Experimental evidence supporting the concept of healthcare workers working “bare below the elbows” to prevent transmission of pathogens to patients via long sleeves was recently presented in San Diego at the IDWeek 2017 conference.

A study using two mannequins and a surrogate DNA marker for Clostridium difficile showed that workers in long sleeves were more likely to contaminate a subsequent patient than workers wearing short sleeves.1

“During simulations of patient care, the sleeve cuff of the long-sleeve white coats frequently transferred the viral DNA marker,” said Amrita John, MBBS, infectious disease epidemiologist at University Hospitals Cleveland Medical Center. “No transmission occurred when short sleeves were worn. During work rounds, the cuffs of physicians in long-sleeved white coats frequently contacted patients or environmental surfaces.”

The healthcare system in the United Kingdom went to a bare-below-the-elbows policy in 2007. In 2014, the Society for Healthcare Epidemiology of America (SHEA) said the practice should be considered in the U.S. “based on biological plausibility and the low likelihood of harm.”2

A sharp decline in C. diff infections in the U.K. after adoption of the policy led to John’s interest in conducting the study.

“This [decline] has been attributed to a decrease in fluoroquinolone prescriptions,” she said. “It’s intriguing to me that it also happens to perfectly coincide with this new bare-below-the-elbows policy.”

The findings have implications for healthcare worker dress in general, but the primary reaction has come from physicians accustomed to wearing the classic white coat.

“This policy has created a lot of angst among physicians,” John said. She cited some of the online reactions to previous studies, including the following comments:

  • “Just because they cultured some bacteria on a couple of white coats does not mean that these are vectors of disease transmission.”
  • “What about patient perceptions?”
  • “Fashion police.”
  • “Another stupid checkbox for healthcare workers that makes no practical sense. Our skin have bacteria on them as well.”

Cross Transmission Possible

In the study, healthcare workers were randomly selected to wear either long-sleeved or short-sleeved white coats while examining a mannequin contaminated with cauliflower mosaic virus DNA, a surrogate pathogen. The workers would then remove their gloves, wash hands, and don new gloves before moving to another “patient” mannequin that was uncontaminated.

“In 25% of interactions when long-sleeved coats were worn, it was noted that the sleeve cuffs and wrists were found to be contaminated with the DNA markers after examining the first mannequin,” she said. “No such contamination was noted with short-sleeved coats. It was then noted that in 15% of interactions when long-sleeved coats were worn, the environment of the second mannequin was contaminated with the DNA marker. Again, no contamination with the short sleeves. Finally, in 5% of interactions when long-sleeved coats were worn, the [second] mannequin was contaminated. Nothing with short sleeves.”

A total of 34 healthcare workers participated in the study, which was supplemented by observational data of physicians wearing long-sleeved coats during clinical rounds.

“In 44% of their interactions between physicians and patients, the sleeves of their coats came into contact with either the patient or the patient environment,” John said. “The environmental surfaces that were most frequently contacted by the sleeves include high-touch surfaces such as bed rails, beddings, and privacy curtains. These results provide support for the recommendation that healthcare personnel wear short sleeves to reduce the risk of pathogen transmission.”

Enacting such a policy in the hospital setting is another matter, as John said it will take more data to move the needle on something involving traditional attire like the long-sleeved coat. This is similar to the outcry among surgeons when it was suggested their traditional skull caps do not sufficiently protect patients in the operating room.

“[This study] has changed my personal preference,” John said. “I now tend to roll up my coat sleeves above my elbows, but institutionally I would say we are not there yet. It would probably take some evidence in terms of larger studies or showing actual transmission in the clinical setting to convince people. I would say this is definitely some evidence pointing in that direction.”


1. John, A, Alhmidi H, Gonzalez-Orta M, et al. Bare Below the Elbows: A Randomized Trial to Determine if Wearing Short-Sleeved Coats Reduces the Risk for Pathogen Transmission. Abstract 996. IDWeek 2017, Oct. 4-8, 2017, San Diego.

2. Bearman G, Bryant K, Leekha S, et al. Healthcare personnel attire in non-operating-room settings. Infect Control Hosp Epidemiol 2014;35(2):107-121.