White Coats; An Effective Nosocomial Transmitting Agent?

Pixabay

If you have been admitted into a hospital before, especially in a teaching hospital setting, you might notice people running here and there, try to learn something while wearing a clean, white coat. However, this piece of clothing does not necessarily wear by people who are working in a teaching hospital; in Malaysia, almost all medical officer trainees (housemen) are required to wear this piece of clothing for three primary purposes:

• Distinguishing doctors from patients
• To allow doctors putting some of their medical equipment in a certain pocket (which can be easier and useful)
• To keep their clothes clean

All of the reasons stated are not that established, some might want to put on a white coat just for the sake of taking pictures or they were forced by the authorities to wear them. Regardless, according to an article which was written by R Farraj in 1991, 72% of all doctors and medical students wear white coats and this piece of clothing would stay more than 75% of the time they were in the hospital (source). Sure, the article is a bit seasoned but you got the gist.

Pixabay

Sometimes, it would be easier for people to just wear them so that people can recognise doctors easily, just in case, if there are some emergencies. Nevertheless, it is difficult to achieve a good rapport with certain populations such as paediatric and psychiatric populations; that's why sometimes, both of these departments wouldn't allow their workers to wear white coats. Kids who were traumatised by their previous experiences in the hospital would scream and cry if they saw people who were wearing white coats approaching. They probably think doctors are someone who comes by and prick people with needles. Well, that's true, but we are most certainly not enjoying it.

Regardless, the issue remains; are white coats act as vehicles for microorganisms to infect other patients thus causing some complications related to their own immunological state in the hospital setting? People who are wearing white coats are not confined or restricted within a specific space; some of them can be found in the library, they wear it while in the toilet and for god sake, please take off your white coat while eating in the cafeteria!

Previously, when I was a medical student, we wore it to lectures, left them on chairs, some people might've dropped them on the floor and then, we went to see patients. Patients might have trusted people with white coats (doctors) but maybe, it would be wise to start doubting them; not on their clinical diagnoses, but what they have been wearing before touching you. Of course, Ignaz Semmelweis has changed the history of medicine by introducing hand washing to prevent disease transmission when people are not familiar with microorganisms but in this case, do you think hand washing would help? Maybe.

Pixabay

In a study which was conducted last year to demonstrate the possibility of disease transmission among people who were wearing a long-cuffed white coat compared to a short-sleeved white coat has shown that 5 out of 20 subjects who were wearing long-cuffed white coats were found to harbour viral DNA markers compared to none of the people who were wearing short-sleeved white coats (source). This is a serious finding and could have affected a significant number of outcomes among people who were hospitalised and treated by the same medical doctors. It's like getting doctor acquired diseases. People who wear long-cuffed white coats would have some difficulties in practising a proper hand wash technique as their wrist would be covered by the cuffed of their long sleeves. It doesn't necessarily mean that people would neglect their hand hygiene just for the sake of conveniences but some did.

According to a paper which was written by Uneke et al in 2010, white coats are considered great tools for nosocomial transmission due to two reasons:

• Doctors (who were wearing white coats) were in close contact with patients who might be shedding infectious microorganisms
• The fabrics used to make a white coat, i.e. cotton, polyester or the combination of both, are capable of housing thousands (possibly millions) of bacteria for 10-98 days

The consequences of those two reasons were reflected and supported by a study which was conducted by Asima Banu et al in 2012 which found that among 100 subjects, 65 males and 35 females, the rate of white coats contamination were 74.3% and 62.8% respectively. Some studies indicate that white coats which belong to females tend to be more contaminated but the point I'm trying to make here is, regardless of gender, pathological organisms which latched to white coats are capable of being spread throughout the community when they were being kept at home.

The commonest microorganism found on white coats, which was similar when compared to other studies, was Staphylococcus aureus. Most of the bacteria which can be found on the white coat are resistant to Penicillin, Erythromycin and Clindamycin and all of them can also be found in susceptible patients suggesting a possible correlation between whitecoat contamination and its capability of transmitting nosocomial agents.

The figure which was presented above by all of the studies involved to prove this point might be limited by its small sample size to provide validation but I think we can agree that apart from exclusivity, white coats can be a dangerous tool at our disposal which could affect patients morbidity and mortality rate. Do no harm, so should we refrain from wearing them? Well, it is not that simple as it seems, it never is. A few recommendations were made by Asima in 2012, to reduce the incidence of nosocomial infections related to white coats:

• It's compulsory for an individual to have 2 or more white coats at a time and all of these white coats should be changed yearly
• White coats should be washed once a week
• Forbid people from wearing white coats in non-clinical areas such as the toilet, library or cafeteria
• Encourage hand washing before and after seeing a patient
• Use alternative dress during procedures such as aprons or gowns to minimise white coat contamination

Being a doctor is not easy. We have to consider everything to optimise the health of our patients and even if it is the smallest thing, if it can affect our patients in a negative way, we should lay out plans and be ready to make minor to major changes to improve patients' health outcome. White coats might seem harmless but it carries a much significant consequence than what you can ever imagine.

Source

• Why do hospital doctors wear white coats?
• White Coats as a Vehicle for Bacterial Dissemination
• The potential for nosocomial infection transmission by white coats used by physicians in Nigeria: implications for improved patient-safety initiatives.
• Long Sleeves on Doctors' White Coats May Spread Germs
• A Randomized Trial to Determine if Wearing Short-Sleeved Coats Reduces the Risk for Pathogen Transmission
• The Physician's White Coat: Iconic and Comforting or Likely Covered in Germs?

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