SAN DIEGO – Going tieless and “bare beneath the elbows” has been touted for infection control. But while some clinicians endorse the practice, others call it inconvenient, unprofessional, and distracting. At an annual conference on infectious diseases, two specialists in the field debated going “BBE” and its evidence base.
Widespread practice of BBE dates to at least 2008, when the National Health Service in the United Kingdom mandated it as part of a set of measures to decrease nosocomial transmission of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. Clinicians at NHS were directed to leave jewelry, neckties, and wrist watches at home, hang up their lab coats, and wear short sleeves. The policy aims not only to reduce points of physical contact between providers and patients, but also to improve hand and wrist washing, said Dr. Michael Edmond, who is at the University of Iowa Hospitals and Clinics in Iowa City.
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Some evidence supports going BBE, said Dr. Edmond. Pathogenic gram-negative rods have been cultured from neckties, scrubs, uniforms, and white coats in multiple studies, he added. Inadequate laundering is part of the problem – clinical faculty in one study reported washing their coats about once every 2 weeks, even less often than medical students did.
“So when is biological plausibility enough to support a change in practice?” Dr. Edmond asked. “There is a potential for benefit in going BBE. There is no risk for harm. And there is minimal cost. On the basis of the same evidence and assumptions, we are willing to wrap ourselves in plastic and confine patients to their hospital rooms – that is, to use contact precautions. And yet, we are not willing to eliminate white coats and ties.”
Patient perception is not at issue, Dr. Edmond argued. Only about half of patients at one British hospital said they wanted physicians to wear traditional white coats, and that proportion dropped to 22% after patients received educational materials on clothing contamination, he noted. In another study, patients ranked their physician’s appearance behind knowledge, compassion, and politeness when asked which characteristics they valued most.
“Without strong evidence for benefit, we should recommend – not mandate – this new practice,” Dr. Edmond concluded.
But Dr. Neil O. Fishman disagreed, calling BBE “an evidence-free zone.” Dr. Fishman, who is at the University of Pennsylvania in Philadelphia, noted a total lack of randomized, controlled trials or well-performed observational studies supporting BBE. “No clinical studies have demonstrated cross-transmission of health care–associated pathogens from a health care provider to a patient,” he said.
Moreover, BBE does not prevent contamination, Dr. Fishman said. Bacterial cultures of the hands of BBE clinicians and controls revealed no differences in total bacteria counts or numbers of clinically significant pathogens, he said. Cultures of white coats and the undersides of wrists also were similar in terms of total bacteria and MRSA counts, he added.
Despite the lack of evidence, BBE has been implemented at NHS “mainly as a political gesture and has had unintended consequences,” Dr. Fishman said. Informal attire has promoted a less-robust view of infection control, junior doctors have adopted scruffy attire and “slovenly” personal hygiene, and all the focus on clothing has distracted from hand washing, he added.
Furthermore, less than 12% of clinicians have complied with BBE, according to Dr. Fishman. Abstainers report feeling cold and not knowing what time it is. Women, in particular, say they have no pockets to carry work essentials. “This is a gender equity issue,” Dr. Fishman said. “Can we afford to promote practices based on limited evidence, a theoretical rationale, or individual opinions? This is a lack of focus on what really matters.”
Dr. Edmond and Dr. Fishman reported no disclosures.