CDC goes OOPS!

How does the CDC really feel about infection control?  Perhaps we can get a hint by looking at the cover of their new Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care.  How many fundemental breaks with basic infection control do you see? I guess we know there is a new low in minimum expectations!

Oh, by the way, the CDC has just released their new Guide to Infection Prevention for Outpatient Settings.

h/t Jan Kluytmans

More calls to eliminate the white coat

Mike has posted several times recently on white coats as vectors for the transmission of hospital pathogens.  William W. Motley, a PhD candidate at the NIH and the University of Oxford, has a nice post in the PLoS Medicice blog titled: "Are White Coats Turncoats?"  I suggest you read the full post, but have pasted my favorite sections below:

I realize that gaining the trust of a patient is an important part of effective doctoring and that this uniform helps instill confidence...But I hope that my communication skills (learned in medical school and before) and knowledge will be more effective tools than an infrequently laundered coat.

I think that more medical schools should start welcoming students with a stethoscope ceremony. White coats are superfluous uniforms; stethoscopes are important diagnostic tools. Stethoscopes also symbolize an even better way to gain the trust of a patient: by listening to them, and by listening to the evidence.

I agree, as long as the stethoscopes are cleaned between exams. (insert smiling emoticon)

The white coat: Is it really going away?

There's an essay in Salon.com by Rahul Parikh, a pediatrician in San Francisco, on the disappearance of the white coat. He postulates a number of reasons for this and draws parallels to the decline in public opinion of physicians. In essence, patients aren't dazzled anymore by the magic of the white coat as they have become more empowered and participatory in their care. All of this is good in my opinion. But I wonder if Dr. Parikh's observations may have a geographic bias. While the coat may be disappearing on the west coast, it's still alive and well on the east coast. Many trends move from west to east, so maybe in a few years, they'll disappear here too.

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. 

I love me some magic!

There's an entertaining essay, Magic by Numbers, in today's New York Times. It's written by a psychologist who asks why we treat infections for durations of time that seem arbitrary (like 7 days). As an infectious diseases doctor, I must admit that duration of antibiotic therapy is one of the most common questions I am asked, and one for which there are few data. I sometimes preface my response to the how-long-to-treat question with, "I'm just making this up," and then pontificate with something like, "but I would treat for 10-14 days." And the intern dutifully enters an order for a 10-day course of vancomycin if the patient needs to stay in the hospital to receive it, or 14 days if the patient can receive IV antibiotics at home. The author of the essay, Daniel Gilbert, nails it when he writes that magic numbers "hold special significance for terrestrial mammals with hands and watches, but they mean nothing to streptococcus." Uh-oh! Our erudite approach has been exposed as nothing more than magical thinking. But there's a lot of magical thinking in medicine. Here are a few examples that come to mind: Wearing a white coat makes a doctor more professional. White coats worn daily for months without washing couldn't possibly be involved in transmitting bacteria to patients. The only way to control MRSA in the hospital is by culturing every patient for MRSA and isolating those that are colonized. And my current favorite: influenza vaccine is so effective that we should fire healthcare workers who don't get one (here's a new paper on that topic).  


P.S. Here's a video of a great TED talk on impact bias and synthetic happiness by Dan Gilbert.

The white coat is back! (Sort of)

There's a new development in the UK with regards to doctor's attire. In 2008, white coats were banned as part of the bare below the elbow campaign. However, some hospitals in the UK are now mandating that doctors put the white coat back on, but there's a twist! The new coats have short sleeves. I wonder what the GQ Style Guy would say about this. I'm not a sartorial expert, but these coats sure look goofy to me. Click here if you want to order one.

Photo:   Internet Workwear Limited

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!