What Not to Wear: New Guidelines for Nonsurgical Care Providers

Although health care facilities have strict policies in place for surgical attire, guidelines for nonsurgical attire are not as clearly defined. But contaminated clothing worn by nonsurgical care providers can play a role in cross transmission of pathogens, possibly leading to healthcare-associated infections (HAIs). A new study looks at the current state of facility policies, the items that pose the highest risk, and what might be done about them.

Awareness of the impact that HAIs have on patient outcomes and health care delivery costs continues to grow. As it does, one area of interest has become the objects in the health care setting that are capable of transmitting infectious diseases. Previous studies have shown that all types of care provider apparel—including scrubs, neckties, and white coats—can become contaminated. However, clinical data defining the role that clothing might play in transmitting microorganisms to patients has not been well investigated. A recent study, conducted by the Society for Healthcare Epidemiology of America (SHEA) and published in Infection Control and Hospital Epidemiology, has analyzed available data and developed initial recommendations while pointing out the need for further research. The study is made up of three components:

• a review of the medical literature regarding both perceptions of attire and evidence for contamination of attire and its potential contribution to cross-transmission
• a review of hospital policies related to nonsurgical attire
• a survey of SHEA members to assess policies relating to nonsurgical attire and perceptions of the role that attire plays in cross transmission.

Research Review and Policy Survey

The SHEA study reviewed findings from five other research studies that showed nursing uniforms and white coats can be sources of cross transmission. A number of factors—such as frequency of use, recent patient contact, and location on the uniform—influence the degree to which these items become contaminated. Not surprisingly, higher bacterial counts were found in areas of clothing most likely to come in contact with the patient. The study also emphasized that clean clothing can become contaminated within a few hours, so the degree of contamination increases over the patient care shift.

The authors of the study also conducted an extensive survey of existing hospital policies on nonsurgical attire at seven large teaching hospitals. All SHEA members were surveyed on attire policies and perceptions of the role of clothing in cross transmission. The authors of the study offered some specific factors for facilities to consider:

• Bare below the elbows (BBE)—Defined as wearing short sleeves and no wristwatch, jewelry, or neckties during clinical practice, BBE is supported by studies in clinical settings. However, its incremental impact on infection control remains unknown.
• White coats—Facilities that require white coats should either ensure that care providers have two or more white coats available with convenient and economical access to launder them (for example, an onsite laundry) or provide coat hooks so that white coats can be removed before patient contact.
• Neckties—Several studies have shown that neckties can carry pathogenic bacteria, such as Staphylococcus aureus, Bacillus species, and gram-negative bacilli. Neckties should be secured so that they do not come in contact with the patient.
• Laundering—The study found that nonsurgical clothing changes and laundering practices were not consistently addressed in hospital policies. Any clothing worn at the bedside should be laundered daily. If it is laundered at home, it should be washed in hot water, preferably with bleach, and either dried in a dryer or ironed to eliminate bacteria. Whether home laundering or professional laundering is more effective is not clear.
• Shared equipment—Any shared equipment, such as stethoscopes, should be cleaned between patients.
• Other items—Guidelines for other items, such as lanyards, identification tags, cell phones, pagers, and jewelry, were not included in the study, but any items that come into direct patient contact should be disinfected, replaced, or eliminated. Other soft surface fabrics, such as privacy curtains and bed linens, also present a contamination risk. The study did not address the impact of antimicrobial scrubs as a method to decrease healthcare-associated infections.

Survey Results

A total of 337 respondents were included in the survey of existing facility policies for nonsurgical attire. The majority of respondents (91%) worked at hospitals. The survey revealed that only 12% of facilities encouraged BBE practices, and only 7% enforced or monitored this policy. White coats were discouraged at only 5% of the facilities surveyed. Watches and jewelry were discouraged at 20% of these facilities and neckties at 8%, but none of these facilities monitored or enforced the policy. Only 36% of the facilities laundered scrubs or uniforms; 3% provided policies for home laundering.

More study needed

The SHEA report takes an important step forward in reviewing hospital policies in light of the risk of cross transmission from clothing but also concludes that more study is needed to determine the effect of a BBE approach, to study laundering practices, and to test the impact of hand hygiene and standard precaution compliance on contamination of clothing. Until research can provide substantive data, evidence-based practices, such as hand hygiene and environmental disinfection and patient isolation protocols, should be emphasized.

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