Healthcare personnel (HCP) attire is embedded in the culture and tradition of the medical profession. Could attire – uniforms, scrubs, white coats – be a fomite involved in the cross-transmission of MRSA, VRE, other MDROs, and the constellation of pathogenic or non-pathogenic organisms? Except for a short period of time when some facilities had staff bring their OR scrubs home to wash, most OR scrubs are laundered by an outsourced laundry so that water temperature, detergent, and drying temperature can be controlled. The question that is now getting more scrutiny: What about staff outside of the OR? Should they continue to take their uniforms and white coats home to wash?
There have been multiple articles published concerning contamination of HCP’s uniforms and white coats. For example, a study from the United Kingdom found that 44% of nurses washed their uniforms below the UK’s recommended temperature.1 In their efforts to prevent healthcare-associated infections (HAIs), the UK prohibits long sleeves, wristwatches, jewelry, and white coats. One survey2 showed that nonsurgical providers laundered their scrubs every 1.7 ± 0.1 days (mean ± standard error) compared with white coats, which were laundered every 12.4 ± 1.1 days (P < .001); however, the reasons for this behavior difference remain unclear. Another aspect of this dilemma is public perception. Patients do not prefer to see clinical staff wearing their uniforms in the park, supermarket, or on public transportation, then also at the bedside. Patients want HCP to have a professional appearance.
The causes of HAIs are multi-factorial. To determine if contaminated clothing contributes to an HAI is a daunting theory to prove. To date, there is no definitive information to implicate attire in the transmission of infection.
To assist healthcare organizations, the Society for Healthcare Epidemiology of America (SHEA), published Expert Guidance on this issue.3 Recommendations made by the workgroup include:
- Bare below the elbows (BBE) - short sleeves and no wristwatch or jewelry.
- Provide hooks for white coats outside of patients’ rooms.
- Secure neckties, if worn, by a white coat or other means.
- Laundering frequency: apparel worn at the bedside that comes into contact with the patient or environment should be laundered daily. White coats worn during patient care should be laundered no less frequently than once a week and when visibly soiled.
- Data from various studies show that HCP apparel is contaminated with multiple pathogenic and non-pathogenic organisms.4 Hypothetically, apparel could serve as a vector for cross-transmission but there is no clinical data to establish that HCP apparel is implicated in the transmission of organisms to patients.
As food for thought: Why do we wear gowns when entering the room of a patient in contact precautions? Perhaps we need to be more consistent, as Dr. Mike Edmond states in his “Controversies in Hospital Prevention” blog.5 Healthcare institutions could also offer guidance on home laundering, such as water temperature and washing work clothes separately but monitoring compliance of home laundering would be difficult Until there is more evidence to establish an association between HCP attire and HAIs, hospitals and infection preventionists should review their policies, procedures, and the SHEA guidelines to determine if recommended approaches have been incorporated into their own practice.
Do you feel your facility’s policies or protocols for home laundering of HCP attired are sufficient? Why or why not?
- Riley K, Laird K, Williams J (2015). Washing uniforms at home: adherence to hospital policy. Nursing Standard. 29, 25, 37−43.A
- Munoz-Price LS, Arheart KL, Lubarsky DA, Birnbach DJ. Differential laundering practices of white coats and scrubs among health care professionals. Am J Infect Control 2013;41:565–567.
- Bearman G, Bryant K, Leekha S, Mayer J, Munoz-Price LS, Murthy R, Palmore T, Rupp ME, White J. SHEA Expert Guidance: Healthcare Personnel Attire in Non-Operating Room Settings. Infect Control Hosp Epidemiol 2014; 35(2):107-121.
- Treakle AM, Thom KA, Furuno JP, Strauss SM, Harris AD, Perencevich EN. Bacterial contamination of healthcare workers’ white coats. Am J Infect Control 2009;37:101-105.
- Controversies in Hospital Infection Prevention. Retrieved from the Internet July 7, 2015. http://haicontroversies.blogspot.com/2015/07/the-white-coat-debate-continues-on-and.html