Twisted logic



Graphic: WeirdSpace


There's a piece in this week's American Medical News on the New York bill to mandate bare below the elbows. It includes this quote from Dr. P.J. Brennan, former President of SHEA:

It's not as though, by eliminating sleeves, you eliminate germs. The key thing to understand is that these environments are not sterile and are never going to be sterile. That goal is unattainable in a clinical setting. The real goal is to adhere to good hand hygiene, isolation practices, gloving, barrier precautions -- that's where we'd put our money.

I think Dr. Brennan's argument represents the conventional wisdom among hospital epidemiologists, but it doesn't make sense to me. He supports contact precautions, but doesn't support bare below the elbows, both of which are based on the same evidence and assumptions. So I think his logic is twisted. It seems to me that you either believe that clothing has the potential to transmit pathogens or you don't.

Giving Doctors Orders

Maureen Dowd's column in the New York Times this morning begins as follows:

When my brother went into the hospital with pneumonia, he quickly contracted four other infections in the intensive care unit.

Anguished, I asked a young doctor why this was happening. Wearing a white lab coat and blue tie, he did a show-and-tell. He leaned over Michael and let his tie brush my sedated brother’s hospital gown.

“It could be anything,” he said. “It could be my tie spreading germs.”

I was dumbfounded. “Then why do you wear a tie?” I asked. He shrugged and left for rounds.

My answers to her question:  (1) ego, (2) dogma.

You can read the rest of her column here.

Pig-Pen went to medical school

There's another paper just recently published on contamination of white coats. This study from Nigeria cultured the white coats of 103 doctors. Pathogens were cultured from nearly half (48%) of the coats. Staph. aureus was found on 19% of the coats, Pseudomonas aeruginosa on 10%, and other gram-negative organisms were found on 19%. The authors of the paper made a number of recommendations regarding the white coat, including frequency of laundering. Unfortunately, they left out the most important one--just get rid of them!

More on bare below the elbows and hand hygiene

I am always on the lookout for studies that evaluate bare below the elbows, but they remain few and far between. I previously blogged about a paper that showed that wrist hygiene was better when bare below the elbows was observed. No cultures were performed in that study, which used a fluorescent marker to determine the surface area of decontamination. A new study in the Journal of Hospital Infection looked at fingertip cultures in 92 doctors (49 were bare below the elbows and 43 were not). No MRSA or VRE was found in any of the cultures and there was no difference in colony counts between the two groups. However, I think the underlying premise of the study is wrong. There is a good argument to be made, in my opinion, that bare below the elbows can improve hand hygiene. But the fingertips would seem to be the least likely place for this to be true. A much stronger study would have involved culturing the wrists, which are hard to wash without getting sleeves wet. I suspect the investigators got the results they wanted given that the tone of the paper is one of anti-bare below the elbow. Now they can claim that bare below the elbow has no effect on hand hygiene. Even if that were true, we would still have the problem of pathogens on the coat potentially being transmitted to patients.

Religion vs. infection control: an update

We've blogged before about Muslim women who are healthcare workers in the UK facing disciplinary action for refusing to follow "bare below the elbows" on religious grounds. Now the National Health Service has made a concession: these women can now wear disposable sleeves with elastic cuffs when they have contact with patients.

More on contaminated neckties

A new study from Ireland of 95 doctor's ties found that 18% had pathogens recovered when cultured. S. aureus was recovered from 10 ties (8 of the isolates were methicillin resistant), gram-negative bacilli were recovered from 10 ties, and 3 ties had both S. aureus and gram-negative bacilli. The doctors also completed a survey, and 81% reported they would be happy not to wear a tie.

So to recap, we have an article of clothing that serves no function, is commonly contaminated with pathogens, and many doctors don't want to wear them. I think it's time to kill the necktie.