What can infection control learn from aviation safety?

We all like to believe that we work in a safe healthcare environment - one that is safe for our patients and colleagues. But the truth is, we care more about our own feelings and time than we do about patient and healthcare worker safety. 

We've discussed the white coat "debate" and the contact precaution "debate" many times already on this blog and elsewhere. If you want to see a nice overview of the white coat debate, Phil Lederer has a new post up on The Conversation. Thus, I don't want to get into the specifics too much, but as a reminder, clinicians wear white coats to carry things, stay warm and as part of our professional uniform. As far as contact precautions, we wear them to significantly (clinical and statistical significance) reduce MRSA infections with the majority of evidence suggesting contact precautions prevent transmission of clinically significant pathogens in inpatient settings.

The major barrier is that healthcare workers hate contact precuations (time, inconvenience) and cling to their white coats and no matter how much evidence we provide them through RCTs, cluster-RCTs and molecular epi studies, they will selectively interpret the data within their own subjective reality (ie cognitive bias). So when our patient safety leaders/deciders are immune from scientfic data (ie the BUGG study or the hundreds of studies that show white coats are covered in pathogens), what are we to do? How can we possibly overcome their cognitive bias (which they hide behind by demanding more and more cluster-RCTs)?

The first thing we can do is point them to the patient safety movement's favorite target: aviation safety. In aviation safety, do they require cluster randomized trials before making us put our tray tables up during takeoff or before banning us from sleeping in the aisles? Is their an RCT that proves that only folks 13yo and older can sit in an exit row? The answer is no. Airline safety is built on logic and scientific evidence but not randomzied trials. For example, you could test to see at what age children can open and lift an exit door safely and use that as a cut-off for setting age restrictions in exit rows. Amazing, huh?  The equivalent in patient safety would be the dozens of studies showing that white coats are coated with pathogens and that long sleeves touch patients. With that level of evidence, an airline safety person would ban white coats in 30 seconds. They wouldn't care if it's inconvenient to carry your iPad without a white coat, just like they don't care that it's inconvenient to put your 5 pound laptop away before landing. Common sense prevails in airline safety! It should also prevail in infection control.

So how do we ultimately create a safe healthcare environment? First, we should continue to demand the highest level of evidence and funding for trials that help develop and test new patient-safety interventions. But in the meantime, we need to put our patients first by using the proven tools (contact precautions) and scientifically sound policies (bare below the elbows) that we already have at our disposal. The highly resistant bacterial pathogens aren't going to sit around waiting for a $20 million dollar cluster randomized trial proving white coats harm patients. And even if they did, there would be folks who would find reasons not to listen anyway - it's cold! Just like aviation safety experts do, we should use the best data available and common sense to make for the safest hospitals today and we should also acknowledge how our cognitive biases cloud our decision making.

To have a truly safe healthcare system, we need to put our patients' safety first and not hide behind a lack of cluster-RCTs that may never be done. If we follow the logic of folks clinging to their white coats or contact precaution deniers, we will soon not even have to wash our hands between patients. Wait, we already don't wash our hands you say? Yes - my point exactly.


  1. great post, Eli. Passionate and well thought out. Phil

    1. thanks. not sure it matters, but fun to occasionally try.

  2. Without directly commenting on the white coat debate, a comment about using aviation safety as a model for infection control/quality improvement, particularly for those who cite "look what I cultured" studies.

    Aviation safety exists for two reasons: 1) avoid passenger morbidity/mortality due to planes, 2) avoid bad publicity. Airlines operate to make money, and turnaround time is a big part of that: http://www.npr.org/2015/06/28/418147961/the-man-who-saved-southwest-airlines-with-a-10-minute-idea

    What is the magnitude morbidity/mortality of pathogen transmission on a plane?

    Q: If airlines are concerned about passenger well-being, why does it seem that the risk of transmission from surface, air, or water contamination isn't improving? And what, if anything, is done to prevent it?
    2005 http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2672.2005.02651.x/full
    2014 http://ocm.auburn.edu/featured_story/airliner.html#.Vfv8xtJVhBe
    2005 https://www.newscientist.com/article/dn8187-dangerous-contamination-found-in-water-on-us-planes/
    2013 http://www.medicaldaily.com/airplane-drinking-water-frequently-contaminated-epa-finds-coliform-bacteria-12-plane-tap-259358
    (A: Money. And not much, based on personal in-flight experiences.)

    As we debate the contribution of white coats to pathogen transmission, let's keep the magnitude of the white coat "failures" and aviation safety "successes" in context.
    Outcomes of aircraft accidents and incidents have been described:

    Does aviation safety focus disproprotionately on headline-grabbing crashes, at the expense of every day risks we know how to mitigate (but aren't)?

    What can aviation safety learn from infection control?

    1. Thanks for your comments. Starting with your comment about airline profit motives, I might also suggest that hospitals aim to make profits (or avoid losses) and that turn-around time is key (i.e. shorter length-of-stay). Hospitals also should aim to avoid morbidity and mortality and bad press - so I suspect we are guilty in hospitals of focusing on preventing big over small errors. As far as infection transmission on planes, I think that is an important point but beyond what I was trying to communicate - which was we shouldn't just wait for randomized trial data before implementing interventions in hospitals. I do agree we can all learn from each other and infection control has a lot to teach other areas, particularly QI.

  3. " Common sense prevails in airline safety! It should also prevail in infection control."
    Should is the operative word Eli. Should. If I had a nickel for every non-sensical based idea or demand that crossed my desk I would no longer have to be employed. Thanks for a great post.

  4. Excellent post, Eli! In the interest of continuing the discussion, and with the utmost respect to the points you made, I’ll make a couple observations:

    (1) I don’t agree with the term “contact precautions (CP) deniers”. In "the parlance of our times", that term (denier, as in vaccine denier or climate change denier) implies that there is a massive amount of data supporting a scientific consensus that the “denier” is ignoring for personal, political or other reasons. Debating CP effectiveness is not like debating climate change or the vaccine-autism link. Having just re-reviewed the literature in preparation for an IDWeek talk, I’m more convinced than ever that the evidence base for CP is awful, and underwhelming, particularly for MRSA and VRE control in endemic settings (see also Mike's recent post on this). I also don’t think there are really any true “CP deniers” in the mainstream infection prevention community—only those who feel that our current use of CP is not well thought out and probably ineffective. For example, I’m not sure you’d find anyone who didn’t feel that CP can be essential in outbreak settings.

    (2) You cited the BUGG study when stating that we use CP “to significantly (clinically and statistically) reduce MRSA infections…”. The BUGG study didn’t demonstrate that. For the primary outcome this excellently designed study was negative—for the secondary outcome of MRSA acquisition only, there was a reduction that met statistical significance (p=0.046) in a setting in which the study period acquisition rate was the same in both intervention and control units (not to say the finding isn’t real, or is definitely due to regression to the mean in the intervention group, but I think it is muddy…and unpersuasive). As the authors themselves (which includes you) wrote, “replication is warranted.” I agree with the authors!


    1. Thanks Dan. Deniers gonna deny. (humor) It is surprising to me that a lack of good cluster-trial data overwhelms quasi-study data in some areas of infection control (contact precautions) and not other areas (hand hygiene). Hopefully Anthony will respond to the BUGG criticisms but of course p-values are not what should be cited here once the threshold is met because closer to 0.05 doesn't really mean much as far as clinical significance. I would mention the 3/1000 person day reduction in MRSA reported in the BUGG study and wonder if we have cluster-RCT data supporting hand hygiene or environmental cleaning as being that beneficial? If not, maybe we should stop doing everything we do in infection control? Probably where we are headed.


Post a Comment

Thanks for submitting your comment to the Controversies blog. To reduce spam, all comments will be reviewed by the blog moderator prior to publishing. However, all legitimate comments will be published, whether they agree with or oppose the content of the post.

Most Read Posts (Last 30 Days)