April 27th, 2011

Scrubs and Sandwiches- A Deadly Combination?

I was enjoying lunch at a popular midtown Sacramento restaurant recently, when two patrons walked in wearing green scrubs.  Both were wearing official badges from a large, local hospital, revealing one to be a physician, the other a registered nurse.  Concerned that these scrubs may have been exposed to antibiotic-resistant bacteria, I politely asked that the healthcare workers leave the restaurant, and return only in regular attire.  Both were mildly annoyed but agreed to depart.  I took this action because I believe the use of scrubs in the community is a serious and avoidable public threat.  I am also convinced that simple public action can play a powerful role in effecting change and that the healthcare community has been remiss in addressing this issue.  I am also hopeful that this action will encourage healthcare organizations and providers to take this issue more seriously, and to address it less equivocally from within their own organizations.

Scrubs are generally worn and laundered inside hospitals, in part to keep dangerous pathogens from colonizing the community at large.  Such pathogens include the antibiotic-resistant superbugs, such as Clostridium difficile (C. Diff.), Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant enterococcus (VRE).

The Infectious Diseases Society of America reports that community-acquired C. Diff. infection is on the rise, and speculates that environmental exposure to this pathogen may be partly to blame. So why would hospital personnel carelessly transport it from hospitals to the community at large?  MRSA-related morbidity and mortality used to be seen almost exclusively in hospitalized patients, but now occurs more frequently in the general population, even among those who have not had hospital exposure.  And it has also been demonstrated that healthcare professionals who enter a hospital room occupied by a MRSA-infected patient will frequently acquire MRSA on their clothing, without actually touching the infected patient. Yet some healthcare workers choose to move about routinely in scrubs, between hospitals and coffee houses, restaurants, and local shops, where they may spread dangerous organisms to tables, dinnerware and a multitude of items that are subsequently handled by many others.  Furthermore, these superbugs are not eliminated by routine cleaning products, and survive on ordinary surfaces for weeks to months, where many others can pick them up unknowingly.

I acknowledge at the outset, this is a controversial issue.  Some will argue that the use of hospital-exposed scrubs in public has never been proven as the proximate cause of a single infection.  Yet this is not the type of study that can be done, ethically or practically – recall the Tuskegee Syphilis Study as an extreme example – which is why prudence, along with inferential decision making, is necessary.   Since we cannot subject a study population to superbugs under the controlled conditions necessary to “prove” a connection, we are forced to create policy based on common sense.  It should hardly require complete proof to connect these dots.

I am also addressing what has become policy at many institutions, yet many providers have trivialized the need for compliance or ignored the policy altogether.  This lack of respect for decisions that are made consensually by the greater medical community, and (as a physician) the very institutions that make our practices possible, is unprofessional and irresponsible.  As other physicians have agreed elsewhere, this in itself undermines the respect of those who depend on us for healthcare services.  The two individuals I encouraged to leave the restaurant are case in point.  Both, as I later learned, came from a hospital that does not allow hospital scrubs outside of patient-care areas.

While I am now advocating direct confrontation (see my posts at reportingonhealth.org), I do so largely because physicians, hospitals and healthcare safety organizations have failed to address the scrubs issue.  Physicians are quick to raise the red flag when policy is thrust upon them, so why not be more proactive and give this issue the attention it is due?  The AMA News reported that Washington State Representative Tom Campbell addressed the rising MRSA-related infection issue by introducing a bill and stated, “If hospitals won’t take meaningful steps to stop drug-resistant infections, then we’ll pass legislation to make sure they do.”  How many readers of CardioExchange welcome this brand of change through legislation?  I would prefer a more proactive approach among those most qualified to study this issue and render sound policy guidelines, and greater compliance by those who feel they are above the rules.

Let me refer to another practice concern, in which noncompliance has been “proven” to cause harm.  The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has launched a bold initiative called “Speak Up,” which encourages individuals to take an active role in reducing our risk of infection by assuring that providers wash their hands and wear gloves.  JCAHO has even published a coloring book for children, to teach, early in life, that it is not disrespectful or inappropriate to speak up and remind physicians and other providers to take appropriate safety measures.  For adults, the Joint Commission issues buttons, to be worn by healthcare providers, which say, “Ask me if I’ve washed my hands.”  This initiative is supported by the American Hospital Association and the Centers for Disease Control and Prevention, among many other quality and safety organizations. Some hospitals and clinics that have embraced and enforced rigorous hand washing protocols have reduced their rate of institution-acquired infections, in some cases quite dramatically.    Yet, believe it or not, many healthcare workers have not complied with institutional policy on hand washing.   While JCAHO is hardly perfect, doesn’t it ring alarm bells when patients are being taught to enforce proper hygiene because healthcare providers have been remiss?  Yet until and unless we take greater responsibility ourselves, I support this effort and encourage more of its kind.

Most area hospitals have official or unofficial policies, which restrict the use of hospital scrubs to surgical suites and related patient-care areas.  Exposure to superbug-infected patients mandates a change of scrubs before moving on to care for others.  Wearing them or laundering them outside of the hospital is forbidden or discouraged, but enforcement of such policy is a difficult task.  I spoke about this concern with quality assurance personnel at two of the four major hospital organizations in my home, the Sacramento area. The two others failed to return several calls. One of the quality assurance staff members shared an observation that her organization had been effective in curtailing scrub misuse by non-physician staff, but that physicians were frequently allowed to break the rules. She said that many considered themselves to be “above the law” in this regard. Some travel to and from their own homes in contaminated scrubs, which suggests that this practice stems less from a disregard for others and more from a curious type of denial and disbelief that hospital-contaminated scrubs offer any real threat.   Are these the same professionals who have resisted aggressive hand-washing protocols, which make a huge difference in institutional infection rates?  As a physician who has spent most of my career in the surgical suite, I find this perplexing.

The notion that physicians and nurses are immune to error, or unapproachable regarding its potential should have been laid to rest long ago.  None of us should share public space with those who unnecessarily risk compromising public safety, knowingly or otherwise.  I believe, as does the medical community at large, that it is time for all of us to take responsibility for our health and safety, rather than displacing the entirety of this onus to our caregivers.  Purging public spaces of hospital-exposed garments could make more than a public fashion statement. It could reduce illness and even death from infectious disease.

It has been credibly estimated that over 100,000 deaths occur each year in the US from preventable medical mistakes.  It has also been observed that such high mortality would never be tolerated in the airline industry, which falls under intense scrutiny for mishaps resulting in tens or hundreds of deaths.  Granted, the airline analogy only goes so far, but why should there be a difference in transparency between these two industries, both of which exercise control over our safety?   Most of us feel quite safe when we fly, even in these turbulent times, but I think most people would speak up if they noticed a public danger while boarding an airplane. So why shouldn’t anyone voice concern when they see a threat to our health? Public accountability and trust are not incompatible in the airline industry; why should they be at odds in healthcare?

So how can people effect change?  Perhaps most people would consider it too forward to actually ask someone to leave a public place.  For those who do feel comfortable doing so, however,  I think it is an entirely reasonable approach.  I strongly believe that most healthcare workers will comply with such a request, and that future transgressions will be reduced as violators learn of the concern among those around them.

For those few who do not comply with such requests or who do not engage in reasonable conversation, people should walk away without confrontation. I have advocated that they call the institutions where those in scrubs are employed or in practice, insisting on the attention of a hospital administrator, president or chief executive officer to explain the concern that medical staff may be introducing potentially dangerous bacteria into the public spaces that everyone shares.

This essay will surely offend some readers.  Some may be concerned that my approach may cause undue fear, though I believe the pathogens themselves are of greater concern.  Others may simply believe that scrubs do not represent a real risk.  And perhaps others will feel that healthcare policy is not in the purview of the public.  I hope to establish dialogue on this topic, which is almost always a signpost on the road of quality improvement.  But let us also abide practices that are known to be safe, and exercise restraint with those in doubt.  Washing hands and changing clothes are small precautions to take.


6 Responses to “Scrubs and Sandwiches- A Deadly Combination?”

  1. Kwei Quartey, MD says:

    I have always considered scrubs STRICTLY AN ATTIRE FOR WORK INSIDE THE HOSPITAL, and as for wearing them to restaurants and shopping malls, that always seemed to me like poor form: “Hey, look at me everyone, I’m an important doctor!”

    But my concern now is, what about street clothes? Most of us do go into our hospitals and clinics wearing our street clothes, and then we come out with the same ones and go to restaurants etc. Does that end up the same issue? Technically, we should be stopping at a changing module outside the facility, change into scrubs, and pass through a UV “zapper” tunnel or something before entering the facility. We would reverse the process when leaving. And what about patients, and ancillary hospital workers, and on and on? Quite problematic!

  2. Dr Quarty has expressed my sentiments exactly. Scrubs aren’t the problem. In fact, scrubs have evolved from a standard, internally laundered garment to minimize outside contamination of ORs to a uniform for working at a healthcare facility. Stores and websites sell scrubs for this purpose. Moreover, the rise of super bugs and spread of c diff and MRSA in the community is not the result of “bad eggs” acting unprofessionally. Instead, it is a result of a dearth of workable solutions to spreading infections. Alcohol hand sanitizer was the biggest innovation to hit this complex problem so far because effective handwashing severely impedes a busy workflow with current pressures to produce. We need something similar to alcohol rub for clothing. A walk through sanitizer would be great if we could rig one up. That’s the kind of thinking that has a chance to impact this problem.

  3. The author correctly identifies the fact that scrubs have never been linked to the direct spread of infection. Unfortunatly the author made an inaccurate and in my view offensive comparison to the innocent individuals of the Tuskegee Syphilis Study. The doctor and nurse the author asked to leave the restaurant did not walk in, offer to pay for Dr. Martin’s meal, then as he went to the bathroom and rub his food in their scrubs. They of course would have soaked their scrubs in c.diff, MRSA, VRE laiden stool, and other bodily fluids first. Then as the “subject” became sick they would just watch to see what happens to the natural history of individuals who get sick from hospital scrubs. While I recognize randomized or prospective studies would be unethical, observational and/or retrospective studies would be possible, and the comparison to one of the most tragic medical experiments in our history could have been avoided.

    Competing interests pertaining specifically to this post, comment, or both:

    • David Martin, M.D. says:

      Reference to Tuskegee will surely offend some readers and I certainly understand the anonymous commentator’s sentiment in this case. I cited this tragedy, acknowledging it as an extreme example, because a shocking number of physicians have held up an impossible standard of “proof” before taking the scrub issue seriously. This is a polarizing issue, and as I continue to address it to a widely disparate audience across multiple media, it has become necessary to offend a few to capture the attention of a small contingent who use the “proof” defense to justify their practice of convenience. While I take no pleasure in offending a colleague, I welcome a more useful contribution that addresses the issue at hand.

  4. I just do not understand how Dr. Martin has identified the wearing of scrubs outside of the hospital as a major reason for the rise of resistant infections in the community. He makes many leaps and ignores the obvious in his rather drawn out argument. As Dr. Qwarty wrote, why is wearing scrubs out of the hospital any different than wearing an oxford shirt, slacks, and a necktie out of the hospital after rounding on inpatients all day? Please step back from your argument for a second and see how little sense it makes. I don’t think we should wear scrubs in the OR that we wear outside of the hospital–that’s maybe a contributor to procedure-related infections and why hospital scrubs really are issued–you risk bringing outside pathogens into the OR on dirt and dust from the bus ride in to work. I think hospitals should crack down on wearing institutional scrubs home because they are hospital property. Dr. Martin fails to acknowledge the vastly more complex and numerous reasons why MRSA, VRE, and c. diff is increasingly common outside of the wards. Lets consider the rise of nursing homes, rehab facilities, LTAC’s, and bounce-back hospitalizations. Let’s look at indiscriminate antibiotic use. Let’s consider the more frenzied pace of healthcare and the movement of people and equipment between patients in a typical inpatient setting. Let’s even think about whether the traditional white coat and necktie make it harder to prevent microbial spread. Only partially in jest, I make a suggestion that we replace the white coat with a hospital-only space-suit with special pockets that will sanitize your hands, stethoscope, pens, and phone between patients. The surface is coated with antimicrobial magic of some kind and you check your suit in and out at the hospital door for maintenance and deep sanitizing between shifts. All I need now is some bright engineers, designers, and some investment capital…

  5. David Martin, M.D. says:

    Now that this blog has run its course, I would like to thank those who took the time to comment. Please note that I never suggested that the misuse of scrubs was the primary reason that community superbug infections are becoming more common, but one of many that (I believe) have not been addressed adequately. As I put this dialogue behind me, let me sign off with a link to a relevant United Press story that posted this morning-
    I am quite pleased to see action of this nature and will work toward establishing more of its kind. Thank you.