author(s): gonzalo bearman, md, mph; kristina bryant, md ......108 infection control and hospital...
TRANSCRIPT
Healthcare Personnel Attire in Non-Operating-Room SettingsAuthor(s): Gonzalo Bearman, MD, MPH; Kristina Bryant, MD; Surbhi Leekha, MBBS, MPH;Jeanmarie Mayer, MD; L. Silvia Munoz-Price, MD; Rekha Murthy, MD; Tara Palmore, MD;Mark E. Rupp, MD; Joshua White, MDSource: Infection Control and Hospital Epidemiology, Vol. 35, No. 2 (February 2014), pp. 107-121Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiologyof AmericaStable URL: http://www.jstor.org/stable/10.1086/675066 .
Accessed: 21/01/2014 08:49
Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at .http://www.jstor.org/page/info/about/policies/terms.jsp
.JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range ofcontent in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new formsof scholarship. For more information about JSTOR, please contact [email protected].
.
The University of Chicago Press and The Society for Healthcare Epidemiology of America are collaboratingwith JSTOR to digitize, preserve and extend access to Infection Control and Hospital Epidemiology.
http://www.jstor.org
This content downloaded from 96.255.251.162 on Tue, 21 Jan 2014 08:49:45 AMAll use subject to JSTOR Terms and Conditions
infection control and hospital epidemiology february 2014, vol. 35, no. 2
s h e a e x p e r t g u i d a n c e
Healthcare Personnel Attire in Non-Operating-Room Settings
Gonzalo Bearman, MD, MPH;1 Kristina Bryant, MD;2 Surbhi Leekha, MBBS, MPH;3 Jeanmarie Mayer, MD;4
L. Silvia Munoz-Price, MD;5 Rekha Murthy, MD;6 Tara Palmore, MD;7
Mark E. Rupp, MD;8 Joshua White, MD9
Healthcare personnel (HCP) attire is an aspect of the medical profession steeped in culture and tradition. The role of attire in cross-transmission remains poorly established, and until more definitive information exists priority should be placed on evidence-based measuresto prevent healthcare-associated infections (HAIs). This article aims to provide general guidance to the medical community regarding HCPattire outside the operating room. In addition to the initial guidance statement, the article has 3 major components: (1) a review andinterpretation of the medical literature regarding (a) perceptions of HCP attire (from both HCP and patients) and (b) evidence forcontamination of attire and its potential contribution to cross-transmission; (2) a review of hospital policies related to HCP attire, assubmitted by members of the Society for Healthcare Epidemiology of America (SHEA) Guidelines Committee; and (3) a survey of SHEAand SHEA Research Network members that assessed both institutional HCP attire policies and perceptions of HCP attire in the cross-transmission of pathogens. Recommendations for HCP attire should attempt to balance professional appearance, comfort, and practicalitywith the potential role of apparel in the cross-transmission of pathogens. Although the optimal choice of HCP attire for inpatient careremains undefined, we provide recommendations on the use of white coats, neckties, footwear, the bare-below-the-elbows strategy, andlaundering. Institutions considering these optional measures should introduce them with a well-organized communication and educationeffort directed at both HCP and patients. Appropriately designed studies are needed to better define the relationship between HCP attireand HAIs.
Infect Control Hosp Epidemiol 2014;35(2):107-121
Affiliations: 1. Virginia Commonwealth University, Richmond, Virginia; 2. University of Louisville, Louisville, Kentucky; 3. Department of Epidemiologyand Public Health, University of Maryland, Baltimore, Maryland; 4. Division of Infectious Diseases, Department of Internal Medicine, University of UtahSchool of Medicine, Salt Lake City, Utah; 5. Departments of Medicine and Public Health Sciences, University of Miami, Miami, Florida; 6. Departmentof Hospital Epidemiology, Cedars-Sinai Medical Center, Los Angeles, California; 7. National Institutes of Health Clinical Center, Bethesda, Maryland;8. University of Nebraska Medical Center, Omaha, Nebraska; 9. Virginia Commonwealth University, Richmond, Virginia.
Received November 21, 2013; accepted November 25, 2013; electronically published January 16, 2014.� 2014 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2014/3502-0001$15.00. DOI: 10.1086/675066
Healthcare personnel (HCP) attire is an aspect of the medicalprofession steeped in culture and tradition. From Hippoc-rates’s admonition that physicians’ dress is essential to theirdignity, to the advent of nurses’ uniforms under the lead-ership of Florence Nightingale, to the white coat ceremoniesthat continue to this day in medical schools, HCP appareland appearance is associated with significant symbolism andprofessionalism. Recent years, however, have seen a risingawareness of the potential role of fomites in the hospitalenvironment in the transmission of healthcare-associated mi-croorganisms. Although studies have demonstrated contam-ination of HCP apparel with potential pathogens, the role ofclothing in transmission of these microorganisms to patientshas not been established. The paucity of evidence has stymiedefforts to produce generalizable, evidence-based recommen-dations, resulting in widely disparate practices and require-ments that vary by country, region, culture, facility, and dis-cipline. This document is an effort to analyze the availabledata, issue reasonable recommendations, and describe the
needs for future studies to close the gaps in knowledge onHCP attire.
intended use
This document is intended to help acute care hospitals de-velop or modify policies related to HCP attire. It does notaddress attire in the operating room (OR), perioperative ar-eas, or other procedural areas and is not intended to guideHCP attire in those settings or in healthcare facilities otherthan acute care hospitals.
society for healthcare epidemiologyof america (shea) writing group
The writing group consists of volunteers among members ofthe SHEA Guidelines Committee, including those with re-search expertise on this topic.
This content downloaded from 96.255.251.162 on Tue, 21 Jan 2014 08:49:45 AMAll use subject to JSTOR Terms and Conditions
108 infection control and hospital epidemiology february 2014, vol. 35, no. 2
key areas addressed
We evaluated and summarized the literature around 2 aspectsof HCP attire (details are provided in “Methods”):
I. Perception of both patients and HCP regarding HCP attirein relation to professionalism and potential risk for trans-mission of microorganisms.
II. Evidence for contamination of HCP attire and the po-tential for HCP attire to contribute to the transmissionof pathogenic microorganisms in hospitals.
In addition, we performed a survey of the SHEA mem-bership and SHEA Research Network to learn more aboutthe policies related to HCP attire that are currently in placein members’ institutions.
guidance and recommendationformat
Because this topic lacks the level of evidence required for amore formal guideline using the GRADE system, no gradingof the evidence level is provided for individual recommen-dations. Each guidance statement is based on synthesis oflimited evidence, theoretical rationale, practical consider-ations, a survey of SHEA membership and the SHEA ResearchNetwork, author opinion, and consideration of potentialharm where applicable. An accompanying rationale is listedalongside each recommendation.
guidance statement
There is a paucity of data on the optimal approach to HCPattire in clinical, nonsurgical areas. Attire choices should at-tempt to balance professional appearance, comfort, and prac-ticality with the potential role of apparel in the cross-trans-mission of pathogens resulting in healthcare-associatedinfections (HAIs).
As the SHEA workgroup on HCP attire, we recommendthe following:
I. Appropriately designed studies should be funded andperformed to better define the relationship between HCPattire and HAIs.
II. Until such studies are reported, priority should be placedon evidence-based measures to prevent HAIs (eg, handhygiene, appropriate device insertion and care, isolationof patients with communicable diseases, environmentaldisinfection).
III. The following specific approaches to practice related toHCP attire may be considered by individual facilities;however, in institutions that wish to pursue these prac-tices, measures should be voluntary and accompanied bya well-organized communication and education effortdirected at both HCP and patients.
A. “Bare below the elbows” (BBE): This article definesBBE as HCP’s wearing of short sleeves, no wristwatch,
no jewelry, and no ties during clinical practice. Facilitiesmay consider adoption of a BBE approach to inpatientcare as an infection prevention adjunct, although theoptimal choice of alternate attire, such as scrub uni-forms or other short-sleeved personal attire, remainsundefined.
1. Rationale: While the incremental infection preven-tion impact of a BBE approach to inpatient care isunknown, this practice is supported by biologicalplausibility and studies in laboratory and clinical set-tings and is unlikely to cause harm.
B. White coats: Facilities that mandate or strongly rec-ommend use of a white coat for professional appearanceshould institute one or more of the following measures:
1. HCP engaged in direct patient care (including housestaff and students) should possess 2 or more whitecoats and have access to a convenient and economicalmeans to launder white coats (eg, institution-pro-vided on-site laundering at no cost or low cost).i. Rationale: These practical considerations may help
achieve the desired professional appearance yet al-low for HCP to maintain a higher frequency oflaundering of white coats.
2. Institutions should provide coat hooks that wouldallow HCP to remove their white coat (or other long-sleeved outerwear) prior to contact with patients orthe patient’s immediate environment.i. Rationale: This practical consideration may help
achieve the desired professional appearance yetlimit patients’ direct contact with potentially con-taminated attire and avoid potential contaminationof white coats that may otherwise be hung on in-appropriate objects in the hospital environment.
C. Other HCP apparel: On the basis of the current evi-dence, we cannot recommend limiting the use of otherspecific items of HCP apparel (such as neckties).
1. Rationale: The role played by neckties and other spe-cific items of HCP apparel in the horizontal trans-mission of pathogens remains undetermined. If neck-ties are worn, they should be secured by a white coator other means to prevent them from coming intodirect contact with the patient or near-patientenvironment.
D. Laundering:1. Frequency: Optimally, any apparel worn at the bed-
side that comes into contact with the patient or pa-tient environment should be laundered after dailyuse. In our opinion, white coats worn during patientcare should be laundered no less frequently than oncea week and when visibly soiled.i. Rationale: White coats worn by HCP who care for
very few patients or by HCP who are infrequentlyinvolved in direct patient care activities may needto be laundered less frequently than white coats
This content downloaded from 96.255.251.162 on Tue, 21 Jan 2014 08:49:45 AMAll use subject to JSTOR Terms and Conditions
shea expert guidance: healthcare personnel attire 109
worn by HCP involved with more frequent patientcare. At least weekly laundering may help achievea balance between microbial burden, visible clean-liness, professional appearance, and resourceutilization.
2. Home laundering: Whether HCP attire for non-surgical settings should be laundered at home or pro-fessionally remains unclear. If laundered at home, ahot-water wash cycle (ideally with bleach) followedby a cycle in the dryer is preferable.i. Rationale: A combination of washing at higher tem-
peratures and tumble drying or ironing has beenassociated with elimination of both pathogenicgram-positive and gram-negative bacteria.
E. HCP footwear: All footwear should have closed toes,low heels, and nonskid soles.
1. Rationale: The choice of HCP footwear should bedriven by a concern for HCP safety and should de-crease the risk of exposure to blood or other poten-tially infectious material, sharps injuries, and slipping.
F. Identification: Name tags or identification badgesshould be clearly visible on all HCP attire for identifi-cation purposes.1. Rationale: Name tags have consistently been identi-
fied as a preferred component of HCP attire by pa-tients in several studies, are associated with profes-sional appearance, and are an important componentof a hospital’s security system.
IV. Shared equipment, including stethoscopes, should becleaned between patients.
V. No guidance can be offered in general regarding prohib-iting items like lanyards, identification tags and sleeves,cell phones, pagers, and jewelry, but those items thatcome into direct contact with the patient or environmentshould be disinfected, replaced, or eliminated.
methods
Using PubMed/Medline, between the months of January andMay 2013 we searched the English literature for articles per-taining to HCP attire in clinical settings focusing on areasoutside the OR. We included all studies dealing with bacterialcontamination and laundering of HCP attire, patients’ andproviders’ perceptions based on the type of attire, and/or HCPfootwear.
Additionally, we reviewed and compared hospital policiesrelated to HCP attire from 7 large teaching hospitals, as sub-mitted by members of the SHEA Guidelines Committee. Fi-nally, between February and May 2013 we sent out a surveyto all SHEA members to assess their institutional HCP attirepolicies (if any) and to determine their perceptions of HCPattire as a vehicle for potential transmission of pathogens.
results
I. Patients’ Perceptions of HCP Attire
We identified 26 studies (published from 1990 onward) thatexamined patients’ perceptions of HCP attire1-26 (Table 1).Most (23/26) studies surveyed patient preference for differenttypes of HCP attire1-6,8-18,20-25 using either pictures of modelsin various dress styles3,4,7-9,15-18,20,22-24 or descriptions of at-tire.1,5,11,14,21,25 Four studies6,10,12,13 asked patients to assess theattire of their actual physicians. Attire descriptions and ter-minology varied among studies (eg, “formal,” “business,”“smart,” “suit and tie,” and “dress”) and will be referred tohereafter as “formal attire.” We use “casual attire” to refer toanything other than formal attire.
A. Formal attire and white coats: Most of the studies usingpictures and models of HCP attire indicated patient pref-erence for formal attire, which was favored over bothscrubs1,3,7,9,18,22 and casual attire.7,9,15,16,19,22 However, severalother studies revealed that physician attire was unlikelyto influence patients’ levels of comfort,4,20 satisfaction,trust, or confidence in physicians’ abilities,2,4,9,19,20,25 evenif patients previously had expressed a preference for onetype of attire.4,9,20,25
Fifteen studies addressed white coats.1,4,7-9,11-17,20-22 In 10of these studies, patients preferred that physicians wearwhite coats,1,7-10,12,15-17 and in 1 study patients reportedfeeling more confident in those physicians.8 Similarly, 2studies showed a significant association between the pres-ence of a white coat, especially on a female physician, andpatients’ trust and willingness to share sensitive infor-mation.22 Patients also indicated less comfort in dealingwith an informally dressed physician,16 describing a shirtand a tie as the most professional and desirable attire forphysicians23-25 in addition to an overall well-groomed ap-pearance.5,15 Moreover, the following items were deemedas inappropriate or undesirable: jeans,5,14 shorts,15
clogs,14,15 and open-toed sandals.15 In the remaining 5studies, patients showed no clear predilection for one dressstyle over another or did not consider a white coat eithernecessary or expected.4,11,13,20,21
Five studies assessed patient satisfaction, confidence, ortrust on the basis of their treating physicians’ dress,2,6,10,12,13
showing little response variations regardless of apparel. Asurvey of patients seen by obstetricians/gynecologists whowere randomly assigned formal attire, casual attire, orscrubs found high satisfaction with physicians regardlessof the group allocation.6 Similarly, in a before-and-aftertrial, emergency department (ED) physicians were askedto wear formal attire with a white coat one week followedby scrubs the subsequent week. Using a visual analog scale,patients rated their physician’s appearance, professional-ism, and satisfaction equally regardless of the week ofobservation.13 Another ED study found no difference in
This content downloaded from 96.255.251.162 on Tue, 21 Jan 2014 08:49:45 AMAll use subject to JSTOR Terms and Conditions
110
ta
ble
1.St
udi
esof
Pat
ien
tan
dH
ealt
hca
reW
orke
rP
erce
ptio
nof
Hea
lth
care
Wor
ker
Att
ire
(199
0–20
12)
Lead
auth
or,
year
(cou
ntr
y)M
etho
dolo
gyFi
ndin
gs
Ard
olin
o,20
09(U
K)1
Surv
ey(n
p10
0):
Pts
Re:
Pre
fere
nce
for
MD
atti
rebe
fore
/aft
eraw
aren
ess
ofB
BE
polic
y
Bef
ore
BB
Epo
licy:
pref
ersu
itm
ore
than
WC
but
WC
pref
erre
dfo
rju
nior
MD
,sc
rubs
not
pref
erre
das
unpr
ofes
sion
alan
ddi
fficu
ltto
dist
ingu
ish
MD
sA
fter
BB
Epo
licy:
pref
ersh
ort-
slee
vesh
irt
wit
hout
tie
(old
erP
ts);
pref
ersc
rubs
(you
nge
rP
ts)
Bae
vsky
,19
98(U
S)2
Surv
ey(n
p59
6):
Urg
ent
care
Pts
seen
byM
Din
WC
and
onal
tern
atin
gda
ys,
scru
bsvs
form
alat
tire
Re:
Sati
sfac
tion
for
cour
tesy
,co
nce
rn,
skill
,an
dlik
elih
ood
Pt
wou
ldre
turn
/rec
omm
end
ED
No
diff
eren
cein
sati
sfac
tion
elem
ents
for
scru
bsvs
form
alat
tire
WC
rank
edhi
gher
whe
nM
Dbr
oke
prot
ocol
and
did
not
wea
r,al
thou
ghw
hen
stra
tifie
dby
scru
bsvs
form
al,
high
erm
ean
rank
sfo
rW
Cn
oted
only
whe
nM
Ds
wor
esc
rubs
Att
itud
e,m
ann
eris
m,
and
prof
essi
onal
ism
likel
ym
ore
impo
rtan
tth
anat
tire
Bon
d,20
10(U
K)3
Surv
ey(n
p16
0):
EN
TIn
Pts
,O
utP
tsR
e:A
ttit
udes
tow
ard
MD
atti
rew
ith
phot
osof
mal
eM
Din
scru
bs,
form
al,
and
BB
E
Mos
tpr
ofes
sion
al:
form
al72
%,
scru
bs23
%,
BB
E5%
Mos
thy
gien
ic:
form
al10
%,
scru
bs87
%,
BB
E3%
Eas
eto
iden
tify
asM
D:
form
al59
%,
scru
bs35
%,
BB
E6%
Ove
rall
pref
eren
ce:
form
al48
%,
scru
bs41
%,
BB
E11
%C
ha,
2004
(US)
4Su
rvey
(np
184)
:O
utP
tsin
pred
omin
antl
yre
side
nt-r
unO
B/
GY
Ncl
inic
Re:
Pre
fere
nce
for
MD
atti
rean
dco
nfi
den
cean
dco
mfo
rtw
ith
phot
osof
MD
inva
riou
sat
tire
Att
ire
pref
eren
ce:
no
pref
eren
ce60
%,
WC
38%
Pt
com
fort
leve
l:at
tire
does
not
affe
ct63
%vs
does
affe
ct28
%C
onfi
denc
ele
vel
inM
D:
atti
redo
esn
otaf
fect
62%
vsdo
esaf
fect
24%
Mea
nsc
ores
for
com
fort
and
con
fide
nce
leve
lsde
crea
sed
asat
tire
mov
edfr
omcl
inic
al/f
orm
al(s
crub
s/W
C)
toca
sual
Dit
chbu
rne,
2006
(UK
)5Su
rvey
(np
100)
:P
ublic
inho
spit
alco
ncou
rse
Re:
Att
itud
esto
MD
not
wea
ring
ties
93%
did
not
obje
ctto
tiel
ess
MD
,bu
tfo
rst
aff
mor
elik
ely
con
side
red
aspr
ofes
-si
onal
ism
fact
orM
ost
impo
rtan
t:w
eari
ng
shir
tan
ddr
ess
trou
sers
(vs
den
im),
bein
gcl
ean,
tidy
,fo
rmal
,w
eari
ngcl
ear
iden
tific
atio
ns
Fisc
her,
2007
(US)
6Su
rvey
(np
1,13
6):
Pts
and
OB
/GY
NM
Dbe
fore
/aft
erra
n-do
miz
atio
nof
MD
atti
rety
peR
e:P
tsa
tisf
acti
onw
ith
MD
atti
re;
MD
sas
ked
for
thei
rpr
efer
ence
Pt
sati
sfac
tion
over
all
was
high
and
did
not
chan
gew
ith
diff
eren
tM
Dat
tire
No
diff
eren
cefo
rpe
rcei
ved
MD
com
pete
ncy
and
prof
essi
onal
ism
MD
pref
eren
ce:
8ca
sual
,7
busi
ness
,5
scru
bs
Gal
lagh
er,
2008
(Ire
land
)7Su
rvey
(np
124)
:O
utP
tsR
e:P
refe
renc
ean
dra
nki
ngof
MD
atti
rew
ith
phot
os(f
orm
al,
casu
al,
WC
,sc
rubs
)
Pre
fer
WC
,fo
rmal
,an
dse
mif
orm
alvs
scru
bsan
dca
sual
WC
mos
tpr
efer
red;
scru
bsan
dca
sual
leas
tpr
efer
red
Ghe
rard
i,20
09(U
K)8
Surv
ey(n
p51
1):
InP
tsR
e:R
ated
phot
osof
MD
inva
riou
sat
tire
toin
spir
eco
nfid
ence
WC
rank
edhi
ghes
tan
dm
ost
con
fiden
cein
spir
ing
All
dres
sst
yles
rate
dab
ove
neu
tral
exce
ptca
sual
(rat
edlo
wer
)O
lder
Pts
foun
dsc
rubs
less
appe
alin
gG
onza
lez
del
Rey
,19
95(U
S)9
Surv
ey(n
p36
0):
Par
ents
ofpe
diat
ric
ED
Pts
show
npi
ctur
esof
MD
dres
sed
inva
riou
sty
pes
ofat
tire
Re:
Whi
chdo
ctor
wou
ldth
eypr
efer
for
thei
rch
ild,
does
atti
rem
atte
r,do
clot
hes
affe
cttr
ust
inM
D?
Mos
tpr
efer
red
atti
re:
form
al44
%(P
!.0
01)
sele
cted
for
all
shif
tsbu
tle
sslik
ely
sele
cted
for
Pt
seen
byn
ight
shift
Leas
tpr
efer
red
atti
re:
casu
alw
itho
utW
C64
%(P
!.0
01)
Ove
rall,
69%
of“m
ost-
liked
”pi
ctur
esha
dW
C,
and
89%
of“l
east
-lik
ed”
pict
ures
did
not
have
WC
Pic
ture
sw
ith
scru
bsfa
vore
dby
pare
nts
wit
hch
ildre
nse
enfo
rsu
rgic
alem
erge
ncie
sM
ajor
ity
did
not
con
side
rm
ost
form
ally
atti
red
asm
ost
capa
ble,
did
not
mat
ter
how
MD
dres
sed
and
did
not
influ
ence
trus
t
This content downloaded from 96.255.251.162 on Tue, 21 Jan 2014 08:49:45 AMAll use subject to JSTOR Terms and Conditions
111
Hen
nes
sy,
1993
(UK
)10Su
rvey
(np
110)
:2
grou
psof
pre-
opP
ts,
seen
bysa
me
anes
-th
etis
t,dr
esse
dfo
rmal
vsca
sual
Re:
Sele
ctad
ject
ives
tode
scri
bean
esth
etis
t/vi
sit,
grad
ed15
dres
sit
ems
asde
sira
ble,
neu
tral
,or
unde
sira
ble
No
diff
eren
cebe
twee
nad
ject
ive
choi
ces
(pro
fess
ion
alis
m,
appr
oach
abili
ty)
ofan
es-
thet
ist
info
rmal
vsca
sual
dres
sD
esir
abili
ty:
nam
eta
g(9
0%),
WC
(66%
),po
lishe
dsh
oes
(62%
),sh
ort
hair
(57%
),su
it(3
6%)
(sui
tan
dti
ese
lect
edm
ore
likel
yde
sira
ble
ifvi
ewed
)U
nde
sira
bilit
y:cl
ogs
(84%
),je
ans
(70%
),tr
ain
ers
(67%
),ea
rrin
gs(6
4%),
lon
gha
ir(6
2%),
open
-nec
ked
shir
t(3
6%)
Hue
ston
,20
11(U
S)11
Surv
ey(n
p42
3):
Out
Pts
Re:
Pre
fere
nce
for
MD
atti
rebe
fore
/aft
erbe
ing
info
rmed
ofpo
ssib
lem
icro
bial
con
tam
inat
ion
Bef
ore
educ
atio
n:
no
clea
rat
tire
pref
eren
cebu
tdi
dn
otfa
vor
scru
bs(6
%),
poor
agre
emen
tw
ith
Pt
pref
eren
cean
dw
hat
thei
rM
Dw
ears
Aft
ered
ucat
ion
:de
crea
sepr
efer
ence
for
WC
/tie
/for
mal
atti
reC
oncl
usio
n:
atti
repr
efer
ence
sm
aych
ange
wit
haw
aren
ess
for
con
tam
inat
ion
Ikus
aka,
1999
(Jap
an)12
Surv
ey:
Out
Pts
seen
bygr
oups
ofM
Din
WC
orpr
ivat
ecl
othe
sR
e:P
tte
nsio
n/s
atis
fact
ion,
pref
eren
cefo
rM
Dat
tire
Ten
sion
:W
Cgr
oup
42%
,pr
ivat
ecl
othe
sgr
oup
33%
Sati
sfac
tion
:n
osi
gnifi
can
tdi
ffer
ence
betw
een
atti
regr
oups
WC
pref
eren
ce:
WC
grou
p(o
lder
Pts
mor
elik
ely
topr
efer
WC
)71
%,
priv
ate
clot
hes
grou
p39
%(P
!.0
01)
Li,
2005
(US)
13B
efor
e/af
ter
tria
l(n
p11
1)of
Pt
opin
ion
inE
DR
e:E
DM
Ds
wor
eW
C/f
orm
alvs
scru
bsN
osi
gnifi
cant
diff
eren
cein
scor
esbe
twee
n2
dres
sst
yles
inap
pear
ance
,sa
tisf
ac-
tion
,or
prof
essi
onal
ism
Maj
or,
2005
(US)
14Su
rvey
(np
410)
:In
Pts
,su
rgeo
ns,
and
publ
icR
e:Su
rgeo
ns’
atti
reW
Cn
eces
sary
:su
rgeo
ns
72%
,In
Pts
69%
,pu
blic
42%
Scru
bsap
prop
riat
e:su
rgeo
ns
73%
,In
Pts
41%
,pu
blic
33%
(P!
.05)
Clo
gsap
prop
riat
e:su
rgeo
ns
63%
,In
Pts
27%
,pu
blic
18%
(P!
.05)
Den
imap
prop
riat
e:su
rgeo
ns
10%
,In
Pts
22%
,pu
blic
31%
Mat
sui,
1998
(Can
ada)
15Su
rvey
(np
220)
:O
utP
tpe
diat
ric
child
ren/
pare
nts
Re:
Ask
edw
hoth
eyw
ould
like
asth
eir
MD
from
phot
osof
MD
wit
han
dw
itho
utW
C;
pare
nts
also
rate
dat
tire
appr
opri
aten
ess
Sele
cted
MD
inW
C:
child
ren
69%
,pa
ren
ts66
%M
ost
appr
opri
ate
and
favo
red:
nam
eta
g,W
C,
wel
lgr
oom
edN
eutr
al:
scru
bs,
form
aldr
ess
Not
favo
red:
open
-toe
dsa
ndal
s,cl
ogs,
shor
tsM
cKin
stry
,19
91(U
K)16
Surv
ey(n
p47
5):
Out
Pts
in5
prac
tice
sR
e:P
tac
cept
abili
tyfo
rdi
ffer
ent
styl
esof
atti
re(p
hoto
sof
mal
ean
dfe
mal
eM
Ds)
for
diff
eren
tat
tire
and
whe
ther
atti
rein
-fl
uenc
edth
eir
resp
ect
for
MD
Form
aldr
ess
favo
red
(sui
t/ti
eor
WC
)28
%w
ould
beun
happ
yse
eing
one
ofM
Ds
show
n,
mor
elik
ely
thos
edr
esse
din
form
ally
64%
thou
ght
how
thei
rM
Ddr
esse
dw
asim
port
ant
Pra
ctic
eto
whi
cha
Pt
belo
nged
was
anin
depe
nde
ntfa
ctor
inP
tch
oice
ofdr
ess
Mis
try,
2009
(UK
)17Su
rvey
(np
200)
:P
edia
tric
dent
alpa
rent
s/ch
ildre
nR
e:A
ttit
udes
onM
Dat
tire
usin
gph
otos
WC
and
mas
km
ost
popu
lar
over
all
but
child
ren
favo
rca
sual
atti
reFo
rmal
WC
pref
erre
dov
erpe
diat
ric
coat
bypa
ren
tsan
dch
ildre
nM
ask
pref
erre
dov
ervi
sor
(eye
cont
act
pote
ntia
llyim
port
ant)
Mon
khou
se,
2008
(UK
)18Su
rvey
(np
50):
Surg
ical
Pts
ran
dom
surv
ey(E
Ran
del
ecti
vead
mit
s)R
e:A
ttit
udes
tow
ard
dres
s(f
orm
alvs
scru
bs)
befo
re/a
fter
edu-
cati
onal
inte
rven
tion
ontr
ansm
issi
onof
mic
roor
gan
ism
son
ties
Bef
ore
educ
atio
n:
pref
erfo
rmal
for
prof
essi
onal
ism
and
appr
oach
abili
ty;
pref
ersc
rubs
for
hygi
ene,
equa
lfo
rid
enti
fiabi
lity;
pref
erfo
rmal
dres
sov
eral
lA
fter
educ
atio
n:
pref
ersc
rubs
(24%
befo
reto
62%
afte
r);
form
alpr
efer
ence
de-
crea
sed
(52%
befo
reto
22%
afte
r)A
utho
rs’
con
clus
ion
s:if
rati
onal
ebe
hin
dm
odes
ofsu
rgic
aldr
ess
are
expl
ain
ed,
Pts
are
mor
elik
ely
topr
efer
scru
bsto
form
alcl
othe
sN
air,
2002
(Aus
tral
ia)19
Surv
ey(n
p1,
680)
:In
Pts
afte
rdi
scha
rge
wit
hcr
osso
ver
tria
lof
MD
sin
vary
ing
atti
reR
e:P
tco
nfid
ence
/tru
stin
MD
inin
form
alvs
“res
pect
able
”at
tire
Pt
con
fide
nce
high
est
wit
h“r
espe
ctab
le”
dres
sLo
ssof
WC
orti
edi
dn
otde
teri
orat
eco
nfide
nce
sign
ifica
ntly
Info
rmal
dres
spr
otoc
ol“a
ffro
nt
tose
nsi
tivi
ties
”an
dpr
esen
ceof
nos
eri
ng
mos
tde
lete
riou
s
This content downloaded from 96.255.251.162 on Tue, 21 Jan 2014 08:49:45 AMAll use subject to JSTOR Terms and Conditions
tabl
e1
(Con
tinu
ed)
Lead
auth
or,
year
(cou
ntr
y)M
etho
dolo
gyFi
ndin
gs
Nie
derh
ause
r,20
09(U
S)20
Surv
ey(n
p32
8):
Pts
atn
aval
OB
/GY
Ncl
inic
Re:
Pre
fere
nce
for
MD
atti
rean
def
fect
onco
mfo
rtor
con
fi-
den
ceus
ing
pict
ures
86%
neu
tral
whe
ther
MD
wor
ea
WC
88%
said
atti
redi
dn
otim
pact
con
fiden
cein
MD
abili
tyA
ctiv
e-du
tyw
omen
wer
em
ore
likel
yth
ande
pen
dent
wiv
esto
say
MD
atti
rein
flu-
ence
dth
eir
com
fort
disc
ussi
ngge
ner
al/s
exua
l/ps
ycho
logi
cal/
pers
onal
topi
csA
utho
rsco
ncl
ude
acti
ve-d
uty
wom
enm
ayw
ithh
old
pert
inen
tm
edic
alin
form
atio
n(e
g,pe
rson
al,
sexu
alhi
stor
y)du
eto
inti
mid
atio
nfr
omm
ilita
ryun
ifor
mof
offi
-ce
rM
DA
spec
tof
mili
tary
unif
orm
uniq
ueto
this
stud
yP
alaz
zo,
2010
(UK
)21Su
rvey
(np
75):
InP
tsR
e:A
ttit
udes
ofM
Dat
tire
Ran
dom
lych
osen
med
ical
/sur
gica
lIn
Pts
rate
d6
stat
emen
ts(m
odal
resp
onse
spr
ovid
ed)
and
prov
ided
reas
ons
for
im-
port
ance
ofM
Ddr
ess
code
;op
inio
ns
solic
ited
afte
red
uca-
tion
ofn
ewdr
ess
code
polic
y
“MD
dres
sim
port
ant”
—st
ron
gly
agre
e(r
easo
n:
dres
sco
dein
still
sco
nfi
den
ce)
“You
rM
Dth
isad
mis
sion
dres
sed
prof
essi
onal
ly”—
stro
ngl
yag
ree
“Scr
ubs
are
acce
ptab
lefo
rmof
dres
s”—
stro
ngl
yag
ree
(rea
son
:ap
pear
scl
ean
)“M
Dsh
ould
wea
rW
C”—
stro
ngl
ydi
sagr
ee(r
easo
n:
slee
ves
mig
hten
cour
age
infe
c-ti
onsp
read
,m
ight
indu
cefe
aran
dan
xiet
yin
Pts
)“M
Dsh
ould
wea
rti
es”—
stro
ngl
ydi
sagr
ee(r
easo
n:
unn
eces
sary
,un
com
fort
able
)“I
sit
easy
todi
stin
guis
hbe
twee
ndi
ffer
ent
grad
esof
doct
orba
sed
onth
eir
dres
s?”—
stro
ngl
ydi
sagr
ee(h
ard
todi
ffer
enti
ate
MD
vsth
epu
blic
)N
oP
tsn
otic
eddr
ess
code
chan
gepr
ior
tobe
ing
info
rmed
ofth
ech
ange
All
Pts
favo
red
dres
sco
dech
ange
whe
nth
esu
gges
ted
impa
cton
infe
ctio
nw
asex
plai
ned
Con
clus
ion
s:M
Dat
tire
impo
rtan
tbu
tn
eckt
iean
dW
Cn
otex
pect
edR
ehm
an,
2005
(US)
22Su
rvey
(np
400)
:P
ts/v
isit
ors
inO
utP
tcl
inic
Re:
Pre
fere
nce
,tr
ust,
will
ing
todi
scus
sse
nsi
tive
issu
esw
ith
phot
osof
MD
sin
vari
ous
atti
re
Pre
fere
nces
:pr
ofes
sion
alat
tire
wit
hW
C76
%,
scru
bs10
%,
busi
ness
dres
s9%
,ca
sual
5%Tr
ust
and
will
ing
tosh
are
sen
siti
vein
form
atio
nsi
gnifi
cant
lyas
soci
ated
wit
hpr
o-fe
ssio
nal
atti
re(P
!.0
01)
Fem
ale
MD
dres
ssi
gnifi
can
tly
mor
eim
port
ant
than
mal
eM
DSh
elto
n,
2010
(UK
)23Su
rvey
(np
100)
:In
Pts
Re:
Rat
eM
Dat
tire
wit
hph
otos
ofm
ale
and
fem
ale
MD
sbe
-fo
re/a
fter
bein
gin
form
edof
mic
robi
alco
nta
min
atio
n
Bef
ore
info
rmat
ion
:n
osi
gnifi
can
tdi
ffer
ence
betw
een
mos
tat
tire
exce
ptca
sual
dres
san
dsh
ort
slee
ves
(con
side
red
less
appr
opri
ate)
Aft
erin
form
atio
n:
scru
bsan
dsh
ort
slee
ves
con
side
red
mos
tap
prop
riat
e,sc
rubs
pref
erre
dfo
rfe
mal
esB
axte
r,20
10(U
K)24
Surv
ey(n
p48
0):
InP
tsR
e:A
ttit
udes
tow
ard
MD
atti
reus
ing
phot
osof
mal
eM
Ds
inlo
ng
slee
ves/
tie,
scru
bs,
shor
tsl
eeve
s
Mos
tpr
ofes
sion
al:
lon
gsl
eeve
s/ti
e77
%,
scru
bs22
%,
BB
E1%
Gre
ates
ttr
ansm
issi
onri
sk:
lon
gsl
eeve
s/ti
e30
%,
scru
bs33
%,
BB
E37
%P
refe
renc
efo
rM
Dat
tire
:lo
ng
slee
ves/
tie
63%
,sc
rubs
33%
,B
BE
4%To
quer
o,20
11(U
K)25
Surv
ey(n
pN
A):
orth
oped
icIn
Pts
Re:
Aw
aren
ess/
pref
eren
cefo
rre
cen
tB
BE
polic
yU
naw
are
ofpo
licy:
86%
Att
ire
pref
eren
ce:
shir
t/ti
e63
%,
suit
s22
%,
shor
tsl
eeve
shir
t6%
,P
ttr
ust
high
desp
ite
chan
geto
less
pref
erre
dat
tire
Gar
vin,
2012
(US)
26Su
rvey
(np
1,49
4):
InP
ts,
MD
s,R
Ns
Re:
Att
itud
esto
war
dM
Dat
tire
MD
appe
aran
ceim
port
ant
for
Pt
care
:M
Ds/
RN
s93
%,
InP
ts83
%(P
!.0
01)
Con
cern
edw
ith
appe
aran
ceof
othe
rpr
ovid
erbu
tdi
dn
oten
gage
them
:M
Ds
39%
,R
Ns
43%
,P
ts16
%(P
!.0
01)
Con
cern
edw
ith
appe
aran
ceof
othe
rpr
ovid
erbu
tdi
dn
oten
gage
them
:M
Ds
39%
,R
Ns
43%
,P
ts16
%(P
!.0
01)
no
te.
BB
E,
bare
belo
wel
bow
s;E
D,
emer
gen
cyde
part
men
t;E
NT,
ear,
nos
e,an
dth
roat
;In
Pt,
inpa
tien
t;M
D,
phys
icia
n;N
A,
not
prov
ided
;OB
/GY
N,o
bste
tric
s/gy
nec
olog
y;O
utP
t,ou
tpat
ien
t;P
t,pa
tien
t;R
N,
nu
rse;
WC
,w
hit
eco
at.
This content downloaded from 96.255.251.162 on Tue, 21 Jan 2014 08:49:45 AMAll use subject to JSTOR Terms and Conditions
shea expert guidance: healthcare personnel attire 113
patients’ satisfaction with the care provided when theirphysicians wore white coats combined with either scrubsor formal attire.2 Similarly, 2 groups of patients who re-ceived preoperative care by the same anesthesiologistwearing either formal attire for one group of patients orcasual attire for the other found no differences in patientsatisfaction between the groups.10 In contrast, one cross-over trial involving physicians dressed in “respectable” orformal versus “retro” or casual attire found that patientconfidence and trust were higher with the respectable-dress protocol.19 Another study evaluating the attire ofpatients’ treating physicians indicated preference for pol-ished shoes and short hair for men, with jeans, clogs,trainers, and earrings on men being rated as undesirable.10
A survey among Japanese outpatients indicated a pref-erence for white coats but no significant difference insatisfaction levels based on attire when presented withphysicians wearing white coats or “noninstitutionalclothes.”12
B. BBE: Preference for BBE was assessed in 6 studies origi-nating in the United Kingdom following implementationof the nationwide BBE policy1,3,23-25 and in 1 US study.11
In these 7 reports, patients did not prefer short sleeves.After informing patients of the BBE policy, older patientswere more likely to prefer short-sleeved shirts without ties,while younger patients favored scrubs.1 After providinginformation about the potential for cross-contaminationfrom shirt sleeve cuffs and neckties, responses changedfrom a preference for formal or long-sleeved attire to apreference for short sleeves or scrubs.11,18,23 In addition,Shelton et al23 also found an association between physiciangender and BBE attire: after a statement informing theparticipants of the potential cross-transmission of micro-organisms by attire, patients preferred scrubs for femalephysicians but did not differentiate between scrubs andshort-sleeved shirts for male physicians.
C. Ties: Neckties were specifically addressed in several studiesfrom the United Kingdom.5,21,24 In one study, patients re-ported that attire was important but that neckties werenot expected.21 Similarly, in a survey among individualsin the public concourse of a hospital, 93% had no ob-jection to male physicians not wearing ties.5 None of thesestudies evaluated neckties in the context of patients’ per-ceptions of infection prevention.
D. Laundering of clothes: In one study, patients identified“daily laundered clothing” as the single most importantaspect of physicians’ appearance.8
E. Other factors: Several additional variables may influencepatient preference for physician attire, including age ofeither the patient or the managing physician, gender ofthe practitioner, time of day, setting, and the attire patientsare accustomed to seeing. In Japan, older patients weremore likely to prefer white coats.12 Similarly, older patientsin England found scrubs less appealing than did youngerpatients.8 Pediatric dental patients were more likely than
their parents to favor casual attire.17 Patients preferredformal attire for senior consultants but thought that juniorphysicians should be less formal.1 Patients identified fe-male physicians’ attire as more important than the attireworn by male physicians.22 Formal attire was less desirableby patients seen during the night shift.9 Parents of childrenbeing seen in the ED favored surgical scrubs. Additionally,2 trials evaluated attire preference on the basis of whatpatients often see their HCP wearing. In one trial, patientsaccustomed to seeing their anesthesiologist in a suit weremore likely to find suits and ties desirable.10 Similarly, thepractice to which a patient belonged was found to be anindependent factor in the patient’s choice of preferredattire;16 however, another study found poor agreement be-tween patient preferences and their physicians’ typicalattire.11
In summary, patients express preferences for certain typesof attire, with most studies indicating a predilection for formalattire, including a white coat, but these partialities had alimited overall impact on patient satisfaction and confidencein practitioners. This is particularly true in trials that eval-uated the effect of attire on patient satisfaction in real-worldsettings. Patients generally do not perceive white coats, formalattire, or neckties as posing infection risks; however, wheninformed of potential risks associated with certain types ofattire, patients appear willing to change their preferences forphysician attire.11,18
II. HCP Perceptions regarding Attire
Few studies evaluated HCP preferences with regard to at-tire.5,6,14,26 While most studies addressed specific elements ofHCP attire, one looked at the overall importance of attireand found that 93% of physicians and nurses versus 83% ofpatients thought that physician appearance was important forpatient care (P ! .001).26
A. White coats: In a survey exploring perceptions of sur-geons’ apparel performed among surgeons themselves, in-patients, and the nonhospitalized public, all 3 groups wereequally likely to consider a white coat necessary and bluejeans inappropriate. Surgeons were more prone to con-sider scrubs and clogs appropriate.14 In another survey of15 obstetricians/gynecologists, 8 preferred casual attire,while 7 preferred formal attire.6 Three studies assessedHCP alongside patient perception of infection risk or lackof hygiene associated with white coats, formal attire, orneckties,3,24,26 with one finding that HCP were more likelythan patients to consider white coats unhygienic.26
B. Ties: In a survey performed in a public concourse of aUK hospital, HCP were more likely than non-HCP toprefer physicians’ wearing of neckties for reasons ofprofessionalism.5
C. Laundering of clothes: A recent survey showed that non-surgical providers preferentially (and without prompting)
This content downloaded from 96.255.251.162 on Tue, 21 Jan 2014 08:49:45 AMAll use subject to JSTOR Terms and Conditions
114 infection control and hospital epidemiology february 2014, vol. 35, no. 2
laundered their scrubs every 1.7 � 0.1 days (mean �standard error) compared with white coats, which werelaundered every 12.4 � 1.1 days (P ! .001); however, thereasons for this divergent behavior remain unclear.27
III. Studies of Microbial Contamination of Apparel inClinical and Laboratory Settings
No clinical studies have demonstrated cross-transmission ofhealthcare-associated pathogens from a HCP to a patient viaapparel; however, a number of small prospective trials havedemonstrated the contamination of HCP apparel with a va-riety of pathogens (Table 2).5,28-37
A. White coats/uniforms: The 5 studies we evaluated indi-cate that physician white coats and nursing uniforms mayserve as potential sources of colonization and cross-trans-mission. Several studies described contamination of ap-parel with Staphylococcus aureus in the range of 5% to29%.30,33-35,38 Although gram-negative bacilli have also beenidentified, these were for the most part of low pathoge-nicity;30,35 however, actual pathogens, such as Acinetobacterspecies, Enterobacteriaceae, and Pseudomonas species,have been reported.38
A number of factors were found to influence the mag-nitude of contamination of white coats and uniforms.First, the degree of contamination was correlated withmore frequent usage of the coat,35 recent work in theinpatient setting,34 and sampling certain parts of the uni-form. Higher bacterial loads were found on areas of cloth-ing that were more likely to come into contact with thepatient, such as the sleeve.35 Additionally, the burden ofresistant pathogens on apparel was inversely correlatedwith the frequency of lab coat change.38 Apparel contam-ination with pathogenic microorganisms increased overthe course of a single patient care shift. Burden et al28
demonstrated that clean uniforms become contaminatedwithin only a few hours of donning them. Similarly, astudy testing nurses’ uniforms at both the beginning andthe end of their shifts described an increase in the numberof uniforms contaminated with one or more microor-ganisms from 39% to 54%, respectively. The proportionof uniforms contaminated with vancomycin-resistant en-terococci (VRE), methicillin-resistant S. aureus (MRSA),and Clostridium difficile was also noted to increase withshift work.33
In the first report of a positive correlation betweencontamination of hands and contamination of white coats,Munoz-Price et al39 cultured the hands, scrubs, and whitecoats of intensive care unit staff. The majority of bacteriaisolated from hands were skin commensals, but HCP werealso found to have contamination of hands, scrubs, andwhite coats with potentially pathogenic bacteria, includingS. aureus, Enterococcus species, and Acinetobacter bau-mannii. Among dominant hands, 17% of 119 hands were
contaminated with one of these species, and staff memberswith contaminated hands were more likely to wear a whitecoat contaminated with the same pathogen. This associ-ation was not observed with scrubs.
B. BBE: Two observational trials evaluated the bacterial con-tamination of HCP’s hands on the basis of BBE attireversus controls, finding no difference in total bacterialcounts or in the number of clinically significant patho-gens.40,41 In contrast, Farrington et al,42 using a fluorescentmethod, examined the efficacy of an alcohol hand washamong BBE providers versus controls. The authors founddecreased efficacy of hand hygiene at the wrist level in thenon-BBE group, suggesting that the BBE approach mayimprove wrist disinfection during hand washing.
The United Kingdom has adopted a BBE approach, onthe basis of the theory that it will limit patient contactwith contaminated HCP apparel and to promote betterhand and wrist hygiene. However, a randomized trial com-paring bacterial contamination of white coats against BBEfound no difference in total bacterial or MRSA counts (oneither the apparel itself or from the volar surface of thewrist) at the end of an 8-hour workday.28
C. Scrubs: The use of antimicrobial-impregnated scrubs hasbeen evaluated as a possible solution to uniform contam-ination. In a prospective, randomized crossover trial of30 HCP in the intensive care unit setting,36 when com-pared with standard scrubs, antimicrobial-impregnatedscrubs were associated with a 4–7 mean log reduction insurface MRSA burden, although there was no differencein MRSA load on HCP hands or in the number of VREor gram-negative bacilli cultured from the scrubs. Thestudy did not assess the HAI impact of the antimicrobialscrubs.
D. Ties: Several studies indicated that neckties may be col-onized with pathogenic bacteria, including S. aureus. Lo-pez et al31 reported a significantly higher bacterial burdenon neckties than on the front shirt pocket of the samesubject. In 3 studies, up to 32% of physician neckties grewS. aureus.5,31,37 Steinlechner et al37 identified additional po-tential pathogens and commensals from necktie cultures,including Bacillus species and gram-negative bacilli. Tworeports found that up to 70% of physicians admitted hav-ing never cleaned their ties.5,31
E. Laundering of clothes: Numerous articles published dur-ing the past 25 years describe the efficacy of launderinghospital linens and HCP clothing,44 but most investiga-tions of the laundering of HCP attire have employed invitro experimental designs that may or may not reflectreal-life conditions. A 2006 study45 demonstrated thatwhile clothes lost their burden of S. aureus, they concom-itantly acquired oxidase-positive gram-negative bacilli inthe home washing machine. These bacteria were nearlyeliminated by tumble drying or ironing. Similarly, inves-tigators found that recently laundered clothing materialacquired gram-negative bacteria from the washing ma-
This content downloaded from 96.255.251.162 on Tue, 21 Jan 2014 08:49:45 AMAll use subject to JSTOR Terms and Conditions
shea expert guidance: healthcare personnel attire 115
chine, which were subsequently eliminated by ironing. An-other in vitro study in the United Kingdom compared thereduction of microorganisms on artificially inoculatednurses’ uniform material after washing at various tem-peratures as well as with and without detergents. Washinguniforms contaminated with MRSA and Acinetobacter spe-cies at a temperature of 60�C, with or without detergent,achieved at least a 7-log reduction in the bacterial burdenof both microorganisms.46 There is no robust evidencethat centralized industrial laundering decontaminatesclothing more effectively than home laundering.43
F. Footwear: Although restrictions on HCP footwear are in-fluenced by a desire to meet patients’ preferences for ap-propriate attire,10,14,15 most are driven by concerns for HCPsafety.47-50 Studies have found that wearing of shoes withclosed toes, low heels, and nonskid soles can decrease therisk of exposure to blood or other potentially infectiousmaterial,47,48,50,51 sharps injuries,48,50,52 slipping,50 and mus-culoskeletal disorders.49
Casual, open footwear, such as sandals, clogs, and foamclogs, potentially expose feet to injury from dropped con-taminated sharps and exposure to chemicals in healthcarefacilities. A comparison of needlestick injury surveillancedata from the standardized Exposure Prevention Infor-mation Network program revealed a higher proportion ofhollow-bore needle injuries to the feet of Japanese HCP,with 1.5% of 16,154 total injuries compared with 0.6% of9,457 total injuries for US HCP (2.5 times higher; P !
.001).48 Although multiple factors were linked to these in-juries, one included the common practice in Japan to re-move outdoor shoes and replace them with open-toedslippers on hospital entry.
Footwear is an area of increased concern in the OR.The Association of periOperative Registered Nurses(AORN) recommends that OR footwear have closed toesas well as backs, low heels, and nonskid soles to preventslipping.50 The US Occupational Safety and Health Ad-ministration (OSHA) requires the use of protective shoesin areas where there is a danger of foot injuries from fallingobjects or objects piercing the soles.47 One study that mea-sured the resistance of shoes to penetration by scalpelsshowed that of the 15 pairs of shoes studied, only 6 weremade of material that was sharp resistant, includingsneaker suede, suede with inner mesh lining, leather withinner canvas lining, nonpliable leather, rubber with innerleather lining, and thicker rubber.52 The OSHA bloodbornepathogens standard mandates that employers determinethe workplace settings in which gross contamination withblood or body fluids is expected, such as the OR, and toprovide protective shoe coverings in those settings.47,48,50,51
Shoe covers are not meant to prevent transmission of bac-teria from the OR floor; in fact, preliminary data showthat the OR floor may play a dynamic role in the horizontaltransmission of bacteria due to frequent floor contact ofobjects that then directly touch the patient’s body (eg,
intravenous tubing, electrocardiogram leads).53
When HCP safety concerns or patient preference con-flict with a HCP’s desire for fashion, a facility’s dress codecan be the arbiter of footwear. OSHA allows employers tomake such dress code determinations without regard to aworker’s potential exposure to blood, other potentially in-fectious materials, or other recognized hazards.
IV. Outbreaks Linked to HCP Apparel
Wright et al54 reported an outbreak of Gordonia potentiallylinked to HCP apparel. In this report, postoperative sternalwound infections with Gordonia bronchialis in 3 patients werelinked to a nurse anesthetist. Gordonia was isolated from theHCP’s scrubs, axillae, hands, and purse and from multiplesites on the HCP’s roommate.
V. Studies from Developing Countries
In Nigeria, factors identified increasing the likelihood of bac-terial contamination of white coats included daily launderingand use limited to patient care rather than nonclinical du-ties.55 In India,56 medical students’ white coats were assessedfor bacterial contamination, paired with surveys about laun-dering habits and attitudes toward white coats. Coats werecontaminated most frequently with S. aureus, followed byPseudomonas species and coagulase-negative staphylococci. Asimilar trial of white coats used by staff in a rural dental clinicalso revealed predominantly gram-positive contamination.57
VI. Hospital Policies Addressing HCP Attire
We reviewed and compared policies related to HCP attirefrom 7 large teaching hospitals or health systems. In general,policies could be categorized into 2 groups:
A. General appearance and dress of all employeesB. Standards for HCP working in sterile or procedure-based
environments (OR, central processing, procedure areas, etc)
Policies were evaluated for the following elements:
A. Recommended clothing (eg, requirement for white coats,designated uniforms) or other options (eg, BBE)
B. Guidance regarding scrubsC. Use of name tagsD. Wearing of tiesE. Requirements for laundering or change of clothingF. Footwear and nonapparel items worn or carried by HCPG. Personal protective equipment
All institutions’ human resources policies outlined generalappearance or dress code requirements for professional stan-dards of business attire; however, institutions varied in job-specific policies and for the most part did not address morespecific attire requirements except for OR-related activities.Few institutional policies included enforcement provisions.The institutions that required accountability varied from de-
This content downloaded from 96.255.251.162 on Tue, 21 Jan 2014 08:49:45 AMAll use subject to JSTOR Terms and Conditions
116
ta
ble
2.A
ppar
elan
dM
icro
bial
Bu
rden
:R
evie
wof
Stu
dies
inLa
bora
tory
and
Clin
ical
Sett
ings
Lead
auth
or,
year
Met
hodo
logy
Find
ings
Bea
rman
,20
1236
Pro
spec
tive
cros
sove
rtr
ial
ofH
CW
sin
ICU
(np
30)
Ran
dom
ized
toan
tim
icro
bial
vsco
ntr
olsc
rubs
Sam
ples
obta
ined
from
scru
bab
dom
inal
area
,po
cket
,an
dha
nds
wee
kly
HC
Wsc
rubs
colo
niz
eddu
rin
gco
urse
ofP
tca
rew
ith
MR
SAA
nti
mic
robi
alsc
rubs
asso
ciat
edw
ith
a4
–7m
ean
log
redu
ctio
nin
MR
SAbu
tn
otV
RE
orG
NR
No
diff
eren
ces
inba
cter
ial
han
dbu
rden
orin
HC
Ws
wit
hun
ique
posi
tive
scru
bcu
ltur
esN
oda
tare
port
edon
cros
s-tr
ansm
issi
onto
Pts
Bur
den,
2011
28R
ando
miz
edtr
ial
com
pari
ng
con
tam
inat
ion
onre
gula
r(d
irty
)W
Cvs
shor
t-sl
eeve
dU
K-s
tyle
MD
unif
orm
laun
dere
dda
ilyN
osi
gnifi
cant
diff
eren
cein
bact
eria
lbu
rden
betw
een
dirt
yW
Cs
and
rece
ntly
was
hed
unif
orm
s;cl
ean
unifo
rms
con
tam
inat
edw
ithi
nfe
who
urs
ofdo
nn
ing
No
info
rmat
ion
onfr
eque
ncy
WC
sw
ere
was
hed
orha
nd
hygi
ene
rate
sSu
gges
tsn
om
icro
biol
ogic
alad
van
tage
ofB
BE
Bur
ger,
2011
40P
rosp
ecti
veob
serv
atio
nal
stud
y(n
p66
)M
Ds
from
mul
tipl
esp
ecia
ltie
s(3
8B
BE
,28
wer
en
ot)
volu
nte
ered
wit
hout
not
ice
duri
ngn
orm
alw
ork
day
Aga
rim
prin
tsof
fin
gers
,pa
lms,
wri
sts,
and
fore
arm
s,re
peat
edaf
-te
rha
nd
hygi
ene;
impr
ints
ofcu
ffs
ofth
ose
not
BB
E
No
sign
ifica
ntdi
ffer
ence
inba
cter
ial
coun
ts(m
any
skin
com
men
sals
,n
oM
RSA
)be
-tw
een
grou
psSo
me
MD
sha
dhi
gher
coun
tsaf
ter
HH
Larg
eva
riat
ion
inn
umbe
rof
colo
nie
scu
ltur
edA
utho
rsco
ncl
ude
“no
diff
eren
cein
den
sity
orty
peof
base
line
flor
aon
han
dsan
dfo
rear
ms
irre
spec
tive
ofdr
ess
code
”H
Hre
duce
dco
lon
yco
unts
from
fing
erti
ps,
palm
s,an
dw
rist
sin
all
grou
psD
itch
burn
e,20
065
MD
ties
cult
ured
(np
40)
MD
ties
capa
ble
ofca
rryi
ngba
cter
ia,
incl
udin
gM
RSA
:40
%of
ties
grew
MSS
A(1
wit
hM
RSA
)70
%ha
dn
ever
laun
dere
dti
e93
%ha
dn
oob
ject
ion
ton
otw
eari
ngti
esA
utho
rssu
gges
tsu
bsti
tute
othe
rat
tire
for
ties
topr
eser
vepr
ofes
sion
alim
age
No
data
repo
rted
oncr
oss-
tran
smis
sion
toP
tsFa
rrin
gton
,20
0942
BB
Evs
non
-BB
Era
ndom
ized
tria
lof
MD
(np
58)
and
med
ical
stud
ents
(np
61)
ata
900-
bed
teac
hing
hosp
ital
Par
tici
pan
tscl
eane
dha
nds
usin
gal
coho
l,w
ith
area
sfl
uore
scin
gby
UV
light
con
side
red
“mis
sed”
and
reco
rded
ona
stan
dard
han
ddi
agra
m
No
sign
ifica
nt
diff
eren
cefo
und
betw
een
2gr
oups
inpe
rcen
tage
area
ofha
nds
mis
sed
The
non
-BB
Egr
oup
mis
sed
mor
ew
rist
vsB
BE
grou
p(P
!.0
02)
Mea
npe
rcen
tar
eam
isse
don
wri
sts
sign
ifica
ntl
yhi
gher
than
han
dsin
both
grou
ps(P
!.0
01)
Stre
ngt
hs:
high
part
icip
atio
nra
tew
itho
utdr
opou
ts,
sing
lein
vest
igat
orcr
eate
dha
nd
diag
ram
sW
eakn
esse
s:H
awth
orn
eef
fect
Aut
hor
con
clus
ion
s:B
BE
did
not
affe
ctqu
alit
yof
HH
,an
dal
thou
ghB
BE
impr
oved
wri
stw
ashi
ng,
the
clin
ical
sign
ifica
nce
isun
cert
ain
Gas
pard
,20
0829
Des
crip
tive
stud
yof
staf
fcl
othi
ngin
3LT
CFs
Un
ifor
ms
(np
256)
from
90R
Ns,
166
care
part
ners
sam
pled
from
wai
stzo
ne
pock
etan
dbe
twee
npo
cket
s
HC
Wap
pare
lfr
eque
ntly
con
tam
inat
edw
ith
MR
SA27
%–8
0%M
RSA
reco
very
from
“wai
stzo
ne”
;18
%–6
0%M
RSA
reco
very
from
“poc
ket
zon
e”A
utho
rsst
ress
edH
Hto
limit
cros
s-tr
ansm
issi
onfr
omap
pare
lto
Pts
via
HC
Wha
nds
No
data
repo
rted
oncr
oss-
tran
smis
sion
toP
ts
This content downloaded from 96.255.251.162 on Tue, 21 Jan 2014 08:49:45 AMAll use subject to JSTOR Terms and Conditions
117
Jaco
b,20
0743
Dep
artm
ent
ofH
ealt
hW
orki
ngG
roup
onU
nif
orm
san
dLa
un-
dry:
evid
ence
-bas
eddo
cum
ent
onw
eari
ngan
dla
unde
ring
uni-
form
sfr
om2
liter
atur
ere
view
s(T
ham
esV
alle
yU
niv
ersi
tyan
dU
niv
ersi
tyC
olle
geLo
ndo
nH
ospi
tal
NH
STr
ust)
Exa
min
edro
leof
unif
orm
sin
infe
ctio
ntr
ansf
er,
effi
cacy
ofla
un-
dry
prac
tice
sin
rem
ovin
gco
nta
min
atio
n,
how
unif
orm
saf
fect
imag
eof
indi
vidu
alan
dor
gani
zati
ons
No
con
clus
ive
evid
ence
that
unif
orm
spo
sea
sign
ifica
nt
haza
rdto
spre
adin
fect
ion
Pub
licdo
esn
otlik
ese
eing
hosp
ital
staf
fin
unif
orm
outs
ide
wor
kpla
ceA
llco
mpo
nen
tsof
prop
erly
desi
gned
and
oper
ated
laun
deri
ng
help
tore
mov
e/ki
llm
i-cr
oorg
anis
ms
onfa
bric
Ten
-min
ute
was
hat
60�C
suffi
cien
tto
rem
ove
mos
tm
icro
orga
nism
sD
eter
gen
tsca
nre
mov
em
any
mic
roor
gan
ism
sfr
omfa
bric
sat
low
erte
mpe
ratu
re(e
g,M
RSA
rem
oved
at30
�C)
No
con
clus
ive
evid
ence
for
diff
eren
cebe
twee
nco
mm
erci
alor
dom
esti
cla
unde
ring
tore
mov
em
icro
orga
nis
ms
Aut
hors
prov
ide
list
ofgo
od(a
ndpo
or)
prac
tice
exam
ples
wit
hre
ason
s:•
Goo
dpr
acti
ceex
ampl
e:“D
ress
ina
man
ner
whi
chis
likel
yto
insp
ire
publ
icco
nfi
denc
e”•
Poo
rpr
acti
ceex
ampl
e:“W
ear
fals
en
ails
for
Pt
care
”Lo
h,20
0030
Ran
dom
sam
ple
(np
100)
Cul
ture
dm
edic
alst
uden
ts’
WC
sM
SSA
reco
vere
dfr
omba
ck,
pock
et,
and
slee
ves
Stud
ents
repo
rtoc
casi
onal
orin
freq
uent
WC
laun
deri
ngA
utho
rssu
gges
tho
spit
als
prov
ide
laun
dere
dW
Cs
for
stud
ents
No
data
repo
rted
oncr
oss-
tran
smis
sion
toP
tsLo
pez,
2009
31Sa
mpl
edsh
irts
/tie
sfr
omin
tern
ists
/sur
geon
s(n
p25
/25)
for
pair
edba
cter
ial
coun
ts16
part
icip
ants
had
nev
ercl
ean
edth
eir
tie;
20pa
rtic
ipan
tsco
uld
not
rem
embe
rw
hen
tie
last
clea
ned
Bac
teri
alco
unts
from
ties
sign
ifica
ntl
yhi
gher
than
thos
epa
ired
from
shir
tsSi
gnifi
can
tfr
acti
onof
phys
icia
ns(1
6)ha
dSt
aphy
loco
ccus
aure
usis
olat
edfr
omcl
othe
sA
ppar
elin
freq
uen
tly
laun
dere
d(t
ies)
asso
ciat
edw
ith
high
erba
cter
ial
burd
enN
oda
tare
port
edon
cros
s-tr
ansm
issi
onto
Pts
Mor
gan,
2012
32C
ohor
tst
udy
ofse
quen
tial
HC
Win
tera
ctio
nw
ith
Pts
wit
hcu
ltur
eof
gow
ns/
han
dslin
ked
toen
viro
nm
enta
lcu
ltur
esSt
udy
wit
hP
FGE
linki
ngen
viro
nm
enta
lis
olat
es,
gow
ns/
glov
es,
and
Pts
in1
80%
ofca
ses
(Aci
neto
bact
er,
MD
RP
seud
omon
as,
MR
SA)
Con
tam
inat
ion
ofgo
wn
s/gl
oves
duri
ngca
reof
MD
RO
Pts
mos
tfr
eque
nt
wit
hA
.ba
uman
nii
En
viro
nm
enta
lco
nta
min
atio
nm
ajor
dete
rmin
ant
oftr
ansm
issi
onto
HC
Wgl
oves
/go
wn
sE
nvi
ron
men
tal
cult
ures
rela
ted
togo
wn
s/gl
oves
mor
eth
ancl
othi
ng
Per
ry,
2001
33C
ross
-sec
tion
alsa
mpl
e(n
p57
)B
acte
rial
con
tam
inat
ion
acro
ss5
serv
ices
Sam
pled
belt
area
–hem
atst
art
vsen
dof
shif
t
MR
SA,
VR
E,
and
Clo
stri
dium
diffi
cile
reco
vere
dB
acte
rial
con
tam
inat
ion
ofho
spit
al-s
uppl
ied
appa
rel
pres
ent
atst
art
ofsh
ift
and
in-
crea
sed
byen
dof
shift
:•
Star
tsh
ift:
39%
ofun
ifor
ms
posi
tive
wit
h≥1
mic
roor
gan
ism
•E
nd
shift
:54
%of
unif
orm
spo
siti
vew
ith
≥1m
icro
orga
nis
mA
llun
ifor
ms
laun
dere
dat
hom
eN
oda
tare
port
edon
cros
s-tr
ansm
issi
onto
Pts
Scot
t,19
9058
Invi
tro
expe
rim
ent:
bact
eria
ltr
ansf
erfr
omla
min
ate
surf
aces
and
clot
hsto
hand
sC
onta
min
ated
inan
imat
esu
rfac
es(e
g,la
min
ates
,te
xtile
s)as
soci
ated
wit
hba
cter
ial
tran
sfer
tofi
nger
s:Es
cher
ichi
aco
li,Sa
lmon
ella
spec
ies,
MSS
ASt
einl
echn
er,
2002
37C
ohor
tof
orth
oped
icsu
rgeo
ns
(np
26)
Sam
pled
ties
for
bact
eria
lgr
owth
Tie
sof
orth
oped
icsu
rgeo
ns
heav
ilyco
lon
ized
wit
hpa
thog
ens
295
bact
eria
lis
olat
es:
45%
wer
eB
acill
usce
reus
,C
NS,
GN
Rs,
S.au
reus
No
data
repo
rted
oncr
oss-
tran
smis
sion
toP
ts
This content downloaded from 96.255.251.162 on Tue, 21 Jan 2014 08:49:45 AMAll use subject to JSTOR Terms and Conditions
tabl
e2
(Con
tinu
ed)
Lead
auth
or,
year
Met
hodo
logy
Find
ings
Trea
kle,
2009
34C
ross
-sec
tion
alst
udy
Att
ende
es(n
p14
9)of
med
ical
and
surg
ical
gran
dro
unds
ata
larg
ete
achi
ngho
spit
alSa
mpl
edW
Cs
for
grow
th
34(2
3%)
WC
sgr
ewS.
aure
us;
6(1
8%)
wer
eM
RSA
No
VR
Ere
cove
red
Larg
efr
acti
onof
HC
PW
Cs
con
tam
inat
edw
ith
S.au
reus
,in
clud
ing
MR
SAW
Cs
may
beve
ctor
sof
S.au
reus
tran
smis
sion
No
data
repo
rted
oncr
oss-
tran
smis
sion
toP
tsW
iene
r-W
ell,
2011
38C
ross
-sec
tion
alco
nve
nie
nce
sam
ple
ofM
Ds/
RN
s(n
p13
5)w
ith
surv
eyan
dcu
ltur
esof
unif
orm
s/W
CN
earl
yal
lH
CW
clot
hin
ghe
avily
con
tam
inat
edw
ith
skin
flor
a,63
%w
ith
pote
nti
alpa
thog
ens
(Aci
neto
bact
ersp
ecie
s,S.
aure
us,
Ent
erob
acte
riac
eae)
No
data
repo
rted
oncr
oss-
tran
smis
sion
toP
tsW
illis
-Ow
en,
2010
41P
rosp
ecti
ve,
cros
s-se
ctio
nal
,ob
serv
atio
nal
stud
y(n
p92
)A
gar
impr
ints
ofM
Dha
nds
from
mul
tipl
esp
ecia
ltie
sdu
rin
gn
or-
mal
wor
kda
y(4
9B
BE
,43
not
)N
o.of
CFU
grad
edlig
ht(!
10),
mod
erat
e(1
0–20
),or
heav
y(1
20)
wit
hpr
esen
ceof
path
ogen
sre
cord
ed
No
sign
ifica
ntdi
ffer
ence
inei
ther
CFU
orpa
thog
ens
inB
BE
vsn
oB
BE
No
MD
RO
cult
ured
from
MD
han
dsP
arti
cipa
nts
not
give
nan
oppo
rtun
ity
for
han
dhy
gien
epr
ior
toen
rollm
ent
Stud
ydo
esn
otid
enti
fygr
oup
for
the
50%
ofM
Ds
who
wor
eun
ifor
ms
wit
han
tiba
c-te
rial
prop
erti
esA
utho
rsco
nclu
ded
that
BB
Epe
rse
does
not
have
impa
cton
degr
eeof
con
tam
inat
ion
onM
Dha
nds
and
BB
Ein
itia
tive
shou
ldn
otdi
vert
from
othe
rim
port
ant
mea
-su
res,
such
asha
nd
hygi
ene,
appr
opri
ate
Pt
:RN
rati
osW
ilson
,20
0759
Syst
emat
icre
view
ofpu
blis
hed
liter
atur
eH
CW
unif
orm
san
dW
Cs
can
beco
me
prog
ress
ivel
yco
nta
min
ated
wit
hba
cter
iaof
low
path
ogen
icit
y(f
rom
HC
Ws)
and
mix
edpa
thog
enic
ity
(fro
men
viro
nmen
t)D
ata
don
otsu
ppor
tro
leof
appa
rel
asve
hicl
esfo
rcr
oss-
tran
smis
sion
Won
g,19
9135
Cro
ss-s
ecti
onal
surv
eyB
acte
rial
con
tam
inat
ion
ofW
Cs
ina
Bri
tish
hosp
ital
25%
MSS
Aco
ntam
inat
ion
ofW
Cs
for
both
phys
icia
nsan
dsu
rgeo
ns
(cuf
fs,
pock
ets)
Deg
ree
ofco
nta
min
atio
nas
soci
ated
wit
hin
crea
sed
freq
uen
cyof
WC
usag
eN
oda
tare
port
edon
cros
s-tr
ansm
issi
onto
Pts
Wri
ght,
2012
54O
utbr
eak
repo
rtC
lust
erof
3P
tsw
ith
deep
ster
nal
wou
nd
infe
ctio
nsdu
eto
Gor
-do
nia
spec
ies
Sam
esp
ecie
sin
RN
anes
thet
ist,
her
clot
hin
g,he
rro
omm
ate,
and
her
room
mat
e’s
clot
hin
g;ho
me
laun
deri
ngof
scru
bsim
plic
ated
(but
not
con
firm
ed)
asor
igin
ofst
aff
clot
hin
gco
lon
izat
ion
Rem
inde
rth
atho
me
laun
deri
ngsc
rubs
can
bepr
oble
mat
ic
no
te.
BB
E,b
are
belo
wel
bow
s;C
NS,
coag
ula
se-n
egat
ive
stap
hyl
ococ
ci;G
NR
,gra
m-n
egat
ive
rod;
HA
I,h
ealt
hca
re-a
ssoc
iate
din
fect
ion
;HC
P,h
ealt
hca
repe
rson
nel
;HC
W,h
ealt
hcar
ew
orke
r;H
H,h
and
hyg
ien
e;IC
U,i
nte
nsi
veca
reu
nit
;In
Pt,
inpa
tien
t;LT
CF,
lon
g-te
rmca
refa
cilit
y;M
D,p
hys
icia
n;M
DR
,mu
ltid
rug
resi
stan
t;M
DR
O,m
ult
idru
g-re
sist
anto
rgan
ism
;M
RSA
,met
hic
illin
-res
ista
nt
Stap
hylo
cocc
usau
reus
;MSS
A,m
eth
icill
in-s
usc
epti
ble
S.au
reus
;NH
S,N
atio
nal
Hea
lth
Serv
ice;
Ou
tPt,
outp
atie
nt;
PFG
E,p
uls
ed-fi
eld
gele
lect
roph
ores
is;
Pt,
pati
ent;
RN
,n
urs
e;V
RE
,va
nco
myc
in-r
esis
tan
ten
tero
cocc
i;W
C,
whi
teco
at.
This content downloaded from 96.255.251.162 on Tue, 21 Jan 2014 08:49:45 AMAll use subject to JSTOR Terms and Conditions
shea expert guidance: healthcare personnel attire 119
tailing the supervisor’s administrative responsibilities to morespecific consequences for employee noncompliance.
Three institutions recommended clothing (such as color-coded attire) for specific types of caregivers (eg, nurses,nurses’ assistants, etc). Policies specific to clinical personnelwere most frequently related to surgical attire, includingscrubs, use of masks, head covers, and footwear in restrictedand semirestricted areas and surgical suites, and to centralprocessing, as consistent with AORN standards. Scrubs wereuniversally provided by the hospital in these settings. Laun-dering policies clearly indicated that laundering of hospital-provided scrubs was to be performed by the hospital or at ahospital-accredited facility. Use of masks, head covers, foot-wear, and jewelry were generally consistent with AORNstandards.
Excluding surgical attire, only one institution providedguidance specific to physicians, outlining a recommendationfor BBE attire during patient care. This policy specified notto use white coats, neckties, long sleeves, wristwatches, orbracelets. Institutional policies also varied in recommenda-tions for laundering and change of clothing other than forsurgical attire. No specific guidance was issued for other uni-forms, other than cleanliness and absence of visible soiling;however, one institution referred to infection control speci-fications for maintenance of clothing. Guidance regardingfrequency of clothing change was variable for scrubs, fromnonspecific requirements (eg, wearing freshly laundered sur-gical attire on entry to restricted/semirestricted areas) to spe-cific requirements (clean scrubs once per shift to once dailyand if visibly soiled). In addition, most policies included in-structions for HCP to remove scrubs and change into streetclothes either at the end of the shift or when leaving thehospital or connected buildings.
VII. Survey Results
A total of 337 SHEA members and members of the SHEAResearch Network (21.7% response of 1,550 members) re-sponded to the survey regarding their institutions’ policiesfor HCP attire. The majority of respondents worked at hos-pitals (91%); additional facilities included freestanding chil-dren’s hospitals (4%), freestanding clinics (1%), and otherfacility types (5%), such as long-term acute care hospitals,multihospital systems, short-term nursing facilities, and re-habilitation hospitals (rounding of numbers accounts for thesum of percentages being greater than 100). The majority ofresponses were from either university/teaching hospitals(39%) or university/teaching-affiliated hospitals (28%). Wereceived additional responses from nonteaching hospitals(24%), Veterans Affairs hospitals (3%), specialty hospitals(2%), and miscellaneous facilities (4%).
Enforcement of HCP attire policies was low at 11%. Amajority of respondents (65%) felt that the role of HCP attirein the transmission of pathogens within the healthcare settingwas very important or somewhat important.
Only 12% of facilities encouraged short sleeves, and 7%enforced or monitored this policy. Pertaining to white coats,only 5% discouraged their use and, of those that did, 13%enforced or monitored this policy. For watches and jewelry,20% of facilities had a policy encouraging their removal. Amajority of respondents (61%) stated that their facility didnot have policies regarding scrubs, scrub-like uniforms, orwhite coats in nonclinical areas. Thirty-one percent re-sponded that their hospital policy stated that scrubs must beremoved before leaving the hospital, while 13% stated thatscrubs should not be worn in nonclinical areas. Neckties werediscouraged in 8% of facilities, but none monitored or en-forced this policy.
Although 43% of respondents stated that their hospitalsissued scrubs or uniforms, only 36% of facilities actually laun-dered scrubs or uniforms. A small number of hospitals pro-vided any type of guidance on home laundering: 13% pro-vided specific policies regarding home laundering, while 38%did not.
In contrast to other items of HCP attire, half of facilitiesrequired specific types of footwear, and 63% enforced and/or monitored this policy.
discussion
Overall, patients express preferences for certain types of attire,with most surveys indicating a preference for formal attire,including a preference for a white coat. However, patientcomfort, satisfaction, trust, and confidence in their physiciansis unlikely to be affected by the practitioner’s attire choice.The ability to identify a HCP was consistently reported asone of the most important attributes of HCP attire in studies.This was particularly true in studies that evaluated the effectof attire of actual physicians on patient satisfaction in a real-world setting rather than those assessing the influence ofphysician attire on patient satisfaction in the abstract. Patientsgenerally did not perceive white coats, formal attire, or tiesas posing infection risks; however, when informed of potentialrisks associated with certain types of attire, patients werewilling to change their preferences for physician attire.11,18
Data from convenience-sample surveys and prospectivestudies confirm that contamination occurs for all types ofHCP apparel, including scrubs, neckties, and white coats, withpathogens such as S. aureus, MRSA, VRE, and gram-negativebacilli. HCP apparel can hypothetically serve as a vector forpathogen cross-transmission in healthcare settings; however,no clinical data yet exist to define the impact of HCP apparelon transmission. The benefit of institutional laundering ofHCP scrubs versus home laundering for non-OR use remainsunproven. A BBE approach is in effect in the United Kingdomfor inpatient care; this strategy may enhance hand hygieneto the level of the wrist, but its impact on HAI rates remainsunknown.
Hospital policies regarding HCP attire were generally con-sistent in their approach to surgical attire; however, general
This content downloaded from 96.255.251.162 on Tue, 21 Jan 2014 08:49:45 AMAll use subject to JSTOR Terms and Conditions
120 infection control and hospital epidemiology february 2014, vol. 35, no. 2
dress code policies varied from guidance regarding formalattire to use of job-specific uniforms. Laundering and changeof clothing was also not consistently addressed other than forsurgical attire. Finally, accountability for compliance with theattire policies by HCP and supervisors was not routinely in-cluded in the policies.
areas for future research
I. Determine the role played by HCP attire in the horizontaltransmission of nosocomial pathogens and its impact onthe burden of HAIs.
II. Evaluate the impact of antimicrobial fabrics on the bac-terial burden of HCP attire, horizontal transmission ofpathogens, and HAIs. Concomitantly, a cost-benefit anal-ysis should be conducted to determine the financial meritof this approach.
III. Establish the effect of a BBE policy on both the horizontaltransmission of nosocomial pathogens and the incidenceof HAIs.
IV. Explore the behavioral determinants of laundering prac-tices among HCP regarding different apparel and examinepotential interventions to decrease barriers and improvecompliance with laundering.
V. Examine the impact of not wearing white coats on pa-tients’ and colleagues’ perceptions of professionalism onthe basis of HCP variables (eg, gender, age).
VI. Evaluate the impact of compliance with hand hygieneand standard precautions on contamination of HCPapparel.
acknowledgments
Financial support. This study was supported in part by the SHEA ResearchNetwork.
Potential conflicts of interest. G.B. reports receiving grants from Pfizer,Cardinal Health, BioVigil, and Vestagen Technical Textiles. M.E.R. reportsreceiving research grants/contracts from 3M and having an advisory/con-sultant role with 3M, Ariste, Care Fusion, and Molnlycke. All other authorsreport no conflicts of interest relevant to this article.
Address correspondence to Gonzalo Bearman MD, MPH, Virginia Com-monwealth University, Internal Medicine, Richmond, VA 23298 ([email protected]).
references
1. Ardolino A, Williams LA, Crook TB, Taylor HP. Bare below theelbows: what do patients think? J Hosp Infect 2009;71:291–293.
2. Baevsky RH, Fisher AL, Smithline HA, Salzberg MR. The influ-ence of physician attire on patient satisfaction. Acad Emerg Med1998;5:82–84.
3. Bond L, Clamp PJ, Gray K, Van DV. Patients’ perceptions ofdoctors’ clothing: should we really be “bare below the elbow”?J Laryngol Otol 2010;124:963–966.
4. Cha A, Hecht BR, Nelson K, Hopkins MP. Resident physician
attire: does it make a difference to our patients? Am J ObstetGynecol 2004;190:1484–1488.
5. Ditchburne I. Should doctors wear ties? J Hosp Infect 2006;63:227–228.
6. Fischer RL, Hansen CE, Hunter RL, Veloski JJ. Does physicianattire influence patient satisfaction in an outpatient obstetricsand gynecology setting? Am J Obstet Gynecol 2007;196:186e.1–186e.5.
7. Gallagher J, Waldron LF, Stack J, Barragry J. Dress and address:patient preferences regarding doctor’s style of dress and patientinteraction. Ir Med J 2008;101:211–213.
8. Gherardi G, Cameron J, West A, Crossley M. Are we dressed toimpress? a descriptive survey assessing patients’ preference ofdoctors’ attire in the hospital setting. Clin Med 2009;9:519–524.
9. Gonzalez del Rey JA, Paul RI. Preferences of parents for pediatricemergency physicians’ attire. Pediatr Emerg Care 1995;11:361–364.
10. Hennessy N, Harrison DA, Aitkenhead AR. The effect of theanaesthetist’s attire on patient attitudes: the influence of dresson patient perception of the anaesthetist’s prestige. Anaesthesia1993;48:219–222.
11. Hueston WJ, Carek SM. Patients’ preference for physician attire:a survey of patients in family medicine training practices. FamMed 2011;43:643–647.
12. Ikusaka M, Kamegai M, Sunaga T, et al. Patients’ attitude towardconsultations by a physician without a white coat in Japan. InternMed 1999;38:533–536.
13. Li SF, Haber M. Patient attitudes toward emergency physicianattire. J Emerg Med 2005;29:1–3.
14. Major K, Hayase Y, Balderrama D, Lefor AT. Attitudes regardingsurgeons’ attire. Am J Surg 2005;190:103–106.
15. Matsui D, Cho M, Rieder MJ. Physicians’ attire as perceived byyoung children and their parents: the myth of the white coatsyndrome. Pediatr Emerg Care 1998;14:198–201.
16. McKinstry B, Wang JX. Putting on the style: what patients thinkof the way their doctor dresses. Br J Gen Pract 1991;41:270, 275–278.
17. Mistry D, Tahmassebi JF. Children’s and parents’ attitudes to-wards dentists’ attire. Eur Arch Paediatr Dent 2009;10:237–240.
18. Monkhouse SJ, Collis SA, Dunn JJ, Bunni J. Patients’ attitudesto surgical dress: a descriptive study in a district general hospital.J Hosp Infect 2008;69:408–409.
19. Nair BR, Attia JR, Mears SR, Hitchcock KI. Evidence-basedphysicians’ dressing: a crossover trial. Med J Aust 2002;177:681–682.
20. Niederhauser A, Turner MD, Chauhan SP, Magann EF, MorrisonJC. Physician attire in the military setting: does it make a dif-ference to our patients? Mil Med 2009;174:817–820.
21. Palazzo S, Hocken DB. Patients’ perspectives on how doctorsdress. J Hosp Infect 2010;74:30–34.
22. Rehman SU, Nietert PJ, Cope DW, Kilpatrick AO. What to weartoday? effect of doctor’s attire on the trust and confidence ofpatients. Am J Med 2005;118:1279–1286.
23. Shelton CL, Raistrick C, Warburton K, Siddiqui KH. Canchanges in clinical attire reduce likelihood of cross-infectionwithout jeopardising the doctor-patient relationship? J Hosp In-fect 2010;74:22–29.
24. Baxter JA, Dale O, Morritt A, Pollock JC. Bare below the elbows:professionalism vs infection risk. Bull R Coll Surg Engl 2010;92:248–251.
This content downloaded from 96.255.251.162 on Tue, 21 Jan 2014 08:49:45 AMAll use subject to JSTOR Terms and Conditions
shea expert guidance: healthcare personnel attire 121
25. Toquero L, Abournarzouk O, Owers C, Chiang R, ThiagarajahS, Amin S. Bare below the elbows—the patient’s perspective.WebmedCentral Qual Patient Saf 2011;2:WMC001401.
26. Garvin K, Ali F, Neradelik M, Pottinger P. Attitudes regardingthe safety of healthcare provider attire. Presented at IDWeek,October 8–12, 2012, Philadelphia, PA. Poster 455.
27. Munoz-Price LS, Arheart KL, Lubarsky DA, Birnbach DJ. Dif-ferential laundering practices of white coats and scrubs amonghealth care professionals. Am J Infect Control 2013;41:565–567.
28. Burden M, Cervantes L, Weed D, Keniston A, Price CS, AlbertRK. Newly cleaned physician uniforms and infrequently washedwhite coats have similar rates of bacterial contamination afteran 8-hour workday: a randomized controlled trial. J Hosp Med2011;6:177–182.
29. Gaspard P, Eschbach E, Gunther D, Gayet S, Bertrand X, TalonD. Meticillin-resistant Staphylococcus aureus contamination ofhealthcare workers’ uniforms in long-term care facilities. J HospInfect 2009;71:170–175.
30. Loh W, Ng VV, Holton J. Bacterial flora on the white coats ofmedical students. J Hosp Infect 2000;45:65–68.
31. Lopez PJ, Ron O, Parthasarathy P, Soothill J, Spitz L. Bacterialcounts from hospital doctors’ ties are higher than those fromshirts. Am J Infect Control 2009;37:79–80.
32. Morgan DJ, Rogawski E, Thom KA, et al. Transfer of multidrug-resistant bacteria to healthcare workers’ gloves and gowns afterpatient contact increases with environmental contamination.Crit Care Med 2012;40:1045–1051.
33. Perry C, Marshall R, Jones E. Bacterial contamination of uni-forms. J Hosp Infect 2001;48:238–241.
34. Treakle AM, Thom KA, Furuno JP, Strauss SM, Harris AD,Perencevich EN. Bacterial contamination of health care workers’white coats. Am J Infect Control 2009;37:101–105.
35. Wong D, Nye K, Hollis P. Microbial flora on doctors’ whitecoats. BMJ 1991;303:1602–1604.
36. Bearman GM, Rosato A, Elam K, et al. A crossover trial ofantimicrobial scrubs to reduce methicillin-resistant Staphylo-coccus aureus burden on healthcare worker apparel. Infect Con-trol Hosp Epidemiol 2012;33:268–275.
37. Steinlechner C, Wilding G, Cumberland N. Microbes on ties:do they correlate with wound infection? Bull R Coll Surg Engl2002:84:307–309.
38. Wiener-Well Y, Galuty M, Rudensky B, Schlesinger Y, Attias D,Yinnon AM. Nursing and physician attire as possible source ofnosocomial infections. Am J Infect Control 2011;39:555–559.
39. Munoz-Price LS, Arheart KL, Mills JP, et al. Associations be-tween bacterial contamination of health care workers’ handsand contamination of white coats and scrubs. Am J Infect Control2012;40:e245–e248.
40. Burger A, Wijewardena C, Clayson S, Greatorex RA. Bare belowelbows: does this policy affect handwashing efficacy and reducebacterial colonisation? Ann R Coll Surg Engl 2011;93:13–16.
41. Willis-Owen CA, Subramanian P, Kumari P, Houlihan-BurneD. Effects of “bare below the elbows” policy on hand contam-ination of 92 hospital doctors in a district general hospital. JHosp Infect 2010;75:116–119.
42. Farrington RM, Rabindran J, Crocker G, Ali R, Pollard N, Dal-ton HR. “Bare below the elbows” and quality of hand washing:a randomised comparison study. J Hosp Infect 2010;74:86–88.
43. Jacob G. Uniforms and Workwear: An Evidence Base for Devel-oping Local Policy. National Health Service Department ofHealth Policy, 2007.
44. Blaser MJ, Smith PF, Cody HJ, Wang WL, LaForce FM. Killingof fabric-associated bacteria in hospital laundry by low-tem-perature washing. J Infect Dis 1984;149:48–57.
45. Patel SN, Murray-Leonard J, Wilson AP. Laundering of hospitalstaff uniforms at home. J Hosp Infect 2006;62:89–93.
46. Lakdawala N, Pham J, Shah M, Holton J. Effectiveness of low-temperature domestic laundry on the decontamination ofhealthcare workers’ uniforms. Infect Control Hosp Epidemiol2011;32:1103–1108.
47. Occupational Safety and Health Administration BloodbornePathogens Standard, 29 CFR 1910.1030 (2013).
48. Yoshikawa T, Kidouchi K, Kimura S, Okubo T, Perry J, JaggerJ. Needlestick injuries to the feet of Japanese healthcare workers:a culture-specific exposure risk. Infect Control Hosp Epidemiol2007;28:215–218.
49. Chiu MC, Wang MJ. Professional footwear evaluation for clin-ical nurses. Appl Ergon 2007;38:133–141.
50. Blanchard J. Wearing shoe covers and appropriate footwear inthe OR. AORN J 2010;92:228–229.
51. Barr J, Siegel D. Dangers of dermatologic surgery: protect yourfeet. Dermatol Surg 2004;30:1495–1497.
52. Watt AM, Patkin M, Sinnott MJ, Black RJ, Maddern GJ. Scalpelsafety in the operative setting: a systematic review. Surgery 2010;147:98–106.
53. Munoz-Price LS, Birnbach DJ, Lubarsky DA, et al. Decreasingoperating room environmental pathogen contaminationthrough improved cleaning practice. Infect Control Hosp Epi-demiol 2012;33:897–904.
54. Wright SN, Gerry JS, Busowski MT, et al. Gordonia bronchialissternal wound infection in 3 patients following open heart sur-gery: intraoperative transmission from a healthcare worker. In-fect Control Hosp Epidemiol 2012;33:1238–1241.
55. Uneke CJ, Ijeoma PA. The potential for nosocomial infectiontransmission by white coats used by physicians in Nigeria: im-plications for improved patient-safety initiatives. World HealthPopul 2010;11:44–54.
56. Banu A, Anand M, Nagi N. White coats as a vehicle for bacterialdissemination. J Clin Diagn Res 2012;6:1381–1384.
57. Priya H, Acharya S, Bhat M, Ballal M. Microbial contaminationof the white coats of dental staff in the clinical setting. J DentRes Dent Clin Dent Prospects 2009;3:136–140.
58. Scott E, Bloomfield SF. The survival and transfer of microbialcontamination via cloths, hands and utensils. J Appl Bacteriol1990;68:271–278.
59. Wilson JA, Loveday HP, Hoffman PN, Pratt RJ. Uniform: anevidence review of the microbiological significance of uniformsand uniform policy in the prevention and control of healthcare-associated infections. Report to the Department of Health (En-gland). J Hosp Infect 2007;66:301–307.
This content downloaded from 96.255.251.162 on Tue, 21 Jan 2014 08:49:45 AMAll use subject to JSTOR Terms and Conditions