Medicine in small doses

Hand hygiene and the demise of the white coat? Working towards a sensible clinical dress code

There is little doubt that hospital-acquired infections have had a significant impact on the incidence of surgical site infections, especially methicillin-resistant Staphylococcus aureus (MRSA). Moreover, the successful ‘five moments of care’ hand hygiene campaign instigated in our hospitals in recent years has seen a reduction in the incidence of MRSA infections (http://www.hha.org.au/home/5-moments-for-hand-hygiene.aspx).

In 2007 the National Health Service (NHS) in the United Kingdom, with the endorsement of the then Minister of Health, Lord Darzi, an eminent academic surgeon, introduced a standardized dress code to promote safe clinical practice in relation to infection prevention and control, with the focus on hand hygiene (Loveday et al. Br. J. Infect. Cont. 2007; 8: 10–21; Duerden BI. J. R. Coll. Physicians Edinb. 2014; 44: 297–8).

The code had four elements: no white coats and jackets; a shirt, blouse or equivalent short sleeves; no ties that could contact with the patient; no wrist jewellery, wristwatch or rings other than plain wedding ring. This code became known as ‘bare below the elbows’, catchy jargon for publicity but not the intent of those who created the code.

The code was not necessarily based on hard core, evidence-based data, but the aim was to increase the efficacy of hand hygiene, especially the wrists, made impractical by the presence of long sleeves and wrist and hand jewellery. The requirement to remove ties followed the logic that ties often became contaminated with a variety of bacteria. Indeed in a simple study, Weber et al. (J. Hosp. Infect. 2012; 80: 252–4) demonstrated that the clothing combination resulting in the highest rate of contamination was long sleeves and necktie. An Australian study showed similar contamination wearing lanyards and identity badges (Kotsanas et al. Med. J. Aust. 2008; 188: 5–8).

The demise of the white coat was not received with universal praise. Indeed in a debate on the topic, Dancer SJ (J. R. Coll. Physicians Edinb. 2014; 44: 293–6) argues that the coat protected the wearer from ever-present pathogens, aerosols, splatter and spillages; it survives the rigours of daily laundering; it helps patients recognize who is their medical practitioner; and its disappearance may well have harmed the status of the medical profession.

A systematic review and survey of dress code policies of hospitals around Australia was conducted by Fraser S (http://www.amsj.org/archives/2490). Most hospitals emulated national guidelines (which includes the NHS code, http://www.nhmrc.gov.au/_files_hhmrc/publications/attachments/cd33_complete.pdf) and mandated bare below the elbows and no lanyard policies. The general response from infection control officers regarding white coats was negative, due to the long sleeves and irregular laundering.

Do we really need white coats as being symbolic of the medical profession, our purpose and pride, as suggested by Van Der Weyden (Med. J. Aust. 2001; 174: 324–5)?

I suspect not. It is time to move on and develop a more reasonable and practical dress code, in keeping with the feedback from the people whose well-being we strive to improve, our patients. A study of patients in orthopaedic outpatients in Scotland (Aitken et al. Surgeon 2014; 12: 40–6) concluded that doctors' appearance is of importance, but they view many other attributes such as compassion, politeness and knowledge as more important than how we choose to dress, and the most popular choice of dress was smart/casual style which does conform with NHS code policy.

The Society of Healthcare Epidemiology of America (Bearman et al. Infect. Control Hosp. Epidemiol. 2014; 35: 107–21) also supports most of the NHS code, and although they allow wearing of white coats, the Society insists on regular laundering and removing the coat before contact with patients, or patients' immediate environment. It adds that stethoscopes should be cleaned between patients. A further dimension covered by these guidelines not aforementioned is about footwear, recommending that all footwear should have closed toes, low heels and non-skid soles, which may be a problem for some of our female colleagues.

So what do we make of all this? The perception exists that there is a definite trend away from wearing white coats. Most younger surgeons have eliminated the necktie, and if wearing long sleeves, roll these up to the elbow, restrict their finger and wrist jewellery and often wear their ID badge attached to their waistline. Many older surgeons still prefer to wear the white coat when consulting, and may I suggest the compromise of a short-sleeved white coat with a short-sleeved business shirt, an approach my mentor taught me in my registrar days.

The real focus should not necessarily be on our dress code, apart from looking neat and professional, but on a robust approach to hand hygiene and improve our compliance in line with our nursing colleagues. Hand hygiene should become part of our daily routine, similar to getting dressed each day with a sensible clinical dress code.