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!

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.

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!

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

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.

More on contaminated neckties

A new study from Ireland of 95 doctor's ties found that 18% had pathogens recovered when cultured. S. aureus was recovered from 10 ties (8 of the isolates were methicillin resistant), gram-negative bacilli were recovered from 10 ties, and 3 ties had both S. aureus and gram-negative bacilli. The doctors also completed a survey, and 81% reported they would be happy not to wear a tie.

So to recap, we have an article of clothing that serves no function, is commonly contaminated with pathogens, and many doctors don't want to wear them. I think it's time to kill the necktie.

New Jersey hospital bans neckties

Jersey City Medical Center will now prohibit healthcare providers from wearing neckties. Bowties are still allowed. From the infection control standpoint, I think banning white coats would have a bigger impact, but it's a good start to push healthcare workers to become more cognizant of the role of clothing in infection control.

SuperFreakonomics and the hospital epidemiologist

In their new book, SuperFreakonomics, Steven Levitt and Stephen Dubner give us their analysis of why hand hygiene compliance is poor among doctors. They cite the following reasons: the large number of patients that may be seen in a day and how busy doctors are; inaccessibility of sinks, though they note that conveniently placed alcohol-product dispensers are often ignored; perception deficit, that is, doctors believe their compliance is much better than it actually is; and arrogance. Then they put on their economist hats and talk about negative externalities. By this they mean that the doctor bears little risk personally when he or she is noncompliant with hand hygiene and thus the doctor has little incentive to comply. So far, so good. But then they downplay trying to change behavior in favor of solutions that bypass the need for change in behavior (e.g., antimicrobial impregnated products). I think the answer is both behavior change and non-behavioral solutions are required since there aren't enough of the latter to overcome dirty hands. I was particularly happy that they advised doctors to stop wearing neckties to improve infection control (though my happiness is not just infection control related). Also of note, they profile our colleague, Dr. Rekha Murthy, hospital epidemiologist at Cedars-Sinai Medical Center, and her successful program on hand hygiene.

So what's the importance of this? The economists haven't really added any new insights or solutions to the problem of healthcare associated infections. But they clearly will have impact by offering their analysis to the general public. Their previous book, Freakonomics, has sold over 4 million copies, and led to the launching of a blog with a full time editor, and a movie is in the works. How did I learn about their interest in infection control? I saw Stephen Dubner on CNN talking about why doctors shouldn't wear neckties. Interestingly, if you do a Google image search of him, you'll note that he rarely wears a tie.