Is it time for clinicians to lose the white coats, long sleeves, and neckties in favor of bare arms for patient care? Citing anecdotal evidence, common sense, and the limited data available in the absence of clinical trials, the University of Iowa Hospital and Clinics is doing just that beginning January 2016, said Michael Edmond, MD, MPH, hospital epidemiologist at the Iowa City facility.

Edmond gave a vigorous defense of the concept recently in San Diego at IDWeek 2015. However, the debate format of the session left him open to some withering cracks by his opponent Neil O. Fishman, MD, an infectious disease physician at the University of Pennsylvania in Philadelphia. Citing the dearth of data to support the practice, Fishman said Edmond was essentially relying on “the audacity of hope.”

Moderator Patrick Joseph MD, an editorial board member of Hospital Infection Control & Prevention, didn’t make Edmond’s job any easier by prefacing a pre-debate electronic vote by the audience with a rather strictly defined question: “Would you formally recommend that healthcare workers with patient contact wear short sleeves? By ‘formally,’ I mean would you recommend it to your infection prevention committee, your hospital, to your surgical center — would you actually recommend that healthcare workers with patient contact wear short sleeves?”

Given those rather rigid instructions to the jury, only 37% said yes, that they would recommend such a practice, which was popularized in the U.K. as a way to reduce Clostridium difficile and MRSA. The U.K. success against C. difficile, in particular, has been the envy of U.S. epidemiologists. But with the multiple interventions at play and certainly no clinical trial with bare arms vs. white coats, Edmond’s task was to piece together the case for “biological plausibility.”

OPENING GAMBIT

He began by showing photographs of caregiver’s coats and clothing touching patients, which of course wouldn’t be the case if contact isolation measures were in effect and a gown was being worn. This was Edmond’s opening gambit, the rationale that has upheld contact precautions for decades supports the concept of bare arms for standard patient care.

“We use contact precautions for epidemiological important organisms, placing patients in private rooms and wearing gowns and gloves when we go into the room,” he said. “This is based on evidence that clothing does become contaminated and the assumption that pathogens on contaminated clothing can be transmitted to patients.”

Thus the logical extension of contact precautions concern with clothing as a fomite, is “bare below the elbows,” which means no sleeves, white coat, neckties, wristwatch and no jewelry except a wedding band, he said.

“The intention of this is to allow a good hand and wrist washing and to avoid contamination of sleeve cuffs,” Edmond said. “I have personally practiced bare below the elbows consistently since 2009.”

The postulated role of clothing in the transmission of pathogens is based on the awareness that patient skin and the surrounding environment are contaminated with pathogens, he said.

“The clothing of the healthcare worker becomes contaminated by being in contact with the patient or the environment,” he said. “We add to that some pieces of clothing are infrequently laundered, particularly neck ties and lab coats, [which harbor] pathogens we presume may be transmitted from the healthcare worker clothing to the subsequent patient.”

Staph aureus and gram negative bugs have been found on clothing, and — though Edmond didn’t mention this in his presentation — spore-forming C. difficile has been consistently difficult to remove from anything.

“For some pathogens and some type of fabrics, the persistence of these organisms in a live state can be quite long,” Edmond said. “For Staph aureus up to a month, and for Enterococcus faecalis up to three months.”

FROM PIGPEN TO PIG SKIN

The pathogens may be able to linger on lab coats in particular, which may be infrequently laundered. Edmond cited a study showing washing of lab coats occurs on average about every two weeks.¹ Edmond surveyed physicians at his former hospital, Virginia Commonwealth University in Richmond. “We found that about a third of people wash their white coats every week; about 40% every month, and most interestingly and quite appalling, almost 20% reported that they had never washed their lab coat. They’re like Pigpen.”

The question becomes, can the pathogens move from the contaminated clothing to the patient’s skin, setting up the possibility of cross transmission? Edmond and colleagues have shown that pathogens on swatches of lab coats can adhere to pig skin.²

“Can we culture the organisms back off of the pig skin? What we found with MRSA, VRE, and pan-resistant acinetobacter is that yes, indeed we can,” he said. “So we can theoretically at least say transfer can occur from the white coat to the skin.”

Other studies have found that pathogens can be transmitted from lab coats to mannequins in simulated patient care experiments. “They found 4 of 5 times with a tie and with long sleeves you do find that the healthcare worker transmitted [microorganisms] to the mannequin,” he said. “The best [result] was when the healthcare worker wore short sleeves and no necktie. There was no transmission in any of the 5 replications of the study.”³

“[Admittedly], we have no evidence at this point that if we took all of the white coats and all the neckties away that we would reduce infection rates,” he said. “I would summarize all of the data by saying we have biologic plausibility that these articles of clothing are involved in transmission of infections to patients. But would we ever use biological plausibility to change practice?”

Giving this question some thought, Edmond concluded that the biological plausibility could be used to alter medical practice if the following three conditions were met:

• A potential for benefit. “Which I think we do here.”
• No risk for harm, “except maybe to some people’s egos.”
• Minimal costs.

“We meet all three of those criteria, so I think it makes sense to argue that biologic plausibility is enough,” Edmond said. “However, I would say as an epidemiologist without hard data, I don’t think we can ever mandate this intervention, but I do think that there is enough there to recommend and encourage people to do it.”

Showing a picture of a dirty cuff sleeve of a lab coat, Edmond said, “Your mother could tell you this is an infection control problem. I don’t think you need a randomized control trial.”

Returning to the whole concept of contact precautions, he tried to close the deal by emphasizing that “based on this same evidence and same assumptions, we are willing to wrap ourselves up in plastic to go into the room [of a patient in] contact precautions.”

FASHION POLICE?

Fishman opened his counterattack by going down a long list of all manner of mandates and requirements for infection control tracking and reporting.

“And you want us to be the fashion police?” he said incredulously. “There are no clinical studies that demonstrate cross-transmission of a healthcare-associated pathogen from a healthcare provider to a patient [via sleeves or clothing]. We did hear that there is evidence demonstrating transmission to pig skin and mannequins, as far as I know none of them were infected.”

The bare elbows campaign in the U.K. was more political than medically motivated, Fishman said, citing some reports of the unintended consequences of physicians looking less professional and undermining patient confidence.

“I think we do need to be concerned about the perception of our profession,” Fishman said. “Can we afford to promote practices based on limited evidence, theoretical rationale, practical considerations, and authors’ opinions? The bare arm is going to be subject to the same fecal patina, the same microbiome clouds, the same dirt on the countertops and bedside tables as the white coat. I don’t think we’re washing up to the elbows — we have enough problems getting people to clean their hands let alone getting clean up to their elbows.”

On the contrary, Edmond said, “As a practitioner of bare below the elbows, I can tell you that when I examine a patient and my arm touches their skin I am very aware of it and I do wash my arm. When I had sleeves on previously, I didn’t really notice it.”

With that, Patrick called for another audience vote, with Edmond winning the battle but losing the war. Those willing to recommend a bare elbows policy after the debate increased 5% to 42%, but still the majority remained unconvinced. With his hospital’s bare elbow policy beginning Jan. 1, Edmond may be able to make a stronger evidence-based argument in the future. Or not.

REFERENCES

1. Munoz-Price SL, Arheart KL, Lubarsky DA. Differential laundering practices of white coats and scrubs among health care professionals. AJIC 2013;41:513-516
2. Butler DL, Major Y, Bearman G, et al. Transmission of nosocomial pathogens by white coats: an in-vitro model. J Hosp Infect. 2010;75:137–138.
3. Weber RL, Khan PD, Fader RC. Prospective study on the effect of shirt sleeves and ties on the transmission of bacteria to patients Journal of Hospital Infection 2012:80:252-254.