19 December 2007

Grotty cravats and microbial stats: taking aim at "functionless clothing items" in British hospitals

No one has ever had an idea in a dress suit. ~ Sir Frederick G. Banting

His vesture was dabbled in blood — and his broad brow, with all the features of the face, was besprinkled with the scarlet horror. ~ Edgar Allan Poe, The Masque of the Red Death

Nowadays the word "cravat" starts with C. difficile. Undoing centuries of tradition and male privilege, British hospitals are banning neckties (4). Scarcely a civil word can be heard in their defence. In 2006 the British Medical Association called them "functionless clothing items." The BMA went on to say: "Ties are rarely laundered but worn daily, commonly outside the healthcare environment. Ties perform no beneficial function in patient care and have been shown to be colonised by pathogens." Take that, Beau Brummel. Now, along with long sleeves and jewelry, this male fashion staple, first introduced to the court of Louis XIV by Croat mercenaries, will become suddenly highly unfashionable as the UK's National Health Service continues its efforts to stop the spread of deadly hospital-borne infections. Even the hallowed white coat will disappear. Its cuffs can become heavily contaminated (1,10). Acute care hospitals are expected to go "bare below the elbows" by January 2008, according to last September's announcement by Health Secretary Alan Johnson.

"guidance" document issued by the UK Department of Health, also in September, provides examples of good and poor dress practice for health professionals, expending special reserves of contumely and guile on unwashed coats and cravats. Cascading hair, false nails, open-toed shoes, wristwatches and other hand adornments (22) are also suspect. As a convenient reminder that complete rationality is rarely achieved in bureaucracies, tattoos are to be covered, not because they are a contamination risk, but because tattoo modesty is required to "maintain a professional appearance." Many hospitals have already changed their regulations in accordance with the new guidelines. Bedford Hospital, for example, launched its "bow-tie, no tie" policy in November.

"We think ties only give the baby boys something to take aim at."
Now that the common tie has become the sartorial equivalent of Typhoid Mary, other countries may soon follow Britain's example. Doctors Kei Lui and Danny Challis, from the Royal Women's Hospital at Randwick, Australia, have a wealth of excuses for not wearing neckties and are happy to add another to their list. "It's always too hot in our nurseries for a tie," says Dr Lui, the hospital's director of newborn care. "No tie is more comfortable. I'd only need to take it off when bending down and, most of all, we think ties only give the baby boys something to take aim at." Male pediatricians often wear ties with cartoon themes to entertain their young patients. They may want to think twice about that, now that we know it's more likely the ties that are taking aim at the patients.

Since at least 1972 there has been evidence that things doctors wear or carry around with them, like stethoscopes, may harbour infection (7,21). Computer keyboards also house germs. Studies done in 2000 and 2002 (6,16) demonstrated that neckties were vectors for nosocomial infection. But it wasn't until 2004 that the media picked up on a conference presentation by a medical student which reported on necktie nosology found at a New York teaching hospital (13). Nearly half (47.6%) of neckties worn by medical personnel in that institution were pullulating colonies of dangerous bacteria. Steven Nurkin and his team reported their findings at the 104th General Meeting of the American Society for Microbiology, and the media loved it. Once it was clear that the heraldic regalia of the well-dressed plutocrat had come under attack, every news organization picked up the story. Research on the germ-carrying potential of other types of hospital garb, including white coats, has been given less prominence (1,10,14,15,17,18,23). It was the grotty knotted cravat that attracted popular attention.

Offered his fifteen minutes, Steven Nurkin gave interviews. The IEQ review quoted him as saying, "I watched the doctors come over for a physical exam or procedure and saw the neckties would swing in front of the patient's face, or patients would cough on them. . . . The necktie is important for the doctor-patient relationship, but it's also there on the front lines — dangling in front of patients as the doctor makes his rounds. . . . Almost everything a doctor carries has bacteria — from a cell phone to a stethoscope. You can get to the point where the doctor is completely naked, but then the skin is covered with bacteria too."

Having lived and worked in Israel, where most doctors go about in shirtsleeves, Nurkin had good reason to question the rather stiff dress codes in North America. "This study brings into question whether wearing a necktie is in the best interest of our patients," commented Nurkin. "Being well dressed adds to an aura of professionalism and has been correlated with higher patient confidence. Senior physicians and hospital administrators often encourage staff to wear neckties in order to help promote this valuable relationship; but in so doing, they may also be facilitating the spread of infectious organisms." Nurkin added: "While there is no direct evidence to implicate neckties in the transmission of infection to patients, the link between contaminated neckties and the potential for transmission must be considered."

On this side of the Atlantic?
With a new year about to begin, we now see just how influential Nurkin's research has been. While British clinicians prepare to bare their necks, infection control societies in the U.S. and Canada are not yet recommending similar dress restrictions. Although there have been serious outbreaks of drug-resistant pathogens in North American hospitals, they have not yet reached the state of Prince Prospero's castellated abbey in Poe's The Masque of the Red Death, doomed by pestilence despite the lofty wall that girdles it in. A search of the AMA and CMA websites found no evidence of serious consideration. But it is probably just a matter of time before clothing policies change. As just a small sample of what can be found on the topic of infection control practice, the Canadian Patient Safety Institute has recently announced its Hand Hygiene campaign, aimed at those who are neglectful of soap and hot water. Ontario has produced a best practice manual for C. difficile. The Manitoba Guidelines for the Prevention and Control of Antibiotic Resistant Organisms contain excellent advice on hand hygiene, and mention that false nails and hand jewelry are not acceptable. But so far, no restrictions that I could find on neckties or coat sleeves. However, there is general agreement that doctors and nurses who don't adequately wash their hands pose a serious risk to patients and that hand-washing should be the focus of infection control efforts in hospitals (search PubMed under Handwashing[MAJR]).

Are lanyards as guilty as ties?
According to a 17 Sept 2007 report in Macleans, Dr. Dick Zoutman, physician director on the board of the Community and Hospital Infection Control Association - Canada, says the British decision on neckties has real merit, and Canadians should take a good look at it. Dr. Allison McGeer, director of infection control at Toronto's Mount Sinai Hospital, says she doesn't see many ties in parts of the hospital where patients are cared for. "It's not about ties; it's about things you don't clean," says McGeer. Common items like lanyards, mobile phones and handhelds that medical staff wear or carry with them can spread germs. (One BMJ rapid responder last September — Are lanyards as guilty as ties? — felt that the former were more of a hazard because they are in direct contact with the user’s skin where their tunic has no collar and are unlikely ever to be washed.) "The reason people are picking on ties is they tend not to go into the laundry. If you took them home and washed them the way you do your shirt, there wouldn't be any problem." (Obviously Dr. McGeer has not seen what happens to a pure silk jacquard weave Charvet cravat after being thrown into a washing machine.) It is not clear if anyone has the authority to ban ties from Canadian hospitals. Dr. Zoutman said that CHICA, an organization that represents about 1,200 infection control practitioners in Canada, needs to discuss the developments in Britain.

The controversy has certainly generated interest (4,5,8,11,12,14,15,17,23). Will anyone miss the necktie? As Oscar Wilde observed, "A well-tied tie is the first serious step in life." As an emblem of accomplishment for the upper-class professional male, it will not go quietly. Half of all neckties are purchased by women, according to a Forbes report. So both sexes are responsible for the persistence of this centuries-old carotid constrictor. But after the Beau Brummels and the four-in-hands of the last two hundred years, the belly-warmers and palm-bestrewed horrors of the 1940s, the shagadelic eyesores of the 1960s and 70s, surely the time has come for cravat harm reduction. This seemingly innocent rag has already been shown to contribute to intracranial pressure and glaucoma (2,9,19,20). Now we know that the necktie is a disease carrier too. The current fashion for ties that are long, pink and extremely bloated reflects either very bad taste or unsavoury phallic fixation. There is now a website that sells The Tie Thing, a washable tie restraint that the vendor claims will "keep potentially infectious ties from falling into places they should not." The SafetyTie is an anitmicrobial, stain-resistant necktie for use in the clinical setting. Can we expect to see condoms for ties in the near future?

Quoth the raven, 'Nevermore.'
It is unlikely that its suppression in a few hospitals will affect the universal domination of the Western cravat. However one looks at it, there is no denying its extraordinary endurance and proliferation around the world. This I would attribute not to some intrinsic beauty or comfort, but rather to its close association with power, particularly male power, in our culture. The symbolic significance of the necktie cannot be overstated. Not unlike the barbaric display of clan colours, it is at once a mark of personal style and a sign of belonging to — or at least aspiring to membership in — the ruling class.

Bakunin foresaw that attaining universal suffrage without an accompanying social revolution prevented ordinary people from achieving their freedom. Instead it forced the ruling elites to make their own depravity universal. The theme is pursued by Theodor Adorno in his Minima moralia: "This is the state to which the ruling consciousness has come — the shameless avowals of the pursuit of extravagant waste and champagne-sipping good times, which were previously the preserve of bemedalled attachés in Hungarian operettas, are now elevated in deadly earnest to a maxim of right living." Hence our tawdry universe of easy money and bored, vicious distraction: voodoo mortgages, video addiction, ridiculous spectacle, mall-formation, and manipulable political apathy. Hence also the snobbery and pitiless conformism of tight cravats and high heels, lavish vacations, real estate, oenophilia, food fads, and, worst of all, liposuction.

The discomfort of the necktie, or the girdle, as a form of attire, is its very significance. As with snaffle bits and hackamores, light but continuous pressure is applied to a region of the body
a constant reminder of your place in the social hierarchy. Are not such functionless clothing items really just tired symbols that are better undone? The cravat when your luck is good: the slipknot when luck runs out. Perhaps we can hope that the hospital ban on the necktie might be extended to other areas, like the increasing restrictions on smoking. We have had great success undermining the noisome reign of tobacco; and gone are the awful stays, bustles and petticoats once imposed on women. Will the cravat's mystique finally be unravelled? Now there's something to take aim at.

Clothes make the man. Naked people have little or no influence on society. ~ Mark Twain

Dress is at all times a frivolous distinction, and excessive solicitude about it often destroys its own aim.
~ Jane Austen


1. The traditional white coat: goodbye, or au revoir? Lancet 2007 Sep 29;370(9593):1102.

2. Tight neckties may increase risk of glaucoma. Geriatr. Aging 2003;6(8):11.

3. Candlin J, Stark S. Plastic apron wear during direct patient care. Nurs.Stand. 2005 Sep 21-27;20(2):41-46

AIM: To identify factors that influence nurses' practice in apron use during direct patient care. METHOD: A small-scale documentary analysis of a purposive sample of 15 journal articles relating to nurses' apron use during patient care was undertaken. The analysis sought to address what factors affect nurses' decisions in relation to apron use. FINDINGS: Nurses' decisions regarding apron use during patient care tend to be ritualistic rather than evidence-based. Their knowledge of infection control is limited. CONCLUSION: Although there is current literature available on infection control, as well as health and safety regulations, if local policy regarding apron use in nursing care is scant this can result in inconsistent and, perhaps, less desirable practices.

4. Day M. Doctors are told to ditch "disease spreading" neckties. BMJ 2006;332(7539):442.

5. Ditchburn I. Should doctors wear ties? J.Hosp.Infect. 2006 Jun;63(2):227-228.

6. Dixon M. Neck ties as vectors for nosocomial infection. Intensive Care Med. 2000 Feb;26(2):250.

This study assessed whether neck ties worn by doctors at an intensive care unit were potential vectors for infection. Heavy growths of coagulase negative staphylococcus on 2/5 ties tested suggest this is possible. Neck ties should be considered a significant potential source of infection. Although this risk can be lessened by wearing plastic aprons when we come into contact with patients maybe we should do without neck ties altogether in critical care areas.

7. Gerken A, Cavanagh S,Winner HI. Infection hazard from stethoscopes in hospital. Lancet. 1972 1/2 i:1214-1215.

8. Jameson M. Dirty ties. Br.J.Perioper.Nurs. 2004 Aug;14(8):332.

9. Jonas JB, Theelen T, Meulendijks CFM. Tight necktie, intraocular pressure, and intracranial pressure [19] (multiple letters). Br. J. Ophthalmol. 2005;89(6):786-787.

10. Loh W, Ng VV, Holton J. Bacterial flora on the white coats of medical students. J.Hosp.Infect. 2000 May;45(1):65-68

This study has demonstrated that the white coats of medical students are more likely to be bacteriologically contaminated at points of frequent contact, such as the sleeve and pocket. The organisms identified were principally skin commensals including Staphylococcus aureus. The cleanliness of the coat as perceived by the student was correlated with bacteriological contamination, yet despite this, a significant proportion of students only laundered their coats occassionally. This study supports the view that the students' white coat is a potential source of cross infection on the ward and its design should be modified in order to facilitate hand washing. Hospitals training medical students should consider taking on the burden of providing freshly laundered white coats for the students.

11. Lomas C. Is your uniform harbouring infection? Nurs.Times 2007 Oct 9-15;103(41):20-21.

12. Magos A, Maclean A, Baker D, Goddard N, Ogunbiyi O. Bare below the elbows: A cheap soundbite. BMJ 2007 Oct 6;335(7622):684.

13. Nurkin S. Is the clinician's necktie a potential fomite for hospital acquired infections? 104th General Meeting of the American Society for Microbiology 2004.

14. Nye KJ, Leggett VA, Watterson L. Provision and decontamination of uniforms in the NHS. Nurs.Stand. 2005 Apr 27-May 3;19(33):41-45

AIM: To ascertain the provision and decontamination of uniforms within a cross-section of NHS trusts in the UK and to compare policies regarding their use. METHOD: A questionnaire was circulated to 170 NHS trust infection control teams in the UK. Eighty-six (51 per cent) responses were received, which represented 101 NHS trusts. RESULTS: Less than half of the trusts (47 per cent) provide adequate numbers of uniforms to allow a clean uniform per shift. Only 26 per cent had adequate on-site staff changing facilities and 65 per cent did not launder uniforms. The majority of nursing staff (91 per cent) were compelled, by a combination of these factors, to launder their uniforms at home. Few were provided with any guidance on how to do this safely. CONCLUSION: There is an urgent need for minimum standards to be set for the provision of uniforms, laundering and changing facilities, to minimise the potential for spread of healthcare-associated infections.

15. Shintani H, Hayashi F, Sakakibara Y, Kurosu S, Miki A, Furukawa T. Relationship between the contamination of the nurse's caps and their period of use in terms of microorganism numbers. Biocontrol Sci. 2006 Mar;11(1):11-16

Nosocomial infections are a great problem in the health care facilities. The white uniforms of nurses are often washed to keep them clean, but the nurse's caps are not washed as frequently in comparison. It could be that the importance of these caps is being overlooked. If these caps are providing a residence for microorganisms causing nosocomial infection in the health care facility, then they should be washed as frequently as the uniforms. So far, the relationship between the contamination of the nurse's caps and nosocomial infection has not yet been studied. Therefore, this study was conducted to confirm if relationships exist among factors regarding the number of microorganisms on the nurse's caps, the period in which caps were used without being washed, and the individual characteristics of nurse wearing the caps. Results showed that the degree of contamination of the nurse's caps depended on individual characteristics and the period of use. Finally, results led to the conclusion that the nurse's caps should not be worn if their only purpose is to symbolize female workers in the health care facilities because, in actually, they provide a resistance for microorganisms causing nosocomial infections.

16. Steinlechner C, Wilding G, Cumberland N. Microbes on ties: do they correlate with wound infection? Ann R Coll Surg Eng 2002, (Suppl) 84(9):307-9.

Many measures are taken to reduce the spread of pathogenic micro-organisms within hospitals, particularly MRSA. It is known that they are transferred by direct contact and that simple measures such as hand washing are highly effective in reducing spread. Many woven fabric items within hospitals have been shown to carry pathogens; the possibility of resultant wound infections cannot be ignored and unnecessary potential vectors should be eliminated. Infection in orthopaedic patients is a disaster which may lead to implant removal and multiple surgical procedures. We tested the ties of our orthopaedic department for pathogenic organism carriage and found that all ties were colonised by bacteria that are frequently cultured from swabs taken from discharging wounds of orthopaedic patients.

17. Sundeep S, Allen KD. An audit of the dress code for hospital medical staff. J.Hosp.Infect. 2006 Sep;64(1):92-93.

18. Takashima M, Shirai F, Sageshima M, Ikeda N, Okamoto Y, Dohi Y. Distinctive bacteria-binding property of cloth materials. Am.J.Infect.Control 2004 Feb;32(1):27-30

BACKGROUND: Nosocomial infections may be caused by pathogens that are transmitted from the hands or clothes of hospital personnel. Handwashing has been evaluated as effective against the spread of pathogens, but transmission through clothes has been little investigated. Evaluation of bacterial adherence to clothes is difficult because of the nonuniform amount of water absorbance by cloth. Therefore, we measured binding of bacteria to cloth fibers made of cotton, nylon, polyester, acrylic, or sheep's wool and tried to characterize bacterial binding to cloth. METHODS: We chose to study the opportunistic pathogens Staphylococcus aureus and Pseudomonas aeruginosa. Cloth fibers were incubated with bacterial suspensions in silicone-coated tubes. We evaluated the reduction of numbers of bacteria in solutions incubated with the fibers and calculated binding ratios of bacteria to the fibers. RESULTS: Polyester or acrylic fibers bound S aureus and P aeruginosa at high ratios (>80%), but cotton fibers bound them at low ratios (<10%). Nylon fibers bound S aureus at low ratios, but P aeruginosa at intermediate ratios. CONCLUSION: The results suggested that polyester, acrylic, or wool clothes could be good carriers of S aureus and P aeruginosa and thus should be covered with cotton clothes to minimize the spread of the pathogens.

19. Tally P, O'Brien PD. Does extended wear of a tight necktie cause raised intraocular pressure? J. Glaucoma 2005;14(6):508-510

20. Teng C, Gurses-Ozden R, Liebmann JM, Tello C, Ritch R. Effect of a tight necktie on intraocular pressure. Br. J. Ophthalmol. 2003;87(8):946-948

21. Waghorn DJ. Stethoscopes: a study of contamination and the effectiveness of disinfection procedures. British Journal of Infection Control. 2005;6(1):15-17

Stethoscopes are universally used by healthcare professionals. They can come into contact with numerous patients and may harbour organisms that can be transferred between individuals. Wycombe hospital has a policy that stethoscopes should be disinfected with a 70% isopropyl alcohol swab after each patient use. A study was undertaken to assess the degree of stethoscope contamination and the effectiveness of the disinfection procedure. A randomly chosen group of healthcare professionals submitted their stethoscopes for microbiological analysis. A selection of ward-based stethoscopes were also tested. Personal stethoscopes were then disinfected with an alcohol wipe and re-sampled. All stethoscopes showed bacterial contamination before disinfection, the highest concentration of organisms being seen on doctors' stethoscopes. Skin flora was grown from all samples and 12% grew Staphylococcus aureus. Following decontamination, bacterial levels were greatly reduced, but three contaminated stethoscopes remained heavily colonised even after the disinfection procedure. Staff need to be made more aware of the need to routinely disinfect stethoscopes correctly between each patient use. The increased placement of bed- or ward-specific stethoscopes needs to be considered.

22. Ward DJ. Hand adornment and infection control. Br.J.Nurs. 2007 Jun 14-27;16(11):654-656

Studies have shown that despite infection control guidelines recommending that false fingernails, nail varnish, stoned rings and wrist watches not be worn by clinical staff, a large proportion of them continue to do so. Hand jewellery and false finger nails should be kept short, clean and free from nail polish. This article discusses the bacterial carriage, contributions to outbreaks of infection and interference with proper hand hygiene practices, thereby explaining why these recommendations are made in infection control policies and guidelines.

23. Wilson JA, Loveday HP, Hoffman PN, Pratt RJ. 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). J.Hosp.Infect. 2007 Aug;66(4):301-307

A systematic search and quality assessment of published literature was conducted to establish current knowledge on the role of healthcare workers uniforms' as vehicles for the transfer of healthcare-associated infections. This review comprised a systematic search of national and international guidance, published literature and data on recent advances in laundry technology and processes. We found only a small number of relevant studies that provided limited evidence directly related to the decontamination of uniforms. Studies concerning domestic laundry processes are small scale and largely observational. Current practice and guidance for laundering uniforms is extrapolated from studies of industrial hospital linen processing. Healthcare workers' uniforms, including white coats, become progressively contaminated in use with bacteria of low pathogenicity from the wearer and of mixed pathogenicity from the clinical environment and patients. The hypothesis that uniforms/clothing could be a vehicle for the transmission of infections is not supported by existing evidence. All components of the laundering process contribute to the removal or killing of micro-organisms on fabric. There is no robust evidence of a difference in efficacy of decontamination of uniforms/clothing between industrial and domestic laundry processes, or that the home laundering of uniforms provides inadequate decontamination.