ICU Dress code

[bryanboling5]

At my hospital, the ICUs have a new policy that you have to take off the white coat and hang it on a hook near the door when you come in. Is this common? The excuse is "infection control" but I've never seen this except in the NICU (where you have to scrub before entering) and the OR. Just wondering if we are weird or if this is the new thing.

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[Adcadet]

Burn units do this all the time.

 

[kwiggo]

the ICU nurses at my hospital are pretty aggressive about infection control. We don't take off our white coats (yet), but if they see you using wound dressings you carried in from outside or not washing your hands, they will be on you in no time. The attendings tell them to be this way. Good infection control does impact mortality rates.

 

[Stitch]

Culture the sleeves of your white coat sometime. how often do you really wash it? They're disgusting.

 

[JayneCobb]

At my hospital, the ICUs have a new policy that you have to take off the white coat and hang it on a hook near the door when you come in. Is this common? The excuse is "infection control" but I've never seen this except in the NICU (where you have to scrub before entering) and the OR. Just wondering if we are weird or if this is the new thing.

This is a great idea for infection control, add in mandatory hand washing and you can make a real impact. There are enough studies to support removing of the white coat and hand washing that i've seen. But we could use one for neck ties.

 

[Stitch]

This is a great idea for infection control, add in mandatory hand washing and you can make a real impact. There are enough studies to support removing of the white coat and hand washing that i've seen. But we could use one for neck ties.

Agreed. There was a study about a year ago looking at neck tie cultures. Really gross.

 

[deleted87716]

Agreed. There was a study about a year ago looking at neck tie cultures. Really gross.

That doesn't prove any link with the spread of infection. Who drapes their necktie across their patients, anyway?

If you're really a believer, start wearing bow ties.

 

[JayneCobb]

That doesn't prove any link with the spread of infection. Who drapes their necktie across their patients, anyway?

If you're really a believer, start wearing bow ties.

It's much more common than what you think, not everyone wears their white coat closed or wear a tie tack. But you're correct, there are no good studies looking at the morbidity or impact of infection control of good neck tie hygiene.

 

[Apollyon]

It's much more common than what you think, not everyone wears their white coat closed or wear a tie tack. But you're correct, there are no good studies looking at the morbidity or impact of infection control of good neck tie hygiene.

No one has brought my name up yet on this, but I'll chime in. As Kent said, just because it has the bacteria on it, where is the connection that these are causing infection? I mean, people live quiescently with the meningococcus in their oropharyngeses. My other example - millions of American kids have had their cuts washed out under the kitchen faucet, yet some of the most virulent, nasty bugs have been cultured off of those same kitchen faucets - but who remembers a skin infection in anyone? And, even then, it was something topical that may or may not have gotten bacitracin, if that.

Just "being there" doesn't mean it's doing anything. Who was the last health care practitioner you saw with an abscess or a "boil"?

 

[MS05']

Does anyone happen to have the reference to the ICU study where they cultured physician ties?

I often wonder how thrilled I'd be with a family member or friend in the ICU because we really do suck at infection control. We have pretty stringent guidelines for ID control at my ICU, yet I frequently see cultures turn positive in room 8, then 9 then 10 and so on....




A continuous quality-improvement program reduces nosocomial infection rates in the ICU.Misset B, Timsit JF, Dumay MF, Garrouste M, Chalfine A, Flouriot I, Goldstein F, Carlet J.
Medical-Surgical Intensive Care Unit, Saint Joseph Hospital, 185 rue Raymond Losserand, 75614 Paris Cedex, France. [email protected]

OBJECTIVE: To assess the impact of a continuous quality-improvement program on nosocomial infection rates. DESIGN AND SETTING: Prospective single-center study in the medical-surgical ICU of a tertiary care center. PATIENTS. We admitted 1764 patients during the 5-year study period (1995-2000); 55% were mechanically ventilated and 21% died. Mean SAPS II was 37+/-21 points and mean length of ICU stay was 9.7+/-16.1 days. INTERVENTIONS: Implementation of an infection control program based on international recommendations. The program was updated regularly according to infection and colonization rates and reports in the literature. MEASUREMENTS AND RESULTS: Prospective surveillance showed the following rates per 1000 procedure days: ventilator-associated pneumonia (VAP) 8.7, urinary tract infection (UTI) 17.2, central venous catheter (CVC) colonization 6.1, and CVC-related bacteremia and 2.0; arterial catheter colonization did not occur. In the 5 years following implementation of the infection control program there was a significant decline in the rate per patient days of UTI, CVC colonization, and CVC-related bacteremia but not VAP. Between the first and second 2.5-year periods the time to infection increased significantly for UTI and CVC-related colonization. CONCLUSIONS: A continuous quality-improvement program based on surveillance of nosocomial infections in a nonselected medical-surgical ICU population was associated with sustained decreases in UTI and CVC-related infections.

PMID: 14673521 [PubMed - indexed for MEDLINE]


: J Hosp Infect. 2006 Apr;62(4):395-405. Epub 2006 Feb 14. Links
Retraction in:
Dancer S. J Hosp Infect. 2006 Oct;64(2):99.
Handwashing: a simple, economical and effective method for preventing nosocomial infections in intensive care units.Akyol A, Ulusoy H, Ozen I.
Department of Anaesthesiology and Critical Care, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey. [email protected]

As most nosocomial infections are thought to be transmitted by the hands of healthcare workers, handwashing is considered to be the single most important intervention to prevent nosocomial infections. However, studies have shown that handwashing practices are poor, especially among medical personnel. This review gives an overview of handwashing in health care and in the community, including some aspects that have attracted little attention, such as hand drying and cultural issues determining hand hygiene behaviour. Hand hygiene is the most effective measure for interrupting the transmission of micro-organisms which cause infection, both in the community and in the healthcare setting. Using hand hygiene as a sole measure to reduce infection is unlikely to be successful when other factors in infection control, such as environmental hygiene, crowding, staffing levels and education, are inadequate. Hand hygiene must be part of an integrated approach to infection control. Compliance with hand hygiene recommendations is poor worldwide. While the techniques involved in hand hygiene are simple, the complex interdependence of factors that determine hand hygiene behaviour makes the study of hand hygiene complex. It is now recognized that improving compliance with hand hygiene recommendations depends on altering human behaviour. Input from behavioural and social sciences is essential when designing studies to investigate compliance. Interventions to increase compliance with hand hygiene practices must be appropriate for different cultural and social needs.

PMID: 16478645 [PubMed - indexed for MEDLINE]

 

[JayneCobb]

Could you toss in a citation for the white coat link to infection? Sounds like an urban myth.

I'll have to dig through my stack of articles, which may be packed at the moment. but I'll try to find it. But don't expect anything huge, it's not a groundbreaking article with stellar methodologies.

No one has brought my name up yet on this, but I'll chime in. As Kent said, just because it has the bacteria on it, where is the connection that these are causing infection? I mean, people live quiescently with the meningococcus in their oropharyngeses. My other example - millions of American kids have had their cuts washed out under the kitchen faucet, yet some of the most virulent, nasty bugs have been cultured off of those same kitchen faucets - but who remembers a skin infection in anyone? And, even then, it was something topical that may or may not have gotten bacitracin, if that.

Just "being there" doesn't mean it's doing anything. Who was the last health care practitioner you saw with an abscess or a "boil"?

True, but if this philosophy were entirely true it wouldn't make a difference whether we physicians washed our hands or not. The problem is not necessarily that we're colonization or that the microbs are there, but that the potential to pass the bugs on to those who are compromised and can be infected exists.

While the data for neck ties has never been investigated as far as the impact on morbidity, mortality or even infection rates, the lack of data does not mean that we should just blow this off as impossible. I think common sense acts should be implemented, don't wear dangling ties, so wear a tie tack or have your white coat buttoned so the tie does not dangle 2) wash the white coat frequently, very frequently. In conjunction with other things which have been shown (hand washing, etc) infection rates from our end can be reduced even more than with hand washing alone (IMHO). I'd bet that

 

[deleted87716]

This is a link referencing the infamous necktie article.

"The contribution that ties make to the transmission of infection is minor compared with that of hands," he [infection control expert Ed Mangini] told New Scientist. "If we could just get people to consistently wash their hands between patients we would cut down on transmission of infection dramatically."

Nurkin, Steven; Carl Urban, Ed Mangini, Norielle Mariano, Louise Grenner, James Maurer, Edmond Sabo, James Rahal (May 2004). "Is the Clinicians' Necktie a Potential Fomite for Hospital Acquired Infections?". Paper presented at the 104th General Meeting of the American Society for Microbiology May 23–May 27 2004, New Orleans, Louisiana, p. 204.

 

[Apollyon]

True, but if this philosophy were entirely true it wouldn't make a difference whether we physicians washed our hands or not. The problem is not necessarily that we're colonization or that the microbs are there, but that the potential to pass the bugs on to those who are compromised and can be infected exists.

While the data for neck ties has never been investigated as far as the impact on morbidity, mortality or even infection rates, the lack of data does not mean that we should just blow this off as impossible. I think common sense acts should be implemented, don't wear dangling ties, so wear a tie tack or have your white coat buttoned so the tie does not dangle 2) wash the white coat frequently, very frequently. In conjunction with other things which have been shown (hand washing, etc) infection rates from our end can be reduced even more than with hand washing alone (IMHO). I'd bet that

It's called "data". It's not there. You even answer it yourself. Now, if there were anecdotes, that's one thing, but there's not even that. Not even that.

 

[Hernandez]

It's called "data". It's not there. You even answer it yourself. Now, if there were anecdotes, that's one thing, but there's not even that. Not even that.

Answer me this, if nothing other than hand hygene impacts nosocomial infections, why do we wear maximal barrier protection during central venous catheter placement? In case you don't know, I'll fill you in. Because there is plenty of data which shows that maximal barrier protection in conjunction with hand hygiene reduces infection rates (Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion.. Infection Control & Hospital Epidemiology. 1994 Apr) and please don't make me go look up the surgeon's data that shows full sterile barriers reduce infection as more indirect evidence. So, if the addition of gowns, face masks, etc reduce infections there, how can any reasonable person not deduce that bacteria spread from doctor to pt from other means than just from our hands?

And Kent, "Multicentre randomised double bind crossover trial on ontamination of conventional ties and bow ties in routine obstetric and gynaecological practice" Long story short, after the difference on day 1, bowties are just as colonized as neckties.

 

[southerndoc]

Answer me this, if nothing other than hand hygene impacts nosocomial infections, why do we wear maximal barrier protection during central venous catheter placement? In case you don't know, I'll fill you in. Because there is plenty of data which shows that maximal barrier protection in conjunction with hand hygiene reduces infection rates (Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion.. Infection Control & Hospital Epidemiology. 1994 Apr) and please don't make me go look up the surgeon's data that shows full sterile barriers reduce infection as more indirect evidence. So, if the addition of gowns, face masks, etc reduce infections there, how can any reasonable person not deduce that bacteria spread from doctor to pt from other means than just from our hands?

And Kent, "Multicentre randomised double bind crossover trial on ontamination of conventional ties and bow ties in routine obstetric and gynaecological practice" Long story short, after the difference on day 1, bowties are just as colonized as neckties.

Every article of clothing we wear is colonized by day 1. That's why it's important to wash them.

I remember reading data that showed that washing hands before placing central lines reduced infection rates. I have tried hard to find the article, but I can't find it. Can anyone help me here? The study randomized participants to either wash their hands or not wash their hands prior to gowning up and donning sterile gloves for central line placement. I've seen many people (and I myself have been guilty more than a few times) place central lines without washing hands before donning sterile gloves.

Out of curiosity, how many people wash their hands before doing a central line?

 

[Hernandez]

Every article of clothing we wear is colonized by day 1. That's why it's important to wash them

Exactly, but I fail to see why people have this mythos that if it's not your hands, it's not capable of contaminating your pt.

 

[Hernandez]

The difference, at least in my uneducated mind, revolves around the nature of the exposure. In central venous access, colonized surfaces have direct access to the blood stream of critically ill (ie - immunocompromised) patients. Ditto for surgical procedures or childbirth. Casual contact with intact skin, however, seems less likely to result in large numbers of infected patients.

I completely agree with this. My point was more that if full barrier protection does cause a statistically significant reduction in nosocomial infections in CVA, why do people have this mythos that neckties and white coats could not be a route of contamination in the rest of the compromised pts we see on a daily basis. I fully believe this should be quantified, but until then, I'm erring on the safe side.

We have a lot of good evidence when it comes to preventing nosocomial infections, but there is also a lot of mythology unsubstantiated by fact. Sterile gloves for suturing simple wounds comes to mind immediately. So does "moving your feet too much in the OR" (supposedly kicks bacteria from the floor up into the air).

True, but bacterial shedding from headlamps and other sterile surgical implements has been shown to occur with a statistically significant higher bacteria count when compared to the controls. Bacterial Shedding in Common Spine Surgical Procedures: Headlamp/Loupes and the Operative Microscope, Spine Volume 32(8), 15 April 2007, pp 918-920. so perhaps we shouldn't move our heads as much.

Taking precautions even in the absence of evidence is, obviously, a good idea. But there has to be limits. If we're going to ask health care workers to substantially change their practice to "prevent infection", then we should have some data to back it up.

As long as their not monetarily prohibitive, I fail to see what the problem is with taking that precaution until it's either disproved or shown statistically significant.

 

[xviii]

I will take off my white coat when the nurses take off their nurse coats. I change my white coat (and was the dirty one) almost daily. Nurses, NPs, and PAs seem to have the same contamination with their coats as doctors do. Why don't we change clothing once arriving at the ICU? That would make more sense to me.

 

[jeesapeesa]

sorry to stray off topic here, but nurses wear their their scrubs everywhere else in addition to the hospital from grocery stores to gatherings after work, even airline flights. my mom is a nurse for almost 30 + years and i've seen this with her friends and coworkers. i say that **** is nasty and the first thing i do when i get in my house is strip down.

 

[Apollyon]

Answer me this, if nothing other than hand hygene impacts nosocomial infections, why do we wear maximal barrier protection during central venous catheter placement? In case you don't know, I'll fill you in.

This is the difference between sutures on the skin, and putting something directly into the bloodstream. I know this (ironic to your statement) because I raised the same question when I was at Duke. The studies on infection control you read, they have written. In the units, we had to wash our hands, gown up and glove in a sterile manner, and prep and drape the patients like in the OR, and then place any central line or arterial line. Even in the ED, whenever practical or possible, I did the same thing; sometimes, people played the "exigency" card ("It's the ED - we don't do that here!"), and I called BS on that when I could.

I still wash my hands and glove and gown in a sterile manner when I can, now that I'm an attending in the community. Likewise, I try to be diligent to use the waterless hand cleaner and to wash my hands in an almost OCD manner.

Your post is slightly condescending.

 

[Hernandez]

Pretty much exactly my point, and I'm assuming by the laugh at the end here, you agree. Colonization and shedding are not clinically meaningful absent data showing increased infections.

No shuffling your feet, no moving your head, no white coat, where does it end? Soon we'll only examine and treat patients if they are in an adult-sized incubator, and we are in full hazmat gear (unless, of course, it is colonized as well).

I'm not fanatical, shuffling feet, and Level A PPE is overboard. But we have contact with very ill pts on a daily basis, I think its

And how long is the medical community supposed to be subject to nonsense theories put forth by infection control nurses? Do we have to disprove every ridiculous theory that gets thrown out there? It's not just a money issue. Physicians have practice habits, and forcing them to change them with every whim seems insulting.

This is a little disingenuous. These are not nonsense theories which have been put forth by infection control nurses, these are proposals which have been put forth by many physicians. I'd give a detailed list if I had more than 5 minutes tonight.

Furthermore, the white coat is an outward symbol of position and authority, and numerous studies show increased patient confidence and satisfaction when the white coat is worn. If you don't want to wear it, I understand and respect your choice, but forcing everyone to do away with it until it is proven "safe" is unreasonable.

Actually, you misunderstand. I wash my white coat q48 hours. I wear a tie tack and/or button my white coat to keep my tie from dangling down when i'm over a pt. You can't tell me you haven't seen your coworkers who have coats which look like they have not washed them in months.

This is the difference between sutures on the skin, and putting something directly into the bloodstream.

If this was all there was to the story, then hand washing would not have the influence on nosocomial infection rates outside of invasive procedures.

I know this (ironic to your statement) because I raised the same question when I was at Duke. The studies on infection control you read, they have written.

This is what is called a "false appeal of authority." Despite your assertion otherwise, Duke isn't he hub of hygiene. And it seems to me that the most of the studies are actually British.

Your post is slightly condescending.

I've been around SDN long enough to know this is ironic coming from (of all people) you........

 

[Apollyon]

I've been around SDN long enough to know this is ironic coming from (of all people) you........

You're a student that speaks with authority you don't have. That's my point. I really, really don't care what you think of me or your interpretation of my posts. And my comment about Duke wasn't an "appeal to authority", nor was I stating it was the end-all, be-all. My point was that I had it shoved down my throat daily for 3 years.

The supreme irony would be even a modicum of humility from you. And, with that, I'm done. Do your duty, whatever it is.

 

[PLT]

It's called "data". It's not there. You even answer it yourself. Now, if there were anecdotes, that's one thing, but there's not even that. Not even that.

I just want to take us back to the beginning here and point out that this is bordering on a fallacy as well. There is a difference between practicing EBM and using an appeal to ignorance. Remember that "an absence of evidence is not evidence of absence."

I'm not saying that people are right to assume something based on general opinion or their personal beliefs, just that certainly does not mean they are wrong when there is no evidence either way.

With this in mind - there should be absolutely no problem with the standard of care reflecting common sense or traditional precautions.

And what's with the "not even anecdotes" comment? Firstly I wouldn't expect them in an investigation where we're talking about something with a low incidence and hard to correlate directly, and that statement "not even that" is just so classic - I really hope that you can see how silly it is. It seems to me like when you were writing it you should have thought "gee, there's no anecdotes for my side either"; but you didn't.

 

[PLT]

You sure you actually read the thread and know what is going on here?

1) "Common sense and traditional precautions" do not involve taking off your tie or white coat. The point is that people are trying to change traditional practice based on supposition, without any sort of evidence. We're not talking about refusing to wear a mask while placing an IJ, we're talking about making doctors disrobe before they see patients.

2) You wouldn't expect an investigation into this? Maybe you should read the literature a bit more. One paper cited here looked at bacterial shedding from headlamps. But you would be shocked at a study trying to correlate infection rates with ties? You sure you're in medicine?

Apollyon was responding to the following post when he said there is no data:

True, but if this philosophy were entirely true it wouldn't make a difference whether we physicians washed our hands or not. The problem is not necessarily that we're colonization or that the microbs are there, but that the potential to pass the bugs on to those who are compromised and can be infected exists.

While the data for neck ties has never been investigated as far as the impact on morbidity, mortality or even infection rates, the lack of data does not mean that we should just blow this off as impossible. I think common sense acts should be implemented, don't wear dangling ties, so wear a tie tack or have your white coat buttoned so the tie does not dangle 2) wash the white coat frequently, very frequently. In conjunction with other things which have been shown (hand washing, etc) infection rates from our end can be reduced even more than with hand washing alone (IMHO). I'd bet that

I assumed that the "this" here referred to ties. I'm right.

I'm also really disappointed that you chided me for potentially not reading the thread when I don't think you're reading my response in context, or even correctly.
I said I wouldn't expect anecdotes (accounts of individual instances) - not research. Although I got the impression from the thread that both OPs were contending that there isn't good evidence either way about neck ties- that's why I posted, to bring up the argument from ignorance fallacy.

I do love sarcasm as a teaching tool though, so I didn't mind your post as much as someone else might have.

 

[Hernandez]

I'm not saying that people are right to assume something based on general opinion or their personal beliefs, just that certainly does not mean they are wrong when there is no evidence either way.

With this in mind - there should be absolutely no problem with the standard of care reflecting common sense or traditional precautions.

And what's with the "not even anecdotes" comment? Firstly I wouldn't expect them in an investigation where we're talking about something with a low incidence and hard to correlate directly, and that statement "not even that" is just so classic - I really hope that you can see how silly it is. It seems to me like when you were writing it you should have thought "gee, there's no anecdotes for my side either"; but you didn't.

You worded this better than I ever could.

we're talking about making doctors disrobe before they see patients.

Not necessarily, I think the main push would be for more frequent laundering of clothing such as ties and white coats.

One paper cited here looked at bacterial shedding from headlamps.

And just to clarify, I was being sarcastic with this article, even if it is real. I was not trying to say that bacterial shedding from ties was what I am concerned about.

 

[southerndoc]

There are no studies relating to ties, but obviously there should be. Why? Because physicians traditionally wear them, and before you demand docs start taking them off or stapling them to their chests, you should have some data (or at minimum, anecdotal evidence) to support this change from "customary practice". Get it now?

Are you saying there are no studies at all examining ties, or there are no studies examining reduction in infection rates by those that do not wear ties?

There are studies that demonstrate that ties are colonized. However, to my knowledge, there has never been a randomized, prospective trial examining infectious complications when physicians wear ties v. those who do not.

Remember, just because something is colonized doesn't mean that transmission occurs. The ED gurney, the otoscope on the wall, the hospital keyboard, the stethoscope, and nearly every single item in a hospital are colonized with multiple bacteria.

Most infections are transferred from dirty hands. I've seen too many physicians not wash their hands before seeing a critically ill patient, and often times they do not wear gloves. I think transferring bacteria from hand-to-patient is a lot easier than coat-to-patient or tie-to-patient. I don't let my white coat or tie touch my patient, but I do realize that my hands touches the coat and tie frequently during the day. However, I wash my hands before seeing any critical patient in an ICU setting. I usually gel my hands with hand sanitizer when seeing patients in the ED.

 

[PLT]

<sigh>

Aww, don't sigh big guy.

I think we'd be getting along fine if we weren't having some kind of serious communication trouble here.

I don't think it will contribute to the discussion but I want to rebut your statements because I'm arrogant.

I guess I'll try one more time.

There are no studies relating to ties, but obviously there should be... before you demand docs start taking them off or stapling them to their chests, you should have some data

- I wholeheartedly agree there should be studies on whether neckties cause infection. I was however under the impression that the "customary practice" was to tuck or staple your damn tie, as per recommendations from some health authorities and associations, and many of the physicians I have worked with. Maybe this is not true in your area and it seems to be a major disconnect.

It's called a "case report" (ie - anecdote). It's all over medicine.

- Thank you for rephrasing me, this time in quotations. Publishing cases is important, but what kind of anecdotes are you looking for here?
I am saying that I would not expect to see a report develop that posits a physician's tie as the source when an immunocompromised patient develops C. difficile in hospital. An example of a study I would like to see is something like comparing MRSA infection rates pre and post necktie bans (we're talking large scale because we need to pick up small changes - this is like a public health intervention)

Also, there's no good data either way on whether physicians' pants spread infection. Please remove yours next time you're in-house, so as not to fall victim to the "ignorance fallacy".

Just so you know, deriving a ridiculous statement from my original argument is also a - you guessed it - logical fallacy.

What in the world makes you think I was trying to teach anything?

Please, how exactly would you describe what you're doing and why you're doing it?

I give up.