Bacterial Contamination of Health Care Workers White Coats, Uniforms - Research Paper Example

Bacterial Contamination of health care workers’ white coats/uniforms Introduction There is growing apprehension about the contamination of clothing of the resident health care workers with nosocomial pathogens. A study by Treakle, et al. concluded that, “…that a large proportion of health care workers white coats may be contaminated with S aureus, including MRSA. White coats may be an important vector for patient-to-patient transmission of S aureus. (201)” Doctors normally wear white coats in their day to day activities. But, regular laundry practice varies from person to person and also depending upon the usage. The discussion about evolution of the phenomenon with regard to the role contaminated white coats in transmission of pathogenic bacteria has shifted arguments progressively from the question “Whether there is any reason for recommending a more frequent change of white coat than once a week” to “Whether the presence of medical professionals in public spaces such as canteen and library with working clothes should be restricted” and eventually to “How to prevent health care associated infections contributed by the health care professionals through their clothing.” Literature review The infection of the new antibiotic-resistant bacteria New Delhi Metallo-beta lactamase-1 (NDM-1) called as Superbug shifted the focus more to the issue of implementation of hospital infection control measures to limit the spread of the bacteria, and in this context bacterial contamination of clothing of the professionals in the field also assumes significance. Kayani reported that The UK’s Health Protection Agency is monitoring the situation… identifying and isolating any hospital patients who are infected should prevent transmission. Normal infection control measures, such as disinfecting hospital equipment and doctors and nurses washing their hands with antibacterial soap should limit any spread of the bacteria. It could be inferred from the statement that disinfection of the uniforms and coats of the surgeons and nurses is also covered. The WHO strongly recommended “strict adherence to infection prevention and control measures, including the use of hand-washing measures, particularly in healthcare facilities.” (The Hindu) Antibiotic resistant bacteria in the human body weaken the resistance to various diseases and resulting into recurrence of the diseases. Antibiotics damage not only damages the bad bacterial responsible for the diseases, but also good bacteria which are essential for good health. Treakle, et al. states “Mortality among patients with methicillin-resistant Stphylococcus aureus (MRSA) and vancomycin-resistant entericocci (VRE bacteremia is significantly higher than mortality among patients with susceptible forms of the same bacteria (201)” Increased stay in hospitals may also lead to infection. Rampant use of disinfectants may also make the bacteria resistant to antibiotics in addition to disinfectants. Bruce, F. (2008) states that, “…patients on antibiotics become a source of infection. The antibiotics kill off the bodys normal bacteria allowing the foreign bacteria to take over for awhile. Eventually the antibiotics also kill off the bad boy bacteria but until they do the patient risks infecting others.” It is also speculated that the health care workers could also contribute for the healthcare-associated infections especially through their clothing. It has been established in the study by Treakle, et al. that the transmission of these bacteria is possible through direct contact including clothing. The participants cultured their white coats before the grand medical rounds and the statistical analysis of the study revealed contamination of the coats. “Overall, 22.8% (95% Confidence Interval = 16.1% to 29.6%) were contaminated with S aureus and 4% (95% Confidence Interval = 0.8% to 7.1%) were contaminated with MRSA… The highest prevalence of coat contamination with S aureus was seen in the residents (30%; 19/64); for MRSA, the prevalence was greatest in the attending (13%; 4/31).” (Treakle, et al. 102) For determining the level of contamination and the risk associated with reference to the transmission of bacteria to other patients, staffs and others through these medical professionals, various studies and surveys have been conducted in the field. The report of a study conducted with 100 participants published in the year 1991 by Wong, D., Nye, K. & Hollis, P. states that “Most of the organisms seen were skin commensals such as coagulase negative Staphylococci and diphtheroid species. A total of 42 isolates of Saureus were found on the white coats of 29 individuals and were more likely to be isolated from the cuff and pocket than the back“ (1603). The study has used contact plates were used for sampling, and considered as the appropriate method considering the risks of cross infection. According to Wilson, J.A. et al. the apprehension about the clothing and its role as a vehicle for the transmission of infections is not founded on any evidence. One of the issues highlighted in the review concerning the subject is about the perception that wearing uniforms or coats in public spaces by the Nurses and Doctors confirms the observation by Wong, D., Nye, K. & Hollis, P. as to its lack of evidence about infection. Regarding the other issue regarding the infection risk involved in home laundering the report states that both the industrial and domestic laundry processes removes or kills the micro-organisms present on fabric and the issue is rarely cited.  Several methods have been used to study the effects of laundry on clothing such as swatches of cloth, impression plates and sampling of effluent water. The review revealed “Uniforms have been found to become frequently contaminated below the waist and heavily contaminated after procedures likely to involve exposure to pathogens, e.g. dressing wounds.” Their observation “Doctors’ white coats have been shown to become contaminated progressively as they were worn, but the majority of organisms isolated were nonpathogenic environmental bacteria or skin commensals probably originating from the wearer” to some extent is in line with the report by Wong, D., Nye, K. & Hollis, P. which suggests that the issue is not in any way alarming, though there is a cause for concern on account of new breeds of bacteria. According to the review “One report describing an epidemiological link between microbial contamination of work clothing and cases of HCAI occurred under very unusual circumstances.” Under certain circumstances, the industrial was more responsible than contamination during use. The following are the important observations in the study conducted by Wong, D., Nye, K. & Hollis, P. Microbial counts did not vary with the time in use of the white coat. A steady state of maximal microbial Contamination was attained within the first week of use and did not change significantly thereafter. There is little microbiological reason for recommending a more frequent change of white coat than once a week. There is potential for cross infection with Saureus, particularly among the surgical specialties. During clinical examinations the cuffs of white coats come into frequent close contact with patients clothing and skin, at which point bacteria may be both acquired from and transferred to the patient. The review by Wilson, J.A., et al. conducted almost after 16 years stating that the hypothesis that uniforms/clothing could be a vehicle for the transmission of infections is not supported by existing evidence, do no vary much with the results of Wong et al. However, the observation is differing in the case of Treakle who states that, Our aim was to determine the level of contamination of the coats with pathogenic bacteria … which would suggest that the coats are potential fomites for transmission of these organisms” and suggests “efforts could be directed at encouraging workers to launder their coats more frequently” and “alternative white coats, including universal use of protective gowns, should be considered”. (104) This study also shows that “many of the S Aureus isolates are methicillin-resistant contradicting the earlier evaluations” (Treakle, et al. 103) . Therefore, considering the sensitive nature of the issue and the latest developments in the field, the line of approach suggested by Treakle, et al. seems to be more reasonable, since precautionary measures should be adopted by way of best practices in the field. The reduction in bacteria in laundering depends upon the volume of water used, usage of detergents and bleaching agents, the number of washes and rinses and the process of drying. Also, with the increase in temperature of the water significant reductions are achieved. The review states that international guidance on the provision and laundering of work clothes is minimal and the evidence base is similarly unclear or not cited. It has been observed that the use of plastic aprons reduces bacterial contamination of the front of the uniform. The researches in the type of fabrics used, design of the uniforms and coats employing the latest developments in technology may effectively reduce contamination; and making these clothing easily washable without losing other qualities might be the important criterion for research and development in the field which would be more useful in future. Use of protective clothing and aprons by the professionals on duty is recommended and use of plastic apron is currently recommended as a standard principle in national infection prevention guidelines. Table showing overall results of the study conducted by Wong, D., Nye, K. & Hollis, P. (1991) and by Treakle, et al.(2009) have been given under Appendix – I and II respectively which shows the level of contamination by demographics and laundering habits related to time in use and level of usage of the coats. It could be observed that the research is limited to the microbial contamination at the various parts of the coats, contamination by demographics and laundering habits. Research Proposal The proposed study is structured to ensure that the risks involved are categorized based on the immunity or resistance quality of the bacteria such as resistance to antibiotics, heat, disinfectants, and microbials which are intended to kill them. Cross resistant bacteria develops survival mechanisms against different types of antimicrobial molecules. The issue of Superbug, the antibiotic resistant bacteria has become a source of great concern among the medical professionals world-wide today. Having accepted that there is a risk of transmission of microorganisms through the health care workers’ clothing, the next logical step will be to assess the risk pathologically in relation to the type of disease, functionally in relation to the type of service and the level of risk associated with the type of microbial contamination with a view to classify the risk in relation to the usage of white coats and uniforms to enable formulation of policies with regard to use of white coats/uniforms. Methodology The studies/surveys conducted so far have analyzed the issue from the angle of uniforms/white coats as a starting point. However, keeping the white coats/uniforms as a basis, a ‘bottom-up’ study is required to be made starting from the services/diseases with regard to various faculties such as surgery, outpatients, other inpatients, end of life care, etc. and proper dress code including advisability or otherwise of the use of white coats in relation to the specific activity, prescribed based on the analysis and evaluation of the results. Research The study seeks to cover source of contamination of healthcare workers’ clothing, its associated risks and the strategies suggested for adoption to minimize the level of impact. Data collection method The participants being attendees of the medical rounds get their coats cultured and complete the questionnaire which will be designed to collect data with regard to the demographic variables such as specialty (medicine, surgery, etc.) and the area of responsibility (Inpatient, surgery, outpatient, ICU, etc.) and laundry habits, are returned after the rounds along with the swabs at the end of the rounds. As the research involves a comprehensive study with a bottom-up approach from the medical wards, the level of participation is expected to be more than 50%, and in such a case, the confidence level would be more than 95%, and the confidence level refers to the degree of certainty that a statistical prediction is accurate. The participants include attending, fellow, resident, student and others from specialties of medicine or surgery working in different locations. The swabs are subjected to laboratory analysis and examination for any growth; if positive sub-cultured to assess for MRSA/VRE or evaluated for the growth of S Aureus, enterococci or other organisms. The questionnaire is the ideal method for collection of basic data. However, the research mainly takes into account the data based on the scientific analysis of the disease, microorganisms and the impact of the transmissions/infections. Therefore, the method ‘focus group’ is involved in addition to the basic data collection through questionnaire. Kitzinger, J. states (1995) “The method is particularly useful for exploring peoples knowledge and experiences and can be used to examine not only what people think but how they think and why they think that way.” Data Analysis More than ninety five percent confidence level can be aimed in the survey and the sample, size suitably considered, for the purpose of analysis. The research proposed in connection with the white coats and uniforms will be mainly in terms the Types of infections (bacterial contamination), the Source of infections (diseases, treatment stage, type of treatment such as chemotherapy, surgery, etc.) and the Curability of the infections. Legal and ethical considerations O’ Brien, D. et al. states “The prevalence and transmission of HCAI were taught by 97% and 100% of medical schools, respectively, but the importance of HCAI as a quality and safety issue was covered in only 60% of medical schools.” Prevention of health care associated infections will improve the quality of the health care and reduce safety as well as legal risks to the medical professionals in future. The ‘Proposal for a Council Recommendation on patient safety, including the prevention and control of healthcare associated infections’ states that: The Committee feels that there is a particular need to develop analysis of the conditions of occurrence of HCAI and adverse events. In this regard – given the possibility of legal action – it would advocate clarifying the status of the data collected, with a view to upholding patient rights, whilst also encouraging analysis by risk-management professionals and structures. (1.8) In the process of collection of data, consent forms need to be obtained from the participants and confidentiality of all gathered information of the participants will be assured and maintained.  Conclusion The proposed research is reoriented to determine whether white coats could be dispensed with completely in respect of certain specified functions of the medical professionals (for example where the transmission of antibiotic resistance bacteria is possible), to specify standards with regard to usage (based on the contamination level observed under analysis for general practice and to establish minimum standards covering all pathological functionalities with an aim to follow the best practices. However, it is also understood that the surveys, studies and research should be extended at all levels covering general as well as all types of specialty hospitals to evolve a sound and balanced procedural guidelines. References Bruce, F. Molecular Healing: Antibiotics and Mutating Bacteria, 24 Aug 2008 28 Aug 2010 . Kayani, R Health and Science: Concern over new antibiotic resistant superbug, 27 Aug 2010. 29 Aug 2010 Kitzinger, J. Qualitative Research: Introducing focus groups Volume 311 Number 7000, BMJ 995;311:299 Pub. 25 Jul 1999. O’Brien, D. et al. Survey of teaching/learning of healthcare-associated infections in UK and Irish medical schools, Journal of Hospital Infection, Volume 73, Issue 2, Pages 171-175. 2009 Official Journal of the European Union, Opinion of the European Economic and Social Committee on the Proposal for a Council Recommendation on patient safety, including the prevention and control of healthcare associated infections, 22 Sep 2009. 28 Aug 2010 . The Hindu. WHO endorses superbug study findings, 21 Aug 2010. 28 Aug 2010. Treakle, Ami M. et al. Bacterial contamination of healthcare workers’ white coats, Department of Medicine, Association for Professionals in Infection Control and Epidemiology, University of Maryland Medical Center, Baltimore, MD, USA.Ajic Journal Vol. 37, No.2. 2009. Wilson, J.A., et al. Uniform: an evidence review of the microbiological significance of uniforms and uniform policy in the prevention and control of healthcare-associated infections. Report to the Department of Health (England), ScienceDirect, Journal of Hospital Infection (2007) 66, 301-307. 29 Aug 2010.< http://www.academia-research.com/files/message/2368126_research%20proposal.pdf>.  Wong, D., Nye, K. & Hollis, P. Microbial flora on doctors white coats, BMJ VOLUME 303 pp. 1602-1604. 2009. 29 Aug 2010. . Appendix – I Microbial flora on doctors white coats Table 1 Bacterial Contamination of white coats of 100 Doctors --------------------------------------------------------------------------------- No. of colony forming units Location of coat Per 25 x 25 cm contact plate Cuff Pocket Back Total --------------------------------------------------------------------------------- Total microbes: 0-19 32 38 53 123 20-49 34 36 29 99 50-99 20 16 12 48 100-199 10 6 4 20 200 & above 4 4 2 10 Geometric mean 30.5 24.0 18.4 23.8 Staphylococcus aureus: 1 8 4 1 13 2-5 11 10 6 27 Above 5 0 2 0 2 Total 19 16 7 42 --------------------------------------------------------------------------------- Appendix – II Bacterial contamination of healthcare workers’ white coats Read More