The “bare below the elbows” approach to infection control, wherein physicians wear short sleeves rather than their traditional white coats, has been met with some derision as a misguided approach by “fashion police.”
On the other hand, proponents argue that staff wearing infrequently washed long-sleeved coats from patient to patient have a swirl of microbes about them equivalent to that on the Peanuts character “Pig-Pen.” (For more information, see Hospital Infection Control & Prevention, January 2016.)
Given similar concerns with stethoscopes and neckties, the bare-below-the-elbows argument makes intuitive sense, but seems to lack the hard data to sway the majority of white-coated physicians. For instance, at a study presented recently in San Diego at IDWeek 2017, the voice of physician dissent to this concept included this example: “Another stupid checkbox for healthcare workers that makes no practical sense. Our skin have bacteria on them as well.”1
The idea, of course, is that one could wash the hands and wrists, but the sleeve cuff of the coat is going to touch successive patients. Could pathogens be spread this way?
A study by Amrita John, MBBS, an epidemiologist at University Hospitals Case Medical Center in Cleveland, sought to answer that question with the help of two mannequins and 34 healthcare workers. A benign surrogate DNA marker for Clostridium difficile was used.
“During simulations of patient care the sleeve cuff of the long-sleeve white coats frequently transferred the viral DNA marker,” John said. “No transmission occurred when short sleeves were worn. During work rounds, the cuffs of physicians in long-sleeve white coats frequently contacted patients or environmental surfaces.”
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. They 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-sleeve 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-sleeve 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-sleeve coats were worn the [second] mannequin was contaminated. Nothing with short sleeves,” John said.
- 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.