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.

***
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.

*****
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.

Patient - Wash Thy Own Hands!

There has been increasing attention over the past decade in engaging patients in patient safety. In infection control this trend has manifest through efforts to have patients monitor and encourage hand hygiene compliance among health care workers. In a related trend, there is also increased interest in patients washing their own hands in a framework called "patient-centered hand hygiene." My understanding of this approach is that having patients clean their own hands could potentially increase their engagement in infection control initiatives including encouraging health care workers to practice hand hygiene. This approach might also have the additional benefit in decreasing the organism burden on patients' hands and interrupting direct or indirect transmission of MDROs in healthcare settings.

It is with this background that Kundrapu and colleagues at CWRU and the Cleveland VA completed a randomized trial of soap and water versus alcohol hand rub in reducing C. difficile spore burden on patients' hands. Forty-four infected or colonized patients were included in the study. Hand cultures were positive in 32% of patients with CDI and 38% of colonized patients prior to hand hygiene. As you can see from the figure below, soap and water significantly reduce the proportion of positive cultures and mean CFUs, while alcohol hand rub did not. Interestingly, around 10% of patients still had C. difficile recovered after washing with soap and water. Seems like a trial is in order to determine the role of patient hands in transmission and whether cleaner patient hands reduces the incidence of CDI and other MDROs in hospital settings. One major limitation is that this intervention could not be implemented in settings where the need is the greatest, namely ICUs, since most patients would be too sick to wash their hands.