New guidance from the Society for Healthcare Epidemiology of America (SHEA) provides recommendations to prevent transmission of healthcare-associated infections through healthcare personnel (HCP) attire in non-operating room settings. The guidance was published online in the February issue of Infection Control and Hospital Epidemiology, the journal of the SHEA, along with a review of patient and healthcare provider perceptions of HCP attire and transmission risk, suggesting professionalism may not be contingent on the traditional white coat.
"While studies have demonstrated the clothing of healthcare personnel may have a role in transmission of pathogens, the role of clothing in passing infectious pathogens to patients has not yet been well established," said Gonzalo Bearman, MD, MPH, a lead author of the study and member of SHEA's Guidelines Committee. "This document is an effort to analyze the available data, issue reasonable recommendations, define expert consensus, and describe the need for future studies to close the gaps in knowledge on infection prevention as it relates to HCP attire."
The authors outlined the following practices to be considered by individual facilities:
- "Bare below the elbows" (BBE): Facilities may consider adopting a BBE approach to inpatient care as a supplemental infection prevention policy; however, an optimal choice of alternate attire, such as scrub uniforms or other short sleeved personal attire, remains undefined. BBE is defined as wearing of short sleeves and no wristwatch, jewelry, or ties during clinical practice.
- White Coats: Facilities that mandate or strongly recommend use of a white coat for professional appearance should institute one or more of the following measures:
a. HCP should have two or more white coats available and have access to a convenient and economical means to launder white coats (e.g. on site institution provided laundering at no cost or low cost).
b. Institutions should provide coat hooks that would allow HCP to remove their white coat prior to contact with patients or a patient's immediate environment.
a. Frequency: Optimally, any apparel worn at the bedside that comes in contact with the patient or patient environment should be laundered after daily use.
b. Home laundering: If HCPs launder apparel at home, a hot water wash cycle (ideally with bleach) followed by a cycle in the dryer or ironing has been shown to eliminate bacteria.
- HCP footwear: All footwear should have closed toes, low heels, and non-skid soles.
- Shared equipment including stethoscopes should be cleaned between patients.
- No general guidance can be made for prohibiting items like lanyards, identification tags and sleeves, cell phones, pagers, and jewelry, but those items that come into direct contact with the patient or environment should be disinfected, replaced, or eliminated.
If implemented, the authors recommend that all practices be voluntary and accompanied by a well-organized communication and education effort directed at both HCP and patients.
In their review of the medical literature, the authors noted that while patients usually prefer formal attire, including a white coat, these preferences had little impact on patient satisfaction and confidence in HCPs. Patients did not tend to perceive the potential infection risks of white coats or other clothing, however when made aware of these risks, patients seemed willing to change their preferences of HCP attire.
The authors developed the recommendations based on limited evidence, theoretical rationale, practical considerations, a survey of SHEA membership and SHEA Research Network, author expert opinion and consensus, and consideration of potential harm where applicable. The SHEA Research Network is a consortium of more than 200 hospitals collaborating on multi-center research projects.