Blog | Thursday, November 5, 2015

Debating bare below the elbows


At IDWeek in San Diego I debated Neil Fishman on bare below the elbows, a topic that regular readers of this blog know is 1 of my favorites. I had 10 minutes to deliver the pro argument and Neil had the same for the con. You can read an unbiased account of the debate here.

So in my 10 minutes, here's what I argued:
• We have conclusive evidence that health care workers' clothing becomes contaminated with pathogens during the care of patients.
• There is some in vitro evidence that pathogens can be transmitted from clothing to patients.
• There is no evidence that intervening (removing white coats and neckties and having health care workers go bare below the elbows) reduces health care associated infections, though of course, absence of evidence is not necessarily absence of effect.
• The literature on patient preference for physician attire shows mixed results in weak studies where patients look at pictures of doctors in different attire, while studies that randomized attire show no difference in patient satisfaction, and others that add context show that attire is one of the least important characteristics that patients consider in evaluating their physician.
• On the basis of biologic plausibility, I argued that we should recommend (but not mandate) bare below the elbows.

Neil argued the following (and I've added my comments in italics):
• We already have too many metrics to follow and we shouldn't add one more. We can't be the “fashion police.” (There's no added work to implement bare below the elbows. Give health care workers permission to do it and provide some encouragement).
• Bare below the elbows is not enforceable (With no mandate there is nothing to enforce).
• Arms are just as likely to be contaminated as the sleeves of the white coat (True, but you can wash your arms between patients; in a survey of physicians that we published, nearly 20% reported that they had NEVER washed their white coats).
• 5% of the population has eczema or psoriasis, and these individuals have higher rates of staphylococcal colonization (True, but we usually don't formulate policy on the 5% exception).
• If the white coat goes, all measures of hygiene will decline. (This is a borderline insane argument borrowed from Stephanie Dancer, that I previously blogged about here).

So what was the verdict? Before the debate, 37% of the audience supported bare below the elbows, and after the debate 42% were in support. So in 10 minutes I moved the needle 5 percentage points. Not dramatic, but I'll take it. But just imagine having this debate 10 years ago, or even 5 years ago; I suspect supporters would account for <10%.

Any intervention that involves changing behavior produces incremental results. But from firsthand experience, I know it can be done. At Virginia Commonwealth University, we recommended a bare below the elbows approach to inpatient care in 2009. It was a very soft rollout—no mandate, just a recommendation. Gonzalo Bearman, Mike Stevens and I consistently wore scrubs and others slowly joined in. It started with just 3 people. Last year, before I left that university, we did a 12-week prevalence survey and we were pleasantly surprised to see that 69% of inpatient encounters were via health care workers bare below the elbows. This year, it has increased to 80%. Compliance was boosted when the medical school bought their students scrubs and nylon vests (see the photo of Gonzalo with some VCU medical students). I think this is an amazing accomplishment, and I will venture a guess that 10 years from now, the vast majority of doctors in the U.S. will look just like those in that picture.

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on improving the quality and safety of health care, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.