The Society for Healthcare Epidemiology of America (SHEA) has just published in the February 2014 issue of Infection Control and Hospital Epidemiology a guidance statement for hospital attire outside the OR (Bearman 2014). The guidance attempts to balance professional considerations against the potential risk of transmission of pathogens to patients. The authors make it clear that the actual role of hospital attire in causing infections in patients remains unclear at this time. Nevertheless, the guidance has recommendations that are based on practical, theoretical and biologically plausible considerations to reduce the likelihood of transmission of pathogens to patients. The guidance reviews the laboratory evidence of contamination of various pieces of healthcare worker’s attire with pathogens, including multi-drug resistant pathogens.
One recommendation is “bare below the elbows (BBE)”. This means healthcare workers should wear short sleeves during patient contact and have no wristwatch, rings or other jewelry below the elbows. Note that BBE has been utilized in the UK now for many years.
There are multiple recommendations regarding the traditional white coats worn by healthcare workers. Workers should have at least 2 white coats available and a convenient and economical way of laundering them. The institution should provide onsite laundering at no cost or low cost when possible. The institution should also provide coat hooks for healthcare workers to remove their white coat (or other long-sleeved outerwear) prior to patient contact. While they note that attire worn in patient contact should be laundered after daily use, they recommend that white coats worn during patient care should be laundered at a minimum once a week or when visibly soiled. While they did not take a firm stance on whether attire should be laundered at home or professionally, they do recommend that if attire is laundered at home a hot-water wash cycle with bleach be used, followed by a cycle in the dryer.
Specific recommendations on footwear are that all footwear should have closed toes, low heels, and nonskid soles. These basically echo AORN recommendations for shoes in the OR.
Equipment that is shared between patients (eg. stethoscopes) should be cleaned between patients.
SHEA did not take a specific stance on issues related to neckties, lanyards, cell phones, pagers, other jewelry but noted that when such come in contact with patients or the patient environment they should be disinfected, replaced or eliminated.
The paper nicely describes the literature on all facets of hospital attire and potential for infection. It notes that while, in general, patients prefer more formal attire and white coats in their clinicians, they are okay with the newer attire once the potential for cross contamination is explained to them.
The paper does include the background studies on the laboratory evidence of pathogens on attire and body parts but emphasizes that there is a paucity of data that links the contamination of attire to actual patient infections. Nevertheless, the new SHEA recommendations are practical and economical and biologically plausible so we would hope that hospitals begin to adopt them.
There is, however, a huge gap between hospital attire policies and their enforcement. The SHEA paper notes that enforcement of hospital attire policies may be as low as 11%. Given the number of healthcare workers we see in scrubs in hospital cafeterias, other parts of the hospital, and even shopping alongside us in our local grocery stores, we know it will take much more than a policy to foster true change.
Bearman G, Bryant K, Leekha S, et al. SHEA Expert Guidance. Healthcare Personnel Attire in Non-Operating-Room Settings. Infect Control Hosp Epidemiol 2014; 35(2): 107-121 February 2014 electronically published January 16, 2014
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