New infection control recommendations could make white coats obsolete

In a move to reduce health care associated infections, certain attire for health care professionals, including the traditional white coat, could become a thing of the past.

“White coats, neckties, and wrist watches can become contaminated and may potentially serve as vehicles to carry germs from one patient to another,” said Mark Rupp, M.D., chief of the division of infectious diseases at the University of Nebraska Medical Center and one of the authors of recommendations issued by the Society for Healthcare Epidemiology of America (SHEA), one of the world’s top infection control organizations.

“However, it is unknown whether white coats and neckties play any real role in transmission of infection,” said Dr. Rupp, who is a past president of SHEA. “Until better data are available, hospitals and doctors' offices should first concentrate on well-known ways to prevent transmission of infection — like hand hygiene, environmental cleaning, and careful attention to insertion and care of invasive devices like vascular catheters.”

The recommendations appear in the February online issue of the journal Infection Control and Hospital Epidemiology. It includes a review of patient and health care professionals’ perceptions of the health professionals’ attire and transmission risk, suggesting professionalism may not be contingent on wearing the traditional white coat.

Dr. Rupp said supplementary infection prevention measures could include efforts to limit the use of white coats and neckties or at least making sure they are frequently laundered.

“As these measures are unproven, they should be regarded as voluntary and if carried out, should be accompanied by careful educational programs,” he said. “There is a need for education because the public, as well as health professionals, regard the white coat as a symbol of professionalism and competence.  In the future, patients may see their health professionals wearing scrubs – without white coats, ties, rings, or watches.”

The U.S. Center for Disease Control and Prevention estimates that there are 1.7 million hospital-acquired infections and 99,000 associated deaths in the U.S. each year.

The authors outlined the following practices to be considered by individual facilities:

1. Bare below the elbows — defined as wearing of short sleeves and no wristwatch, jewelry, or ties during clinical practice. Facilities may consider adopting this 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.
2. 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:
   1. The health professional should have two or more white coats available and have access to a convenient and economical means to launder white coats.
   2. Institutions should provide coat hooks that would allow removal of the white coat before contact with patients or a patient’s immediate environment.
3. Laundering:
   1. Frequency: any apparel worn at the bedside that comes in contact with the patient or patient environment should be laundered frequently.
   2. Home laundering: If laundered 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.
4. Footwear: all footwear should have closed toes, low heels, and non-skid soles.
5. Shared equipment including stethoscopes should be cleaned between patients.
6. 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 health professionals 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 health professionals. 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.

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.

SHEA is a professional society representing more than 2,000 physicians and other health care professionals around the world with expertise in health care epidemiology and infection prevention and control. SHEA's mission is to prevent and control health care-associated infections and advance the field of health care epidemiology. The society leads this field by promoting science and research and providing high-quality education and training in epidemiologic methods and prevention strategies. SHEA upholds the value and critical contributions of health care epidemiology to improving patient care and health care worker safety in all health care settings. Visit SHEA online at www.shea-online.org, www.facebook.com/SHEApreventingHAIs and @SHEA_Epi.

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