Friday, January 24, 2014

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?"


artiger said...

A lot of these guys have never been around truly dirt-poor patients, have they? They do realize that the coat is sometimes used to protect the doctor (and his ties)?

And yes, I launder my coat (and clothes) professionally and regularly.

Libby said...

Any attire will transfer germs, the white coat is something that can be removed when visibly soiled or to leave for home or elsewhere.

Side note: my new family doctor wears a white coat...he's 3 yrs. post residency and has his (what I call them) cheat sheets (they're actually books) in the pockets. He says they're more security than anything. He does use them when I stump him. And I'm ok with that-I think that shows maturity more than ineptness. Gosh, I'm going to doctors who are my kid's ages now!

Skeptical Scalpel said...

Libby, I agree. White coats are also very easy to clean. I like a doctor who can admit he doesn't know everything. You might tell him that he could lighten his load by carrying a smartphone. I hear they can be used to look stuff up on what they call "the Internet."

Skeptical Scalpel said...

Artiger, yes, the coat works both ways.

Anonymous said...

I would rather have a doctor that looks up stuff than one who doesn't. Makes me crazy, because the ones that won't, I've found their "standards of care" are about 3-5 years (at least) behind their own medical journals.

That being said, the ones who always had a pristine white coat were the ones who said they knew everything. I guess medical science didn't advance past when they finished residency.

Skeptical Scalpel said...

Anon, I agree that doctors should not be afraid to say "I don't know." It's impossible to know everything and the information can usually be found quickly these days.

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