Healthcare attire and infection prevention

Can healthcare personnel in non-OR settings transmit healthcare-associated infections via their uniforms or attire? Possibly. That’s why, as more evidence is being developed, hospitals should take precautions. The Society for Healthcare Epidemiology of America (SHEA) published a series of recommendations on the subject in February.

Studies have demonstrated the clothing of healthcare personnel may have a role in the transmission of pathogens, said Gonzalo Bearman, MD, MPH, a lead author of the recommendations and member of SHEA’s Guidelines Committee. “This document is an effort to analyze the available data, issue reasonable recommendations, define expert consensus, and describe the need for future studies to close the gaps in knowledge on infection prevention as it relates to [healthcare personnel] attire.”

Healthcare facilities should consider a number of practices, according to the recommendations.

“Bare below the elbows” (BBE). Facilities may consider adopting a BBE approach to inpatient care as a supplemental infection prevention policy. (BBE is defined as wearing of short sleeves and no wristwatch, jewelry, or ties during clinical practice.) However, an optimal choice of alternate attire, such as scrub uniforms or other short-sleeved personal attire, remains undefined. “While the incremental infection prevention impact of a BBE approach to inpatient care is unknown, this practice is supported by biological plausibility and studies in laboratory and clinical settings, and is unlikely to cause harm,” wrote the authors.

White coats. Facilities that mandate or strongly recommend use of a white coat for professional appearance should institute one or more of the following measures:

  • Personnel engaged in direct patient care (including house staff and students) should have two or more white coats available and access to a convenient and economical means to launder them (e.g. onsite, institution-provided laundering at no cost or low cost).
  • Institutions should provide coat hooks that allow personnel to remove their white coat prior to contact with patients or a patient’s immediate environment.

Other apparel. The authors fell short of recommending limiting the use of other specific items of apparel, such as neckties. “The role played by neckties and other specific items of [healthcare personnel] apparel in the horizontal transmission of pathogens remains undetermined. If neckties 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.”

Laundering. Optimally, any apparel worn at the bedside that comes in contact with the patient or patient environment should be laundered after daily use, says SHEA. White coats worn during patient care should be laundered no less frequently than once a week and when visibly soiled. At least weekly laundering may help achieve a balance between microbial burden, visible cleanliness, professional appearance, and resource utilization. If personnel launder apparel at home, a hot-water wash cycle (ideally with bleach) followed by a cycle in the dryer or ironing has been shown to eliminate bacteria.

Footwear. All footwear should have closed toes, low heels, and non-skid soles. “The choice of [healthcare personnel] footwear should be driven by a concern for [their] safety and should decrease the risk of exposure to blood or other potentially infectious material, sharps injuries, and slipping.”

Identification. Name tags or identification badges should be clearly visible on all healthcare personnel attire for identification purposes. Name tags are associated with professional appearance, and are an important component of a hospital’s security system.

Shared equipment, including stethoscopes, should be cleaned between patients.

The authors refrained from offering general guidance for prohibiting items such as lanyards, identification tags and sleeves, cellphones, pagers, and jewelry. However, items that come into direct contact with the patient or environment should be disinfected, replaced, or eliminated.

If implemented, all practices should be voluntary and accompanied by a well-organized communication and education effort directed at both HCP and patients, according to the authors of the recommendations.

To view the recommendations, which were published in the February 2014 issue of Infection Control and Hospital Epidemiology, go to

By the numbers

  • A total of 337 Society for Healthcare Epidemiology of America members and members of the SHEA Research Network (21.7 percent response of 1,550 members) responded to the survey regarding their institutions’ policies for healthcare personnel attire. The majority (91 percent) worked at hospitals.
  • A majority of respondents (65 percent) felt that the role of healthcare personnel attire in the transmission of pathogens within the healthcare setting was very important or somewhat important.
  • Twelve percent of facilities encouraged short sleeves, and 7 percent enforced or monitored this policy.
  • Five percent discouraged the use of white coats, and of those that did, 13 percent enforced or monitored this policy.
  • Twenty percent of facilities had a policy encouraging the removal of watches and jewelry.
  • A majority of respondents (61 percent) stated that their facility did not have policies regarding scrubs, scrub-like uniforms, or white coats in non-clinical areas.
  • Thirty-one percent responded that their hospital policy stated that scrubs must be removed before leaving the hospital, while 13 percent stated that scrubs should not be worn in non-clinical areas.
  • Neckties were discouraged in 8 percent of facilities, but none monitored or enforced this policy.
  • Although 43 percent of respondents stated that their hospitals issued scrubs or uniforms, only 36 percent of facilities actually laundered scrubs or uniforms. A small number of hospitals provided some guidance on home laundering: 13 percent provided specific policies regarding home laundering, while 38 percent did not.
  • Half of facilities required specific types of footwear, and 63 percent enforced and/or monitored this policy.