Bare below the elbow and implications for infection control

What are the key concepts of bare below the elbow?

Bare below is an infection prevention strategy intended to reduce transmission of pathogens that may occur due to contact of the patient with healthcare workers’ contaminated clothing. The key implication is that by allowing good hand and wrist washing and avoiding contamination of sleeve cuffs (shirt and/or white coat), there may be a reduction in rates of patients colonized or infected with epidemiologically important organisms (i.e., those organisms that are targeted by contact precautions).

What principles of bare below the elbow are necessary for effective infection control?

The principles of bare below the elbows for healthcare worker attire are

Short sleeves must be worn
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No wrist jewelry is permitted
No rings are permitted except a wedding band
Neck ties are not permitted
White (lab) coats are not permitted

Neck ties and white coats are not permitted because these are articles of clothing that are laundered infrequently. Scrub attire provides one way in which bare below the elbows can be followed.

What are the consequences of ignoring the concept of bare below the elbows?

Since the concept of bare below the elbows has never been formally tested in a clinical trial, the consequences of not following this strategy are unknown.

What other evidence supports the research regarding this method of infection control, e.g., case control studies and case series?

There is conclusive evidence shown by numerous studies that clothing worn by healthcare workers can become contaminated with clinically important bacteria and fungi. In fact, contact precautions, recommended by CDC to reduce transmission of epidemiologically important organisms, is based on the same evidence. In addition, there are in vitro models that demonstrate that healthcare worker clothing can transmit clinically important bacteria to skin.

Summary of current controversies.

To reduce colonization and infection with epidemiologically important organisms in healthcare settings, bare below the elbows represents an intervention for which biologic plausibility exists; however, the intervention has not been formally tested in observational studies or clinical trials. Some are also concerned that loss of the white coat and neck tie will adversely impact relationships with patients or not be aligned with patients’ expectations, though several studies now show that patients are not concerned by less formal dress by doctors.

Evaluating all the existing evidence

Evaluating all the existing evidence regarding bare below the elbows, one can conclude that biological plausibility exists for this intervention to be effective.

See Table I, Table II, and Table III.

Table I.

Study	Item	Number tested	Organisms tested & percent positive
Perry C, 2001 [2]	Nurse uniforms	57	MRSA: 14%VRE: 38%
Lopez PJ, 2009 [3]	Shirts, neckties	50	S. aureus (shirts): 16%S. aureus (neckties): 26%
Ditchburn I, 2006 [4]	Neckties	40	S. aureus: 20%
Wong D, 1991 [5]	White coats	100	S. aureus: 29%
Loh W, 2000 [6]	White coats	100	S. aureus: 5%Acinetobacter spp: 7%
Osawa K, 2003 [7]	White coats	14	MRSA: 79%
Treakle AM, 2008 [8]	White coats	149	S. aureus: 23%
Uneke CJ, 2010 [9]	White coats	103	S. aureus: 19%P. aeruginosa: 10%
Pandey A, 2010 [10]	White coats	130	S. aureus: 6%E. coli: 11%P. aeruginosa: 2%Acinetobacter spp: 2%

Table II.

Organism	Length of survival
Cotton	Polyester
S. aureus (methicillin-suscpetible)	4-19 days	10-56 days
S. aureus (methicillin-resistant)	4-21 days	1-40 days
E. faecalis (vancomycin-susceptible)	11-33 days	>90 days
E. faecalis (vancomycin-resistant)	18-22 days	73-80 days
E. faecium (vancomycin-susceptible)	22-90 days	43->90 days
E. faecium (vancomycin-resistant)	62->90 days	>80 days
P. aeruginosa	2 hours – 1 day	1-2 days
S. marsescens	1-2 days	4-7 days
E. coli	1-2 days	3-9 days
K. pneumoniae	4-6 days	4-11 days
Acinetobacter spp	2-9 days	7-9 days
Enterobacter spp	10-35 days	7-19 days
C. albicans	1-3 days	1 day
C. parapsilosis	9-27 days	27->30 days
A. fumigatus	1->30 days	1-30 days

Inoculum sizes: gram-positive organisms, mean 4.1 x 10⁵colony forming units; gram-negative and fungal organisms, 10⁴ to 10⁵ colony forming units.

In the early 1970s, it was demonstrated that nurses’ clothing contaminated with S. aureus during patient care could serve as a source of organisms transmitted to subsequent simulated patients [14]. An in vitro model demonstrated that E. coli, P. aeruginosa, E. aerogenes, and S. marsescens could be transferred from inoculated fabric to human skin [15]. More recently, an in vitro model that evaluated whether swatches of white coat inoculated with important nosocomial pathogens (methicillin-resistant S. aureus, vancomycin-resistant enterococci, and pan-resistant Acinetobacter spp) could transfer pathogens to pig skin found that the organisms could be consistently transferred at inocula ≥10⁵ colony forming units [16].

Table III.

Component	Strength of evidence
Pathogens contaminate patients’ skin and the environment	Conclusive
Healthcare worker clothing becomes contaminated with pathogens	Conclusive
Healthcare worker clothing can transmit pathogens	In vitro evidence
Bare below the elbows reduces infection rates	No evidence to date

Controversies in detail.

In summary, there is biologic plausibility for healthcare worker clothing to transmit infection in healthcare settings. Rarely though is biologic plausibility enough to justify a change in practice or for the implementation of an intervention. However, biologic plausibility could be considered sufficient if all three of the following criteria are fulfilled: (1) there is potential for benefit; (2) there is no risk for harm; and (3) there is minimal cost. Bare below the elbows is an implementation that fulfills all three criteria. Nonetheless, the lack of high level evidence would make a mandate of bare below the elbows difficult. Therefore, a recommendation for the practice is better justified than a mandate.

In the typical patient-provider encounter, there are three common points of physical contact: (1) hands/wrists of the provider with the patient’s skin and clothing; (2) provider sleeves with the patient’s skin and clothing; and (3) stethoscope (and other diagnostic equipment) with the patient’s skin and clothing. Infection prevention efforts have focused predominantly on hand hygiene, while ignoring contamination of healthcare worker clothing and equipment. A comprehensive approach to pathogen control should not only emphasize hand hygiene, but reduce clothing contamination (via bare below the elbows), and use reminders to clinicians to wipe down diagnostic equipment after each patient contact with an antiseptic wipe.

Controversies regarding bare below the elbows:

(1) Clinical trials of the intervention have not been conducted; therefore, the efficacy of the intervention is unknown. A common argument against bare below the elbows is that no one has ever shown that white coats or other articles of clothing have transmitted pathogens to patients.

(2) Many clinicians believe that the white coat is an iconic symbol of medicine that patients expect physicians to wear (i.e., it is an issue of professionalism). Studies of patient expectations often show patients a series of photographs of physicians dressed in various types of attire (e.g., scrub suit, suit and tie, or white coat) and ask the patient which doctor they would prefer. Early studies often found that patients preferred more formal attire for their doctors; however, this appears to be changing, and several more recent studies have shown that patients either have no preference or prefer less formal attire.

Two studies have shown that after patients are informed of the ability of pathogens to contaminate clothing, they demonstrate preference for physicians in scrub attire. An extensive qualitative and quantitative study of professionalism involving over 400 patients from two disparate geographic regions of the United States found that while 92% of patients felt that good hygiene was an important part of professional behavior for physicians, only 35% felt that how the physician dressed was important for professionalism. Importantly, two randomized studies of actual patient encounters with physicians dressed in various ways found there was no relationship between physician attire and patient satisfaction.

(3) While contact precautions is recommended by the CDC and most infection control experts have implemented contact precautions in their hospitals, few support bare below the elbows. This is paradoxical since both interventions are based on the same evidence that clothing can become contaminated by common pathogens, and that contaminated clothing may transmit pathogens to patients. This raises the question as to whether physicians have deeply held biases regarding the white coat.

(4) Some Muslim women have objected to bare below the elbows on the basis that their religion forbids them to show their arms in public.

What national and international guidelines for bare below the elbows exist, and what are the implications for infection control?

The National Health Service in the United Kingdom has issued a guideline for bare below the elbow. This was issued as part of a larger plan to reduce infections due to methicillin-resistant S. aureus and C. difficile in the healthcare setting. This is the only national or international guideline which addresses the issue.

What other consensus group statements exist, and what do key leaders advise?

There are no other consensus group statements on this topic. The Infection Control Committee at Virginia Commonwealth University Medical Center recommended but did not mandate a bare-below-the-elbows approach for inpatient care in January 2009.

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