SHEA Infection Control Recommendations On HCW Attire

MRSA - Photo Credit CDC PHIL

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While exotic infectious diseases like bird flu make for fascinating study, in reality you are far more likely to be adversely impacted by an HAI (Hospital Acquired Infection) than you are by  H5N1 or H7N9 right now.  MRSA, Pseudomonas, CRE, NDM-Producing CRKP are just a few of the invasive, and often deadly, bacteria that can spread easily in a healthcare setting.

This oft quoted assessment from the CDC on the burden of Hospital Acquired Infections in the United States is from 2010.

 

A new report from CDC updates previous estimates of healthcare-associated infections. In American hospitals alone, healthcare-associated infections account for an estimated 1.7 million infections and 99,000 associated deaths each year. Of these infections:

• 32 percent of all healthcare-associated infection are urinary tract infections
• 22 percent are surgical site infections
• 15 percent are pneumonia (lung infections)
• 14 percent are bloodstream infections

 

In recent years we’ve looked at a number of infection control programs and policies designed to reduce these infections, including:

Aye, There’s The Rub

Study: Exam Gloves, Dispensers & Bacterial Contamination

NEJM: Targeted vs Universal Decolonization For ICU Patients

 

While hand hygiene and environmental surface cleaning have been at the forefront of the battle against HAIs, a debate over the impact of HCW (health care worker) attire in the spread of infections has raged, largely unresolved for several years.

 

Contaminated lab coats, long sleeves, neckties, and jewelry have all come under scrutiny as potential vectors for bacteria, and we’ve seen attempts by both governmental regulation, and hospital policy, to address these concerns.

 

While `textile transfer’ of bacteria in the healthcare setting makes sense, the scientific evidence linking sleeve cuffs and neckties to actual HAIs is scant, mostly anecdotal, and sometimes even contradictory.

 

In 2011, a study (see The Long And The Short Of It) found no statistical difference between the amount of bacteria of freshly laundered short sleeve uniforms versus infrequently laundered white coats after only 8 hours wear.

 

The argument can still be made, however, that long sleeve cuffs (and neckties) are more likely to come in contact with a series of patients than the fabric of short sleeved shirts.

 

In 2007, Britain’s NHS decided to ban the wearing of long-sleeved white coats, wristwatches, and neckties by healthcare providers in hospital wards. In the United States, the AMA (American Medical Assoc.) considered a “bare below the elbows” dress code during their annual meeting in 2009, but decided the issue needed more study. 

 

Some healthcare facilities – like the Mayo Clinic – have pushed ahead with their own dress codes to address the issue.  

 

In 2011, in Lab Coat Legislation, I reported on attempts by the New York State legislature to enact a  `hygienic dress code for medical professionals’ – one that would  eventually prohibit the wearing of jewelry, wristwatches, neckties, long sleeves, and the iconic white lab coat.

 

Fast forward to 2014, and SHEA (the Society for Healthcare Epidemiology of America) – while acknowledging gaps in our understanding of the role that attire can play in the spread of HAIs -  has released updated recommendations for HCW attire in clinical settings.

 

For Immediate Release: January 20, 2014
Society for Healthcare Epidemiology of America
Contact: Tamara Moore / tmoore@gymr.com/ 202-745-5114
Study contact: Gonzalo Bearman MD, MPH/ gbearman@mcvh-vcu.edu

Infectious Diseases Experts Issue Guidance on Healthcare Personnel Attire

Recommendations to help prevent healthcare-associated infections transmitted through clothing

CHICAGO (January 20, 2014) – New guidance from the Society for Healthcare Epidemiology of America (SHEA) provides recommendations to prevent transmission of healthcare-associated infections through healthcare personnel (HCP) attire in non-operating room settings. The guidance was published online in the February issue of Infection Control and Hospital Epidemiology, the journal of the SHEA, along with a review of patient and healthcare provider perceptions of HCP attire and transmission risk, suggesting professionalism may not be contingent on the traditional white coat.

" studies have demonstrated the clothing of healthcare personnel may have a role in transmission of pathogens, the role of clothing in passing infectious pathogens to patients has not yet been well established," said Gonzalo Bearman, MD, MPH, a lead author of the study and member of SHEA's Guidelines Committee. "This document is an effort to analyze the available data, issue reasonable recommendations, define expert consensus, and describe the need for future studies to close the gaps in knowledge on infection prevention as it relates to HCP attire."

The authors outlined the following practices to be considered by individual facilities:

1. "Bare below the elbows" (BBE): Facilities may consider adopting a BBE approach to inpatient care as a supplemental infection prevention policy; however, an optimal choice of alternate attire, such as scrub uniforms or other short sleeved personal attire, remains undefined. BBE is defined as wearing of short sleeves and no wristwatch, jewelry, or ties during clinical practice.
2. White Coats: Facilities that mandate or strongly recommend use of a white coat for professional appearance should institute one or more of the following measures:
   1. HCP should have two or more white coats available and have access to a convenient and economical means to launder white coats (e.g. on site institution provided laundering at no cost or low cost).
   2. Institutions should provide coat hooks that would allow HCP to remove their white coat prior to contact with patients or a patient's immediate environment.
3. Laundering:
   1. Frequency: Optimally, any apparel worn at the bedside that comes in contact with the patient or patient environment should be laundered after daily use.
   2. Home laundering: If HCPs launder apparel at home, a hot water wash cycle (ideally with bleach) followed by a cycle in the dryer or ironing has been shown to eliminate bacteria.
4. HCP footwear: All footwear should have closed toes, low heels, and non-skid soles.
5. Shared equipment including stethoscopes should be cleaned between patients.
6. No general guidance can be made for prohibiting items like lanyards, identification tags and sleeves, cell phones, pagers, and jewelry, but those items that come into direct contact with the patient or environment should be disinfected, replaced, or eliminated.

If implemented, the authors recommend that all practices be voluntary and accompanied by a well-organized communication and education effort directed at both HCP and patients.

In their review of the medical literature, the authors noted that while patients usually prefer formal attire, including a white coat, these preferences had little impact on patient satisfaction and confidence in HCPs. Patients did not tend to perceive the potential infection risks of white coats or other clothing, however when made aware of these risks, patients seemed willing to change their preferences of HCP attire.

The authors developed the recommendations based on limited evidence, theoretical rationale, practical considerations, a survey of SHEA membership and SHEA Research Network, author expert opinion and consensus, and consideration of potential harm where applicable. The SHEA Research Network is a consortium of more than 200 hospitals collaborating on multi-center research projects.

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