Should clothing and shoes be a priority in surgery's battle against infections?

You know you need to enforce infection control practices such as proper equipment sterilization. But should you require "bare below the elbows" for clinicians? Enforce dedicated shoes or shoe covers in the OR? Ban scrubs outside the facility, and go to one-color scrubs to help with enforcement?

These are just some of the infection control issues being debated as European facilities go to stricter rules. Earlier this year, the British National Health Service implemented a "bare below the elbows" rule that banned doctors from wearing long sleeves, as well as ties.1 England's Department of Health also enforces such a rule and includes wristwatches and jewelry, because they can accumulate germs from patients.2 "The new clothing guidance will ensure good hand and wrist washing," the department says. It also has banned the doctor's traditional white coat, because the cuffs are likely to be heavily contaminated, the department says. When staff members have direct patient contact, they should wear "suitable protection — for example, plastic aprons," it says.

There is some scientific basis: A study from The New York Hospital Queens compared the ties worn by 40 doctors and medical students with those worn by 10 security guards. The study was presented at the 104th General Meeting of the American Society for Microbiology. Half of the ties worn by the clinicians in surgery and other areas were contaminated with bacteria, while just 10% of the security guards' ties showed contamination. Also, a just-published study from the University of Maryland Medical Center in Baltimore found that a large proportion of health care workers' lab coats, including those of surgical staff, might be contaminated with Staphylococcus aureus, including methicillin-resistant S. aureus (MRSA).3 White coats might be an important mode of patient-to-patient transmission of S. aureus, the study concludes.

For its part, the Association of periOperative Registered Nurses (AORN) recommends that providers who wear warm-up style jackets roll down the sleeves to the wrists to prevent skin shedding, according to Joan Blanchard, RN, MSS, CNOR, CIC, perioperative nursing specialist at the AORN Center for Nursing Practice. "Skin shedding makes up most of what dust is," she says.

Pushing the pendulum in the other direction

Some hospitals in Europe are requiring staff to change into scrubs and sanitized plastic shoes provided by the facility when they arrive for work.1

"Europeans have pushed the pendulum way in the other direction," says Ann Marie Pettis, RN, BSN, CIC, infection prevention director at the University of Rochester (NY) Medical Center and a spokeswoman for the Association for Professionals in Infection Control and Epidemiology (APIC). "There's not much scientific evidence to support that, especially I think with shoes."

While providers want every surface to be as germ-free as possible, floors are not typically as involved as clothing in causing infections such as those in surgical wounds, Pettis says. For that reason, many U.S. hospitals have dropped requirements for shoe covers, she says. At one of the facilities that is part of the Rochester system, dedicated shoes are required for ORs, which she describes as a somewhat "old-fashioned approach." The other facility requires shoe covers. "We look at covering of shoes as an OSHA [Occupational Safety and Health Administration] situation, protecting the health care worker from body fluid exposure," she says.

OSHA says shoe covers or boots, as well as surgical caps or hoods, must be worn when gross contamination reasonably can be anticipated [OSHA 910.1030(d)(3)(wii)]. Circumstances where such equipment may be necessary would include autopsies and orthopedic surgery, OSHA says.

Pettis prefers that her staff not wear Croc brand shoes with holes. "It's not for infection control, but for the safety of the employee," she says. However, "in terms of evidence that these are the sorts of things that protect patients, it's weak at best," Pettis says. While clothing is not at the top of her list of priorities, her facility has designated one-color scrubs for the OR to make it easier to enforce the requirement that those scrubs be worn only inside the facility.

Infection prevention in outpatient surgery settings should focus on areas that are known to make a difference, Pettis maintains. "Honestly, I prefer for health care workers to focus on hands and hand hygiene, and gloves," she says. Also, she emphasizes devices and equipment being sanitized from one patient to another.

"We're really trying to focus on things we do have all the evidence for: not coming in sick, getting flu shots, hand hygiene before and after patient contact — those are things we're trying to continue to hammer," Pettis says.


  1. Parker-Pope T. The doctor's hands are germ-free. the scrubs too? The New York Times, Sept. 22, 2008. Accessed at
  2. Department of Health (National). Johnson outlines new measures to tackle hospital bugs. Sept. 17, 2007. Accessed at
  3. Treakle AM, Thom KA, Furuno JP, et al. Am J Infect Control 2008 [Epub ahead of print]. Accessed at