Can a Hospital Dress Code Prevent Infection?

A Canadian hospital has just issued a lengthy dress code for its employees. It mandates that personnel in patient care areas “…must wear hospital-issued [emphasis theirs] garments (uniforms, scrubs, lab coats)…” and such garments cannot be worn outside of the hospital. The purpose of the policy is to help patients and families distinguish the various strata of employees. Although not explicitly stated, the ban on wearing the clothing to and from work is likely an attempt to reduce contamination.

I have no problem with the proposal to make identification of nurses, doctors, technicians and all the rest easier. I’m not so sure about the role the policy may play in reducing infection.

The literature on contamination of clothing is clear. I’ve blogged about it before. One can find organisms on ties, lab coats and many other inanimate objects. What has not been proven is that the organisms are causing disease in humans.

An experiment to answer the question would be formidable to undertake. To do it correctly would require a randomized prospective study. Let’s say we wanted to answer this, “Is there an increased incidence of infection in patients cared for by staff who wear scrub suits to and from home? Half of a hospital’s staff would need to be assigned to two groups. In one, staff would wear hospital-issued scrubs not to be worn home versus the other consisting of staff who would wear their own scrubs to and from work.

Here are some of the problems. Uniforms would need to be cultured frequently, perhaps every day. Patients who developed infections would have to be cultured and the organisms grown would need to be compared to those grown from the uniforms. Blinding of the staff would be impossible. The real kicker would be something called “power.” A power analysis would have to be done in order to establish the number of patients needed to avoid what is known as a “Type 2 Error” which is accepting that there is no difference between the two groups when a difference really exists. Since it is likely that the number of infections transmitted via clothing is fairly low if at all, it would take hundreds of patients with infections in each group to make the study valid. Who would fund such as study?

It isn’t going to happen. And it shouldn’t. The paper about contaminated uniforms that everyone cites (J.A. Wilson, et al. Uniform: an evidence review of the microbiological significance of uniforms and uniform policy in the prevention and control of healthcare-associated infections. Report to the Department of Health (England) J Hosp Infect 2007;66(4):301–07) is yet another example of either misreading the abstract and/or not reading the whole paper. The abstract clearly states, “The hypothesis that uniforms/clothing could be a vehicle for the transmission of infections is not supported by existing evidence.” The paper goes into some detail in explaining that skin flora of the wearer are responsible for many of the contaminants recovered. Skin flora would of course be present whether the wearer dons a hospital-issued or home-based uniform. Much of the paper deals with the laundering of uniforms. The authors concluded that there is no difference between industrial and home laundering in the cleaning of clothing. In 2010, The AMA stated that hand washing was far more important than dithering about uniforms despite the decision of authorities in the UK to mandate short or rolled up sleeves and no ties for doctors. This led to the comic spectacle of a senior orthopedic surgeon throwing the UK Prime Minister out of a hospital room because the PM and his entourage were wearing long sleeves. (It wasn’t so funny when the surgeon was suspended.)

Personally, I don’t care for the way many doctors and nurses dress. I too have problems telling the nurses from the housekeepers. I would welcome a dress code. I now justify not wearing a tie by saying I’m trying to help prevent infections. But in the era of “evidence-based” medicine, I see no proof that a dress code will have any impact on the rate of hospital-acquired infection. 

ADDENDUM 11/15/15

Links to the hospital website and the dress code, which were present in the original post, have been removed because they no longer work. It makes me wonder what happened. Was the dress code established? Did it reduce the rate of infections?