SHEA Healthcare Personnel Attire PDF

Healthcare Personnel Attire in Non-Operating-Room Settings
Author(s): Gonzalo Bearman, MD, MPH; Kristina Bryant, MD; Surbhi Leekha, MBBS, MPH;
Jeanmarie Mayer, MD; L. Silvia Munoz-Price, MD; Rekha Murthy, MD; Tara Palmore, MD;
Mark E. Rupp, MD; Joshua White, MD
Source: Infection Control and Hospital Epidemiology, Vol. 35, No. 2 (February 2014), pp. 107-
121
Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology
of America
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infection control and hospital epidemiology february 2014, vol. 35, no. 2
s he a e x p e rt g ui da nc e
Healthcare Personnel Attire in Non-Operating-Room Settings
Gonzalo Bearman, MD, MPH;
1
Kristina Bryant, MD;
2
Surbhi Leekha, MBBS, MPH;
3
Jeanmarie Mayer, MD;
4
L. Silvia Munoz-Price, MD;
5
Rekha Murthy, MD;
6
Tara Palmore, MD;
7
Mark E. Rupp, MD;
8
Joshua White, MD
9
Healthcare personnel (HCP) attire is an aspect of the medical profession steeped in culture and tradition. The role of attire in cross-
transmission remains poorly established, and until more denitive information exists priority should be placed on evidence-based measures
to prevent healthcare-associated infections (HAIs). This article aims to provide general guidance to the medical community regarding HCP
attire outside the operating room. In addition to the initial guidance statement, the article has 3 major components: (1) a review and
interpretation of the medical literature regarding (a) perceptions of HCP attire (from both HCP and patients) and (b) evidence for
contamination of attire and its potential contribution to cross-transmission; (2) a review of hospital policies related to HCP attire, as
submitted by members of the Society for Healthcare Epidemiology of America (SHEA) Guidelines Committee; and (3) a survey of SHEA
and SHEA Research Network members that assessed both institutional HCP attire policies and perceptions of HCP attire in the cross-
transmission of pathogens. Recommendations for HCP attire should attempt to balance professional appearance, comfort, and practicality
with the potential role of apparel in the cross-transmission of pathogens. Although the optimal choice of HCP attire for inpatient care
remains undened, we provide recommendations on the use of white coats, neckties, footwear, the bare-below-the-elbows strategy, and
laundering. Institutions considering these optional measures should introduce them with a well-organized communication and education
effort directed at both HCP and patients. Appropriately designed studies are needed to better dene the relationship between HCP attire
and HAIs.
Infect Control Hosp Epidemiol 2014;35(2):107-121
Afliations: 1. Virginia Commonwealth University, Richmond, Virginia; 2. University of Louisville, Louisville, Kentucky; 3. Department of Epidemiology
and Public Health, University of Maryland, Baltimore, Maryland; 4. Division of Infectious Diseases, Department of Internal Medicine, University of Utah
School of Medicine, Salt Lake City, Utah; 5. Departments of Medicine and Public Health Sciences, University of Miami, Miami, Florida; 6. Department
of Hospital Epidemiology, Cedars-Sinai Medical Center, Los Angeles, California; 7. National Institutes of Health Clinical Center, Bethesda, Maryland;
8. University of Nebraska Medical Center, Omaha, Nebraska; 9. Virginia Commonwealth University, Richmond, Virginia.
Received November 21, 2013; accepted November 25, 2013; electronically published January 16, 2014.
2014 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2014/3502-0001$15.00. DOI: 10.1086/675066
Healthcare personnel (HCP) attire is an aspect of the medical
profession steeped in culture and tradition. From Hippoc-
ratess admonition that physicians dress is essential to their
dignity, to the advent of nurses uniforms under the lead-
ership of Florence Nightingale, to the white coat ceremonies
that continue to this day in medical schools, HCP apparel
and appearance is associated with signicant symbolism and
professionalism. Recent years, however, have seen a rising
awareness of the potential role of fomites in the hospital
environment in the transmission of healthcare-associated mi-
croorganisms. Although studies have demonstrated contam-
ination of HCP apparel with potential pathogens, the role of
clothing in transmission of these microorganisms to patients
has not been established. The paucity of evidence has stymied
efforts to produce generalizable, evidence-based recommen-
dations, resulting in widely disparate practices and require-
ments that vary by country, region, culture, facility, and dis-
cipline. This document is an effort to analyze the available
data, issue reasonable recommendations, and describe the
needs for future studies to close the gaps in knowledge on
HCP attire.
i ntended use
This document is intended to help acute care hospitals de-
velop or modify policies related to HCP attire. It does not
address attire in the operating room (OR), perioperative ar-
eas, or other procedural areas and is not intended to guide
HCP attire in those settings or in healthcare facilities other
than acute care hospitals.
soci ety for healthcare epi demi ology
of ameri ca (shea) wri ti ng group
The writing group consists of volunteers among members of
the SHEA Guidelines Committee, including those with re-
search expertise on this topic.
108 infection control and hospital epidemiology february 2014, vol. 35, no. 2
key areas addressed
We evaluated and summarized the literature around 2 aspects
of HCP attire (details are provided in Methods):
I. Perception of both patients and HCP regarding HCP attire
in relation to professionalism and potential risk for trans-
mission of microorganisms.
II. Evidence for contamination of HCP attire and the po-
tential for HCP attire to contribute to the transmission
of pathogenic microorganisms in hospitals.
In addition, we performed a survey of the SHEA mem-
bership and SHEA Research Network to learn more about
the policies related to HCP attire that are currently in place
in members institutions.
gui dance and recommendati on
format
Because this topic lacks the level of evidence required for a
more formal guideline using the GRADE system, no grading
of the evidence level is provided for individual recommen-
dations. Each guidance statement is based on synthesis of
limited evidence, theoretical rationale, practical consider-
ations, a survey of SHEA membership and the SHEAResearch
Network, author opinion, and consideration of potential
harm where applicable. An accompanying rationale is listed
alongside each recommendation.
gui dance statement
There is a paucity of data on the optimal approach to HCP
attire in clinical, nonsurgical areas. Attire choices should at-
tempt to balance professional appearance, comfort, and prac-
ticality with the potential role of apparel in the cross-trans-
mission of pathogens resulting in healthcare-associated
infections (HAIs).
As the SHEA workgroup on HCP attire, we recommend
the following:
I. Appropriately designed studies should be funded and
performed to better dene the relationship between HCP
attire and HAIs.
II. Until such studies are reported, priority should be placed
on evidence-based measures to prevent HAIs (eg, hand
hygiene, appropriate device insertion and care, isolation
of patients with communicable diseases, environmental
disinfection).
III. The following specic approaches to practice related to
HCP attire may be considered by individual facilities;
however, in institutions that wish to pursue these prac-
tices, measures should be voluntary and accompanied by
a well-organized communication and education effort
directed at both HCP and patients.
A. Bare below the elbows (BBE): This article denes
BBE as HCPs wearing of short sleeves, no wristwatch,
no jewelry, and no ties during clinical practice. Facilities
may consider adoption of a BBE approach to inpatient
care as an infection prevention adjunct, although the
optimal choice of alternate attire, such as scrub uni-
forms or other short-sleeved personal attire, remains
undened.
1. Rationale: While the incremental infection preven-
tion impact of a BBE approach to inpatient care is
unknown, this practice is supported by biological
plausibility and studies in laboratory and clinical set-
tings and is unlikely to cause harm.
B. White coats: Facilities that mandate or strongly rec-
ommend use of a white coat for professional appearance
should institute one or more of the following measures:
1. HCP engaged in direct patient care (including house
staff and students) should possess 2 or more white
coats and have access to a convenient and economical
means to launder white coats (eg, institution-pro-
vided on-site laundering at no cost or low cost).
i. Rationale: These practical considerations may help
achieve the desired professional appearance yet al-
low for HCP to maintain a higher frequency of
laundering of white coats.
2. Institutions should provide coat hooks that would
allow HCP to remove their white coat (or other long-
sleeved outerwear) prior to contact with patients or
the patients immediate environment.
i. Rationale: This practical consideration may help
achieve the desired professional appearance yet
limit patients direct contact with potentially con-
taminated attire and avoid potential contamination
of white coats that may otherwise be hung on in-
appropriate objects in the hospital environment.
C. Other HCP apparel: On the basis of the current evi-
dence, we cannot recommend limiting the use of other
specic items of HCP apparel (such as neckties).
1. Rationale: The role played by neckties and other spe-
cic items of HCP apparel in the horizontal trans-
mission of pathogens remains undetermined. If neck-
ties are worn, they should be secured by a white coat
or other means to prevent them from coming into
direct contact with the patient or near-patient
environment.
D. Laundering:
1. Frequency: Optimally, any apparel worn at the bed-
side that comes into contact with the patient or pa-
tient environment should be laundered after daily
use. In our opinion, white coats worn during patient
care should be laundered no less frequently than once
a week and when visibly soiled.
i. Rationale: White coats worn by HCP who care for
very few patients or by HCP who are infrequently
involved in direct patient care activities may need
to be laundered less frequently than white coats
shea expert guidance: healthcare personnel attire 109
worn by HCP involved with more frequent patient
care. At least weekly laundering may help achieve
a balance between microbial burden, visible clean-
liness, professional appearance, and resource
utilization.
2. Home laundering: Whether HCP attire for non-
surgical settings should be laundered at home or pro-
fessionally remains unclear. If laundered at home, a
hot-water wash cycle (ideally with bleach) followed
by a cycle in the dryer is preferable.
i. Rationale: A combination of washing at higher tem-
peratures and tumble drying or ironing has been
associated with elimination of both pathogenic
gram-positive and gram-negative bacteria.
E. HCP footwear: All footwear should have closed toes,
low heels, and nonskid soles.
1. Rationale: The choice of HCP footwear should be
driven by a concern for HCP safety and should de-
crease the risk of exposure to blood or other poten-
tially infectious material, sharps injuries, and slipping.
F. Identication: Name tags or identication badges
should be clearly visible on all HCP attire for identi-
cation purposes.
1. Rationale: Name tags have consistently been identi-
ed as a preferred component of HCP attire by pa-
tients in several studies, are associated with profes-
sional appearance, and are an important component
of a hospitals security system.
IV. Shared equipment, including stethoscopes, should be
cleaned between patients.
V. No guidance can be offered in general regarding prohib-
iting items like lanyards, identication tags and sleeves,
cell phones, pagers, and jewelry, but those items that
come into direct contact with the patient or environment
should be disinfected, replaced, or eliminated.
methods
Using PubMed/Medline, between the months of January and
May 2013 we searched the English literature for articles per-
taining to HCP attire in clinical settings focusing on areas
outside the OR. We included all studies dealing with bacterial
contamination and laundering of HCP attire, patients and
providers perceptions based on the type of attire, and/or HCP
footwear.
Additionally, we reviewed and compared hospital policies
related to HCP attire from 7 large teaching hospitals, as sub-
mitted by members of the SHEA Guidelines Committee. Fi-
nally, between February and May 2013 we sent out a survey
to all SHEA members to assess their institutional HCP attire
policies (if any) and to determine their perceptions of HCP
attire as a vehicle for potential transmission of pathogens.
results
I. Patients Perceptions of HCP Attire
We identied 26 studies (published from 1990 onward) that
examined patients perceptions of HCP attire
1-26
(Table 1).
Most (23/26) studies surveyed patient preference for different
types of HCP attire
1-6,8-18,20-25
using either pictures of models
in various dress styles
3,4,7-9,15-18,20,22-24
or descriptions of at-
tire.
1,5,11,14,21,25
Four studies
6,10,12,13
asked patients to assess the
attire of their actual physicians. Attire descriptions and ter-
minology varied among studies (eg, formal, business,
smart, suit and tie, and dress) and will be referred to
hereafter as formal attire. We use casual attire to refer to
anything other than formal attire.
A. Formal attire and white coats: Most of the studies using
pictures and models of HCP attire indicated patient pref-
erence for formal attire, which was favored over both
scrubs
1,3,7,9,18,22
and casual attire.
7,9,15,16,19,22
However, several
other studies revealed that physician attire was unlikely
to inuence patients levels of comfort,
4,20
satisfaction,
trust, or condence in physicians abilities,
2,4,9,19,20,25
even
if patients previously had expressed a preference for one
type of attire.
4,9,20,25
Fifteen studies addressed white coats.
1,4,7-9,11-17,20-22
In 10
of these studies, patients preferred that physicians wear
white coats,
1,7-10,12,15-17
and in 1 study patients reported
feeling more condent in those physicians.
8
Similarly, 2
studies showed a signicant association between the pres-
ence of a white coat, especially on a female physician, and
patients trust and willingness to share sensitive infor-
mation.
22
Patients also indicated less comfort in dealing
with an informally dressed physician,
16
describing a shirt
and a tie as the most professional and desirable attire for
physicians
23-25
in addition to an overall well-groomed ap-
pearance.
5,15
Moreover, the following items were deemed
as inappropriate or undesirable: jeans,
5,14
shorts,
15
clogs,
14,15
and open-toed sandals.
15
In the remaining 5
studies, patients showed no clear predilection for one dress
style over another or did not consider a white coat either
necessary or expected.
4,11,13,20,21
Five studies assessed patient satisfaction, condence, or
trust on the basis of their treating physicians dress,
2,6,10,12,13
showing little response variations regardless of apparel. A
survey of patients seen by obstetricians/gynecologists who
were randomly assigned formal attire, casual attire, or
scrubs found high satisfaction with physicians regardless
of the group allocation.
6
Similarly, in a before-and-after
trial, emergency department (ED) physicians were asked
to wear formal attire with a white coat one week followed
by scrubs the subsequent week. Using a visual analog scale,
patients rated their physicians appearance, professional-
ism, and satisfaction equally regardless of the week of
observation.
13
Another ED study found no difference in
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patients satisfaction with the care provided when their
physicians wore white coats combined with either scrubs
or formal attire.
2
Similarly, 2 groups of patients who re-
ceived preoperative care by the same anesthesiologist
wearing either formal attire for one group of patients or
casual attire for the other found no differences in patient
satisfaction between the groups.
10
In contrast, one cross-
over trial involving physicians dressed in respectable or
formal versus retro or casual attire found that patient
condence and trust were higher with the respectable-
dress protocol.
19
Another study evaluating the attire of
patients treating physicians indicated preference for pol-
ished shoes and short hair for men, with jeans, clogs,
trainers, and earrings on men being rated as undesirable.
10
A survey among Japanese outpatients indicated a pref-
erence for white coats but no signicant difference in
satisfaction levels based on attire when presented with
physicians wearing white coats or noninstitutional
clothes.
12
B. BBE: Preference for BBE was assessed in 6 studies origi-
nating in the United Kingdom following implementation
of the nationwide BBE policy
1,3,23-25
and in 1 US study.
11
In these 7 reports, patients did not prefer short sleeves.
After informing patients of the BBE policy, older patients
were more likely to prefer short-sleeved shirts without ties,
while younger patients favored scrubs.
1
After providing
information about the potential for cross-contamination
from shirt sleeve cuffs and neckties, responses changed
from a preference for formal or long-sleeved attire to a
preference for short sleeves or scrubs.
11,18,23
In addition,
Shelton et al
23
also found an association between physician
gender and BBE attire: after a statement informing the
participants of the potential cross-transmission of micro-
organisms by attire, patients preferred scrubs for female
physicians but did not differentiate between scrubs and
short-sleeved shirts for male physicians.
C. Ties: Neckties were specically addressed in several studies
from the United Kingdom.
5,21,24
In one study, patients re-
ported that attire was important but that neckties were
not expected.
21
Similarly, in a survey among individuals
in the public concourse of a hospital, 93% had no ob-
jection to male physicians not wearing ties.
5
None of these
studies evaluated neckties in the context of patients per-
ceptions of infection prevention.
D. Laundering of clothes: In one study, patients identied
daily laundered clothing as the single most important
aspect of physicians appearance.
8
E. Other factors: Several additional variables may inuence
patient preference for physician attire, including age of
either the patient or the managing physician, gender of
the practitioner, time of day, setting, and the attire patients
are accustomed to seeing. In Japan, older patients were
more likely to prefer white coats.
12
Similarly, older patients
in England found scrubs less appealing than did younger
patients.
8
Pediatric dental patients were more likely than
their parents to favor casual attire.
17
Patients preferred
formal attire for senior consultants but thought that junior
physicians should be less formal.
1
Patients identied fe-
male physicians attire as more important than the attire
worn by male physicians.
22
Formal attire was less desirable
by patients seen during the night shift.
9
Parents of children
being seen in the ED favored surgical scrubs. Additionally,
2 trials evaluated attire preference on the basis of what
patients often see their HCP wearing. In one trial, patients
accustomed to seeing their anesthesiologist in a suit were
more likely to nd suits and ties desirable.
10
Similarly, the
practice to which a patient belonged was found to be an
independent factor in the patients choice of preferred
attire;
16
however, another study found poor agreement be-
tween patient preferences and their physicians typical
attire.
11
In summary, patients express preferences for certain types
of attire, with most studies indicating a predilection for formal
attire, including a white coat, but these partialities had a
limited overall impact on patient satisfaction and condence
in practitioners. This is particularly true in trials that eval-
uated the effect of attire on patient satisfaction in real-world
settings. Patients generally do not perceive white coats, formal
attire, or neckties as posing infection risks; however, when
informed of potential risks associated with certain types of
attire, patients appear willing to change their preferences for
physician attire.
11,18
II. HCP Perceptions regarding Attire
Few studies evaluated HCP preferences with regard to at-
tire.
5,6,14,26
While most studies addressed specic elements of
HCP attire, one looked at the overall importance of attire
and found that 93% of physicians and nurses versus 83% of
patients thought that physician appearance was important for
patient care (P ! .001).
26
A. White coats: In a survey exploring perceptions of sur-
geons apparel performed among surgeons themselves, in-
patients, and the nonhospitalized public, all 3 groups were
equally likely to consider a white coat necessary and blue
jeans inappropriate. Surgeons were more prone to con-
sider scrubs and clogs appropriate.
14
In another survey of
15 obstetricians/gynecologists, 8 preferred casual attire,
while 7 preferred formal attire.
6
Three studies assessed
HCP alongside patient perception of infection risk or lack
of hygiene associated with white coats, formal attire, or
neckties,
3,24,26
with one nding that HCP were more likely
than patients to consider white coats unhygienic.
26
B. Ties: In a survey performed in a public concourse of a
UK hospital, HCP were more likely than non-HCP to
prefer physicians wearing of neckties for reasons of
professionalism.
5
C. Laundering of clothes: A recent survey showed that non-
surgical providers preferentially (and without prompting)
laundered their scrubs every 1.7 0.1 days (mean
standard error) compared with white coats, which were
laundered every 12.4 1.1 days (P ! .001); however, the
reasons for this divergent behavior remain unclear.
27
III. Studies of Microbial Contamination of Apparel in
Clinical and Laboratory Settings
No clinical studies have demonstrated cross-transmission of
healthcare-associated pathogens from a HCP to a patient via
apparel; however, a number of small prospective trials have
demonstrated the contamination of HCP apparel with a va-
riety of pathogens (Table 2).
5,28-37
A. White coats/uniforms: The 5 studies we evaluated indi-
cate that physician white coats and nursing uniforms may
serve as potential sources of colonization and cross-trans-
mission. Several studies described contamination of ap-
parel with Staphylococcus aureus in the range of 5% to
29%.
30,33-35,38
Although gram-negative bacilli have also been
identied, these were for the most part of low pathoge-
nicity;
30,35
however, actual pathogens, such as Acinetobacter
species, Enterobacteriaceae, and Pseudomonas species,
have been reported.
38
A number of factors were found to inuence the mag-
nitude of contamination of white coats and uniforms.
First, the degree of contamination was correlated with
more frequent usage of the coat,
35
recent work in the
inpatient setting,
34
and sampling certain parts of the uni-
form. Higher bacterial loads were found on areas of cloth-
ing that were more likely to come into contact with the
patient, such as the sleeve.
35
Additionally, the burden of
resistant pathogens on apparel was inversely correlated
with the frequency of lab coat change.
38
Apparel contam-
ination with pathogenic microorganisms increased over
the course of a single patient care shift. Burden et al
28
demonstrated that clean uniforms become contaminated
within only a few hours of donning them. Similarly, a
study testing nurses uniforms at both the beginning and
the end of their shifts described an increase in the number
of uniforms contaminated with one or more microor-
ganisms from 39% to 54%, respectively. The proportion
of uniforms contaminated with vancomycin-resistant en-
terococci (VRE), methicillin-resistant S. aureus (MRSA),
and Clostridium difcile was also noted to increase with
shift work.
33
In the rst report of a positive correlation between
contamination of hands and contamination of white coats,
Munoz-Price et al
39
cultured the hands, scrubs, and white
coats of intensive care unit staff. The majority of bacteria
isolated from hands were skin commensals, but HCP were
also found to have contamination of hands, scrubs, and
white coats with potentially pathogenic bacteria, including
S. aureus, Enterococcus species, and Acinetobacter bau-
mannii. Among dominant hands, 17% of 119 hands were
contaminated with one of these species, and staff members
with contaminated hands were more likely to wear a white
coat contaminated with the same pathogen. This associ-
ation was not observed with scrubs.
B. BBE: Two observational trials evaluated the bacterial con-
tamination of HCPs hands on the basis of BBE attire
versus controls, nding no difference in total bacterial
counts or in the number of clinically signicant patho-
gens.
40,41
In contrast, Farrington et al,
42
using a uorescent
method, examined the efcacy of an alcohol hand wash
among BBE providers versus controls. The authors found
decreased efcacy of hand hygiene at the wrist level in the
non-BBE group, suggesting that the BBE approach may
improve wrist disinfection during hand washing.
The United Kingdom has adopted a BBE approach, on
the basis of the theory that it will limit patient contact
with contaminated HCP apparel and to promote better
hand and wrist hygiene. However, a randomized trial com-
paring bacterial contamination of white coats against BBE
found no difference in total bacterial or MRSA counts (on
either the apparel itself or from the volar surface of the
wrist) at the end of an 8-hour workday.
28
C. Scrubs: The use of antimicrobial-impregnated scrubs has
been evaluated as a possible solution to uniform contam-
ination. In a prospective, randomized crossover trial of
30 HCP in the intensive care unit setting,
36
when com-
pared with standard scrubs, antimicrobial-impregnated
scrubs were associated with a 47 mean log reduction in
surface MRSA burden, although there was no difference
in MRSA load on HCP hands or in the number of VRE
or gram-negative bacilli cultured from the scrubs. The
study did not assess the HAI impact of the antimicrobial
scrubs.
D. Ties: Several studies indicated that neckties may be col-
onized with pathogenic bacteria, including S. aureus. Lo-
pez et al
31
reported a signicantly higher bacterial burden
on neckties than on the front shirt pocket of the same
subject. In 3 studies, up to 32% of physician neckties grew
S. aureus.
5,31,37
Steinlechner et al
37
identied additional po-
tential pathogens and commensals from necktie cultures,
including Bacillus species and gram-negative bacilli. Two
reports found that up to 70% of physicians admitted hav-
ing never cleaned their ties.
5,31
E. Laundering of clothes: Numerous articles published dur-
ing the past 25 years describe the efcacy of laundering
hospital linens and HCP clothing,
44
but most investiga-
tions of the laundering of HCP attire have employed in
vitro experimental designs that may or may not reect
real-life conditions. A 2006 study
45
demonstrated that
while clothes lost their burden of S. aureus, they concom-
itantly acquired oxidase-positive gram-negative bacilli in
the home washing machine. These bacteria were nearly
eliminated by tumble drying or ironing. Similarly, inves-
tigators found that recently laundered clothing material
acquired gram-negative bacteria from the washing ma-
chine, which were subsequently eliminated by ironing. An-
other in vitro study in the United Kingdom compared the
reduction of microorganisms on articially inoculated
nurses uniform material after washing at various tem-
peratures as well as with and without detergents. Washing
uniforms contaminated with MRSA and Acinetobacter spe-
cies at a temperature of 60C, with or without detergent,
achieved at least a 7-log reduction in the bacterial burden
of both microorganisms.
46
There is no robust evidence
that centralized industrial laundering decontaminates
clothing more effectively than home laundering.
43
F. Footwear: Although restrictions on HCP footwear are in-
uenced by a desire to meet patients preferences for ap-
propriate attire,
10,14,15
most are driven by concerns for HCP
safety.
47-50
Studies have found that wearing of shoes with
closed toes, low heels, and nonskid soles can decrease the
risk of exposure to blood or other potentially infectious
material,
47,48,50,51
sharps injuries,
48,50,52
slipping,
50
and mus-
culoskeletal disorders.
49
Casual, open footwear, such as sandals, clogs, and foam
clogs, potentially expose feet to injury from dropped con-
taminated sharps and exposure to chemicals in healthcare
facilities. A comparison of needlestick injury surveillance
data from the standardized Exposure Prevention Infor-
mation Network program revealed a higher proportion of
hollow-bore needle injuries to the feet of Japanese HCP,
with 1.5% of 16,154 total injuries compared with 0.6% of
9,457 total injuries for US HCP (2.5 times higher; P !
.001).
48
Although multiple factors were linked to these in-
juries, one included the common practice in Japan to re-
move outdoor shoes and replace them with open-toed
slippers on hospital entry.
Footwear is an area of increased concern in the OR.
The Association of periOperative Registered Nurses
(AORN) recommends that OR footwear have closed toes
as well as backs, low heels, and nonskid soles to prevent
slipping.
50
The US Occupational Safety and Health Ad-
ministration (OSHA) requires the use of protective shoes
in areas where there is a danger of foot injuries from falling
objects or objects piercing the soles.
47
One study that mea-
sured the resistance of shoes to penetration by scalpels
showed that of the 15 pairs of shoes studied, only 6 were
made of material that was sharp resistant, including
sneaker suede, suede with inner mesh lining, leather with
inner canvas lining, nonpliable leather, rubber with inner
leather lining, and thicker rubber.
52
The OSHA bloodborne
pathogens standard mandates that employers determine
the workplace settings in which gross contamination with
blood or body uids is expected, such as the OR, and to
provide protective shoe coverings in those settings.
47,48,50,51
Shoe covers are not meant to prevent transmission of bac-
teria from the OR oor; in fact, preliminary data show
that the OR oor may play a dynamic role in the horizontal
transmission of bacteria due to frequent oor contact of
objects that then directly touch the patients body (eg,
intravenous tubing, electrocardiogram leads).
53
When HCP safety concerns or patient preference con-
ict with a HCPs desire for fashion, a facilitys dress code
can be the arbiter of footwear. OSHA allows employers to
make such dress code determinations without regard to a
workers potential exposure to blood, other potentially in-
fectious materials, or other recognized hazards.
IV. Outbreaks Linked to HCP Apparel
Wright et al
54
reported an outbreak of Gordonia potentially
linked to HCP apparel. In this report, postoperative sternal
wound infections with Gordonia bronchialis in 3 patients were
linked to a nurse anesthetist. Gordonia was isolated from the
HCPs scrubs, axillae, hands, and purse and from multiple
sites on the HCPs roommate.
V. Studies from Developing Countries
In Nigeria, factors identied increasing the likelihood of bac-
terial contamination of white coats included daily laundering
and use limited to patient care rather than nonclinical du-
ties.
55
In India,
56
medical students white coats were assessed
for bacterial contamination, paired with surveys about laun-
dering habits and attitudes toward white coats. Coats were
contaminated most frequently with S. aureus, followed by
Pseudomonas species and coagulase-negative staphylococci. A
similar trial of white coats used by staff in a rural dental clinic
also revealed predominantly gram-positive contamination.
57
VI. Hospital Policies Addressing HCP Attire
We reviewed and compared policies related to HCP attire
from 7 large teaching hospitals or health systems. In general,
policies could be categorized into 2 groups:
A. General appearance and dress of all employees
B. Standards for HCP working in sterile or procedure-based
environments (OR, central processing, procedure areas, etc)
Policies were evaluated for the following elements:
A. Recommended clothing (eg, requirement for white coats,
designated uniforms) or other options (eg, BBE)
B. Guidance regarding scrubs
C. Use of name tags
D. Wearing of ties
E. Requirements for laundering or change of clothing
F. Footwear and nonapparel items worn or carried by HCP
G. Personal protective equipment
All institutions human resources policies outlined general
appearance or dress code requirements for professional stan-
dards of business attire; however, institutions varied in job-
specic policies and for the most part did not address more
specic attire requirements except for OR-related activities.
Few institutional policies included enforcement provisions.
The institutions that required accountability varied from de-
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tailing the supervisors administrative responsibilities to more
specic consequences for employee noncompliance.
Three institutions recommended clothing (such as color-
coded attire) for specic types of caregivers (eg, nurses,
nurses assistants, etc). Policies specic to clinical personnel
were most frequently related to surgical attire, including
scrubs, use of masks, head covers, and footwear in restricted
and semirestricted areas and surgical suites, and to central
processing, as consistent with AORN standards. Scrubs were
universally provided by the hospital in these settings. Laun-
dering policies clearly indicated that laundering of hospital-
provided scrubs was to be performed by the hospital or at a
hospital-accredited facility. Use of masks, head covers, foot-
wear, and jewelry were generally consistent with AORN
standards.
Excluding surgical attire, only one institution provided
guidance specic to physicians, outlining a recommendation
for BBE attire during patient care. This policy specied not
to use white coats, neckties, long sleeves, wristwatches, or
bracelets. Institutional policies also varied in recommenda-
tions for laundering and change of clothing other than for
surgical attire. No specic guidance was issued for other uni-
forms, other than cleanliness and absence of visible soiling;
however, one institution referred to infection control speci-
cations for maintenance of clothing. Guidance regarding
frequency of clothing change was variable for scrubs, from
nonspecic requirements (eg, wearing freshly laundered sur-
gical attire on entry to restricted/semirestricted areas) to spe-
cic requirements (clean scrubs once per shift to once daily
and if visibly soiled). In addition, most policies included in-
structions for HCP to remove scrubs and change into street
clothes either at the end of the shift or when leaving the
hospital or connected buildings.
VII. Survey Results
A total of 337 SHEA members and members of the SHEA
Research Network (21.7% response of 1,550 members) re-
sponded to the survey regarding their institutions policies
for HCP attire. The majority of respondents worked at hos-
pitals (91%); additional facilities included freestanding chil-
drens hospitals (4%), freestanding clinics (1%), and other
facility types (5%), such as long-term acute care hospitals,
multihospital systems, short-term nursing facilities, and re-
habilitation hospitals (rounding of numbers accounts for the
sum of percentages being greater than 100). The majority of
responses were from either university/teaching hospitals
(39%) or university/teaching-afliated hospitals (28%). We
received additional responses from nonteaching hospitals
(24%), Veterans Affairs hospitals (3%), specialty hospitals
(2%), and miscellaneous facilities (4%).
Enforcement of HCP attire policies was low at 11%. A
majority of respondents (65%) felt that the role of HCP attire
in the transmission of pathogens within the healthcare setting
was very important or somewhat important.
Only 12% of facilities encouraged short sleeves, and 7%
enforced or monitored this policy. Pertaining to white coats,
only 5% discouraged their use and, of those that did, 13%
enforced or monitored this policy. For watches and jewelry,
20% of facilities had a policy encouraging their removal. A
majority of respondents (61%) stated that their facility did
not have policies regarding scrubs, scrub-like uniforms, or
white coats in nonclinical areas. Thirty-one percent re-
sponded that their hospital policy stated that scrubs must be
removed before leaving the hospital, while 13% stated that
scrubs should not be worn in nonclinical areas. Neckties were
discouraged in 8% of facilities, but none monitored or en-
forced this policy.
Although 43% of respondents stated that their hospitals
issued scrubs or uniforms, only 36% of facilities actually laun-
dered scrubs or uniforms. A small number of hospitals pro-
vided any type of guidance on home laundering: 13% pro-
vided specic policies regarding home laundering, while 38%
did not.
In contrast to other items of HCP attire, half of facilities
required specic types of footwear, and 63% enforced and/
or monitored this policy.
di scussi on
Overall, patients express preferences for certain types of attire,
with most surveys indicating a preference for formal attire,
including a preference for a white coat. However, patient
comfort, satisfaction, trust, and condence in their physicians
is unlikely to be affected by the practitioners attire choice.
The ability to identify a HCP was consistently reported as
one of the most important attributes of HCP attire in studies.
This was particularly true in studies that evaluated the effect
of attire of actual physicians on patient satisfaction in a real-
world setting rather than those assessing the inuence of
physician attire on patient satisfaction in the abstract. Patients
generally did not perceive white coats, formal attire, or ties
as posing infection risks; however, when informed of potential
risks associated with certain types of attire, patients were
willing to change their preferences for physician attire.
11,18
Data from convenience-sample surveys and prospective
studies conrm that contamination occurs for all types of
HCP apparel, including scrubs, neckties, and white coats, with
pathogens such as S. aureus, MRSA, VRE, and gram-negative
bacilli. HCP apparel can hypothetically serve as a vector for
pathogen cross-transmission in healthcare settings; however,
no clinical data yet exist to dene the impact of HCP apparel
on transmission. The benet of institutional laundering of
HCP scrubs versus home laundering for non-OR use remains
unproven. A BBE approach is in effect in the United Kingdom
for inpatient care; this strategy may enhance hand hygiene
to the level of the wrist, but its impact on HAI rates remains
unknown.
Hospital policies regarding HCP attire were generally con-
sistent in their approach to surgical attire; however, general
dress code policies varied from guidance regarding formal
attire to use of job-specic uniforms. Laundering and change
of clothing was also not consistently addressed other than for
surgical attire. Finally, accountability for compliance with the
attire policies by HCP and supervisors was not routinely in-
cluded in the policies.
areas for future research
I. Determine the role played by HCP attire in the horizontal
transmission of nosocomial pathogens and its impact on
the burden of HAIs.
II. Evaluate the impact of antimicrobial fabrics on the bac-
terial burden of HCP attire, horizontal transmission of
pathogens, and HAIs. Concomitantly, a cost-benet anal-
ysis should be conducted to determine the nancial merit
of this approach.
III. Establish the effect of a BBE policy on both the horizontal
transmission of nosocomial pathogens and the incidence
of HAIs.
IV. Explore the behavioral determinants of laundering prac-
tices among HCP regarding different apparel and examine
potential interventions to decrease barriers and improve
compliance with laundering.
V. Examine the impact of not wearing white coats on pa-
tients and colleagues perceptions of professionalism on
the basis of HCP variables (eg, gender, age).
VI. Evaluate the impact of compliance with hand hygiene
and standard precautions on contamination of HCP
apparel.
acknowledgments
Financial support. This study was supported in part by the SHEA Research
Network.
Potential conicts of interest. G.B. reports receiving grants from Pzer,
Cardinal Health, BioVigil, and Vestagen Technical Textiles. M.E.R. reports
receiving research grants/contracts from 3M and having an advisory/con-
sultant role with 3M, Ariste, Care Fusion, and Molnlycke. All other authors
report no conicts of interest relevant to this article.
Address correspondence to Gonzalo Bearman MD, MPH, Virginia Com-
monwealth University, Internal Medicine, Richmond, VA 23298 (gbearman
@mcvh-vcu.edu).
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