Saturday, August 11, 2007

Why Do We Wear These?

I was reading the "America's Best Hospitals 2007" feature in US News & World Report recently, and one article in particular caught my attention. The article addressed bacterial contamination in the hospital; apparently, even though restaurants and cruise ships are routinely checked for germs, hospitals are NOT. No one routinely checks the amount of MRSA on the floor or operating table in the OR; no one swabs the ventilator machines in the ICU for VRE; no one looks to see which surfaces are contaminated with resistant Acinetobacter. This in itself is rather shocking to me; if we check the place which packages our hamburger meat, how can we not check the place where we allow our bodies to be cut open?

The most shocking point of the article, though, was the accusation that doctors' white coats are a source of infection. I fall into the 16% of doctors in one survey who admitted not washing their white coats in over a month. While they don't present actual data, the most recent article I found (BMJ, 1991) showed Staph aureus contamination on the pockets and cuffs of over 25% of doctors' coats. They recommended washing coats once a week and removing them when checking surgical wounds.

It's rather shocking that the most recent article I found on Pubmed was done in 1991. Similarly, articles on stethoscope contamination are hard to come by, but seem to suggest that frequent wiping with alcohol, at least once a day, can prevent transference of bacteria within the hospital.

This leaves me with a few questions:

  • Why aren't more studies being done in these areas? Is there a lack of funding, or a lack of interest? Are we afraid to see just how often WE cause the infections?
  • Why isn't this data more widely known? Signs about hand-washing blare on every wall of the hospital. I've never seen a sign that said "Wash your coat!" or "Take this alcohol wipe and use it on your stethoscope!"
  • Why do we wear the white coat?

So, why do we wear the white coat? Sure, it differentiates doctors from non-doctors (generally), and the short coat differentiates the medical student, but is this all? I mean, I stuff the pockets with books, H&P paper, pens, PDA, etc., but pockets in pants or a sweater would do as well. Alternately, we could all wear fanny packs, which the anesthesiologists are keeping in style, or carry back packs or purses. There are other ways to tote what we need--so why the coat?

Is it the tradition? Just like medical rounds, or the tradition of medical hierarchy, or "residency", or pimping, any of the other crap we do just because it's always been done that way. Is it because wearing a white coat makes us feel special, important, and causes people to call us "Doctor"? A well-displayed name badge can do the same thing.

Reading that article just really got me to thinking. It's difficult to unload my white coat, use the bleach pen on the pen marks, wash it, dry it, and reload it. Or is it? Am I just lazy? (Yes!) Would it be better, for purposes of infection control, to have a laundry service for lab coats? Some hospitals have such a thing, but even then doctors often don't utilize it (I've watched my residents). If this is such a problem, wouldn't it be in the hospitals' best interest to require a coat exchange or laundry service?

It's interesting that the hospitals are so scared of JCAHO finding an order that isn't dated, timed, signed, stamped, with a pager and dictation number on it, but no one's checking up on the VRE which may be on the EKG wires or the C. difficile on the blood pressure cuffs (EWWWWW--just remember this is fecal-oral!). I doubt these incidents are unique to the hospitals mentioned in the article. I'd imagine that if all hospitals were routinely swabbed and cultured like we do our patients, we'd find sources of these "super bugs" in unusual places, places we don't usually think to check. Apparently, though, JCAHO only bothers to investigate a "visibly dirty" room, but does not routinely check bacterial contamination on its hospital accreditation inspections.

For example, a friend of mine went to school in the Northeast, where computer kiosks were located throughout the campus. Between classes, students would be found at these computers messaging each other. One day, a few students present to the student health clinic with pink eye. It's only a couple of cases, and the most common cause of pink eye is viral, so the doctors tell the students not to worry, just use some eye drops, avoid touching their eyes and wash their hands frequently, as it's quite contagious. Only more and more students start to come to the health center with pink eye. The first to be infected aren't getting better, either, as you'd expect with a viral conjunctivitis. Finally, someone requests antibiotics, takes them, and recovers; finally everyone realizes the infection is bacterial, the affected students are treated, and the incident resolves.

So how did a large percentage (14%) of this campus contract bacterial conjunctivitis? It turns out that the infection had found a nice place to reside: the keyboards of these computer kiosks. In addition to other means of infection control (hand-washing, etc.), they replaced the keyboards, as they're difficult to disinfect.

How many patients have I touched after using the computer to look up labs? I really try to use the alcohol gel before and after I see patients, but I forget. How about the phones? The doorknobs?

Here's why we don't routinely culture hospitals, even though we used to until 1970: Yet the CDC's latest guidelines still deem routine testing for bacteria unnecessary. "If you culture on a regular basis, you're always going to find something," says Denise Cardo, who runs the CDC's division of healthcare quality promotion. "You don't want the labs to be used for that instead of tests on patients."

If you culture on a regular basis, you're going to find something? I realize cultures can be contaminated themselves, and they're not perfect, but my god, the reason you find something is perhaps because there's something to find! Sure, we assume that the floor is dirty, but who thinks about touching a telephone? Or our personal cellphone? Our pager or our pen?

It's enough to make anyone OCD.

Fortunately, the article suggests a simple solution: more soap and water. The British National Health Service tried doubling the hours of the cleaning staff on one ward, and reduced MRSA infections by 90%. The cost reduction from having fewer infections paid for the janitorial staff increase many times over. An article in the current Journal of Hospital Infections (July 2007) describes simple modifications in cleaning technique which reduced "residual organic soil"--bacteria breeding ground--from 86-100% after cleaning to 0-14% after cleaning.

In other words, we know what we have to do. What is keeping us from doing it?

I think I'm going to go wash my white coat now.


The Peanut Gallery said...

I'm having insomnia tonight and just woke up, but I think the point of the white coat is to show we are 'clean and sterile.' I think it is why docs started wearing them. Oh the irony.
I had no idea that JHACO didn't look for microbes. It is disgusting. Imagine what is happening in the A/C ducts/vents. I bet it is fungi central.

Rach said...

Off topic, but do you have to wear your White coat on your psych rotation?

Tiny Shrink said...

I don't have to, but a) everyone else on my team wears one and b) people don't ask me what I'm up to if I'm wearing one. It's funny that I wear a name tag all the time, and that should identify me, but if I'm wearing the white coat no one ever asks questions.

As for the white coat looking crisp and clean, it certainly CAN provide that image, but then, it can also look exactly the opposite--a dirty white coat just looks NASTY. (I should know, as I'm really bad about washing mine.)

Tiny Shrink said...

A little Pseudomonas in the AC vent, perhaps?

crazedturkey said...

Interesting actually, given that here in Aus, we do swab. Everything. We also isolate MRSA patients, and have to gown and glove to see them, then wash our hands afterwards.

Do you guys have the alcohol hand rub on the end of the bed?

And we don't wear white coats, just street clothes, and then put on gowns to work in areas with a high risk of infection like ICU.

Best check your stethoscope too, you'd be amazed how much crap gets carried on those (I douse mine in alcohol between patients too!)

- crazedturkey (an Aus med student)

medrecgal said...

Wow...when I was hospitalized with MRSA, there were strict isolation precautions in place, and I couldn't even go anywhere without a gown and gloves on (keep in mind I was the patient). Just about anyone who had anything to do with my care had to follow the same protocol, and anything that was a fomite was scrubbed down regularly. Those nice white coats can develop that propensity, too, particularly since they're worn into so many different places, some of which can be hotbeds for infection. If I had something I wore that frequently, I'd be washing it at least once a week, mostly now out of pure paranoia and a desire to stay OUT of the hospital (at least as a patient; I'd be more than happy to return for a job in medical records).