Neck ties as vectors for nosocomial infection

The Effect of an Orthopedic Hand Surgeon's Attire on Patient Confidence and Trust

Background: Multiple studies have concluded that patients are more likely to understand and trust physicians who dress in more formal attire (shirt and tie) as opposed to casual attire (t-shirts and jeans). The white coat has repeatedly been reported as a major source of trust and confidence in a patient's eyes. Methods: This study explores the effect an orthopedic hand surgeon's attire has on a patient's perception of their surgeon's clinical values. All patients 18 years of age and older who visited our orthopedic hand surgeon's suburban outpatient practice were asked to participate in our survey-based study. Results: Ninety-seven surveys were completed and included. A majority of our responders are female (n = 59, 60.8%), Caucasian (n = 83, 85.6%) between the ages of 55 and 74 years (n = 40, 41.2%), currently employed (n = 59, 60.8%) with private health insurance (n = 69, 71.1%), and married (n = 64, 66.0%). Patients rated male and female hand surgeons wearing a white coat highest using the Likert scale and when asked about their perceived clinical qualities. Patients consistently poorly rated their surgeons wearing casual attire. Patients did note that the white coat, or any specific attire, was not necessary during the initial encounter to build a strong patient-surgeon relationship. Finally, goatees and beards do not positively or negatively impact a surgeon's patient-constructed image. Conclusions: Combining strong clinical skills with appropriate clinical attire highlighted by the physician wearing a white coat appears to be an effective way to enhance patient satisfaction while ultimately gaining the trust and respect needed to properly care for patients.

Clients' attitudes toward veterinarians' attire in the small animal emergency medicine setting

OBJECTIVE To determine how veterinarians' attire affected clients' perceptions and trust in the small animal emergency medicine setting. DESIGN Cross-sectional study. SAMPLE 154 clients of a 24-hour small animal emergency clinic in a rural location. PROCEDURES A survey was administered to clients in the waiting room over a 1-month period to elicit their impressions of veterinarians' attire in various clinical scenarios and whether that attire would affect their perceptions. Respondents completed the survey after examining photographs of 1 male and 1 female veterinarian in 5 styles of attire (business, professional, surgical, clinical, and smart casual). RESULTS 83 (53.9%) respondents were female, and 71 (46.1%) were male; age was evenly distributed. Across all clinical scenarios, the most common response was no preference regarding the way a male or female veterinarian was dressed and that this attire would have no effect on the respondents' trust in their veterinarian. Most respondents were indifferent or preferred that their veterinarians not wear neckties and white coats. Twenty-six percent (40/154) of respondents indicated that they believed their veterinarian's attire would influence their opinion of the quality of care their pet received. CONCLUSIONS AND CLINICAL RELEVANCE In this small animal emergency medicine setting, most clients indicated no preference regarding their veterinarian's attire, yet approximately one-fourth indicated this attire would influence their perception of the quality of care their pet received. Further studies are warranted in other practice settings and locations to determine whether these findings are generalizable or unique to this particular setting.

Health care professionals' neckties as a source of transmission of bacteria to patients: a systematic review

BACKGROUND

There is growing concern that neckties worn by health care professionals may contribute to infections contracted in health care settings. We evaluated the evidence for health-care-associated infections resulting from neckties and whether the evidence is sufficient to warrant a tieless policy in Canada.

METHODS

We performed a systematic review to determine whether neckties worn by health care professionals colonize harmful pathogenic bacteria and whether they contribute to the spread of infection to patients in the inpatient or outpatient setting. We searched PubMed (1966 to 2017) and Embase (1974 to 2017). The level of evidence was appraised according to the Oxford Centre for Evidence-Based Medicine levels of evidence. We evaluated the quality of evidence and the risk of bias using the Jadad scale or the Newcastle-Ottawa Scale.

RESULTS

We screened 1675 citations, of which 6 were ultimately included in the systematic review. Only 1 study gave level 1b evidence (randomized controlled trial). Neckties were more likely than shirt pockets to colonize bacteria. There is limited evidence that neckties may be contaminated with pathogenic bacteria (e.g., methicillin-resistant Staphylococcus aureus) and very limited evidence that contaminated neckties may transmit bacteria (in a controlled experimental setting to a mannequin).

INTERPRETATION

There is no evidence of increased rates of health-care-associated infections related to the wearing of neckties by health care professionals. There is weak evidence that neckties are contaminated with pathogenic (and nonpathogenic) bacteria. The level of evidence was weak and the studies were heterogeneous. Evidence to support the need for a tieless dress code policy is lacking.

Comprehensive review of methicillin-resistant Staphylococcus aureus: screening and preventive recommendations for plastic surgeons and other surgical health care providers

BACKGROUND

Up to 2.3 million people are colonized with methicillin-resistant Staphylococcus aureus in the United States, causing well-documented morbidity and mortality. Although the association of clinical outcomes with community and hospital carriage rates is increasingly defined, less is reported about asymptomatic colonization prevalence among physicians, and specifically plastic surgeons and the subsequent association with the incidence of patient surgical-site infection.

METHODS

A review of the literature using the PubMed and Cochrane databases analyzing provider screening, transmission, and prevalence was undertaken. In addition, a search was completed for current screening and decontamination guidelines and outcomes.

RESULTS

The methicillin-resistant S. aureus carriage prevalence of surgical staff is 4.5 percent. No prospective data exist regarding transmission and interventions for plastic surgeons. No studies were found specifically looking at prevalence or treatment of plastic surgeons. Current recommendations by national organizations focus on patient-oriented point-of-care testing and intervention, largely ignoring the role of the health care provider. Excellent guidelines exist regarding screening, transmission prevention, and treatment both in the workplace and in the community. No current such guidelines exist for plastic surgeons.

CONCLUSIONS

No Level I or II evidence was found regarding physician screening, treatment, or transmission. Current expert opinion, however, indicates that plastic surgeons and their staff should be vigilant for methicillin-resistant S. aureus transmission, and once a sentinel cluster of skin and soft-tissue infections is identified, systematic screening and decontamination should be considered. If positive, topical decolonization therapy should be offered. In refractory cases, oral antibiotic therapy may be required, but this should not be used as a first-line strategy.

Prospective study on the effect of shirt sleeves and ties on the transmission of bacteria to patients

Costs associated with hospital-acquired infections lead to policies aimed at decreasing their incidence. Clothing restrictions are often implemented in response, but they are based on little scientific evidence. This study is a prospective, controlled investigation of the effect of shirt sleeves and ties on the transmission of bacteria from doctors to patients. Results show that wearing an unsecured tie results in greater transmission, but that sleeve length does not affect transmission rate. The design is a possible model for further controlled experiments to fill the evidence gap regarding the transmission of micro-organisms from healthcare workers to patients.

Reusable venesection tourniquets: a potential source of hospital transmission of multiresistant organisms

OBJECTIVE

To determine the prevalence of multiresistant organism (MRO) colonisation of reusable venesection tourniquets.

DESIGN AND SETTING

A prospective study in a tertiary hospital to collect and analyse reusable venesection tourniquets for the presence of MROs - methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and extended-spectrum β-lactamase and metallo-β-lactamase-producing Enterobacteriaceae - using a sensitive enrichment method. Tourniquets were collected and tested during a 10-week period between September and November 2010.

MAIN OUTCOME MEASURE

Prevalence of MRO colonisation of tourniquets.

RESULTS

The overall colonisation rate of 100 tourniquets randomly collected from general wards, ambulatory care areas and critical care areas was 78%. MROs were isolated from 25 tourniquets collected from a variety of hospital locations, including general wards, the intensive care unit, burns unit and anaesthetic bay. MRSA was isolated from 14 tourniquets and VRE from 19; both MRSA and VRE were isolated from nine tourniquets. There were no microorganisms isolated from 22 tourniquets.

CONCLUSION

Reusable tourniquets can be colonised with MROs and may be a potential source of transmission of MROs to hospitalised patients.

Effectiveness of low-temperature domestic laundry on the decontamination of healthcare workers' uniforms

OBJECTIVE

Most professionals in the healthcare environment wear uniforms. For the purpose of this study, we concentrated on nurses' uniforms. In the United Kingdom, many nurses are expected to launder their uniforms at home by using a domestic washing machine that frequently has low-temperature wash cycles. We have investigated whether the use of low-temperature wash cycles results in a microbiologically acceptable product to wear on the wards.

METHODS

We have assessed the bioburden on uniforms before and after laundry and the effectiveness of low-temperature wash cycles and ironing on removal of methicillin-resistant Staphylococcus aureus (MRSA) and Acinetobacter baumannii. We did not assess the role of tumble drying.

RESULTS

We demonstrate contamination of uniforms by gram-negative bacteria after wash, the removal of MRSA at low-temperature wash cycles in the presence of detergent, and the eradication of gram-negative bacteria after ironing.

CONCLUSIONS

Our conclusions are that laundry in a domestic situation at 60°C (140°F) for 10 minutes is sufficient to decontaminate hospital uniforms and reduces the bacterial load by more than 7-log reduction, that items left in the pockets are decontaminated to the same extent, that the addition of either a biological detergent or a nonbiological detergent is beneficial in removing MRSA from experimentally contaminated swatches, and that uniforms become recontaminated with low numbers of principally gram-negative bacteria after laundry but that these are effectively removed by ironing.

Informed Consent for Anaesthesia in Australia and New Zealand

The legal and ethical requirements related to an anaesthetist's communication with patients in preparing them for anaesthesia, assisting them in making appropriate decisions and obtaining consent in a formal sense are complex. Doing these things well takes time, skill and sensitivity. The primary focus should be to adequately prepare patients for surgery and to ensure that they are sufficiently well informed to make the choices that best meet their own needs. This is just an affirmation of the importance of patient-centred care.

"Can religious icons be vectors of infectious diseases in hospital settings?"

According to Jewish tradition, Mezuzahs should be affixed on all doorposts leading to communal places. We evaluated the bacterial pathogenic load on the Mezuzah covers in our hospital. Mezuzahs were sampled in all hospital departments, and cultures were carried out. Serving as a control group, door handles belonging to the same departments were tested as well. Most samples harbored potential pathogens. Few cultures were positive in the control group, demonstrating that regular disinfection is carried out, but apparently religious artifacts are overlooked.

Patients' perspectives on how doctors dress

Infection in hospitals is a serious problem. Attempting to address the spread of infection, many UK National Health Service trusts have adopted a 'bare-below-the-elbows' and tie-less dress-code policy. This followed publication of Department of Health guidelines on staff uniforms in September 2007. Although the potential for colonisation of clothing with pathogens has been investigated, patients' opinions on dress-code and policy change have not. This survey of 75 patients in Great Western Hospital, Swindon, UK, used questionnaires to address this. The survey showed that, although patients did feel that doctors' dress was important, neckties and white coats were not expected. Moreover, surgical scrubs were considered acceptable forms of attire. Problems of identifying doctors and determining their grade were repeatedly raised. Patients were generally unaware of the new dress-code, and few knew anything of its relationship to infection control. This work demonstrates that more 'traditional' dress is not expected. Given the problems of identification and perception of surgical scrubs as suitable, their introduction as a 'uniform for doctors' should be considered. Furthermore, work needs to be done to advertise policy change and increase patient awareness of infection control.

Use of atmospheric non-thermal plasma as a disinfectant for objects contaminated with methicillin-resistant Staphylococcus aureus

BACKGROUND

Health care-associated infections because of methicillin-resistant strains of Staphylococcus aureus (MRSA) are increasing worldwide despite current infection control measures. Novel methods for disinfection of MRSA would be useful.

METHODS

We tested the effectiveness of atmospheric, non-thermal plasma discharge at killing S aureus, including USA300 strains, and at disinfecting experimentally contaminated hospital pagers.

RESULTS

Exposure of S aureus to plasma at different concentrations and for varying lengths of time resulted in up to a 4- to 5-log(10) kill on tryptic soy agar plates within 10 minutes and was not toxic to epithelial cells. USA300 strains of MRSA were more resistant to plasma-based killing than other tested strains. Disinfection of hospital pagers experimentally coated with clinically relevant amounts of MRSA could be achieved in as little as 30 seconds.

CONCLUSION

Generation of plasma is a promising method for disinfection of objects or surfaces that warrants further study in hospital settings. The USA300 strains of S aureus may be more resistant to disinfection than other strains.

Bacterial counts from hospital doctors' ties are higher than those from shirts

Doctor ties are often contaminated with bacteria, and it has been suggested that they should not be worn. We have compared bacterial counts from the ties and shirt pockets of 50 doctors. Counts were higher (P = .002) from ties that were rarely, if ever, cleaned than from shirts that were washed every 2 days or more frequently. The results support the need for further research on unwashable clothing of hospital staff.

Prevention of hospital-acquired infections: review of non-pharmacological interventions

Hospital-acquired (nosocomial) infections (HAIs) increase morbidity, mortality and medical costs. In the USA alone, nosocomial infections cause about 1.7 million infections and 99 000 deaths per year. HAIs are spread by numerous routes including surfaces (especially hands), air, water, intravenous routes, oral routes and through surgery. Interventions such as proper hand and surface cleaning, better nutrition, sufficient numbers of nurses, better ventilator management, use of coated urinary and central venous catheters and use of high-efficiency particulate air (HEPA) filters have all been associated with significantly lower nosocomial infection rates. Multiple infection control techniques and strategies simultaneously (‘bundling’) may offer the best opportunity to reduce the morbidity and mortality toll of HAIs. Most of these infection control strategies will more than pay for themselves by saving the medical costs associated with nosocomial infections. Many non-pharmacological interventions to prevent many HAIs will also reduce the need for long or multiple-drug antibiotic courses for patients. Lower antibiotic drug usage will reduce risk of antibiotic-resistant organisms and should improve efficacy of antibiotics given to patients who do acquire infections.

Evidence-based physicians' dressing: a crossover trial

OBJECTIVE

To describe the effect of physicians' dress on patient confidence and trust.

DESIGN

A prospective crossover trial involving physicians dressed in "respectable" versus "retro" attire.

SETTING

A general medicine ward at a tertiary hospital.

PARTICIPANTS

12 male general physicians and 1680 patients.

MAIN OUTCOME MEASURES

Patient trust and confidence as measured by a questionnaire mailed after hospital discharge.

RESULTS

Formal attire was correlated with higher patient confidence and trust. Nose rings were particularly deleterious to patients' reported trust and confidence. A minimum threshold of two items of formal attire (dress pants, dress shirt, tie, or white coat) were necessary to inspire a reasonable amount of confidence; this is the NND (number needed to dress).

CONCLUSIONS

We highlight the need for more research into the effects of physician dress, and coin the term "evidence-based dressing".