Wednesday, January 15, 2014

Preventing infection: The "bare below the elbows" rule for doctors doesn't go far enough



Here's a post about a paper on the possible transmission of bacteria on doctors' clothing that drew over 1000 comments on reddit in 24 hours.

It linked to a blog by an infectious disease/hospital epidemiologist physician. He discussed a small study which showed that bacteria could be transmitted by neckties.

The study looked at four different combinations of dress—long sleeves with and without ties and short sleeves with and without ties worn by a single physician who rounded on five mannequins simulating patients.

From the Methods section of the paper. "Micrococcus luteus (ATCC) was suspended in sterile saline and adjusted turbidometrically to a concentration of ~1.5X10 8th colony-forming units (cfu)/mL .A Dacron swab was dipped into the bacterial suspension and was rubbed over the terminal 6 cm [about 2.4 inches] of the tie for those tests involving the tie and the corresponding location on the front of the shirt for tests involving no tie. The terminal circumferential 2 cm of the cuffed portion of long and short sleeve shirts were inoculated in a similar manner."

The study found that wearing an unsecured (I guess meaning no clasp) tie was significantly associated with elevated level of contamination of the mannequins. The degree of  mannequin contamination was not significantly different whether long or short sleeves were worn.

The blogger concluded that everyone should wear short sleeves and no ties.

But wait a second—6 cm of tie covered with bacteria? How many people are getting that much contamination on their ties? If you are, then you need to reassess your approach to not only infected patients, but maybe activities of daily living in general. 

Some might counter that even though the short sleeve portion of the experiment was not conclusive, what is the harm of having everyone wear short sleeve shirts and no ties?

In a recent editorial in the BMJ, Stephanie J. Dancer, a consultant microbiologist in England, wrote that there is no evidence to support the "bare below the elbows" rule [which has been in effect in the UK for several years], and it may be having some unforeseen consequences.


From her piece: "It could be argued that ditching the white coat and tie for hygiene purposes has had the converse effect, in that the informal attire now gracing our wards has encouraged a less robust view of infection control." She based this on the fact that since the bare below the elbows rule, junior doctors have adopted "scruffy" [her word] attire and slovenly personal hygiene.

She went on to say, "The dress code for UK doctors was imposed more as a political gesture than as an evidence based strategy likely to reduce infections acquired in hospitals."

A surgeon from the UK designed what he thought was the perfect uniform for doctors and published a description of it in the BMJ in 2012. Here is how it looked.


He said the "S" stands for "Surgeon." It was not accepted, probably because of the cape.

Maybe bare below the elbows doesn't go far enough.

I think all hospital personnel should dress like this.

Notice he has no stethoscope, no ID card, no cell phone or pager—they can harbor bacteria!







27 comments:

Jeff Matthews said...

The empiricist has no clothes.

Anonymous said...

Not at all surprised that this topic blew up on Reddit. They're a very anti-tie crowd over there.

Now that nurses, physician assistants, dieticians, physical therapists, pharmacists, and social workers all wear white coats in the hospital, I like when doctors dress up so that you can tell who the physicians are!

RegionsTrauma said...

All right, enough! We've got a bunch of research weenies running around culturing stuff. And they are finding bacteria! Sometimes pathological bacteria. When will we realize that everything is normally covered with bacteria? Sometimes pathological bacteria. The only time it matters is if the people coming into contact with them have impaired immune systems. So protect them and ditch any future research in the area. The lay papers and journals just sensationalize it.

artiger said...

My thanks to Anon above. I have office hours twice a week (dedicated time when I am not in the OR), and I wear a clean white coat, with a dress shirt and tie on those days. Many of my patients remark about this in a positive light. Some of them, especially the older ones, often put on their "Sunday best" when they come in for an appointment. Seems like mutual respect.

Anonymous said...

The commentary on Reddit seems to be driven largely by premeds and medical students.

Anonymous said...

People on Reddit are basically sheep who will believe any "scientific" news article, especially those that confirm their biases.

Skeptical Scalpel said...

Jeff, that's not me in the photo. :-)

Anon and Artiger, it might be that patients would prefer getting advice from someone who looks like a doctor over the theoretical risk of bacterial contamination from a tie dipped in 6 cm of bacteria.

Regions, we agree. I'm sure you are aware that I've been harping about this issue for years. See the "Infection" label to your right for more posts about the "bacteria are on everything" craze.

Anons, I realize reddit is not a scientific sample representing a cross-section of the public. But still, >1000 comments--that's a lot.

Robert Modugno said...

Bow ties!

Skeptical Scalpel said...

Robert, many docs wear them. I find it hard to take anyone wearing a bow tie seriously. Also, nearly all men look dorky in them.

Anonymous said...

Senior academic neurologists seem to be able to pull off the bow tie in a way that medical students and plastic surgeons cannot.

Anonymous said...

I thought the increase in bacterial contamination was due to the overuse and possible under-dosing of antibiotics for specific organisms, whether it be on the farm or in the doctors' office. The "bug" and access to it is far more important than whether you wear a tie or long sleeved shirt. Silly article!

Skeptical Scalpel said...

First Anon, I would add pediatric surgeons to to the list of folks who can get away with wearing a bow tie.

Second Anon, I agree that the overuse of antibiotics is a far bigger problem than the menace of neckties.

Anonymous said...

As an older physician, I can recall from my training days that I was told that scrub dresses were phased out in favor of scrub pants after studies showed a reduced infection rate. I cannot recall if undergarment type or "commando" status was part of the evaluation.

Peavy said...

Your post made me laugh. I remember in the 1980s doing some (paper) research. Issues hot at the time included underwear, e.g. T-shirts, under scrubs; scrub dresses (and what on the legs) vs. unisex scrubs; bathing/showering the night before work vs. the morning of; scrubbing with brushes vs. sponges (no alcohol gels); sex differences.

The best study, and I truly wish I'd kept a copy, surveyed results of a number of research articles from several different countries. Their conclusion was that for maximal safety/minimal microbial exposure, one wished to have one's operation performed by a naked, female, Swedish surgeon not using a brush to scrub.

Skeptical Scalpel said...

I'm old enough to remember that too. I just did quick PubMed and Google searches and was unable to find any papers on this. My recollection is that the change from dresses occurred in the early 1970s. I wonder if there actually was research done on the topic.

One thing I do know is not many nurses were going commando in those days.

Skeptical Scalpel said...

Peavy, thank you for providing the definitive answer.

Anonymous said...

Is this where I sign up for the naked female Swedish Surgeons?

Skeptical Scalpel said...

I'm afraid not.

Anonymous said...

If you would forgive me for trolling, I'm curious to know how you were aware of the commando status of said nurses. Regardless, I find your blog very informative....

Skeptical Scalpel said...

I was a rather dashing figure as a young man. Women told me their secrets.

Anonymous said...

I remember (yeah, I'm that old) an episode of St. Elsewhere in which they did surgery - unclothed:

http://www.channel4.com/programmes/st-elsewhere/episode-guide

Episode 18 - The Naked Civil Surgeon

Some of the doctors shyly agree to an experimental surgery procedure which requires them to work unclothes (sic). A dewy-eyed Auschlander greets the son he never knew.

Skeptical Scalpel said...

Anon, thanks for the laugh and the link.

Anonymous said...

I don't think that it is just medical students and residents posting on reddit. The issue is that ties look professional, they are not hygenic. We know this. Its been shown * many* times. As younger MDs we wonder who our older colleagues are trying to convince-- their patients that they are "serious" or themselves that they being taken more seriuosly. When I see my partners making post-op rounds in a suit and tie and dress watch I cringe.

Skeptical Scalpel said...

Yes, bacteria have been found on ties. Bacteria have been found just about everywhere. There is no evidence that ties transmit disease. I used the tie literature as an excuse to stop wearing them late in my career. Feel free to go without a tie yourself, but please don't tell me they spread disease.

Do you wear only short sleeve shirts? What about scrubs? Do you wear them outside of the OR?

Anonymous said...

As a young surgical registrar, I was chastised one evening by a senior theatre nurse for wearing a scrub dress (there were no trousers left) and my teds stockings. I was told that scrub dresses must be worn with pantyhose to "avoid pubic shed". Seriously. This was 6 years ago.

No matter that I was going to theatre to drain a perianal abscess, my choice of legwear was deemed an infection control issue.

Skeptical Scalpel said...

Anon, great comment. It reminds me of a post I wrote 2 years ago called "A rule without foundation." you might enjoy it. Read the comments too.

Skeptical Scalpel said...

Sorry. Here's the link http://skepticalscalpel.blogspot.com/2012/05/rule-without-foundation.html

Post a Comment