05/07/2019
Aaron CarrollFor a lot of doctors and patients, the physician’s traditional white coat is a big part of a doctor’s identity, and contributes to their authority. Those white coats can also spread disease! It turns out, fabrics in doctors coats can be a breeding ground for bacteria, and they probably don’t get cleaned often enough.
This episode was adapted from a column Austin wrote for the Upshot. Links to sources can be found there.
05/01/2019 Austin FraktThe following originally appeared on The Upshot (copyright 2019, The New York Times Company). It also appeared on page A11 of the print edition on April 30, 2019.
A recent study of patients at 10 academic hospitals in the United States found that just over half care about what their doctors wear, most of them preferring the traditional white coat.
Some doctors prefer the white coat, too, viewing it as a defining symbol of the profession.
What many might not realize, though, is that health care workers’ attire — including that seemingly “clean” white coat that many prefer — can harbor dangerous bacteria and pathogens.
A systematic review of studies found that white coats are frequently contaminated with strains of harmful and sometimes drug-resistant bacteria associated with hospital-acquired infections. As many as 16 percent of white coats tested positive for MRSA, and up to 42 percent for the bacterial class Gram-negative rods.
Both types of bacteria can cause serious problems, including skin and bloodstream infections, sepsis and pneumonia.
It isn’t just white coats that can be problematic. The review also found that stethoscopes, phones and tablets can be contaminated with harmful bacteria. One study of orthopedic surgeons showed a 45 percent match between the species of bacteria found on their ties and in the wounds of patients they had treated. Nurses’ uniforms have also been found to be contaminated.
Among possible remedies, antimicrobial textiles can help reduce the presence of certain kinds of bacteria, according to a randomized study. Daily laundering of health care workers’ attire can help somewhat, though studies show that bacteria can contaminate them within hours.
Several studies of American physicians found that a majority go more than a week before washing white coats. Seventeen percent go more than a month. Several London-focused studies had similar findings pertaining both to coats and ties.
A randomized trial published last year tested whether wearing short- or- long-sleeved white coats made a difference in the transmission of pathogens. Consistent with previous work, the study found short sleeves led to lower rates of transmission of viral D.N.A. It may be easier to keep hands and wrists clean when they’re not in contact with sleeves, which themselves can easily brush against other contaminated objects. For this reason, the Society for Healthcare Epidemiology of America suggests clinicians consider an approach of “bare below the elbows.”
With the use of alcohol-based hand sanitizer — often more effectiveand convenient than soap and water — it’s far easier to keep hands clean than clothing.
But the placement of alcohol-based hand sanitizer for health workers isn’t as convenient as it could be, reducing its use. The reason? In the early 2000s, fire marshals began requiring hospitals to remove or relocate dispensers because hand sanitizers contain at least 60 percent alcohol, making them flammable.
Fire codes now limit where they can be placed — a minimum distancefrom electrical outlets, for example — or how much can be kept on site.
Hand sanitizers are most often used in hallways, though greater use closer to patients (like immediately before or after touching a patient) could be more effective.
One creative team of researchers studied what would happen if dispensers were hung over patients’ beds on a trapeze-bar apparatus. This put the sanitizer in obvious, plain view as clinicians tended to patients. The result? Over 50 percent more hand sanitizer was used.
Although there have been fires in hospitals traced to alcohol-based hand sanitizer, they are rare. Across nearly 800 American health care facilities that used alcohol-based hand sanitizer, one study found, no fires had occurred. The World Health Organization puts the fire risk of hand sanitizers as “very low.”
An article in The New York Times 10 years ago said the American Medical Association, concerned about bacteria transmission, was studying a proposal “that doctors hang up their lab coats — for good.” Maybe one reason the idea hasn’t taken hold in the past decade is reflected in a doctor’s comment in the article that “the coat is part of what defines me, and I couldn’t function without it.”
It’s a powerful symbol. But maybe tradition doesn’t have to be abandoned, just modified. Combining bare-below-the-elbows white attire, more frequently washed, and with more conveniently placed hand sanitizers — including wearable sanitizer dispensers — could help reduce the spread of harmful bacteria.
Until these ideas or others are fully rolled out, one thing we can all do right now is ask our doctors about hand sanitizing before they make physical contact with us (including handshakes). A little reminder could go a long way.
04/29/2019 Austin FraktMy Upshot post today is about bacterial contamination of and by health care workers’ attire. It also covers a little-known issue about hand hygiene — sometimes alcohol-based hand sanitizer isn’t placed as conveniently as it could be due to fire safety concerns.
I thank Rohan Rastogi, an MPH student in Health Policy at the Harvard T.H. Chan School of Public Health and a medical student at the Boston University School of Medicine, who did an excellent lit review to support my post. He wrote a previous post on the fire safety/hand sanitizer issue.
02/12/2019 guest contributorThe following post is by Rohan Rastogi, an MPH student in Health Policy at the Harvard T.H. Chan School of Public Health and a medical student at the Boston University School of Medicine. He tweets about health policy and medicine at @rorastog.
Your clinician’s hands pose the greatest risk for acquiring an infection while in the hospital. Despite adequate education, clinicians are notoriously non-compliant with hand hygiene guidelines, which recommend frequent use of alcohol-based hand sanitizer.
Though making hand sanitizer more accessible improves compliance, an unexpected antagonist may prevent hospitals from optimally locating dispensers—fire safety codes.
Historically, alcohol-based hand sanitizer was not always recognized as a key component of hospital hand hygiene. The 1983 CDC guidelines recommended using hand sanitizers only in emergency situations where a sink was not readily available.
More recent evidence, however, indicates that using alcohol-based hand sanitizer is usually better than traditional handwashing with soap and water. It’s faster, more accessible than sinks, less irritating to skin, and more effective at reducing transfer of the majority of dangerous bacteria.
Although hand hygiene is considered the single most important strategy to control infection transfer between clinicians and patients, health care workers sanitize less than half as often as they should. With one in every 31 patients acquiring an avoidable infection while in the hospital, understanding how to encourage clinicians to consistently use hand sanitizer has become a billion-dollar question.
In an experiment on behavior change, researchers found that easily accessible hand sanitizer dispensers doubled clinician hand hygiene compliance, while hand hygiene education, feedback, and patient awareness campaigns had no effect. A closer look on accessibility found that improving dispenser placement is more impactful than increasing the number of dispensers. All this to say, the real estate mantra of location, location, location holds true when it comes improving clinician hand sanitizer compliance.
Hand hygiene experts have gone to great lengths to find the perfect hand sanitizer dispenser location. In a particularly notable study, researchers suspended dispensers over patient beds using a trapeze-bar apparatus to improve visibility, which improved compliance compared to a traditional wall-mounted location.
When interviewed, clinicians say that hand sanitizer dispensers have to be in their line of sight, on their workflow route, unobstructed, standardized, within arm’s reach during procedures, and near the patient. A literature review recommended five dispenser locations to improve clinician hand hygiene compliance: outside the patient room, at the room entrance, immediately beside the point of care, immediately adjacent to the patient bed, and at the foot of every patient bed.
It’s unsurprising that placing dispensers as close to patient care activity as possible improves hand sanitizer use. And yet, controversy arose in the early 2000s, when fire marshals began forcing hospitals to move their dispensers.
Given that hand sanitizers must contain at least 60% alcohol by weight to be effective, alcohol-based hand sanitizers are flammable. Isolated incidents, such as the 2013 Oregon case and the 2002 Kentucky case, implicated hand sanitizers in burn injuries when a static spark ignited residual undissolved solution.
Despite these well-publicized events, fires involving alcohol-based hand sanitizer are exceedingly rare. A World Health Organization report states that “although alcohol-based hand rubs are flammable, the risk of fires associated with such products is very low.” The scientific community seems to agree that current hospital fire regulations “represent an abundance of caution.” As such, the minor fire risk must be weighed against the substantial potential benefit for hospital infection safety.
Answering the question of whether fire codes prevent optimal dispenser placement, and thereby hamper hand hygiene, requires a closer look at the codes. The Center for Medicare and Medicaid Services (CMS) and the Joint Commission (JC) adopted sections (18.3.2.6 and 19.3.2.6) of the National Fire Protection Agency’s 2012 Life Safety Code in 2016.
Among the rules: dispensers must be separated from each other by at least 4 feet of space and dispensers cannot be installed within 1 inch of an ignition source (e.g. electrical outlet, appliance, device). According to Dr. Eli Perencevich, an infectious disease physician and researcher from the Iowa Carver College of Medicine, however, these CMS/JC rules may serve as a template for more restrictive state and local fire marshal regulations.
The CMS ruling, in fact, explicitly allows this practice: “States and local jurisdictions may choose to retain stricter codes that prohibit or otherwise restrict the installation of [alcohol-based hand rub] dispensers in health care facilities. Facilities will still be required to comply with those stricter State and local codes.”
The end result—the practice of hospital hand hygiene stops at the patient doorway. A study in Dartmouth’s hospital found that only 37% of hand hygiene events involved in-room dispensers, of which 75% involved the dispenser located just inside the doorway…far away from the patient. This finding led the authors to conclude that there exists “a focus on hand hygiene before and after patient contact but not during patient care.”
In the US, this emphasis on sanitizing upon entering and exiting rooms originates from the most basic compliance monitoring strategy—direct observation at the doorway. The complexities of observing hand hygiene at the point of care have likely exacerbated its neglect.
The red tape of hand hygiene may be hindering hospitals’ ability to protect patients from their clinicians. Some suggest that hospitals should put the power to sanitize back into the hands of clinicians—provide them with personal carry sanitizer bottles. While the idea of sidestepping the wall placement regulations may be enticing, further studies will show whether it improves compliance or reduces infection transmission. Until then…ask your doctor about handwashing.
12/11/2015 Nicholas BagleyWith the shooting in San Bernardino and Donald Trump’s malignant anti-Muslim comments, any reminder of humanity’s capacity for good is especially welcome. With that in mind, let me recommend William Foege’s House on Fire: The Fight to Eradicate Smallpox.
To call it inspiring doesn’t do justice to the word. Foege played an integral role in a global effort to wipe smallpox from the face of the earth, perhaps the greatest achievement of modern public health. As his wise and humble book reminds us, smallpox’s eradication was not inevitable and it was no accident.
[S]mallpox disappeared because of a plan, conceived and implemented on purpose, by people. Humanity does not have to live in a world of plagues, disastrous governments, conflict, and uncontrolled health risks. The action of a group of dedicated people can plan for and bring about a better future. The fact of smallpox eradication remains a constant reminder that we should settle for nothing less.
Amen.
12/19/2014 Aaron CarrollI was perusing this RWJF sponsored report, “Outbreaks: Protecting Americans from Infectious Diseases”:
The Ebola outbreak has been a major wake-up call to the United States — highlighting serious gaps in the country’s ability to manage severe disease outbreaks and contain their spread.
It is alarming that many of the most basic infection disease controls failed when tested. After more than a decade of focus on preparing for public health emergencies in the wake of the September 11 and anthrax tragedies, there have been troubling errors, lapses and scrambles to recreate practices and policies that were supposed to have been long considered and well established.
And that’s just the first paragraph. More than a third of seniors and most adults don’t get all recommended vaccinations. Thirty-six states couldn’t vaccinate even half their population against the flu. Fifteen states didn’t even get 90% of kids vaccinated to Hepatitis B. Still, one out of 25 hospitalizations results in a hospital-acquired infection. Forty states failed to reduce the number of central line-associated bloodstream infections in recent years. New HIV infections in certain populations are still increasing. Three million baby boomers have hepatitis C, and most of them don’t know it.
And about 48 million people get a foodborne illness each year.
I got all of that from just the key findings on the lower half of page 5. The document is 112 pages long. There are some decent charts, like this one:
We can do better.
04/22/2014 Austin FraktWe suggest that the workload is higher during economic booms and thus employees have to go to work despite being sick. In a theoretical model focusing on infectious diseases, we show that this will provoke infections of coworkers leading to overall higher sickness absence during economic upturns. Using state-level aggregated data from 112 German public health insurance funds (out of 145 in total), we find that sickness absence due to infectious diseases shows the largest procyclical pattern, as predicted by our theoretical model.
That’s from the abstract of a new paper by Stefan Pichler, which I have not read in full. The findings point to another reason (among many others) why working-age individuals might see health improvements during recessions, and why health spending might be lower during them.
03/27/2012 Austin FraktThe Determinants of Mortality (ungated pdf), by David Cutler, Angus Deaton, and Adriana Lleras-Muney is worth a full read. Here are some teasers.
For most of human history, life was properly described in the famous phrase of Thomas Hobbes as “nasty, brutish, and short.” From the dawn of Homo sapiens perhaps 100,000 years ago until the first agricultural revolution in roughly 10,000 BCE, world population was about four million people. Life expectancy at birth for our hunter–gatherer ancestors was perhaps 25 years. There had been little, if any, progress by the Roman Empire, and even in 1700, life expectancy at birth in England—after the Netherlands, the richest country in the world at the time—was only 37 years (Wrigley and Schofield, 1981).
One driver of change in life expectancy would seem to be wealth. On the other hand, longer lives themselves may promote wealth. Cross-nationally, wealth, as measured by GDP per capita is correlated with life expectancy, but check out the huge change in slope somewhere around $4,000.
Yet, wealth is not decisive:
Many countries have shown remarkable improvements in health with little or no economic growth, and vice versa. For the two largest countries, India and China, there is a negative correlation between decadal rates of economic growth and progress in reducing infant and child mortality. Almost all of China’s remarkable post–World War II reduction in infant mortality happened prior to the acceleration in economic growth after 1980, after which there was relatively little progress in child health. Similarly, in India, the acceleration of the rate of growth after the economic reforms in the early 1990s was accompanied by a slowdown in the rate of decline in infant mortality.
In the US and countries with similar development paths, recent longevity gains have come principally from lower mortality from cardiovascular disease and infectious diseases.
Looking at this evidence as a whole, we see the history of mortality reduction [in now-developed countries] as encompassing three phases. The first phase, from the middle of the eighteenth century to the middle of the nineteenth century, is the one where improved nutrition and economic growth may well have played a large role in health— although this is hotly debated, and incipient public health measures were certainly important as well. In the closing decades of the nineteenth century and into the twentieth, the second phase occurred, in which public health mattered more—first negatively, because of high mortality in cities, then positively in the delivery of clean water, removal of wastes, and advice about personal health practices. The third phase, dating from the 1930s on, has been the era of big medicine, starting with vaccination and antibiotics, and moving on to the expensive and intensive personal interventions that characterize the medical system today.
