I'm still in scrubs...

There's a new paper in the Journal of Hospital Medicine that takes a look at one of my favorite topics, the role of the white coat in the transmission of nosocomial infections and the impact of bare below the elbows.

Investigators at Denver Health performed a randomized, controlled trial to assess the degree of bacterial colonization and contamination by MRSA on work clothes. The participants were 100 physicians (residents and attendings) on the internal medicine service who were randomized to wear either their personal white coat (subjects were not given prior notification to avoid laundering for the purpose of the study) or a freshly laundered short-sleeved uniform. After eight hours at work, the coats and uniforms were cultured at designated sites using RODAC plates.

The main findings of the study were:

• No difference in overall bacterial counts between the white coats and the uniforms
• No difference in MRSA contamination (16% for white coats vs. 20% for uniforms, p=0.6)

There are a number of potentially confounding issues for which we don't have information:

• What is the prevalence of MRSA infection and colonization among internal medicine service patients at this hospital?
• Does the hospital have a MRSA active detection and isolation program for MRSA?
• Are patients with MRSA placed in contact precautions? If so, what is the compliance with contact precautions?
• Are the white coats hospital issued (thereby implying a uniform fabric) or purchased by physicians (implying various types of fabric) and of what type of fabric were the uniforms constructed? Previous studies have shown that duration of contamination by important pathogens can vary with the type of fabric.

Also, were there any differences after randomization between those who wore the white coats vs. those who wore the uniforms? More importantly, I think the biggest concern with the study is that it's relatively small, from a single service in a single hospital, making external validity questionable. And MRSA is only one of several important pathogens that need consideration.   

One of the most important issues in hospital infection prevention today is the role of clothing in the transmission of nosocomial pathogens. This not only impacts the issue of whether healthcare workers should wear neckties and white coats, but also has an impact on whether contact precautions should continue. It's important to note that the entire rationale for plastic gowns in contact precautions is the assumption that contaminated clothing can transmit pathogens to patients. If that's not true we sure could save the planet from a huge amount of disposable plastic and healthcare workers a lot of grief. We desperately need a funded, large, multicenter, well designed trial to answer the questions once and for all as to whether we go bare below the elbows or kill contact precautions.

While I think the authors of this study should be commended for addressing an important topic, I don't think many people will be swayed by its results. Those believers in the white coat will find the results reassuring and the pro-bare-below-the-elbows crowd will focus on the external validity of the study.