Emperors with their cuffs rolled up

The DoH ‘Bare Below the Elbows’ theme has been going on for a few years now. The original document, you may remember, is here, from 2007, and stated that research on workwear and infection prevention had been done, was not yet published, but contained the following:

“There is no conclusive evidence that uniforms (or other work clothes) pose a significant hazard in terms of spreading infection.”

They also noted that

“It is good practice to…..Dress in a manner which is likely to inspire public confidence. Why? People may use general appearance as a proxy measure of competence. It is good practice to……wear short sleeved shirts/blouses and avoid wearing white coats when providing patient care. Why? Cuffs become heavily contaminated and are more likely to come into contact with patients.”

One might wonder about the sense of this in a somewhat wider context of risk, given that some wards have scarce nurses, one shared commode and holes in the roof which may present a more pressing infection problem. But what is the evidence for rolling one’s sleeves up? Where was it, and why did the authors declare that clothes are not a risk and then say that we should wear short sleeves anyway?

Here is one abstract on the research. Note the following; ” The hypothesis that uniforms/clothing could be a vehicle for the transmission of infections is not supported by existing evidence”.

Yet we have so-called ‘good practice’ statements from the DoH which are not based in evidence. But  though they seem anodyne enough, they are still capable of actually doing harm.

Here’s a little study, 160 patients, asked which attire they thought was most professional, most hygenic, and most identifiable for their doctors to ear. The choice was between scrubs, professional traditional dress, and bare-below-the elbow. The latter scored lowest in all categories. Patients thought what doctors have been commanded to wear from on high was least professional, least hygenic, and least identifiable. The DoH made dangerous suppositions, not evidence based guidance – and at their, and our, peril.

This is important. Patients who are confident in their professionals tend to do better. One of the recurrent complaints I get from people who have been to the hospital is that they don’t know who is who – people have a right to know who they are being treated by and what their qualifications are.

It might be fair enough to make everyone look ghastly and unprofessional if it cut MRSA rates, but there was no evidence for this to start with. Instead, the DoH have ordered doctors to change their wardrobe and look worse with no benefit for anyone and even introducing new harms. The sensible thing to do would be to withdraw this commandment (and all the clipboard bearers in the hospital who are not doing properly useful duties and instead are just monitoring which doctors are ‘compliant’ with dress codes ) and let doctors dress with long sleeved shirts and ties and blouses and etc. I won’t hold my breath; I suspect this emperor will be naked a while yet.

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