Wearing white coats and sitting on beds: why should it matter?

Abstract

A healthcare-associated infection (HCAI) is defined as any infection acquired as a consequence of a person's treatment by a healthcare provider, or which is acquired by a healthcare worker in the course of their duties.1 The Health and Social Care Act 2008 makes it clear that prevention and control of HCAI should be part of everyday practice and applied consistently by everyone.1 In 2006, about 8% of inpatients in acute hospitals in England were identified as having a HCAI.2 HCAIs obviously waste NHS resources. A patient with a methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia spends an average additional 10 days in hospital and for Clostridium difficile the additional length of stay is 21 days. Infections can cost a trust an extra £4,000–£10,000 per patient.3 Although it is not possible to prevent all infections,1 the emphasis placed on MRSA bacteraemias and C. difficile has shown it is possible to reduce numbers of these specific infections. A national target was introduced by the Department of Health (DH) in November 2004 to reduce MRSA bloodstream infection by 50% by 2008, against the baseline figure for 2003–4. Aggregate numbers for 2007–8 showed a 42% decrease, and a 61% decrease for 2008–9.4 Following the mandatory surveillance scheme introduced in January 2004, a national target was introduced in October 2007 to reduce numbers of C. difficile infection by 30% across all age groups by 2010–11, against the 2007–8 baseline. By December 2008, the numbers reported showed a 41% reduction.4 Although these two infections have been the main focus of the DH's national approach to reducing HCAI, they represent only 15% of all such infection.5 Bloodstream infections represent 7% of infections of which 19% are Staphylococcus aureus (4% are MRSA).5 The overall prevalence of HCAI in England has remained relatively constant over the past two decades, although a modest decrease in prevalence from 9% to 8.2% has been shown between the national prevalence surveys carried out in 1993–4 and 2006.5 However during this period hospital infection prevention and control teams have had to meet the challenges posed by additional new or increasingly common pathogens such as vancomycin-resistant Enterococci (VRE), extended spectrum beta lactamase (ESBL) producing coliforms, virulent C. difficile 027 strains and the newly recognised multiantibiotic resistant carbapenemase producing (NDM-1) coliforms, with increasing numbers of elderly and immunocompromised patients being treated within hospitals. Hospital medical staff in recent years have been expected to completely change the way they dress and hence how they may be perceived by patients. Compare the consultants of the 1970s, 1980s and 1990s wearing smart suits or long white coats over double cuff shirts and ties with the average hospital doctor in a short sleeved open necked shirt with no white coat. The impetus for the change was the publication of the bare-below-the-elbows (BBE) dress code.6,7 This requirement has been challenged on many fronts including not having a wristwatch8–10 and the lack of evidence that it is necessary to achieve adequate hand hygiene11,12 and the effect it has on patient perception.13 Other measures introduced for infection control reasons have also been challenged, such as not sitting on patients' beds14 and doing away with white coats.15–17 The challenges are understandable given the uncertainty about which measures introduced for infection prevention and control purposes are actually crucial and which ones have little or no effect.18 There is a concern that putting excessive time and resource into promoting hand decontamination will mean that other equally important initiatives are not fully implemented including prudent antimicrobial prescribing, ensuring optimal wound, urinary catheter and intravascular catheter care together with increased nurse:patient ratios, reduced bed occupancy and optimal cleaning. Decontaminating hands needs to be viewed as just one component of a hospital's infection prevention and control programme19 which is seen as part of the responsibility of all healthcare workers.1 The BBE campaign is just one part of the important hand decontamination initiative but there is a danger that the importance of the message about hand hygiene will be lost in the debate about specific components of the programme. There is, however, an argument that healthcare workers who roll up their sleeves, remove wrist watches and ties are taking their role in infection prevention and control seriously and offers a visible sign that the hospital is a different environment to other workplaces.