September 29, 2008 -- Going to a hospital when you are sick is bad enough. The last thing you want to worry about is what kinds of germs your doctor or nurse could be carrying around.
There are a variety of standards and practices in place to keep hospital staff, and thus patients, as germ-free as possible. But with so many unmonitored variables -- clothing, equipment, a patient's degree of illness -- microbes have the potential to reverse a good doctor's hard work.
As iconic as scrubs are for hospital staff, the garments can be seen almost as frequently outside the hospital walls.
"It bothered me inherently throughout the years... Did they sleep in these things? Did they go on the subway with them?" said Dr. Donald M. Kastenbaum, assistant vice president and medical director at Beth Israel Medical Center in New York. "I thought, you know what? They can't be clean."
Though it seems like a simple idea that clothing worn in a hospital should be removed before leaving, Kastenbaum said an increasingly lax professional and cultural view towards the garments have made it acceptable not to do so.
But there are no studies or data on the cleanliness of hospital garb, which makes it difficult to determine the risks they pose, said Marcia Patrick, Infection Control Director for MultiCare Health System, a consortium of four hospitals in Tacoma, Wash.
"With ties and stuff, if you tuck them in so they're not dangling, it's fine," Patrick said. "If they go in and touch a patient and their sleeves never touch the patient, it's no big deal."
Some hospitals are taking bold steps to improve their commitment to clean work clothing.
Kastenbaum recently began an initiative he calls "Purple is 'In'" for all operating room staff, from doctors to secretaries, to wear purple scrubs.
"We changed the whole environment at the Beth Israel Medical Center hospital," Kastenbaum said, citing increased confidence in hospital cleanliness. "No one is allowed out of the hospital in purple scrubs. The guards will stop you."
The Barney-like purple scrubs serve dual purposes -- to identify OR staff and to make it clear that the OR was a sterile environment.
"We don't want to have infections for us or our families either," Kastenbaum said.
Hike Up Those Sleeves
Improvements in operating room standards and practices mean less risk of infection for patients, but some also feel that hospital staff outside the OR deal with other problems.
"The [clothes] that people wear day to day in patient care are far more risky than OR scrubs where they are also wearing a sterile gown," Patrick said. "They are probably cleaner than people on the floors, in the ICU, or in nursing units."
Rubbing up against hospital beds and rails or turning, lifting or rolling hospital patients can contaminate clothes, particularly sleeves.
"I don't think long sleeves should ever be worn at the bedside," Patrick said.
There may be merit to ideas like these, given the incidence of intra-hospital disease. About 1.7 million infections and 99,000 deaths each year are the result of infection-causing germs spread in U.S. hospitals, according to the CDC.
"Compliance is always an issue," Patrick said, in terms of wearing sterile gowns and masks, where appropriate, to see patients. "Because it takes longer. And it's annoying."
Disciplinary action is taken at the discretion of each hospital, but Patrick said serious cases of hygiene noncompliance area rare.
In general, hospitals do their best to keep staff well trained and updated in hospital procedure regarding cleanliness and infection risk reduction, with refresher courses about once a year, said Patrick, who is also a member of the Association of Professionals in Infection Control and Epidemiology.
"At Baylor, each year we are updated," said Dr. Benoy Benny, assistant professor of physical medicine and rehabilitation at Baylor College of Medicine in Houston, Texas. "We don't want to bring infections in to [patients] if they are immunocompromised."
Virulent diseases and cancers, particularly ones such as leukemia in which the immune system is weak and the white blood cell count is low, are ones where a visitor should take more care than usual with their cleanliness.
Wash Those Hands
The practice which sticks best for people is hand hygiene. Washing hands before and after seeing a patient and using gel hand sanitizers is standard practice in every hospital, Patrick said, and the best way to minimize infections.
A 2005 study at the University of North Carolina at Chapel Hill testing different methods of hand hygiene showed that a 10 second scrub with soap and water could remove about 90 percent of the bacteria on the hands. Alcohol-based hand gels removed about 50 percent of bacteria.
The key, it seems, is having the right products in the right places.
Dispensers of soap or gel hand sanitizers are usually located in each room and at strategic locations in hallways and on desks.
"If there's anything procedural, physicians will was their hands before and after," Benny said. "It's part of a normal routine."
Patrick said that the Tacoma hospitals could, in a busy month, go through over two gallons of soap and gel.
"Our motto is 'gel in, gel out'," Patrick said.
But the nature of a hospital is to harbor germs, and sometimes illnesses are impossible to avoid. Nor is it easy to keep work contaminants from spreading to other areas of a staffer's life.
"As soon as I step into [my] house, I always wash my hands again," Benny said. But with a 20-month-old son waiting at home, he admits it is sometimes hard to shower and change out of the clothing he wore at work first.
But changes such as the purple scrubs Kastenbaum instituted may be the direction in which the medical community wishes to go. He said the outfits have boosted the reputation and the professionalism of the hospital staff.
"We've got to get back to being strict," Kastenbaum said. "Some people are going to get an infection, we can't be perfect. But boy we've got to try."