Friday, July 15, 2011

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?


Nurse and Hospital Stories said...

"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."

Well said doc. I don't know with many hospitals for having a great fuss when it comes to dress code especially with the uniforms. Oh, I believe that this policy is good for the reason of identification of medical personnel, but with accordance to infection it is in a way doubtful.

Thanks for the post, eh
Peny@Baby phat scrubs

Anonymous said...

The absence of evidence doesn’t mean there is no risk — it just means there is no good research.

Skeptical Scalpel said...

I guess one could say that about any subject which has no evidence. Are you advocating a dress code for hospital staff?

Unknown said...

Ah yes, there is only evidence over bacterial colonization of personal clothing and equipment - never any documented transmission.

But, the question is - before we all switch to short-sleeves and scrubs - should it be proven that this colonization results in pathogenic spread, or should it be proven that this colonization does _not_ result in pathogenic spread?

I tend to feel like the elimination of the long sleeves and rarely-washed coats is a zero-cost intervention, and if the intervention is zero cost, it doesn't matter of the number needed to treat is hundreds of thousands - it's still worth it.

I can see how some would argue, however, that not wearing the formal trappings of a physician might result in lesser patient compliance, and in the end, more folks would be harmed by non-compliance than by pathogenic transmission. Or some other unanticipated consequence of decreased formality until a new generation adjusted to the accepted appearance of physicians.

Or maybe I just get too hot in my coat, and it's always in the way in the ED, regardless.

Skeptical Scalpel said...

Thanks for commenting, Radecki. But where does it end? With short sleeves, won't all the bacteria land on your arms? Then the thought police will make you wash to above your elbows. And don't wear a watch.

HopeSpringsATurtle said...

After 12 years of Catholic school and an Air Force career, uniforms are a familiar and welcome addition to the hospital workplace. The idea that they will decrease nosocomial infections seems a bit far-fetched but I think uniforms do provide a sense of 'team'and playing well together in a healthcare setting is what makes for better outcomes ultimately.

Skeptical Scalpel said...

Hope, I love your name. I'm sure someone really said that instead of "hope springs eternal."

I have no problems with uniforms. I wish nurses, docs and others dressed with more attention to neatness and cleanliness.

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