Controversies in OR infection control

Like professional athletes, Skeptical Scalpel sometimes talks about himself in the third person. A recent article in Clinical Infectious Diseases [CID] confirms what Skeptical Scalpel has said about a couple of controversial topics in infection control.

The article by surgeons from the University of Washington was published online in late May of this year and gives historical context to some of the standard operating room practices we currently argue about.

Regarding operating room headgear, the authors dissect and refute the positions endorsed by the Association of periOperative Nurses (AORN) that hair and airborne bacteria cause infections. In fact, they say wearing of any kind of hat in the OR may actually disperse more bacteria due to the effect of the hat rubbing against the hair and causing an increase in bacterial shedding.

They conclude “there is little reason to support the AORN recommendations regarding head covering.”

New guidelines for health care personnel attire are short on evidence

The Society for Healthcare Epidemiology of America (SHEA) guidelines for healthcare workers attire have just been published.

Science Daily led with the headline "New Infection Control Recommendations Could Make White Coats Obsolete," which is rather misleading since the guidelines say no such thing.

I won't reproduce the entire 15-page document here since the full text is available online. But here are some highlights along with my comments.

The guidelines say that facilities may consider adopting a "bare below the elbows" (short sleeves, no watch, no jewelry, no ties) policy. They concede that the incremental infection prevention impact of a BBE approach to inpatient care is unknown but it is probably not harmful. I recently wrote about some comments from a microbiologist in the UK on the possible disadvantages of the BBE mandate already ongoing there.

Despite the Science Daily headline, the guidelines actually say that white coats are acceptable as long as they are removed before contact with patients and are laundered regularly. What constitutes "regularly"? The guideline says In our opinion, white coats worn during patient care should be laundered no less frequently than once a week and when visibly soiled. They discuss the debate about whether patients prefer to see doctors in white coats. I blogged about this a while ago too.

They stayed on the fence about whether clothing worn in the hospital should be laundered professionally or at home and surprisingly, did not recommend prohibiting the wearing of neckties.

The Science Daily story contained some interesting quotes from one of the authors of the guidelines.

"White coats, neckties, and wrist watches can become contaminated and may potentially serve as vehicles to carry germs from one patient to another," said Dr. Mark Rupp, who added, "However, it is unknown whether white coats and neck ties play any real role in transmission of infection," I wonder if he reads my blog?

Dr. Rupp did speculate that sometime in the future if studies show that white coats are harmful, they might disappear to be replaced by scrub suits. That is interesting because the wearing of scrub suits as also been criticized by many.

It's hard to disagree with two of the recommendations:

Appropriately designed studies should be funded and performed to better define the relationship between HCP attire and HAIs [hospital acquired infections].

Until such studies are reported, priority should be placed on evidence-based measures to prevent HAIs (eg, hand hygiene, appropriate device insertion and care, isolation of patients with communicable diseases, environmental disinfection).

But until those studies are done, the guidelines may produce more controversy than compliance.

If I could ask the well-meaning folks at SHEA one question, it would be, "Why issue guidelines if you have no evidence to base them on?"

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!