A study published in the Sept. issue of the American Journal of Infection Control indicated more than 60 percent of hospital nurses' and doctors' uniforms tested positive for potentially dangerous bacteria. Russell Olmsted, MPH, CIC, APIC 2011 president and director, infection prevention and control services, at St. Joseph Mercy Health System in Ann Arbor, Mich., discusses the attention the study has received, what healthcare workers can learn from the study's results and the questions the study raises which require more attention.
Q: The study has received quite a bit of media attention and buzz in the healthcare industry. Why do you think that is the case and is the attention justified?
Russell Olmsted: Studies that identify which microorganisms are recovered from a variety of surfaces, attire and equipment (stethoscope, blood pressure cuff, hospital bed rails, etc.) do elicit a lot of attention from healthcare professionals and the general public. This probably reflects our (human population) desire to maintain good hygiene, appeals to our collective "yuck factor radar" and fascination that a surface or uniform that looks clean can be contaminated with microbes (germs). However, infection preventionists (IP)/healthcare epidemiologists (HE) and clinical microbiologists are not as surprised as microbes are on and inside humans and we actually depend on them for our survival and maintaining normal health status. It's when these microbes get into an area where we don't want them to, e.g., the bloodstream or on an implanted prosthetic hip or knee joint, and cause infection, that endangers the safety of the patients we serve.
This latest study by Dr. Wiener-Well is well done and a useful addition to the scientific literature but is only one piece of the "puzzle" involving cross transmission of microbes to patients. The additional pieces include whether the microbes on the healthcare worker's uniform can be picked up on their hands — survive on the hands — and then be transferred to the patient. Even once these arrive to the patient, they may or may not cause infection. There are multiple steps involved in transmission and development of infection and the mere recovery of microbes on the uniform do not necessarily mean they are going to cause infection in a patient. There are laboratory techniques to help show an exact match between the microbe on the uniform is the same as that causing an infection in a patient. This is harder to do, however, as there is an incubation period between exposure to a microbe while in a hospital and onset of infection that can range between two days and several weeks, depending on the specific organism. In most instances the transfer of a microbe to a patient's skin does not cause infection, so this is a harder study to perform.
Q: You have previously stated these study results needed to be put into perspective. What then do you see as the key takeaways from the study?
RO: Yes, perspective and consideration of other studies on the role of the uniform in cross-transmission is important. I've mentioned previously that a systematic review [extensive analysis of the strength and quality of peer reviewed studies] of the role of HCW attire in causing healthcare-associated infections (HAIs) has been done by Dr. Jennie Wilson and her colleagues in the UK [Journal of Hospital Infection 2007;66:301-307]. After analyzing several studies that had been published they concluded, "…Although it has been hypothesised that contaminated uniforms are a potential vehicle for the transmission of pathogens, no studies demonstrated the transfer of micro-organisms from uniforms to patients in the clinical situation…"
One of the factors that prompted this study by Dr. Wilson was the UK's "Bare below the elbows" initiative that the National Health Service launched wherein physicians were not to wear white coats, long sleeve shirts or neckties. A more recent study by Dr. Willis-Owen and others [Journal of Hospital Infection 75 (2010) 116–119] cultured the hands of physicians who adhered to the bare below vs. another group that did not and found no difference in the concentration of microbes on their hands nor recovered any multidrug-resistant organisms (MDROs) like MRSA.
Last, Dr. Marisha Burden and here co-investigators published a study of medical residents examining the level of contamination of freshly laundered, short sleeve uniforms vs. a traditional white coat [Journal of Hospital Medicine 2011;6:177-82.]. Their findings were, "Bacterial contamination occurs within hours after donning newly laundered short-sleeved uniforms. After 8 hours of wear, no difference was observed in the degree of contamination of uniforms versus infrequently laundered white coats. Our data do not support discarding long-sleeved white coats for short-sleeved uniforms that are changed on a daily basis…"
Takeaways from the new study in AJIC and these other ones are as follows:
- HCW continue to need to place emphasis on hand hygiene just before providing patient care and after, e.g., as they leave a patient's room.
- Wear clean uniforms, keep them laundered and change them if they become soiled with blood or body fluids during the course of care.
- There is no evidence that wearing scrub attire outside the operating room presents a risk of bringing microbes back into the OR. The primary reason is that anyone who wears scrub attire during the course of their work shift in the OR is going to put on a new, sterile gown for each case. This gown goes over the scrub attire and protects the patient from microbes that might be present on the scrub attire. Prior investigations of use of a cover gown (put on when leaving a patient care area) for personnel who care for newborns in the nursery found it had no impact on risk of infection and has therefore largely been abandoned.
- HCW are not likely to carry microbes home on their uniforms and there is little, if any, evidence that the uniform represents a risk of exposure to other family members. Likewise, IPs and HEs know that we see a substantial proportion of patients being admitted with infections caused by MDROs like MRSA — meaning these are being transmitted in the community. It is very unlikely that MRSA on a uniform of a HCW would cause a MRSA infection in someone in a community setting, e.g., at a grocery store. Instead these strains of MRSA are present on skin and are being transmitted between people in a situations where there might be breaks in the skin allowing the MRSA to get past the normal skin barrier, e.g., during a team sport like wrestling, soccer or football.
- Keep your hands, uniform, and environmental surfaces around a patient or the equipment used during care clean and don't spend undue amount of worry about what might be on your uniform.
Q: Should organizations do anything different with their HAI prevention efforts considering these study results?
RO: More study is worthwhile but healthcare professionals and organizations need to avoid disproportionate attention on uniforms or creating an unrealistic expectation that uniforms be sterile. Instead they need to continue to work with their IP/HE to address prevention of HAIs that has a broad focus, e.g., hand hygiene, use of "prevention bundles" aimed at stopping central line-associated bloodstream infection, catheter-associated UTI and ventilator-associated pneumonia. Collaborate with the perioperative care professionals on preventing surgical site infections and, last, make sure there is attention paid to environmental hygiene.
Q: You previously said the study raises additional questions that need to be investigated. What questions do you see it raising, and how would answering these questions help with future HAI prevention efforts?
RO: As highlighted above, we need to assure that "microbe discovery studies" do not allow us to take our eye off the primary prevention strategies. Additional questions remain on techniques and strategies from experts such as social scientists on how we can embed hand and environmental hygiene into almost an automated approach when caring for patients in healthcare facilities. We have lots of effective products — the human behavioral element remains perhaps one of the more challenging factors however. Can microbes on the uniform survive, for how long and what is the critical dose needed to move them from one location to another? What's the relative contribution of microbes on a HCW's uniform in the cross-transmission of microbes to patients? Last, can we show using more advanced laboratory tests that the microbe on the uniform is transmitted and causes an infection? These are continued questions that IPs and HEs have.
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