Why are hospital staff wearing uniforms, scrubs and white coats in public?

by Carolyn Thomas

One of our big hospitals is around the corner from my local grocery store. This location is handy for hospital staff, who can pop in for groceries on their way home from a long shift. And it also makes it über-creepy for those of us who watch them leaning over the produce bins while still wearing the same bacteria-laden scrubs, white coats or uniforms they’ve been wearing at work.

Here’s why I get the heebie-jeebies at this sight.  John Gever, Senior Editor at MedPage Today, has reported recently on a study* suggesting that more than 60% of physicians’ coats and nurses’ uniforms sampled tested positive for disease-causing bacteria, including antibiotic-resistant Staphylococcus aureus. 

A research team led by Dr. Yonit Wiener-Well found that for 63% of the physicians and nurses studied, at least one spot sampled on their outer clothing carried pathogenic bacteria. Their study was published in the September 2011 issue of the American Journal of Infection Control. These researchers were following up previous studies that had also found bacterial contamination on a variety of clothing articles worn by physicians, nurses, and other health care workers.

Here’s where the study’s findings soar decidedly higher on the Cringe Scale: just under 60% of participants said their garments were fresh that day, whereas 18% admitted that they hadn’t been changed in four or more days – and most of this group were physicians’ white coats.

Nearly one-quarter of participants rated their own clothing as “not clean”.

Antibiotic-resistant strains of bacteria were found in 6% of the physician samples and 14% of those taken from nurses’ clothing.

Acinetobacter species were the most common pathogens found, identified in 37% of samples. Others included S. aureus (13%), enterobacteria (8%) and Pseudomonas and Acinetobacter species.

Similar rates of pathogen contamination were seen in scrubs, white coats, and uniforms. The researchers also tested specifically for antibiotic-resistant species including the so-called ‘super bug’ MRSA, vancomycin-resistant enterococci, extended spectrum beta-lactamase producing enterobacteria, meropenem-resistant Acinetobacter, and Pseudomomas resisting gentamicin, ciprofloxacin, and ceftazidime.

Uniforms worn in the hospital wards were sampled at the middle abdomen and either at the sleeve end or, for short-sleeved garments, the side pockets. Operating room scrub suits were sampled at the abdominal site because they lacked sleeves and pockets. In addition, four unworn uniforms straight from the hospital laundry were sampled as controls. (No pathogens were found on the unworn freshly-laundered control uniforms).

The spectre of bug-infested clothing worn by health care professionals is not new.  Back in 2000, researchers at Shriners Hospitals for Children in Cincinnati and the University of Cincinnati found that the superbug MRSA and vancomycin-resistant enterococci (VRE), survived up to 90 days on hospital uniforms and other fabrics found in the hospital.

And in 2006, a British Medical Journal article warned doctors to ditch disease-ridden neckties during their hospital rounds because, according to the British Medical Association, the dangling neckties can spread disease. At that time, the BMA issued guidelines on how best to reduce hospital infections due to germ-laden items worn by medical staff.

The Canadian Medical Association Journal reported earlier this year that The Ottawa Hospital had declared:

“Hospital staff are required to don their scrubs and lab coats whenever they enter the hospital, and take them off when they leave, even for a quick trip to the convenience store. This strengthens the quality of patients’ interactions with staff, improves infection control, and ensures that The Ottawa Hospital will continue to portray a professional image.”

The CMA Journal added:

“Such safety concerns appear justified in the wake of studies that have demonstrated that hospital attire may place patients at risk of infections.

“Over the past decade, research has shown that C. difficile and Methicillin-resistant Staphylococcus aureus (MRSA), two common culprits behind hospital-acquired infections, may be transmitted to patients via lab coats and nurses’ uniforms.

“The evidence, though not conclusive, helped lead to measures in the United Kingdom that eliminate dangling bits of clothing, such as neckties, as well as jewelry.” (J Hosp Infect 2007;4:301–07)

Ah, those words “not conclusive” may be at the heart of what some critics call a hysterical reaction to those nasty bugs on hospital uniforms. In other words, although these bacteria do indeed sound sickening, are they actually making us sick?

Another study in the same issue of the American Journal of Infection Control noted, for example, that our pets are also a potentially “important community reservoir” of pathogenic bacteria – as are public telephones, towels, escalator and public transit stairway handrails, mall food court tables, toy stores, fitting rooms, makeup samples, and ATM keypads.

Why zero in on dirty hospital uniforms, scrubs and white coats when we should be going nuts over other potentially dangerous infection sites out there?

That’s where Dr. Julia Hallisy of San Francisco has stepped into the fray.  In April, she told William Heisel at Reporting On Health:

“We know that scrubs can carry harmful pathogens. No one has effectively gathered enough data to show how scrubs contribute to infection rates.

“Here’s what we do know. We know that transmission modes are far more prevalent than previously understood. Because of decades of pathogens travelling along these routes and spreading throughout the larger community, pathogens that used to be confined to hospitals are now commonplace.

“As a result, we are now we are facing a serious public health threat from dangerous drug-resistant pathogens, and, so far, we have not found a silver bullet. Given what we do know, it is long overdue to address the issue of contaminated scrubs being worn out in the community.

“When I started to write about these issues and advise patients and their advocates to clean and disinfect their own hospital room, staff members scoffed at my suggestions. They used the same argument over a decade ago that they use now when concerns are raised about sanitary practices – that these occurrences were not proven sources of hospital-associated infections.

“Of course, common sense tells us – how could they not be?”

Well, we do know one proven source of hospital-associated infections. Dr. Wiener-Well and colleagues speculated that inadequate hand hygiene was at least partly responsible for the contamination they discovered during their research.

This theory is particularly disturbing since the Wall Street Journal‘s report last month that hand hygiene compliance in many North American hospitals is less than 50%.

I’ll translate this for you:

Half of the doctors, nurses and health care employees who are caring for you while you’re a hospital patient have dirty hands.

A study reported in the British Medical Journal (BMJ) suggested that nurses can contaminate their hands with bacteria even during “clean” activities (like lifting a patient, taking a patient’s pulse, blood pressure, or oral temperature; or touching a patient’s hand, shoulder, or groin).

Research published in the Archives of Internal Medicine indicated that direct patient contact and respiratory-tract care were most likely to contaminate the fingers of caregivers.

And the duration of patient care activity (how much time the doctor or nurse spent working directly with a patient) was strongly associated with the intensity of bacterial contamination of health care workers’ hands. The Journal of Hospital Infections also reported a study that linked understaffing of nurses in Intensive Care settings to facilitation of the spread of the superbug MRSA through “relaxed attention to basic control measures (e.g., hand hygiene)”.

Proposed new solutions for hand hygiene infractions, the WSJ reported, have included:

• penalizing non-compliant physicians and nurses
• using undergraduate volunteers to monitor hospital staff hygiene
• employing high-tech sensors to detect whether a health care worker has recently used a hand-cleansing alcohol gel

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1.  Wiener-Well Y, et al “Nursing and physician attire as possible source of nosocomial infections,” Am J Infect Control 2011; 39:555-59.