Amid growing concerns about hospital infections and a rise in drug-resistant bacteria, the attire of doctors, nurses and other health care workers—worn both inside and outside the hospital—is getting more attention. While infection control experts have published extensive research on the benefits of hand-washing and equipment sterilization in hospitals, little is known about the role that ties, white coats, long sleeves and soiled scrubs play in the spread of bacteria.
The discussion was reignited this year when the British National Health Service imposed a “bare below the elbows” rule, barring doctors from wearing ties and long sleeves, both of which are known to accumulate germs as doctors move from patient to patient. In the US, hospitals generally require doctors to wear “professional” dress but have no specific edicts about ties and long sleeves.
But while some data suggest that doctors’ garments are crawling with germs, there’s no evidence that clothing plays a role in the spread of hospital infections. And some researchers report that patients have less confidence in a doctor whose attire is casual.
Last month, the medical journal BJU International cited the lack of data in questioning the validity of the new British dress code. Still, experts say the absence of evidence doesn’t mean there is no risk—it just means there is no good research. A handful of reports do suggest that the clothing of health workers can be a reservoir for germs.
In 2004, a study from the New York Hospital Medical Center of Queens compared the ties of 40 doctors and medical students with those of 10 security guards.
It found that about half the ties worn by medical personnel were a reservoir for germs, compared with just one in 10 of the ties taken from the security guards. The doctors’ ties harboured several pathogens, including those that can lead to staph infections or pneumonia.
Another study at a Connecticut hospital sought to gauge the role clothing plays in the spread of methicillin-resistant Staphylococcus aureus (MRSA). It found that if a worker entered the room where the patient had MRSA, the bacteria would end up on the worker’s clothes about 70% of the time, even if the person never actually touched the patient.
“We know it can live for long periods of time on fabrics,” says Marcia Patrick, an infection control expert in Tacoma, Washington, and co-author of the Association for Professionals in Infection Control and Epidemiology guidelines for eliminating MRSA in hospitals.
Hospital rules typically encourage workers to change soiled scrubs before leaving, but infection control experts say enforcement can be lax. Doctors and nurses can often be seen wearing scrubs on subways and in grocery stores.
Patrick, director of infection prevention and control for the MultiCare Health System in Tacoma, says it’s unlikely that brief contact with a scrub-wearing health care worker on the subway would lead to infection. “The likelihood is that the risk is low, but it’s also probably not zero,” she says.
While the role of clothing in the spread of infection hasn’t been well-studied, some hospitals in Denmark and other European countries have adopted wide-ranging infection-control practices that include provisions for the clothing that health care workers wear both in and out of the hospital.
Workers of both sexes must change into hospital-provided scrubs when they arrive at work and even wear sanitized plastic shoes, also provided by the hospital. At the end of the day, they change back into their street clothes to go home. The focus on hand-washing, sterilization, screening and clothing control appears to have worked: In Denmark, fewer than 1% of staph infections involve resistant strains of the bacteria; in the US, the numbers have surged to 50% in some hospitals.
But American hospitals operate on tight budgets and can’t afford to provide clothes and shoes to every worker. In addition, many hospitals don’t have the extra space for laundry facilities.
Ann Marie Pettis, director of infection prevention for the University of Rochester Medical Center, Rochester, New York, says most hospitals are focusing on hand-washing and equipment sterilization, which are proven methods known to reduce the spread of infection. But she adds that her hospital, like many others, has a policy against wearing scrub attire to and from work, even though there is no real evidence that dirty scrubs pose a risk to people in the community.
“Common sense tells us that the things we are wearing as health care providers should be freshly laundered,” says Pettis. After all, she adds, wearing scrubs in public “raises fear” among consumers. “I don’t think we should feed into that. Scrubs shouldn’t be worn out and about.”
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