's been a fairly soft sell. My perception has been that over time a greater proportion of our healthcare workers have adopted (BBE), but we've never formally measured it. Since our hand hygiene observers roam throughout the hospital, we asked them to simultaneously record BBE status while they were collecting their hand hygiene compliance data. So here's a first look: 2 weeks of observations (n=1,560). Note that HCWs were not counted repeatedly and our definition of BBE was strict (i.e., a wrist watch or bracelet was defined as noncompliance). The graph below shows the overall compliance and the compliance stratified by job category:

Nurses and nursing students demonstrate high rates of compliance. On the other hand, physicians and medical students are least likely to comply. Nonetheless, nearly 40% compliance in physicians is higher than I would have predicted. Medical students have two problems: they just love the white coat and they are concerned about how they will be perceived by their evaluators if they don't wear it. Clearly, we have some work to do there. Overall, though, I'm pleased with these results: 2/3 of patient encounters are by HCWs who are BBE. One caveat is that these data were collected in June. I expect the data will look different in January. We'll keep watching....

Laundering White Coats - We are asking the wrong question!

There is a very nice survey of bare-below-the-elbows perceptions and practice in this month's ICHE by co-blogger Mike's group. They asked 300 attendees (190 or 63% responded) at medical and surgical grand rounds about their beliefs and behavior concerning wearing white coats, neckties and wristwatches. I've posted the results below. As expected (since Mike has recommended BBE at his hospital since 2009), most thought that white coats were vectors and that not wearing a white coat would not alter patients' perceptions of them. Most did not wear white coats daily, neckties (males only) or wristwatches. Approximately half practiced the bare-below-the-elbows approach.

This all seems great except that it occurred to me that this group, and me and everyone else have asked the wrong questions as far as laundering practices of white coats. We've generally asked if the clinicians washed their coats daily, weekly, monthly, etc., when we should be asking them if they washed their white coats between patients! Asking about daily or monthly! laundering would be like asking about daily or monthly hand hygiene! Of course, this is ridiculous! I bet we could get hand hygiene compliance to 99% if the denominator was days instead of moments. By including a white coat laundering question with a lower bound of daily somehow implies that daily laundering is acceptable. Which it really isn't. Given that 96% of folks in this survey didn't wash their coats daily or every other day, this point is largely moot. Practically, we gotta give white coats the boot!

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.

The Antimicrobial Hospital Room

Earlier this month I gave a talk at ICAAC where I shared my thoughts concerning the role that environmental coatings and antimicrobial textiles might play in limiting pathogen spread in hospital settings.  Several readers asked for copies of my talk, so I thought I'd just post a (moderately) modified version here.  In the same session, Mike gave an excellent talk describing the primary importance of hand hygiene, Andrew Stewardson discussed the counter point that hand hygiene wasn't the most important intervention and Andreas Widmer covered no touch disinfection methods (e.g. UV light hydrogen peroxide vapor). A great session - wish you were there!

The Jumbo Squirting Bow Tie - Infection Prevention Dream Attire

There are so few effective interventions available to improve hand hygiene compliance. In addition, there are other infection policies, such as bare below the elbows, that are gaining acceptance as methods to prevent pathogen transmission. For example, Mike posted a few months ago about a JHI study that quantified the transmission of organisms from long vs short sleeved shirts and tie vs. no tie. The study reported that the lowest transmission from clinician to mannequin occurred when the attire was short sleeves and no tie. However, the significant flaw in this study was that ties were narrowly defined as neckties and excluded bow ties.

Enter a solution to all of our infection control problems: the Jumbo Squirting Bow Tie! This often overlooked clothing accessory is a veritable infection prevention dream. A bow tie can increase our professionalism and limit pathogen transmission. Add in the "Jumbo Squirting" action and you can squirt alcohol hand rub into the eyes of non-compliant clinicians (operant conditioning) and also into your own hands to improve compliance with the WHO 5 Moments. When you think about it, it doesn't get much better than that.

image source: halloweencostumes.com

You are what you wear

Mike has posted extensively on appropriate attire in clinical settings and perhaps folks are starting to notice. This month's ACP Hospitalist has a balanced piece by Charlotte Huff on the subject and quotes extensively from the good doctor Edmond. The most compelling part of the article for me was how much ideas and standards of what attire is considered appropriate change over time AND can be changed through education.  For example, a highlighted 1987 JAMA study reported that 34% of patients wanted female physicians to wear skirts. Can you imagine that in 2013? - makes 1987 seem almost Victorian. What was most encouraging to me was the 2008 JHI study Mike mentioned in the article. That study found that a simple education session could shift the proportion of patients preferring their surgeons wear scrubs from 24% to 62%. Hopefully soon, we will all be wearing scrubs... and black vests.

More dirty laundry......

A new study in the American Journal of Infection Control by Dr. Silvia Munoz-Price and her team at the University of Miami provides additional insights on laundering of clothing worn in the clinical setting. In a convenience sample of 160 physicians and medical students, the Miami team found that white coats were laundered on average every 12.4 days, while scrubs were laundered every 1.7 days. I found it a little surprising that for scrubs the frequency wasn't closer to 1.0, but that's tremendously better than 12 days! For both coats and scrubs, faculty laundered their attire more often than housestaff or students. Interestingly, the major reasons given for wearing white coats were: (1) ego (makes me looks and feel like a doctor, 29%), and (2) storage needs (25%). Neither is a good reason.

Late last year, the same team published a study that found that white coats were more commonly contaminated with pathogens than were scrubs in the ICU setting. Moreover, if the hands were contaminated with a pathogen, white coats were more commonly contaminated than were scrubs. And all of the HCWs with negative hand cultures were dressed in scrubs.

Both studies were relatively small and performed in a single (though very large) medical center. Nonetheless, there is a body of evidence accumulating that clothing contamination in the clinical setting is a real phenomenon and probably should no longer be ignored by infection prevention programs. So I was delighted a few days ago to see that West Virginia University Hospitals is considering banning ties and white coats.

Photo:  Dr. Munoz-Price (far right), in scrubs!

Am I an indicator of a decline in hygiene?

A few weeks ago I was seeing patients at a clinic in an affluent suburb. My first patient of the day was a professional woman. At the end of the encounter, she said: "Can I ask you a question?" I had no idea where this was going, sensing that this was probably not going to be a medical question, but said, "of course." She then proceeded to ask me how I liked my Toms, as she wanted to buy her husband a pair. I was in my typical summer clinic attire, which consists of a polo jersey, khakis, and Toms (no socks). Now I think Toms are great--they're comfortable, not made of leather (i.e., animal friendly), and for every pair sold a pair is given away to a child in need. But this post isn't really about Toms.

The Toms question from my patient was a great segue for me to ask the patient about doctor's clothing. I asked her what she thought about how I was dressed and her expectations of how physicians should dress. She said that she saw me walk into the clinic and knew I was her doctor because she had Googled me before the visit. She noted the way I was dressed and thought I would probably put a lab coat on (by the tone of her voice I could tell she didn't like the lab coat concept). She went on to tell me that my clothes made me "a real human" and it made her more comfortable in interacting with me. I suspect that some other patients may feel differently, but I carefully follow my patient satisfaction scores and must admit that if my clothes are problematic, it's not reflected in my scores. Patients don't really care how their doctor is dressed, as long as the doctor demonstrates empathy, communicates well, and ensures that the patient has access to him/her when they have a problem.

There's an essay in this week's BMJ by Dr. Stephanie Dancer, former editor of the Journal of Hospital Infection. It's entitled, Put your ties back on: scruffy doctors damage our reputation and indicate a decline in hygiene. In her poorly argued essay, which I think is sexist and borders on crazy talk, she attempts to link the bare-below-the-elbows concept to lower standards for infection prevention. She writes:

"No tie"--along with stubble, spitting, picking your nose, and gravity defying trousers--symbolize the real status of hygiene in today's society.

In one paragraph she discounts the role of clothing in infection prevention:

Given that bed linen and pajamas are habitually contaminated with their owners' personal microbial flora, the focus on transmission from what staff are wearing seems disproportionate and perhaps even irrelevant. 

This, of course, fails to distinguish between endogenous and exogenous pathogens. A paragraph later she chastises doctors for wearing the same clothes for several days as it "showers the environment with millions of skin organisms."  However, the vast majority of clinicians who wear white coats wear the same coat for days to weeks without laundering them.

I continue to believe that bare below the elbows is useful in infection prevention as it reduces clothing contamination and makes compliance with hand hygiene easier. And I wholeheartedly believe that doctors should appear neat and clean. But I'm still trying to determine biologic plausibility for how banning neck ties has led to nose picking... Maybe it's because neckties function as handkerchiefs!

The newest tool to prevent infections

Over the past few years there has been a huge push across the country to reduce healthcare associated infections (HAIs). This has created a big market for entrepreneurs. In fact, according to BCC Research the market for HAI prevention products is expected to be $14 billion by 2016, at which time the market for antibiotics to treat HAIs is expected to be only $6 billion. Some hospitals have purchased high-tech hand hygiene monitoring devices that use radiofrequency identification, some have installed video cameras to observe hand hygiene, while others have invested in hydrogen peroxide robots. At my hospital we're investing in coat hooks. As we prepare to roll back contact precautions (i.e., no longer requiring patients with VRE or MRSA to be isolated except in special circumstances), we thought it would be good to re-visit bare below the elbows to reduce clothing contamination and promote good hand hygiene.

Several years ago, our infection control committee endorsed the bare-below-the-elbows concept. This means short sleeves, no neck ties, and no white coats. We specifically crafted our policy as a recommendation not a mandate since we believed there was enough evidence to recommend this intervention but not enough to require it. It was an intentional soft sell. Since the recommendation was made we have seen more physicians in scrubs, and our nurses are nearly all in scrubs. We still have the issue of long sleeves under scrubs when the weather is chilly, and we still have many doctors who just can't ditch the white coat.

So our latest effort, the "Hang it up" campaign, is a little more pragmatic, giving healthcare workers more options to comply with bare below the elbows. We're placing coat hooks in all physician team rooms and nurse work rooms with a poster (the physician poster is shown below) asking healthcare workers to hang up their jacket or white coat before going to see a patient. If a male doctor feels compelled to wear a necktie, we advise him to tuck it in his shirt.

We would have preferred to have coat hooks placed between patient rooms on wards, but fire regulations wouldn't allow that.

As I have said before, the longer I work in infection prevention, the more I believe it's a behavioral science. Old habits die hard, so the next few months should be quite interesting to observe.

Coat hook photo:  Binns 

My new white coat is a cool black vest

Those of you who have followed our blog for the past few years probably know that one of my favorite topics in infection prevention is the role of clothing in transmission of pathogens. But I'm also fascinated by the sociologic aspects of clothing in medicine, which is usually framed around questions of professionalism (for example, is a doctor in a white coat more "professional" than a doctor wearing scrubs?). So I was interested to see another paper on this topic in JAMA Internal Medicine (the journal formerly known as Archives of Internal Medicine). The study was a survey of family members of ICU patients in three Canadian ICUs. Over three hundred persons viewed photographs of physicians dressed in scrubs, business suits, white coats with neckties, or blue jeans. The study subjects were then asked to match the variously dressed doctors with certain attributes. In a nutshell, they found that families deemed the doctors in white coats to be most knowledgable, most honest, and best overall. Doctors in scrubs and white coats were deemed equally most competent and most caring.

I'm always amused by these studies because I've never met a patient who chose their doctor on a sartorial basis. It would be like buying a red car because you love that color even though you know nothing else about the car and never took it for a test drive. These types of studies, in my opinion, sell patients short. Yes, all of us form rapid first opinions about those we encounter, but almost all of us are sophisticated enough to quickly move past superficial qualities to assess a person's honesty, ability to communicate, and for physicians, his/her ability to demonstrate empathy. Lastly, the entire premise of the study seems strange--while you might choose your primary care doctor, it's extremely unlikely that you will choose your intensivist. The accompanying editorial is congruent with my line of thinking and concludes that professional behavior is far more important to patients and families than professional appearance.

I stopped wearing a white coat a decade ago, but many physicians still cling to it. Some wear them for storage, which my wife (also a doctor) tells me is more important for women since their clothing has fewer pockets. Some wear white coats as a form of identification, which may have held true when doctors were the only people in the hospital wearing them. Some wear them for warmth. And some just need the ego boost.

I was an early adopter of bare below the elbows and have only worn scrubs when seeing inpatients for the last five years. Smart phones and cargo scrub pants have taken care of my storage needs. But the one downside of scrubs is feeling cold in the winter. My partners and I recently solved that problem. We found vests that are lined but are constructed of nylon on the exterior surface, which allows them to be easily wiped down. They fit snugly so they don't drape onto the patient when performing an exam. And yes, they are warm! I'd like to take credit for the idea, but actually we copied our intensivists, most of whom are also bare below the elbows.

On April 1, we embark on a new policy at my hospital that no longer requires contact precautions for patients with MRSA and VRE. As we educate our staff on the change, we're reminding them that it's ok to shed the white coat and tie. If we're not going to wrap ourselves in plastic, bare below the elbows seems even more important.

Don't tie one on!

A new study in the Journal of Hospital Infection seeks to shed some light on an area of true controversy in infection prevention: whether clothing is involved in the transmission of organisms between providers and patients. The party line thinking in the infection prevention world goes something like this: infrequently laundered white coats and neckties do not transmit pathogens to patients, but if a patient is infected or colonized with MRSA, VRE or MDR-gram negative organisms wear a plastic gown when you enter his room. I have yet to have anyone explain to me the logic behind this paradoxical thinking. In my simple mind, clothing either has the potential to transmit pathogens or it does not. If it does, then minimize that risk. Shedding white coats, ties and long sleeves makes sense to me. The real question, I believe, is not whether infections are reduced by these simple interventions, but to what degree.

In the JHI study, a physician simulated a physical exam on a mannequin. The physician wore 4 different combinations of shirts and neckties (short sleeved shirt, long sleeved shirt, with tie, without tie). Prior to each simulated physical exam, specified areas of the shirts and ties were inoculated with Micrococcus luteus. After the exam, the mannequin was then cultured for the presence of Micrococcus. Each clothing combo experiment was repeated 5 times.

The clothing combo resulting in the highest rate of mannequin contamination was long sleeves + tie (transmission occurred in 4/5 experiments) and lowest with short sleeves sans tie (0/5). Looking at each item separately, long sleeved shirts were associated with more frequent transmission than short sleeved (5/10 vs 2/10), and ties more frequently than no ties (6/10 vs 1/10). Based on the application of a statistical test to the proportions shown above, the investigators concluded that ties increased the risk of transmission of bacteria, but long sleeves did not. Given that there were only 20 experiments I don't think we can draw many conclusions here, except that it's another study which adds to the biologic plausibility that clothing may be involved in transmission of pathogens in the hospital. As a guy who still follows the bare-below-the-elbow approach (i.e., what follows may reflect my bias), I find it intriguing that the only clothing combo in which no transmission occurred was short sleeves + no tie. Aren't we still trying to get to zero?

Photo: Brown Medicine

No White Coats in Miami!!

I know it never gets cold in Miami, so they have one less excuse to hear from clinicians, but we wanted to share with you a new practice at Jackson Memorial Hospital in Miami, Florida.  Silvia Munoz-Price, Medical Director for Infection Control, shared that this past month they have found that white coats and scrubs were contaminated with the same pathogens as found on the hands of providers wearing the coats/scrubs. Thus, for the past 2 weeks they have been doing ID rounds wearing scrubs or bare below the elbow and without white coats. They report receiving "no negative feedback from the staff nor patients." Way to go Team Miami!

CDC goes OOPS!

How does the CDC really feel about infection control?  Perhaps we can get a hint by looking at the cover of their new Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care.  How many fundemental breaks with basic infection control do you see? I guess we know there is a new low in minimum expectations!

Oh, by the way, the CDC has just released their new Guide to Infection Prevention for Outpatient Settings.

h/t Jan Kluytmans

Now this takes balls...

In this video a British surgeon barges into a room where the Prime Minister is talking with a patient and kicks out the cameraman because he's not bare below the elbows. Interestingly. the Prime Minister is bare below the elbows and tieless. You can read about the scandalous surgeon here.

Twisted logic



Graphic: WeirdSpace


There's a piece in this week's American Medical News on the New York bill to mandate bare below the elbows. It includes this quote from Dr. P.J. Brennan, former President of SHEA:

It's not as though, by eliminating sleeves, you eliminate germs. The key thing to understand is that these environments are not sterile and are never going to be sterile. That goal is unattainable in a clinical setting. The real goal is to adhere to good hand hygiene, isolation practices, gloving, barrier precautions -- that's where we'd put our money.

I think Dr. Brennan's argument represents the conventional wisdom among hospital epidemiologists, but it doesn't make sense to me. He supports contact precautions, but doesn't support bare below the elbows, both of which are based on the same evidence and assumptions. So I think his logic is twisted. It seems to me that you either believe that clothing has the potential to transmit pathogens or you don't.

Bare below the elbow: New interest in the US?

Graphic: YNN-NY

A group of lawmakers in the New York state senate are considering a legislative mandate for bare below the elbow in New York hospitals, and perhaps even requiring hospitals to supply uniforms or on-site laundry facilities. You can read about it here.

5/8/11 addendum:  Here's an update with more detail.

MRSA Video - If this doesn't get you excited "almost" nothing will

The video was made by The University Hospital of South Manchester.

Things to note:
1) They start off by washing their hands and not swabbing their noses
2) Ties are tucked, sleeves are rolled up and they're mostly bare below the elbows.

Source: BBC News