It’s Time to Hang Up the White Coat!

Michael Edmond, MD, MPH, MPA
Richard P. Wenzel Professor of Internal Medicine │ Hosp...
Goals
• To raise awareness of
the role of clothing in
the transmission of
pathogens in the
healthcare setting
• To examine...
The patient-provider encounter
• Common points of physical contact
– Hands/
wrists
– Sleeves
– Stethoscope
– Wristwatch
Contact precautions
• Patients with epidemiologically important organisms:
– Placed in a private room or cohorted with ano...
Bare below the elbows:

How it began
• In January 2008, the UK’s NHS mandated
measures to decrease MRSA & C. difficile in ...
Bare below the elbows
• Short sleeves
• No wrist watch
• No jewelry except
wedding band
• No neck ties
• No white coats
• ...
Postulated role of white coats in the
transmission of pathogens
Patients’ skin & environment are
contaminated with pathoge...
Contamination in the clinical setting:

Neckties

Study
Ditchburn I
2006

Nurkin S
2005

Lopez PJ
2009

Pathogen

N

% pos...
Contamination in the clinical setting:

White coats

Study

Pathogen

N

% positive

Wong D

S. aureus

100

29

Loh W

S....
Contamination in the clinical setting:

Scrubs & Uniforms

Study

Pathogen

N

% positive

Perry C
2001

MRSA
VRE

57

14
...
Survival of Pathogens on Fabric
Length of survival (days)
Organism

Cotton

Polyester

S. aureus (methicillin S)

4, 5, 19...
White coats & scrubs:

Frequency of laundering
Mean frequency (days)

N=160

Munoz-Price LS et al. Am J Infect Control 201...
White coat:

Frequency of laundering
Survey of 183 attending
physicians, housestaff
and medical students

Pellerin J, Edmo...
Transfer of pathogens from white coat to skin
Number of organisms inoculated onto lab coat
Time
(min)

103

102

+

+

–

...
Experimental transmission of bacteria
to patients
•
•
•

Clothing was inoculated with Micrococcus (distal tie or
correspon...
Summary of evidence:

White coats & the cycle of transmission
Component

Strength of evidence

Pathogens contaminate patie...
When is biologic plausibility enough to
support a change in practice?
• Potential for benefit
• No risk for harm
• Minimal...
The action threshold
• The action threshold is the probability
of an outcome at which it makes
sense to undertake an inter...
Parachute use to prevent death and major
trauma related to skydiving
•
•
•
•
•

Objective: To determine whether parachutes...
Conventional wisdom:
The paradox
• On the basis of the same evidence:
– We are willing to wrap ourselves in plastic &
rest...
Origin of the white coat
Late 1800s:
Earliest use was in the
operating room

Instruction in Surgery: Scene in the
Operatin...
Functions of the white Coat
•
•
•
•
•

Storage
Protects clothing
Identification
Warmth
Symbolism
The White Coat as Symbol
•
•
•
•
•
•
•

Purity
Cleanliness
Superhuman power
Candor
Trust
Integrity
Goodness

Blumhagen DW....
Reasons for wearing a white coat
Warmth
12%

N = 160
Munoz-Price LS et al. Am J Infect Control 2013;41:565-7.
White coat
as vector?
Percentage of
respondents who
believe the white
coat can transmit
pathogens

Pellerin J, Edmond MB e...
Surveys of patient attitudes
regarding physician attire
Which doctor would you prefer?

• Graduated near the bottom
of his class
• Failed board certification
exam on first attemp...
Patient preference studies
Site

Setting

N

Findings

UK

ENT clinic

93

• 49% preferred shirt & tie
• 40% preferred scr...
Flaws in many studies of patient
attitudes regarding physician attire
• Lack external validity
– Mostly small, single cent...
Patient preferences for physician attire:

Impact of education



Before & after survey of 50 randomly selected
surgical...
Patient preferences for physician attire:

Randomized studies of actual encounters
Method

Findings

Conclusion

596 patie...
“I have had the good fortune to encounter a wide and
rich spectrum of opinions from patients, friends,
and colleagues on t...
Differences between humanism &
professionalism
Characteristic

Humanism

Professionalism

Types of problems

Universal

Lo...
Humanism

•Courage
•Loyalty
•Patience
•Humility

Professionalism

•Empathy
•Compassion
•Respect
•Integrity

• Appropriate ...
The White Coat Ceremony
“We do not need to teach students how
to put on their white coats, but how to
take them off. Rathe...
What do patients want from their doctors?
Observations from both ends of the stethoscope

• Competency
• Access
– Undivide...
VCU Medical
Center Infection
Control Committee
recommended (but
did not mandate) a
bare below the
elbow approach in
the in...
Scaling back contact precautions
• Patients colonized or infected with
MRSA or VRE are placed on contact
precautions only ...
Preliminary findings 6 months after
discontinuing contact precautions for
MRSA & VRE
• Institution-wide surveillance (~850...
Summary:

Clothing & pathogen transmission
• Clothing has the potential to transmit pathogens
• The white coat serves the ...
Follow our
blog!
On the web:
www.stopinfections.org
OR
On Facebook:
hospital.infection
OR
On Twitter:
@eliowa
@mike_edmond
Clothing and infection control (nj talk)
Clothing and infection control (nj talk)
Clothing and infection control (nj talk)
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Clothing and infection control (nj talk)

  1. 1. It’s Time to Hang Up the White Coat! Michael Edmond, MD, MPH, MPA Richard P. Wenzel Professor of Internal Medicine │ Hospital Epidemiologist
  2. 2. Goals • To raise awareness of the role of clothing in the transmission of pathogens in the healthcare setting • To examine the conflict between optimal infection prevention and professional values with regard to clothing
  3. 3. The patient-provider encounter • Common points of physical contact – Hands/ wrists – Sleeves – Stethoscope – Wristwatch
  4. 4. Contact precautions • Patients with epidemiologically important organisms: – Placed in a private room or cohorted with another patient infected or colonized with the same organism – All persons don gowns & gloves on entry to the room • Based on the evidence that clothing can become contaminated & the assumption that pathogens on contaminated clothing can be transmitted to patients
  5. 5. Bare below the elbows: How it began • In January 2008, the UK’s NHS mandated measures to decrease MRSA & C. difficile in the healthcare setting – Public reporting by hospitals on: • compliance with infection control & cleanliness standards • all MRSA BSIs & C. difficile cases – Greater use of single rooms, cohort nursing & better management of isolated patients – Extension of the hand hygiene campaign to the outpatient setting – Bare below the elbows
  6. 6. Bare below the elbows • Short sleeves • No wrist watch • No jewelry except wedding band • No neck ties • No white coats • Intent: allow good hand/wrist washing, & avoid contamination of sleeve cuffs
  7. 7. Postulated role of white coats in the transmission of pathogens Patients’ skin & environment are contaminated with pathogens White coat becomes contaminated via contact with patient or environment + infrequent laundering Pathogens are transmitted from the white coat to a subsequent patient
  8. 8. Contamination in the clinical setting: Neckties Study Ditchburn I 2006 Nurkin S 2005 Lopez PJ 2009 Pathogen N % positive S. aureus 40 20 S. aureus Gram-negative rod Aspergillus spp 42 42 42 29 12 2 S. aureus 50 26
  9. 9. Contamination in the clinical setting: White coats Study Pathogen N % positive Wong D S. aureus 100 29 Loh W S. aureus Acinetobacter 100 5 7 Osawa K MRSA 14 79 Treakle AM S. aureus 149 23 Uneke CJ S. aureus Ps. aeruginosa 103 19 10 22 32 32 5 1991 2000 2003 2008 2010 S. aureus Munoz-Price LS Acinetobacter 2012 Enterococcus
  10. 10. Contamination in the clinical setting: Scrubs & Uniforms Study Pathogen N % positive Perry C 2001 MRSA VRE 57 14 38 Munoz-Price LS 2012 S. aureus Acinetobacter Enterococcus 97 11 11 3 Krueger CA 2012 S. aureus 268 33
  11. 11. Survival of Pathogens on Fabric Length of survival (days) Organism Cotton Polyester S. aureus (methicillin S) 4, 5, 19 10, 12, 56 S. aureus (methicillin R) 4, 5, 21 1, 16, 40 E. faecalis (vancomycin S) 11, 33 >90, >90 E. faecalis (vancomycin R) 18, 22 73, 80 E. faecium (vancomycin S) 22, 90 43, >90 E. faecium (vancomycin R) 62, >90 >80, >80 C. albicans 1, 3 1, 1 C. parapsilosis 9, 27 27, >30 1, 10, >30 1, 7, 30 A. fumigatus Neely AN, Orloff MM. J Clin Microbiol 2001; 39:3360-3361. Neely AN, Maley MP. J Clin Microbiol 2000;38:724-726.
  12. 12. White coats & scrubs: Frequency of laundering Mean frequency (days) N=160 Munoz-Price LS et al. Am J Infect Control 2013;41:565-7.
  13. 13. White coat: Frequency of laundering Survey of 183 attending physicians, housestaff and medical students Pellerin J, Edmond MB et al. Unpublished data, 2013.
  14. 14. Transfer of pathogens from white coat to skin Number of organisms inoculated onto lab coat Time (min) 103 102 + + – – – 5 + + – – – + + – – – 1 + + – – – 5 + + – – – 30 + + – – – 1 + + – – – 5 + + – – – 30 PRA 104 30 VRE 105 1 MRSA 106 + + + – – + = organism transferred from coat to skin Butler D, Edmond M. J Hosp Infect 2010;75:137-138.
  15. 15. Experimental transmission of bacteria to patients • • • Clothing was inoculated with Micrococcus (distal tie or corresponding area on shirt, cuffs of long and short sleeves) Standardized 2.5 minute exam was performed on a mannequin Mannequin cultured Mannequins contaminated With tie Without tie Long sleeve 4/5 1/5 Short sleeve 2/5 0/5 Tie vs. no tie: p = 0.036 Long sleeve vs short sleeve: p > 0.05 Weber RL et al. J Hosp Infection 2012:80:252-254.
  16. 16. Summary of evidence: White coats & the cycle of transmission Component Strength of evidence Pathogens contaminate patients’ skin & the environment Conclusive White coats become contaminated with pathogens Conclusive White coats can transmit pathogens Some in vitro evidence Removal of white coats reduces infection rates No evidence to date Biologic plausibility
  17. 17. When is biologic plausibility enough to support a change in practice? • Potential for benefit • No risk for harm • Minimal cost But without strong evidence for benefit, we should recommend, not mandate, the new practice
  18. 18. The action threshold • The action threshold is the probability of an outcome at which it makes sense to undertake an intervention OR how sure to you need to be? • AT = harm / improvement Antibiotics for strep pharyngitis 0% Gross R. Making Medical Decisions, 1999:45-51. Cancer chemotherapy 100%
  19. 19. Parachute use to prevent death and major trauma related to skydiving • • • • • Objective: To determine whether parachutes are effective in preventing major trauma related to gravitational challenge. Design: Systematic review of randomized controlled trials (RCTs). Main outcome measure: Death or major trauma. Results: We were unable to identify any randomized controlled trials of parachute intervention. Conclusions: As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using RCTs. Advocates of evidence based medicine have criticized the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organized and participated in a double blind, randomized, placebo controlled, crossover trial of the parachute. Smith GCS, Pell JP. BMJ 2003;327:1459-1461.
  20. 20. Conventional wisdom: The paradox • On the basis of the same evidence: – We are willing to wrap ourselves in plastic & restrict patients to their hospital room (contact precautions) – We are not willing to eliminate white coats & ties
  21. 21. Origin of the white coat Late 1800s: Earliest use was in the operating room Instruction in Surgery: Scene in the Operating Room Amphitheater of the Massachusetts General Hospital, Boston, 1888. Early 1900s: Physicians began to wear white coats outside the OR to reinforce the stereotype of physicians as scientists Howard Kelly, MD Professor of Gynecology, Johns Hopkins Hospital, 1920
  22. 22. Functions of the white Coat • • • • • Storage Protects clothing Identification Warmth Symbolism
  23. 23. The White Coat as Symbol • • • • • • • Purity Cleanliness Superhuman power Candor Trust Integrity Goodness Blumhagen DW. Ann Intern Med 1979;91:111-6. Wear D. Ann Intern Med 1998;129:734-7. Flannery MC. Thyroid 2001;11:947-51. Russell PC. Teach Learn Med 2002;14:56-9. • Hierarchy & authority • Control • Social & economic privilege • Inclusion in an elite community • Separation from the mass of society because of superior knowledge & thinking skills
  24. 24. Reasons for wearing a white coat Warmth 12% N = 160 Munoz-Price LS et al. Am J Infect Control 2013;41:565-7.
  25. 25. White coat as vector? Percentage of respondents who believe the white coat can transmit pathogens Pellerin J, Edmond MB et al. Unpublished data, 2013.
  26. 26. Surveys of patient attitudes regarding physician attire
  27. 27. Which doctor would you prefer? • Graduated near the bottom of his class • Failed board certification exam on first attempt • Has difficulties with communication • Several nurses & medical students have filed complaints against him for dehumanizing comments • Graduated near the top of his class • Scored at the 95th percentile on board certification exam • Numerous patients have written letters to hospital administration regarding his kind demeanor & exceptional availability
  28. 28. Patient preference studies Site Setting N Findings UK ENT clinic 93 • 49% preferred shirt & tie • 40% preferred scrubs • 11% preferred open collared shirt, sleeves UK ENT clinic 100 • 76% preferred no tie • 63% preferred no white coat Virginia OB-GYN clinic 328 • 61% preferred scrubs • 86% preferred no white coat or didn’t matter UK 75 Inpatients • 82% felt doctors should not be expected to wear ties • 75% felt doctors should not wear white coats • 83% felt scrubs acceptable Hathorn IF et al. Clinical Otolaryngology 2008;33:505-506. Pothier DD et al. British Medical Journal 2007;335:684-b. Neiderhauser A et al. Military Medicine 2009;174:817-820. Palazzo S, Hocken DB. J Hosp Infect 2010;74:30-34.
  29. 29. Flaws in many studies of patient attitudes regarding physician attire • Lack external validity – Mostly small, single center studies • Confounding – Age – Geography/culture – Socioeconomic factors • Bias – Infer professionalism on the basis of attire – Underestimate how patients choose their doctors – Ignore context
  30. 30. Patient preferences for physician attire: Impact of education   Before & after survey of 50 randomly selected surgical inpatients in a British hospital Intervention: patients were given evidence-based information on contamination of clothing Initial Response (%) After intervention (%) Traditional (tie, white coat) 52 22 Scrubs 24 62 No preference 24 8 Unsure 0 8 Monkhouse SJW. J Hosp Infect 2008;69:408-409.
  31. 31. Patient preferences for physician attire: Randomized studies of actual encounters Method Findings Conclusion 596 patients Emergency Dept. Half of patients cared for by MD in white coat + shirt/tie or blouse/slacks vs. half cared for by MD in white coat + scrubs No significant difference between the groups on 6 questions assessing satisfaction with care Post-visit interview: 70% 110 patients disapproved of jeans, 67% tennis shoes; no significant Pre-op visit by anesthesiologist difference b/w 2 groups with regard to selection of Half seen by MD in suit & tie descriptors denoting vs. half seen by MD in jeans, open collar shirt & tennis shoes professionalism or approachability Baevsky RH et al. Acad Emerg Med 1998;5:82-84. Hennessy N. Anaesthesia 1993; 48:219-222. No relationship between appearance & satisfaction
  32. 32. “I have had the good fortune to encounter a wide and rich spectrum of opinions from patients, friends, and colleagues on the matter of proper physician Matt Bianchi, MD, PhD attire, perhaps encouraged by my absent white coat, absent necktie, shaved head, bilateral black hoop earrings, and tattoos covering approximately 17% of my skin (according to the Lund-Browder burn chart). With only one exception (a mildly demented man in heart failure), every one of the uncommon suggestions to upgrade my appearance for the sake of patient care has come from a physician colleague. In contrast, there have been countless moments of connection with patients who confided that some aspect of my appearance made them feel more comfortable… One can only hope that each doctor-patient interaction affords the participants the chance to transcend the cursory impressions of attire and engage in the “real” work of medicine, the alleviation of suffering and the healing potential of a positive, productive relationship.” Bianchi MT. J Gen Int Med 2008;23:641-3.
  33. 33. Differences between humanism & professionalism Characteristic Humanism Professionalism Types of problems Universal Local Sources of learning Human experience Socialization into profession Motivation Human welfare Strengthening of professional identity Primary duty To other humans; to society To the professional group Cognitive basis Postconventional thinking: judging behavior through deliberation about universal values Conventional thinking: judging behavior by comparison with the accepted social norms of a specific group Outcome Links physicians to patients Separates physicians from patients Modified from: Goldberg JL. Academic Medicine 2008;83:715-722.
  34. 34. Humanism •Courage •Loyalty •Patience •Humility Professionalism •Empathy •Compassion •Respect •Integrity • Appropriate dress • Demeanor • Language • Habits • Touching strangers • Blend clinical care with teaching • Envision medicine as a science • Protection of the autonomy & integrity of the profession Adapted from: Goldberg JL. Acad Med 2008; 83:715-722.
  35. 35. The White Coat Ceremony “We do not need to teach students how to put on their white coats, but how to take them off. Rather than cloak the students in the coats of the elite, I would borrow a scene from the 1991 film The Doctor and dress students in the common garb of human frailty: a hospital gown. Vulnerable and slightly exposed, they could stand in front of a crowd that only slightly outnumbers the daily census of an average hospital room and pledge never to forget how unforgiving medical care can be stripping patients down to their bare humanity. Perhaps students would thus embark on their medical education with a reminder of what they share with their patients rather than what sets them apart.” Goldberg JL. Acad Med 2008; 83:715-722.
  36. 36. What do patients want from their doctors? Observations from both ends of the stethoscope • Competency • Access – Undivided attention & active listening during the encounter – Ability to contact the doctor readily & to be seen quickly when necessary • Interest in them as patients and people
  37. 37. VCU Medical Center Infection Control Committee recommended (but did not mandate) a bare below the elbow approach in the inpatient setting, 1/09
  38. 38. Scaling back contact precautions • Patients colonized or infected with MRSA or VRE are placed on contact precautions only under the following conditions: – Outbreak situation – Wound drainage that is not contained within a dressing – Uncontained respiratory secretions
  39. 39. Preliminary findings 6 months after discontinuing contact precautions for MRSA & VRE • Institution-wide surveillance (~850 beds) for all device associated infections: MRSA VRE Device days CLABSI 1 2* 19,160 CAUTI 0 0 11,807 Possible/probable VAP 0 0 3,431 TOTAL 1 2* 34,848 *both VRE infections were met criteria for mucosal barrier injury BSI
  40. 40. Summary: Clothing & pathogen transmission • Clothing has the potential to transmit pathogens • The white coat serves the doctor & the profession to a much greater extent than the patient – Vestigial article of clothing that is neither necessary nor sufficient for good patient care • Maximizing patient safety should trump concerns for “professional” appearance • SHEA guidance document on healthcare worker attire is in press
  41. 41. Follow our blog! On the web: www.stopinfections.org OR On Facebook: hospital.infection OR On Twitter: @eliowa @mike_edmond

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