Bacterial flora on the white coats of medical students

Microbial Colonization, Biofilm Formation, and Malodour of Washing Machine Surfaces and Fabrics and the Evolution of Detergents in Response to Consumer Demands and Environmental Concerns

Bacterial attachment and biofilm formation are associated with the contamination and fouling at several locations in a washing machine, which is a particularly complex environment made from a range of metal, polymer, and rubber components. Microorganisms also adhere to different types of clothing fibres during the laundering process as well as a range of sweat, skin particles, and other components. This can result in fouling of both washing machine surfaces and clothes and the production of malodours. This review gives an introduction into washing machine use and surfaces and discusses how biofilm production confers survival properties to the microorganisms. Microbial growth on washing machines and textiles is also discussed, as is their potential to produce volatiles. Changes in consumer attitudes with an emphasis on laundering and an overview regarding changes that have occurred in laundry habits are reviewed. Since it has been suggested that such changes have increased the risk of microorganisms surviving the laundering process, an understanding of the interactions of the microorganisms with the surface components alongside the production of sustainable detergents to meet consumer demands are needed to enhance the efficacy of new antimicrobial cleaning agents in these complex and dynamic environments.

Public Perceptions of Surgeon Attire in Saudi Arabia

Introduction

Surgeon attire significantly affects patients' perceptions and can improve patient-surgeon relationships, which are crucial for patient comfort, experience, satisfaction, and treatment adherence. Understanding patient preferences for surgeon attire is essential, particularly in Saudi Arabia, for establishing appropriate dress codes in healthcare institutions. This national cross-sectional study aimed to fill this gap by assessing patient preferences for surgeon attire and its impact on patients' confidence in their surgeons across various medical settings.

Methods

The study used a questionnaire with 16 questions and images of surgeons in different attire styles, focusing on trust, care, approachability, and comfort ratings. The questionnaire included options like scrubs with a white coat, formal attire, and traditional Saudi attire for male surgeons, and various options including niqab and skirts for female surgeons. The survey had four sections covering ratings, attire preferences, opinions on white coats, and demographic data.

Results

A total of 612 patients completed the questionnaires, mainly aged 35-54 (33%). Skirt and niqab and white coat attire for females received the highest ratings. Attire other than scrubs, especially jeans and heels with a white coat, had significantly lower ratings. Scrubs and white coats were the most preferred attire for male (23.7%) and female (17%) surgeons. Additionally, 71.24% of participants agreed that surgeons should wear white coats.

Conclusion

In Saudi Arabia, male surgeons are preferred in scrubs and white coats, while female surgeons are preferred in skirts with white coats and niqabs. These preferences reflect notions of formality, professionalism, and cultural influences. Jeans received the lowest ratings, possibly due to perceptions of informality. Patients favor scrubs and white coats for hygiene benefits and conveying dedication and expertise. Future research should validate these findings across diverse cultures and medical fields.

What do physicians think about the white coat, about patients' view of the white coat, and how empathetic are physicians toward patients in hospital gowns? An enclothed cognition view

The receipt of the white coat by medical students is a significant milestone. Extensive research has focused on the white coat, its purity, representation of authority and professionalism, its role in consolidating a medical hierarchy, and the professional status attributed to physicians wearing it. Studies suggest that the white coat is a symbol of medical competence, and patients expect physicians to wear it. Research, however, has paid little attention to what physicians think about their white coat, how they perceive the patient's view of the white coat and the hospital gown, within the patient-physician power asymmetry, which is the focus of the current study. In total, 85 physicians from three Israeli medical centers completed a questionnaire (62% Muslims, 33% Jewish, and 5% Christians; 68% men, ages ranging from 21 to 73 years). Employing the enclothed cognition theory and adopting a within-person approach, we found that the more physicians perceived the white coat as important, the more they attributed a positive view of the white coat to patients and the more they perceived the patient's view of the hospital gown as positive. In addition, the higher the perceived importance of the white coat, the higher the reported empathy of physicians toward inpatients, which is consistent with the hospital's values of care. Interestingly, although medicine is a symbol of protection and care for others, the symbolic meaning of the white coat was potent enough to elicit empathy only when physicians perceived it as important. This study extends the theoretical knowledge on the theory of enclothed cognition in healthcare regarding self-perceptions and professional conduct.

Knowledge, attitude, and practice of white coat use among medical students during clinical practice (LAUNDERKAP): A cross-sectional study

BACKGROUND

Recent studies found white coats to be reservoirs for bacteria and medical students did not conform to proper hygiene measures when using these white coats. We investigated the knowledge, attitude, and practice (KAP) of medical students toward white coat use in clinical settings (LAUNDERKAP).

METHODS

A validated, online-based survey was disseminated to 670 students from four Malaysian medical schools via random sampling. Scores were classified into good, moderate, or poor knowledge and practice, and positive, neutral, or negative attitude. Mann-Whitney U and Kruskal-Wallis tests were used to analyze the relationship between demographic variables and knowledge, attitude, and practice scores.

RESULTS

A total of 492/670 students responded (response rate: 73.4%). A majority showed negative attitudes (n = 246, 50%), poor knowledge (n = 294, 59.8%), and moderate practice (n = 239, 48.6%). Senior and clinical year students had more negative attitudes. Male students had higher knowledge, while students from private medical schools and preclinical years had better practice. There was a significant relationship between attitude and practice (r = 0.224, P < .01), as well as knowledge and practice (r = 0.111, P < .05).

CONCLUSIONS

The results demonstrate the need for more education to improve medical students' infection control practices. Our results can also guide decision-making among administrators on the role of white coats as part of medical student attire.

Textiles as fomites in the healthcare system

Nosocomial infections or healthcare-associated infections (HAIs) are acquired under medical care in healthcare facilities. In hospital environments, the transmission of infectious diseases through textiles such as white coats, bed linen, curtains, and towels are well documented. Textile hygiene and infection control measures have become more important in recent years due to the growing concerns about textiles as fomites in healthcare settings. However, systematic research in this area is lacking; the factors contributing to the transmission of infections through textiles needs to be better understood. The review aims to critically explore textiles as contaminants in healthcare systems, and to identify potential risks they may pose to patients and healthcare workers. It delineates different factors affecting bacterial adherence on fabrics, such as surface properties of bacteria and fabrics, and environmental factors. It also identifies areas that require further research to reduce the risk of HAIs and improve textile hygiene practices. Finally, the review elaborates on the strategies currently employed, and those that can be employed to limit the spread of nosocomial infections through fabrics. Implementing textile hygiene practices effectively in healthcare facilities requires a thorough analysis of factors affecting fabric-microbiome interactions, followed by designing newer fabrics that discourage pathogen load. KEY POINTS: • Healthcare textiles act as a potential reservoir of nosocomial pathogens • Survival of pathogens is affected by surface properties of fabric and bacteria • Guidelines required for fabrics that discourage microbial load, for hospital use.

Development and validation of the knowledge, attitude and practice questionnaire (LAUNDERKAP) regarding white coat use among medical students during clinical practice

BACKGROUND

Medical students' white coats were found to harbor harmful organisms. This could be due to non-compliance to white coat hygiene measures. Therefore, we aim to develop and validate a questionnaire to assess the of knowledge, attitude, and practice (LAUNDERKAP) of white coat use among medical students in Malaysia.

METHODS

This study was conducted in 4 local medical schools. LAUNDERKAP was developed via literature review and had 3 domains: attitude, knowledge, practice. An expert panel assessed the content validity and clarity of wording. LAUNDERKAP was then piloted among 32 medical students. To test construct validity and internal consistency, 362 medical students were approached. Construct validity was assessed using exploratory factor analysis. Internal consistency was evaluated using Cronbach alpha for attitude and practice, while Kuder-Richardson 20 (KR-20) was used for knowledge.

RESULTS

A total of 319 of 362 students responded. Exploratory factor analysis extracted 1 factor each for attitude and knowledge respectively, and 3 factors for practice. Cronbach alpha for attitude was 0.843 while KR-20 for knowledge was 0.457. Cronbach alpha for practice ranged from 0.375 to 0.689. The final LAUNDERKAP contained 32-items (13 attitude, 9 knowledge, 10 practice).

CONCLUSIONS

LAUNDERKAP had adequate psychometric properties and can be used to assess KAP of medical students towards white coat use.

Role of bioaerosol in virus transmission and material-based countermeasures

Respiratory pathogens transmit primarily through particles such as droplets and aerosols. Although often overlooked, the resuspension of settled droplets is also a key facilitator of disease transmission. In this review, we discuss the three main mechanisms of aerosol generation: direct generation such as coughing and sneezing, indirect generation such as medical procedures, and resuspension of settled droplets and aerosols. The size of particles and environmental factors influence their airborne lifetime and ability to cause infection. Specifically, humidity and temperature are key factors controlling the evaporation of suspended droplets, consequently affecting the duration in which particles remain airborne. We also suggest material-based approaches for effective prevention of disease transmission. These approaches include electrostatically charged virucidal agents and surface coatings, which have been shown to be highly effective in deactivating and reducing resuspension of pathogen-laden aerosols.

Identification of human-dependent routes of pathogen's transmission in a tertiary care hospital

OBJECTIVES

The purpose of the study was to validate the risk of patients' exposure to pathogenic flora carried on hands of students, visitors, and patients themselves, analyzing its density and genera and to compare them with the microflora of healthcare workers (HCWs).

PATIENTS AND METHODS

Between May and June 2018, five groups of participants were included. Each group consisted of eight individuals. Palmar skin imprints were obtained from dominant hands of doctors, nurses, students, visitors, and patients in orthopedics ward. Imprints were incubated at 37°C under aerobic conditions, and colony-forming units (CFU) on each plate were counted after 24, 48, and 72 h. Microorganisms were identified.

RESULTS

Hands of doctors were colonized more often by Gram - positive non-spore-forming rods bacteria than hands of nurses (p<0.05). A higher number of Staphylococcus epidermidis CFUs was observed on doctors' than on nurses' hands (p<0.05), whereas Staphylococcus hominis was isolated from doctor's and patients' imprints, but was not from nurses' and students' imprints (p<0.05). Micrococcus luteus colonized patients' hands more often than students' (p<0.05), visitors' hands than doctors' (p<0.05), students' than nurses' (p<0.05), visitors' than nurses' (p<0.05) and patients' hands (p<0.05). Staphylococcus aureus (S. aureus) was isolated only from one doctor and one nurse (203 and 10 CFUs/25 cm2 ). Imprints taken from the hands of patients, students and visitors were S. aureus-free. No methicillin-resistant S. aureus (MRSA), vancomycin-resistant enterococci, nor expanded spectrum betalactamase-positive or carbapenemase-positive rods were isolated. The number of Gram-negative rods was the highest on visitors' hands, significantly differing from the number on patient's, doctor's, nurse's, and student's hands. Spore-forming rods from genus of Bacillus were isolated from representatives of all tested groups. Bacillus cereus occurred more commonly on visitors' hands than doctors' hands (p<0.05).

CONCLUSION

Patients, students, and visitors may play the causal role in the spread of pathogenic bacteria, particularly spore-forming rods. Our study results confirm the effectiveness of educational activities, that is the hospital's hand hygiene program among HCWs, patients, and visitors. Hand hygiene procedures should be reviewed to put much more effort into reducing the impact of all studied groups on the transmission of infectious diseases.

What's Up Your Sleeve? A Scoping Review of White Coat Contamination and Horizontal Microbial Transmission

OBJECTIVES

White coats have been suggested to serve as fomites carrying and transmitting pathogenic organisms and potentially increasing the risk of healthcare-associated infections (HAIs). We aimed to examine the current evidence regarding white coat contamination and its role in horizontal transmission and HAIs risk. We also examined handling practices and policies associated with white coat contamination in the reviewed literature.

METHODS

We conducted a literature search through PubMed and Web of Science Core Collection/Cited Reference Search, and manually searched the bibliographies of the articles identified in electronic searches. Studies published up to March 3, 2021 that were accessible in English-language full-text format were included.

RESULTS

Among 18 included studies, 15 (83%) had ≥100 participants, 16 (89%) were cross-sectional studies, and 13 (72%) originated outside of the United States. All of the studies showed evidence of microbial colonization. Colonization with Staphylococcus aureus and Escherichia coli was reported in 100% and 44% of the studies, respectively. Antibacterial-resistant strains, including methicillin-resistant Staphylococcus aureus and multidrug-resistant organisms were reported in 8 (44%) studies. There was a lack of studies assessing the link between white coat contamination and HAIs. The data regarding white coat handling and laundering practices showed inconsistencies between healthcare facilities and a lack of clear policies.

CONCLUSIONS

There is robust evidence that white coats serve as fomites, carrying dangerous pathogens, including multidrug-resistant organisms. A knowledge gap exists, however, regarding the role of contaminated white coats in HAI risk that warrants further research to generate the evidence necessary to guide the current attire policies for healthcare workers.

Predictors of growth of Escherichia coli on lab coats as part of hospital-acquired infection transmission through healthcare personnel attire

OBJECTIVES

Previous research has documented the presence of microbes on healthcare personnel (HCP) attire. This study aimed to explore the bacterial contamination and predictors of Escherichia coli (E coli) growth, as well as, hygiene and handling practices of HCP attire that could influence growth of E coli.

METHODS

Descriptive, cross-sectional study was used in this study. Convenience sampling of the 188 HCP was recruited from a main comprehensive hospital in the northern part of Jordan. Three swab samples were collected from three different parts of lab coats used by each participant. The generalised mixed linear model was used for the categorical variables and to identify the predictors of E coli growth on HCP attire.

RESULTS

Enterococcus faecalis was the most common species of bacteria found on lab coat. The HCP attire coming from the emergency department (ED) was highlighted with slightly higher contamination of E coli compared with other departments, such as critical care units. Factors associated with significant E coli growth on HCP attire were lab coat use over scrubs and borrowing of lab coats. The predictors of positive E coli growth were working in the ED, storing HCP attire in hospital lockers, believing the transmission of pathogens by HCP attire and carrying attire wrapped around arms.

IMPLICATIONS

Hygiene practices and policies, including a washing facility on the hospital premises, are a must to keep the lab coats clean.

CONCLUSION

HCP should be cautious about the method of use and storage of lab coats they wear.

Assessing personal protective equipment needs for healthcare workers

BACKGROUND

Personal protective equipment (PPE) is critical for healthcare workers (HCWs) since it acts as a barrier to infection transmission; however, current PPE is not ideally suited to their needs due to limitations in protection and comfort. Thus, the purpose of this study was to identify major issues of current PPE for body protection and assess its needs within health care.

METHODS

An online survey was conducted with a convenience sample of 200 U.S. healthcare professionals who interact with patients. The survey was designed to identify the types of PPE that HCWs currently use, assess current PPE design features for body protection, examine the effect of PPE design features for body protection, and HCWs' years of work experiences on overall PPE acceptability, and explore current PPE maintenance practices. Both quantitative and qualitative data were used for analyses.

RESULTS

This study showed the need for current PPE improvement in terms of fit, comfort, mobility, and donning and doffing for HCWs' safety and health. Donning and doffing plays an important role in HCWs' overall acceptance of PPE for body protection. This study revealed that most HCWs dispose of their PPE in a trashcan in a healthcare unit and non-disposed PPE is laundered at home, which may expose their family members to a health risk if a proper precaution is not followed.

CONCLUSION

This study provides critical insights for the needs of (a) novel PPE design research and (b) proper donning and doffing training and its strict regulatory effort to ensure HCWs' safety and health.

Patient Perception of Physician Attire in the Outpatient Setting During the COVID-19 Pandemic

Introduction:

In response to the SARS-CoV-2 pandemic, physician attire has evolved to incorporate personal protective equipment (PPE). Although PPE is mandated for all healthcare workers, variability exists in choice and availability. The purpose of this study was to determine patient perception of physician attire during the COVID-19 pandemic in an outpatient setting.

Methods:

Three hundred sixty-eight patients who presented to our outpatient orthopaedic clinics completed an anonymous survey. In addition to demographic characteristics, patient preferences for attire, PPE, and social distancing were obtained.

Results:

Scrubs (81%, 298/368) were found to be the most acceptable physician attire. Eye protection (34.2%, 126/368) and gloves (32.6%, 120/368), however, were deemed much less acceptable; 93.5% (344/368) of patients reported that no mask was unacceptable, with 41.0% (151/368) preferring a surgical mask. Predilection for a surgical mask and N95 rose with increasing patient education level. Interestingly, 55.2% (203/368) responded that physicians should stop wearing PPE only when the Center for Disease Control recommends.

Conclusion:

During the COVID-19 pandemic, most of the patients found scrubs to be the most acceptable attire in an office-based outpatient setting. Patients also found physician mask-wearing to be important but are less accepting of providers wearing eye and hand protection.

Bacteria on Medical Professionals' White Coats in a University Hospital

The transient contamination of medical professional's attires including white coats is one of the major vehicles for the horizontal transmission of microorganisms in the hospital environment. This study was carried out to determine the degree of contamination by bacterial agents on the white coats in a tertiary care hospital in Nepal. Sterilized uniforms with fabric patches of 10 cm × 15 cm size attached to the right and left pockets were distributed to 12 nurses of six different wards of a teaching hospital at the beginning of their work shift. Worn coats were collected at the end of the shifts and the patches were subjected for total bacterial count and identification of selected bacterial pathogens, as prioritized by the World Health Organization (WHO). Fifty percent of the sampled swatches were found to be contaminated by pathogenic bacteria. The average colony growth per square inch of the patch was 524 and 857 during first and second workdays, respectively, indicating an increase of 63.6% in colony counts. The pathogens detected on patches were Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, and Acinetobacter sp. Additional bacteria identified included Bacillus sp., Micrococcus sp., and coagulase-negative staphylococci (CoNS). The nurses working in the maternity department had their white coats highly contaminated with bacteria. On the other hand, the least bacterial contamination was recorded from the nurses of the surgery ward. One S. aureus isolate from the maternity ward was resistant to methicillin. This study showed that pathogens belonging to the WHO list of critical priority and high priority have been isolated from white coats of nurses, thus posing the risk of transmission to patients. White coats must be worn, maintained, and washed properly to reduce bacterial contamination load and to prevent cross-contamination of potential superbugs. The practice of wearing white coats outside the healthcare zone should be strictly discouraged.

Microbial Contamination of Medical Staff Clothing During Patient Care Activities: Performance of Decontamination of Domestic Versus Industrial Laundering Procedures

The efficacy of domestic laundering of healthcare staff clothing is still debated. This study aimed to compare the performance of decontamination of different domestic laundering with that of industrial laundering. Fourteen naturally contaminated white coats of healthcare workers (5 fabric squares from each coat) and fabric squares of artificially contaminated cotton cloth (30 fabric squares per each bacterial strain used) were included. Four domestic laundering procedures were performed; two different washing temperatures (40 °C and 90 °C) and drying (tumble dry and air dry) were used. All fabric squares were ironed. Presence of bacterial bioburden on the fabric squares after domestic and industrial laundering was investigated. None of the naturally contaminated fabric squares resulted completely decontaminated after any of the domestic washes. At 24, 48, and 72 h of incubation, bacterial growth was observed in all the laundered fabric squares. Besides environmental microorganisms, potentially pathogenic bacteria (i.e., Acinetobacter lwoffii, Micrococcus luteus, coagulase-negative staphylococci) were isolated. On the artificially contaminated fabric squares, the bioburden was reduced after the domestic laundries; nevertheless, both Gram-negative and -positive pathogenic bacteria were not completely removed. In addition, a contamination of the fabric squares by environmental Gram-negative bacteria was observed. In both the naturally and artificially contaminated fabric squares, no bacterial growth at all the time-points analyzed was observed after industrial laundering, which provided to be more effective in bacterial decontamination than domestic washes. For those areas requiring the highest level of decontamination, the use of specialized industrial laundry services should be preferred.

Bacterial contamination of medical providers' white coats and surgical scrubs: A systematic review

BACKGROUND

Horizontal transmission of bacteria, especially multidrug-resistant organisms (MDROs), remains an important concern in hospitals worldwide. Some studies have implicated provider attire in the transmission of organisms within hospitals, whereas others have suggested that evidence supporting this notion is limited.

METHODS

PubMed was searched for publications between 1990 and 2018 to identify studies of bacterial contamination of, or dissemination of, bacteria from physician, nursing, or trainee attire, with a specific focus on white coats and surgical scrubs. A total of 214 articles were identified. Of these, 169 were excluded after abstract review and 33 were excluded after in-depth full manuscript review.

RESULTS

Twenty-two articles were included: 16 (73%) cross-sectional studies, 4 (18%) randomized controlled trials, and 2 (9%) cohort studies. Results are organized by microbial contaminants, antibiotic resistance, types of providers, fabric type, antimicrobial coating, and laundering practices. Provider attire was commonly colonized by MDROs, with white coats laundered less frequently than scrubs. Studies revealed considerable differences among fabrics used and laundering practices.

CONCLUSIONS

Findings suggest that provider attire is a potential source of pathogenic bacterial transmission in health care settings. However, data confirming a direct link between provider attire and health care-associated infections remain limited. Suggestions outlined in this article may serve as a guideline to reduce the spread of bacterial pathogens, including MDROs, that have the potential to precipitate hospital-acquired infections.

Clothing-Mediated Exposures to Chemicals and Particles

A growing body of evidence identifies clothing as an important mediator of human exposure to chemicals and particles, which may have public health significance. This paper reviews and critically assesses the state of knowledge regarding how clothing, during wear, influences exposure to molecular chemicals, abiotic particles, and biotic particles, including microbes and allergens. The underlying processes that govern the acquisition, retention, and transmission of clothing-associated contaminants and the consequences of these for subsequent exposures are explored. Chemicals of concern have been identified in clothing, including byproducts of their manufacture and chemicals that adhere to clothing during use and care. Analogously, clothing acts as a reservoir for biotic and abiotic particles acquired from occupational and environmental sources. Evidence suggests that while clothing can be protective by acting as a physical or chemical barrier, clothing-mediated exposures can be substantial in certain circumstances and may have adverse health consequences. This complex process is influenced by the type and history of the clothing; the nature of the contaminant; and by wear, care, and storage practices. Future research efforts are warranted to better quantify, predict, and control clothing-related exposures.

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.

Unhygienic Practices of Health Professionals in Brazilian Public Hospital Restaurants: An Alert to Promote New Policies and Hygiene Practices in the Hospitals

This study aimed to evaluate health professionals’ unhygienic practices and the stages of behaviour change in Brazilian public hospital restaurants. We evaluated all medium/large-sized public hospital restaurants (HRs) from the Brazilian Federal District (n = 9); a representative sample of 128 users). We evaluated the HRs’ physical structures, their consumers’ socio-demographic characteristics, their unhygienic practices, as well as the stages of behavioural change concerning unhygienic practices. All the HRs presented their menus for self-service distribution, so customers entered in lines to serve themselves. All the HRs had hand-wash sinks for customers; 77.8% offered antiseptic liquid soap; 33.3% offered alcohol gel; and 77.8% offered storage for professional accessories before serving food. Almost half (46.8%) of the customers did not sanitise their hands (with water and antiseptic soap and/or use of alcohol gel) immediately before serving, and 24.2% wore professional uniforms at HRs. Almost half (43.5%) of the customers spoke with each other in line while serving their plates and arranged the food on their plates with the serving utensils from the distribution counter. The declaration of behavioural change was inversely associated with the hygiene practices. Almost half of the individuals did not sanitize their hands; however, 90.4% declared “changed behaviour” when this contaminant practice was presented to them. We verified a high percentage of hygiene practices inconsistent with most of the customers´ answers about their stage of behaviour change. Based on the observations of this study, it is necessary for an awareness program to be developed that is focused on customers of HRs in order to reduce unhygienic practices. Also, it is important to promote new policies for proper hygiene practices in hospital restaurants.

Staff Uniforms and Uniform Policy

Personnel in contact with patients or equipment and textiles should always use the hospital’s work attire. It includes anyone handling food, medicines, textile, waste or cleaning tools. By caring, treating, examining and transporting patients, there will be direct contact between own work clothes and the patient’s cloths/bedding or skin. The same is true when working with used patient equipment such as bedpans, toilet chairs, beds and other aids and working in patient rooms, toilets and bathrooms or when handling bedding and bandages, giving physiotherapy, etc. The work uniform is particularly exposed to organic matter and microbes, for example, in ambulances, in emergency services, in restless and anxious patients and children, during sampling and examination/treatment, etc. In acute wards, the staff is often exposed to splashes from patients, especially blood but also vomit, sputum, pus, faeces and urine. This chapter is focused on practical measures to prevent transmission of infections via contaminated staff uniforms.

Comparing colony-forming units in inpatient nurses: Should military nurses who provide patient care wear hospital-provided scrubs?

OBJECTIVE

To compare bacterial contamination of military-approved uniforms and hospital-provided scrubs donned by nursing staff in an inpatient setting.

DESIGN

Randomized experimental crossover study.

SETTING

Large academic military medical center.

METHODS

Inpatient units were randomized to predetermine the order of uniform sampling. Participants included nursing staff who provided direct patient care across 7 eligible inpatient units. Sampling of 6 designated sites on the uniform was completed on arrival to work, at ~4 hours into their shift, and at the 8-hour time point, for a total of 18 samples. Sampling of each participant occurred on 2 separate occasions, once in a military-approved uniform, and once in hospital-provided scrubs. After 24 hours of incubation, a colony-counting machine was used to calculate the total colony-forming units (CFU) of the sample.

RESULTS

Across all time points, military-approved uniforms demonstrated a 2-fold bacterial increase at the abdominal site and 3-fold increases at the sleeve cuff and waist pocket regions compared to the same regions on hospital-provided scrubs.

CONCLUSION

Nurses should be aware that bacteria are present at much higher levels on their personal military uniforms compared to hospital-provided scrubs. Additional research is needed to determine whether these findings are a function of wear, laundering, or environmental factors. Nurses should adhere to daily uniform washing to reduce bacterial load and minimize risk of nosocomial infections to the patients they care for.

Understanding patient preference for physician attire: a cross-sectional observational study of 10 academic medical centres in the USA

OBJECTIVE

Several large studies have shown that improving the patient experience is associated with higher reported patient satisfaction, increased adherence to treatment and clinical outcomes. Whether physician attire can affect the patient experience-and how this influences satisfaction-is unknown. Therefore, we performed a national, cross-sectional study to examine patient perceptions, expectations and preferences regarding physicians dress.

SETTING

10 academic hospitals in the USA.

PARTICIPANTS

Convenience sample of 4062 patients recruited from 1 June 2015 to 31 October 2016.

PRIMARY AND SECONDARY OUTCOMES MEASURES

We conducted a questionnaire-based study of patients across 10 academic hospitals in the USA. The questionnaire included photographs of a male and female physician dressed in seven different forms of attire. Patients were asked to rate the provider pictured in various clinical settings. Preference for attire was calculated as the composite of responses across five domains (knowledgeable, trustworthy, caring, approachable and comfortable) via a standardised instrument. Secondary outcome measures included variation in preferences by respondent characteristics (eg, gender), context of care (eg, inpatient vs outpatient) and geographical region.

RESULTS

Of 4062 patient responses, 53% indicated that physician attire was important to them during care. Over one-third agreed that it influenced their satisfaction with care. Compared with all other forms of attire, formal attire with a white coat was most highly rated (p=0.001 vs scrubs with white coat; p<0.001 all other comparisons). Important differences in preferences for attire by clinical context and respondent characteristics were noted. For example, respondents≥65 years preferred formal attire with white coats (p<0.001) while scrubs were most preferred for surgeons.

CONCLUSIONS

Patients have important expectations and perceptions for physician dress that vary by context and region. Nuanced policies addressing physician dress code to improve patient satisfaction appear important.

Clothing as a transport vector for airborne particles: Chamber study

Strong evidence suggests that clothing serves as a reservoir of chemical pollutants and particles, including bioaerosols, which may have health significance. However, little is known about the role that clothing may play as a transport vector for inhaled airborne particles. Here, we contribute toward bridging the knowledge gap by conducting experiments to investigate clothing release fraction (CRF), determined as the size-dependent ratio of released to deposited particulate matter in the diameter range 0.5-10 μm. In a fully controlled chamber with low background particle levels, we deployed a programmable robot to reproducibly quantify the size-dependent CRF as a function of motion type and intensity, dust loadings, and activity duration. On average, 0.3%-3% of deposited particles were subsequently released with fabric motion, confirming that clothing can act as a vehicle for transporting airborne particles. The CRF increased with the vigor of movement and with dust loading. Rubbing and shaking the fabric were more effective than fabric stretching in resuspending particles. We also found that most of the release happened quickly after the onset of the resuspension activity. Particle size substantially influenced the CRF, with larger particles exhibiting higher values.

Handling of laundry in nursing homes in Frankfurt am Main, Germany, 2016 - laundry and professional clothing as potential pathways of bacterial transfer

Background: In accordance with the German Infection Protection Act, the treatment and handling of laundry was checked by the Public Health Department in 2016 in all Frankfurt nursing homes with special focus on the staff's clothing. Methods: On-site visits and surveys were conducted in all 44 nursing homes in Frankfurt/Main, Germany, and random microbiological examinations of 58 reprocessed and 58 already worn protective gowns were performed to determine the numbers of the colony forming units (cfu) and microbiological differentiation of the pathogen species. Results: 41 (93%) of the 44 homes tested had contracted a certified laundry service. 23 (52%) of the homes also ran a laundry of their own; in 21 of these, laundry was reprocessed and disinfected in an industrial washing machine. Regular technical or microbiological tests were carried out in 16 or 12 of the home-owned laundries, respectively. Only 31 homes (70%) provided uniforms for their employees. The staff's clothing was processed in 25 homes by the external laundry, in 9 homes by the internal laundry, and in 12 homes, the nursing staff had to do this privately at their own home. Used coats exhibited significantly higher contamination than freshly prepared ones (median: 80 vs. 2 cfu/25 cm2; P 95 percentile: 256 cfu vs. 81 cfu/25 cm2). Clothing prepared in private homes showed significantly higher contamination rates than those washed in the certified external laundry or in the nursing homes themselves (Median: 16 cfu/25 cm2 vs. 0.5-1 cfu/25 cm2). Conclusion: Considering various publications on pathogen transfers and outbreaks due to contaminated laundry in medical facilities, the treatment of laundry, in particular the uniforms, must be given more attention, also in nursing homes for the elderly. The private reprocessing of occupational clothing by the employees at home must be rejected on hygienic principles, and is furthermore prohibited by law in Germany.

The Antimicrobial Scrub Contamination and Transmission (ASCOT) Trial: A Three-Arm, Blinded, Randomized Controlled Trial With Crossover Design to Determine the Efficacy of Antimicrobial-Impregnated Scrubs in Preventing Healthcare Provider Contamination

OBJECTIVE

To determine whether antimicrobial-impregnated textiles decrease the acquisition of pathogens by healthcare provider (HCP) clothing.

DESIGN

We completed a 3-arm randomized controlled trial to test the efficacy of 2 types of antimicrobial-impregnated clothing compared to standard HCP clothing. Cultures were obtained from each nurse participant, the healthcare environment, and patients during each shift. The primary outcome was the change in total contamination on nurse scrubs, measured as the sum of colony-forming units (CFU) of bacteria.

PARTICIPANTS AND SETTING

Nurses working in medical and surgical ICUs in a 936-bed tertiary-care hospital.

INTERVENTION

Nurse subjects wore standard cotton-polyester surgical scrubs (control), scrubs that contained a complex element compound with a silver-alloy embedded in its fibers (Scrub 1), or scrubs impregnated with an organosilane-based quaternary ammonium and a hydrophobic fluoroacrylate copolymer emulsion (Scrub 2). Nurse participants were blinded to scrub type and randomly participated in all 3 arms during 3 consecutive 12-hour shifts in the intensive care unit.

RESULTS

In total, 40 nurses were enrolled and completed 3 shifts. Analyses of 2,919 cultures from the environment and 2,185 from HCP clothing showed that scrub type was not associated with a change in HCP clothing contamination (P=.70). Mean difference estimates were 0.118 for the Scrub 1 arm (95% confidence interval [CI], −0.206 to 0.441; P=.48) and 0.009 for the Scrub 2 rm (95% CI, −0.323 to 0.342; P=.96) compared to the control. HCP became newly contaminated with important pathogens during 19 of the 120 shifts (16%).

CONCLUSIONS

Antimicrobial-impregnated scrubs were not effective at reducing HCP contamination. However, the environment is an important source of HCP clothing contamination.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT 02645214

Infect Control Hosp Epidemiol 2017;38:1147–1154

Emission rates and the personal cloud effect associated with particle release from the perihuman environment

Inhalation exposure to elevated particulate matter levels is correlated with deleterious health and well-being outcomes. Despite growing evidence that identifies humans as sources of coarse airborne particles, the extent to which personal exposures are influenced by particle releases near occupants is unknown. In a controlled chamber, we monitored airborne total particle levels with high temporal and particle-size resolution for a range of simulated occupant activities. We also sampled directly from the subject's breathing zone to characterize exposures. A material-balance model showed that a sitting occupant released 8 million particles/h in the diameter range 1-10 μm. Elevated emissions were associated with increased intensity of upper body movements and with walking. Emissions were correlated with exposure, but not linearly. The personal PM₁₀ exposure increment above the room-average levels was 1.6-13 μg/m³ during sitting, owing to spatial heterogeneity of particulate matter concentrations, a feature that was absent during walking. The personal cloud was more discernible among larger particles, as would be expected for shedding from skin and clothing. Manipulating papers and clothing fabric was a strong source of airborne particles. An increase in personal exposure was observed owing to particle mass exchange associated with a second room occupant.

Healthcare Personnel Attire and Devices as Fomites: A Systematic Review

BACKGROUND Transmission of pathogens within the hospital environment remains a hazard for hospitalized patients. Healthcare personnel clothing and devices carried by them may harbor pathogens and contribute to the risk of pathogen transmission. OBJECTIVE To examine bacterial contamination of healthcare personnel attire and commonly used devices. METHODS Systematic review. RESULTS Of 1,175 studies screened, 72 individual studies assessed contamination of a variety of items, including white coats, neckties, stethoscopes, and mobile electronic devices, with varied pathogens including Staphylococcus aureus, including methicillin-resistant S. aureus, gram-negative rods, and enterococci. Contamination rates varied significantly across studies and by device but in general ranged from 0 to 32% for methicillin-resistant S. aureus and gram-negative rods. Enterococcus was a less common contaminant. Few studies explicitly evaluated for the presence of Clostridium difficile. Sampling and microbiologic techniques varied significantly across studies. Four studies evaluated for possible connection between healthcare personnel contaminants and clinical isolates with no unequivocally direct link identified. CONCLUSIONS Further studies to explore the relationship between healthcare personnel attire and devices and clinical infection are needed. Infect Control Hosp Epidemiol 2016;1-7.

[Contamination of workwear in medical doctors and nursing stuff]

BACKGROUND

The hands of medical stuff are the most important vectors for the transmission of pathogens in the hospital. Furthermore a "bare below the elbows dress code" has been introduced in Great Britain.

OBJECTIVES

Aim of this study was to investigate whether workwear contamination of the medical stuff by pathogens is similar to the contamination of their hands and whether wearing workwear is associated with increased transmission risk.

MATERIAL AND METHODS

In total 54 swabs were collected from nursing stuff, medical doctors, patients and hospital work material.

RESULTS

Patients had a statistically significant more dense colonization with bacteria (median = 73 colony-forming units (CFU)), than the sleeves of the doctor's coat (median = 36 CFU, p = 0,005), followed by workwear of the nursing stuff at the end of a shift (median = 23 CFU, p < 0,001) and the hospital work material (median = 15 CFU, p < 0,001). Isolated pathogens were coagulase-negative staphylococci, Staphylococcus aureus, Enterobacter cloacae and Acinetobacter species.

CONCLUSIONS

Contaminated work wear presents a relevant risk for the transmission of pathogens. A "bare below the elbow dress-code" or the daily change of the doctor's coat appear both to represent reasonable measures to reduce the transmission risk of pathogens in hospitals.

Isolation gowns in health care settings: Laboratory studies, regulations and standards, and potential barriers of gown selection and use

Although they play an important role in infection prevention and control, textile materials and personal protective equipment (PPE) used in health care settings are known to be one of the sources of cross-infection. Gowns are recommended to prevent transmission of infectious diseases in certain settings; however, laboratory and field studies have produced mixed results of their efficacy. PPE used in health care is regulated as either class I (low risk) or class II (intermediate risk) devices in the United States. Many organizations have published guidelines for the use of PPE, including isolation gowns, in health care settings. In addition, the Association for the Advancement of Medical Instrumentation published a guidance document on the selection of gowns and a classification standard on liquid barrier performance for both surgical and isolation gowns. However, there is currently no existing standard specific to isolation gowns that considers not only the barrier resistance but also a wide array of end user desired attributes. As a result, infection preventionists and purchasing agents face several difficulties in the selection process, and end users have limited or no information on the levels of protection provided by isolation gowns. Lack of knowledge about the performance of protective clothing used in health care became more apparent during the 2014 Ebola epidemic. This article reviews laboratory studies, regulations, guidelines and standards pertaining to isolation gowns, characterization problems, and other potential barriers of isolation gown selection and use.

Bacterial Exchange in Household Washing Machines

Household washing machines (WMs) launder soiled clothes and textiles, but do not sterilize them. We investigated the microbial exchange occurring in five household WMs. Samples from a new cotton T-shirt were laundered together with a normal laundry load. Analyses were performed on the influent water and the ingoing cotton samples, as well as the greywater and the washed cotton samples. The number of living bacteria was generally not lower in the WM effluent water as compared to the influent water. The laundering process caused a microbial exchange of influent water bacteria, skin-, and clothes-related bacteria and biofilm-related bacteria in the WM. A variety of biofilm-producing bacteria were enriched in the effluent after laundering, although their presence in the cotton sample was low. Nearly all bacterial genera detected on the initial cotton sample were still present in the washed cotton samples. A selection for typical skin- and clothes-related microbial species occurred in the cotton samples after laundering. Accordingly, malodour-causing microbial species might be further distributed to other clothes. The bacteria on the ingoing textiles contributed for a large part to the microbiome found in the textiles after laundering.

Nursing students' knowledge and practices of standard precautions: A Jordanian web-based survey

BACKGROUND

The main purpose of this web-based survey was to evaluate Jordanian nursing students' knowledge and practice of standard precautions.

METHODS

A cross-sectional, descriptive design was used. Six public and four private Jordanian universities were invited to participate in the study. Approximately, seventeen hundred nursing students in the participating universities were invited via the students' portal on the university electronic system. For schools without an electronic system, students received invitations sent to their personal commercial email.

RESULTS

The final sample size was 594 students; 65.3% were female with mean age of 21.2 years (SD=2.6). The majority of the sample was 3rd year students (42.8%) who had no previous experience working as nurses (66.8%). The mean total knowledge score was 13.8 (SD=3.3) out of 18. On average, 79.9% of the knowledge questions were answered correctly. The mean total practice score was 67.4 (SD=9.9) out of 80. There was no significant statistical relationship between students' total knowledge and total practice scores (r=0.09, p=0.032).

CONCLUSION

Jordanian nursing educators are challenged to introduce different teaching modalities to effectively translate theoretical infection control knowledge into safe practices.

Bacterial Contamination of Medical Doctors and Students White Coats at Kilimanjaro Christian Medical Centre, Moshi, Tanzania

Background. Microbial transmission from patient to patient has been linked to transient colonization of health care workers attires. Contamination of health care workers' clothing including white coats may play a big role in transmission of microbes. Study Objective. This study was conducted to determine the type of bacterial contamination on the white coats of medical doctors and students and associated factors. Methods. A cross-sectional study with purposive sampling of the bacterial contamination of white coats was undertaken. Demographic variables and white coats usage details were captured: when the coat was last washed, frequency of washing, washing agents used, and storage of the white coats. Swabs were collected from the mouth of left and right lower pockets, sleeves, and lapels of white coat in sterile techniques. Results. Out of 180 participants involved in the current study, 65.6% were males. Most of the coats were contaminated by staphylococci species and other bacteria such as Gram negative rods. Conclusion and Recommendations. White coats are potential source of cross infection which harbour bacterial agents and may play a big role in the transmission of nosocomial infection in health care settings. Effort should be made to discourage usage of white coats outside clinical areas.

Contamination of health care workers' coats at the University Teaching Hospital in Lusaka, Zambia: the nosocomial risk

Background

Health care Associated Infections (HAIs) are a major public health problem in both developed and developing countries. They pose a severe impact in resource-poor settings, where the rate of infection is estimated to be relatively high. Therefore, this study was conducted to establish empirical evidence related to HAIs in Zambia.

Method

This was a prospective cross-sectional study conducted from October, 2013 to May 2014 at the University Teaching Hospital (UTH) in Lusaka. A total of 107 white coats worn by health care-workers at UTH were sampled for possible bacteriological contamination.

Results

Of the 107 white coats screened, 94 (72.8 %) were contaminated with bacteria. There was no difference in the contamination levels between white coats worn for more than 60 min (47.8 %) compared to those worn for 30–60 min (46.7 %) (p = 0.612). Further, the antibiotic sensitivity tests indicated that the bacterial isolates were resistant to some of the antibiotics assessed. Isolates of Staphylococcus aureus and Klebsiella pnumoniae exhibited the highest resistance to most of the antibiotics assessed.

Conclusion

This study has shown that white coats worn by health care-workers at the University Teaching Hospital generally have high microbial contaminations and hence pose a nosocomial risk. It is therefore, recommended that white coats be regularly sanitized, and health care workers also be sensitized on public health risk of HAIs associated with contaminated coats.

Role of healthcare apparel and other healthcare textiles in the transmission of pathogens: a review of the literature

Healthcare workers (HCWs) wear uniforms, such as scrubs and lab coats, for several reasons: (1) to identify themselves as hospital personnel to their patients and employers; (2) to display professionalism; and (3) to provide barrier protection for street clothes from unexpected exposures during the work shift. A growing body of evidence suggests that HCWs' apparel is often contaminated with micro-organisms or pathogens that can cause infections or illnesses. While the majority of scrubs and lab coats are still made of the same traditional textiles used to make street clothes, new evidence suggests that current innovative textiles function as an engineering control, minimizing the acquisition, retention and transmission of infectious pathogens by reducing the levels of bioburden and microbial sustainability. This paper summarizes recent literature on the role of apparel worn in healthcare settings in the acquisition and transmission of healthcare-associated pathogens. It proposes solutions or technological interventions that can reduce the risk of transmission of micro-organisms that are associated with the healthcare environment. Healthcare apparel is the emerging frontier in epidemiologically important environmental surfaces.

Persistence of nosocomial pathogens on various fabrics

OBJECTIVE

Fabrics can become contaminated with high numbers of microorganisms that may be pathogenic to patients in a hospital setting and can play an important role in the chain of infection. The aim of this study was to investigate the survival of several clinical bacterial and fungal isolates on several fabrics commonly used in hospitals.

MATERIALS AND METHODS

Bacterial and fungal survival was tested on the following materials, each of which are commonly used in our hospital: 100% smooth cotton, 60% cotton-40% polyester, 100% wool and 100% silk. One isolate each of Candida albicans, Candida tropicalis, Candida krusei, Candida glabrata, Candida parapsilosis, Geotrichum candidum, Aspergillus fumigatus, Cryptococcus neoformans, vancomycin resistant Enterococcus faecium (VRE, methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase (ESBL) positive Escherichia coli, inducible beta-lactamase (IBL) positive Pseudomonas aeruginosa, IBL-positive Acinetobacter baumannii and Stenotrophomonas maltophilia were used to contaminate fabrics. The survival of these microorganisms was studied by testing the fabric swatches for microbial growth.

RESULTS

The median survival times for all the tested bacteria and fungi were as follows: 26 days on cotton, 26.5 days on cotton-polyester, 28 days on silk, and 30 days on wool. Among the bacterial species tested, E. faecium had the longest survival time on cotton-polyester fabrics. For the fungal isolates, it was observed that C. tropicalis and C. krusei survived for the shortest amount of time on cotton fabrics in the present study.

CONCLUSION

This survival data indicate that pathogenic microorganisms can survive from days to months on commonly used hospital fabrics. These findings indicate that current recommendations for the proper disinfection or sterilization of fabrics used in hospitals should be followed to minimize cross-contamination and prevent nosocomial infections.

Contamination of medical charts: an important source of potential infection in hospitals

OBJECTIVE

This prospective study aims to identify and compare the incidence of bacterial contamination of hospital charts and the distribution of species responsible for chart contamination in different units of a tertiary hospital.

METHODS

All beds in medical, surgical, pediatric, and obstetric-gynecologic general wards (556) and those in corresponding special units (125) including medical, surgical, pediatric intensive care units (ICUs), the obstetric tocolytic unit and delivery room were surveyed for possible chart contamination. The outer surfaces of included charts were sampled by one experienced investigator with sterile cotton swabs rinsed with normal saline.

RESULTS

For general wards and special units, the overall sampling rates were 81.8% (455/556) and 85.6% (107/125) (p = 0.316); the incidence of chart contamination was 63.5% and 83.2%, respectively (p<0.001). Except for obstetric-gynecologic charts, the incidence was significantly higher in each and in all ICUs than in corresponding wards. Coagulase-negative staphylococci was the most common contaminant in general wards (40.0%) and special units (34.6%) (p>0.05). Special units had a significantly higher incidence of bacterial contamination due to Staphylococcus aureus (17.8%), Methicillin-resistant Staphylococcus aureus (9.3%), Streptococcus viridans (9.4%), Escherichia coli (11.2%), Klebsiella pneumoniae (7.5%), and Acinetobacter baumannii (7.5%). Logistic regression analysis revealed the incidence of chart contamination was 2- to 4-fold higher in special units than in general wards [odds ratios: 1.97-4.00].

CONCLUSIONS

Noting that most hospital charts are contaminated, our study confirms that a hospital chart is not only a medical record but also an important source of potential infection. The plastic cover of the medical chart can harbor potential pathogens, thus acting as a vector of bacteria. Additionally, chart contamination is more common in ICUs. These findings highlight the importance of effective hand-washing before and after handling medical charts. However, managers and clinical staff should pay more attention to the issue and may consider some interventions.

Healthcare personnel attire in non-operating-room settings

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 measures to prevent healthcare-associated infections (HAIs). This article aims to provide general guidance to the medical community regarding HCP attire outside the operating room. In addition to the initial guidance statement, the article has 3 major components: (1) a review and interpretation of the medical literature regarding (a) perceptions of HCP attire (from both HCP and patients) and (b) evidence for contamination of attire and its potential contribution to cross-transmission; (2) a review of hospital policies related to HCP attire, as submitted by members of the Society for Healthcare Epidemiology of America (SHEA) Guidelines Committee; and (3) a survey of SHEA and 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 practicality with the potential role of apparel in the cross-transmission of pathogens. Although the optimal choice of HCP attire for inpatient care remains undefined, we provide recommendations on the use of white coats, neckties, footwear, the bare-below-the-elbows strategy, and laundering. Institutions considering these optional measures should introduce them with a well-organized communication and education effort directed at both HCP and patients. Appropriately designed studies are needed to better define the relationship between HCP attire and HAIs.

epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were originally commissioned by the Department of Health and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were first published in January 2001(1) and updated in 2007.(2) A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective for the prevention of HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. The Department of Health commissioned a review of new evidence and we have updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the epic2 guidelines published in 2007 remain robust, relevant and appropriate, but some guideline recommendations required adjustments to enhance clarity and a number of new recommendations were required. These have been clearly identified in the text. In addition, the synopses of evidence underpinning the guideline recommendations have been updated. These guidelines (epic3) provide comprehensive recommendations for preventing HCAI in hospital and other acute care settings based on the best currently available evidence. National evidence-based guidelines are broad principles of best practice that need to be integrated into local practice guidelines and audited to reduce variation in practice and maintain patient safety. Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care in NHS hospitals in England can be minimised.

Perceptions of patients, physicians, and Medical students on physicians' appearance

OBJECTIVE

To investigate the impressions made by different styles of dress and appearance adopted by physicians on patients, medical students and other physicians in Brazil.

METHODS

Two hundred fifty nine patients, 119 students, and 99 physicians answered questions related to a panel of male and female physicians' pictures covering the following styles: white clothing; white coat; formal, informal, and casual garments; and surgical scrubs. They also reported their level of discomfort with a list of 20 items for professional appearance of both genders.

RESULTS

Most of the answers of the volunteers involved using white clothes or white coat, and in many situations the percentages of preference referred for these styles were close. Physicians and students preferred physicians wearing surgical scrubs for emergency visits, and doctors with informal style for discussing psychological problems with male professionals. Patients most often chose white clothing in response to questions. Regarding male professionals, all three groups reported high degree of discomfort for the use of shorts and bermuda shorts, multiple rings, facial piercing, sandals, extravagant hair color, long hair, and earrings. For females, high levels of discomfort were reported to shorts, blouses exposing the belly, facial piercing, multiple rings, extravagant hair color, and heavy makeup.

CONCLUSION

Brazilian patients, physicians, and medical students form a better initial impression of physicians using clothing traditionally associated with the profession and exhibiting more conventional appearance. The use of entirely white garments appears to be a satisfactory option in this country.

Bacterial contamination of healthcare workers' uniforms: a randomized controlled trial of antimicrobial scrubs

BACKGROUND

Healthcare workers' (HCWs) uniforms become contaminated with bacteria during normal use, and this may contribute to hospital-acquired infections. Antimicrobial uniforms are currently marketed as a means of reducing this contamination.

OBJECTIVE

To compare the extent of bacterial contamination of uniforms and skin when HCWs wear 1 of 2 antimicrobial scrubs or standard scrubs.

DESIGN

Prospective, randomized, controlled trial.

SETTING

University-affiliated, public safety net hospital

PARTICIPANTS

Hospitalist physicians, nurse practitioners, physician assistants, housestaff, and nurses (total N = 105) working on internal medicine units.

INTERVENTION

Subjects were randomized to wear standard scrubs or 1 of 2 antimicrobial scrubs.

MEASUREMENTS

Bacterial colony counts in cultures taken from the HCWs' scrubs and wrists after an 8-hour workday.

RESULTS

The median (interquartile range) total colony counts was 99 (66-182) for standard scrubs, 137 (84-289) for antimicrobial scrub type A, and 138 (62-274) for antimicrobial scrub type B (P = 0.36). Colony counts from participants' wrists were 16 (5-40) when they wore standard scrubs and 23 (4-42) and 15 (6-54) when they wore antimicrobial scrubs A and B, respectively (P = 0.92). Resistant organisms were cultured from 3 HCWs (4.3%) randomized to antimicrobial scrubs and none randomized to standard scrubs (P = 0.55). Six participants (5.7%) reported side effects to wearing scrubs, all of whom wore antimicrobial scrubs (P = 0.18).

CONCLUSIONS

We found no evidence that either antimicrobial scrub product decreased bacterial contamination of HCWs' uniforms or skin after an 8-hour workday.

Differential laundering practices of white coats and scrubs among health care professionals

The role played by health care worker's uniforms on the horizontal transmission of organisms within the hospital is still controversial. To determine the differential laundering practices in regards to white coats and scrubs, we surveyed physicians present at the 3 weekly academic conferences with largest attendance at our hospital (medicine, pediatrics, and anesthesiology). Out of 160 providers, white coats were washed every 12.4 ± 1.1 days and scrubs every 1.7 ± 0.1 days (mean ± standard error; P < .001). Faculty physicians washed their scrubs more frequently than house staff (1.0 vs 1.9 days, respectively, P = .018), and no differences were observed among specialties.

Methicillin-resistant staphylococcal contamination of clothing worn by personnel in a veterinary teaching hospital

OBJECTIVE

To determine the methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant Staphylococcus pseudintermedius (MRSP) contamination rate of white coats (WC) and surgical scrubs (SS) worn by personnel at the Ontario Veterinary College Health Sciences Centre (OVCHSC) and to identify risk factors associated with clothing contamination.

STUDY DESIGN

Cross-sectional study.

SAMPLE POPULATION

Personnel including clinical faculty, house officers, technicians, and veterinary students working at the OVCHSC.

METHODS

Electrostatic cloths were used to sample WC and SS of hospital personnel. Samples were tested for MRSA and MRSP and isolates were typed. Participants completed a self-administered questionnaire and data was evaluated for risk factors.

RESULTS

Of 114 specimens, MRS were isolated from 20 (17.5%), MRSA from 4 (3.5%), and MRSP from 16 (14.0%). Technicians were 9.5× (OR = 0.95, 95% CI: 1.2-∞, P = .03) more likely than students to have clothing contaminated with MRSA. No risk factors were identified for MRSP or for overall MRS contamination.

CONCLUSIONS

Standard hospital clothing was found to have a high prevalence of MRS contamination in a veterinary teaching hospital and could be a source of hospital-acquired infections.

Associations between bacterial contamination of health care workers' hands and contamination of white coats and scrubs

BACKGROUND

Uniforms are potential reservoirs for hospital organisms, potentially reinfecting the hands of health care workers (HCWs). The study aimed to determine the association between the bacterial contamination of HCWs' hands and uniforms (white coats and scrubs).

METHODS

HCWs working in 5 intensive care units had cultures obtained from their hands and uniforms (white coats or scrubs). Pathogens were defined as any gram-negative bacilli, Staphylococcus aureus, and enterococci.

RESULTS

Bacterial growth was detected on 103 hands (86%); 13 (11%) grew S aureus, 7 (6%) grew Acinetobacter spp, 2 (2%) grew enterococci, and 83 (70%) grew only skin flora. The presence of pathogens on the hands was associated with a greater likelihood of the presence of pathogens on white coats (κ = 0.81; P < .001), but not on scrubs (κ = 0.31; P = .036). Similarly, the presence of Acinetobacter on HCWs' hands was associated with a greater likelihood of Acinetobacter contamination of white coats (κ = 0.70; P < .001), but not of scrubs (κ = 0.36; P = .024).

CONCLUSIONS

Contamination of provider's hands with pathogens or Acinetobacter baumannii was associated with contamination of white coats. This association was not observed between hands and scrubs, however.