TITLE: Lab Coats and Scrubs for the Reduction of Infection Transmission: Clinical Evidence and Guidelines

DATE: 14 August 2015

RESEARCH QUESTIONS

1. What is the clinical evidence regarding the laundering and wearing of lab coats and scrubs to reduce the spread of infection in health care facilities?

2. What are the evidence-based guidelines regarding the laundering and wearing of lab coats or scrubs in health care facilities?

KEY FINDINGS

One randomized controlled trial and one evidence-based guideline were identified regarding the laundering and wearing of lab coats and scrubs to reduce the spread of infection in health care facilities.

METHODS

A limited literature search was conducted on key resources including PubMed, The Cochrane Library, University of York Centre for Reviews and Dissemination (CRD) databases, Canadian and major international health technology agencies, as well as a focused Internet search. No filters were applied to limit the retrieval by study type. Where possible, retrieval was limited to the human population. The search was also limited to English language documents published between January 1, 2010 and August 4, 2015. Internet links were provided, where available.

The summary of findings was prepared from the abstracts of the relevant information. Please note that data contained in abstracts may not always be an accurate reflection of the data contained within the full article.

Disclaimer: The Rapid Response Service is an information service for those involved in planning and providing health care in Canada. Rapid responses are based on a limited literature search and are not comprehensive, systematic reviews. The intent is to provide a list of sources of the best evidence on the topic that CADTH could identify using all reasonable efforts within the time allowed. Rapid responses should be considered along with other types of information and health care considerations. The information included in this response is not intended to replace professional medical advice, nor should it be construed as a recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality evidence does not necessarily mean a lack of effectiveness particularly in the case of new and emerging health technologies, for which little information can be found, but which may in future prove to be effective. While CADTH has taken care in the preparation of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that effect. CADTH is not liable for any loss or damages resulting from use of the information in the report.

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SELECTION CRITERIA

One reviewer screened citations and selected studies based on the inclusion criteria presented in Table 1.

Table 1: Selection Criteria Population All patients admitted to a health care facility (e.g., hospital, long-term care) Intervention Hospital laundered lab coats or hospital laundered scrubs (also known as “greens”) worn by health care providers Comparator Q1: Home laundered lab coats or scrubs worn by health care providers; No lab coat or scrubs worn by health care providers No comparator Q2: No comparator necessary Outcomes Q1: Infection rates Q2: Guidelines regarding when and where health care professionals should wear lab coats and scrubs, as well as frequency and location of laundering Study Designs Health technology assessments, systematic reviews, meta-analyses, randomized controlled trials, non-randomized studies, evidence-based guidelines

RESULTS

Rapid Response reports are organized so that the higher quality evidence is presented first. Therefore, health technology assessment reports, systematic reviews, and meta-analyses are presented first. These are followed by randomized controlled trials, non-randomized studies, and evidence-based guidelines.

One randomized controlled trial and one evidence-based guideline were identified regarding the laundering and wearing of lab coats and scrubs to reduce the spread of infection in health care facilities. No relevant health technology assessments, systematic reviews, meta-analyses, or non-randomized studies were identified.

Additional references of potential interest are provided in the appendix.

OVERALL SUMMARY OF FINDINGS

One randomized controlled trial1 compared bacterial contamination of doctor’s white coats and freshly laundered short-sleeved hospital uniforms after an eight hour hospital work day. While the freshly laundered uniforms initially had colony count of zero, after eight hours there was no significant difference in contamination between uniforms and white coats. One guideline,2 from the Association of Perioperative Registered Nurses, recommends healthcare workers entering into operative spaces wear hospital-laundered or disposable scrubs.

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REFERENCES SUMMARIZED

Health Technology Assessments No literature identified.

Systematic Reviews and Meta-analyses No literature identified.

Randomized Controlled Trials

1. Burden M, Cervantes L, Weed D, Keniston A, Price CS, Albert RK. Newly cleaned physician uniforms and infrequently washed white coats have similar rates of bacterial contamination after an 8-hour workday: a randomized controlled trial. J Hosp Med. 2011 Apr;6(4):177-82. PubMed: PM21312328

Non-Randomized Studies No literature identified.

Guidelines and Recommendations

2. Spruce L, Van Wicklin SA, Conner RL. Guideline for surgical attire. In: 2015 guidelines for perioperative practice. Denver (CO): Association of Perioperative Registered Nurses (AORN); 2014. p. 97-120 http://www.guideline.gov/content.aspx?id=48868&search=laundry

PREPARED BY: Canadian Agency for Drugs and Technologies in Health Tel: 1-866-898-8439 www.cadth.ca

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APPENDIX – FURTHER INFORMATION:

Non-Randomized Studies

Colonization Studies

3. Nordstrom JM, Reynolds KA, Gerba CP. Comparison of bacteria on new, disposable, laundered, and unlaundered hospital scrubs. Am J Infect Control. 2012 Aug;40(6):539-43. PubMed: PM22177668

Washing Setting Not Specified

4. Vikke HS, Giebner M. UniStatus - a cross-sectional study on the contamination of uniforms in the Danish ambulance service. BMC Res Notes. 2015;8:95. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4376367 PubMed: PM25889860

5. Chen YL, Yeh MY, Huang SY, Liu CM, Sun CC, Lu HF, et al. Feasibility study for epidemic prevention and control in a regional hospital. Mol Med Rep. 2012 Mar;5(3):859- 65. PubMed: PM22200785

Non-Comparative

6. Scott E, Goodyear N, Nicoloro JM, Marika DJ, Killion E, Duty SM. Laundering habits of student nurses and correlation with the presence of Staphylococcus aureus on nursing scrub tops pre- and postlaundering. Am J Infect Control. 2015 Jul 1. PubMed: PM26143576

7. Munoz-Price LS, Arheart KL, Mills JP, Cleary T, Depascale D, Jimenez A, et al. Associations between bacterial contamination of health care workers' hands and contamination of white coats and scrubs. Am J Infect Control. 2012 Nov;40(9):e245-e248. PubMed: PM22998784

8. Lakdawala N, Pham J, Shah M, Holton J. Effectiveness of low-temperature domestic laundry on the decontamination of healthcare workers' uniforms. Infect Control Hosp Epidemiol. 2011 Nov;32(11):1103-8. PubMed: PM22011538

9. Wiener-Well Y, Galuty M, Rudensky B, Schlesinger Y, Attias D, Yinnon AM. Nursing and physician attire as possible source of nosocomial infections. Am J Infect Control. 2011 Sep;39(7):555-9. PubMed: PM21864762

Length of Wear

10. Gouraud D, Dumont R, Asehnoune K, Lejus C. White coats: how long should doctors wear them? Ann Fr Anesth Reanim. 2014 Jan;33(1):e23-e25. PubMed: PM24378050

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Not Specific to Healthcare

11. Oie S, Furukawa H, Kobayashi H, Okubo T. Cleanliness of Linen and Clothing Items Professionally Laundered or Dry-cleaned. Jpn J Infect Dis. 2015 Jun 12. PubMed: PM26073734

Qualitative Studies

12. Riley K, Laird K, Williams J. Washing uniforms at home: adherence to hospital policy. Nurs Stand. 2015 Feb 20;29(25):37-43. PubMed: PM25690234

13. Munoz-Price LS, Arheart KL, Lubarsky DA, Birnbach DJ. Differential laundering practices of white coats and scrubs among health care professionals. Am J Infect Control. 2013 Jun;41(6):565-7. PubMed: PM23219673

14. Potter YC, Justham D. Washing and changing uniforms: is guidance being adhered to? Br J Nurs. 2012 Jun 14;21(11):649-3. PubMed: PM22875349

Clinical Practice Guidelines and Recommendations – Methodology Not Specified

15. Bearman G, Bryant K, Leekha S, Mayer J, Munoz-Price LS, Murthy R, et al. Healthcare personnel attire in non-operating-room settings. Infect Control Hosp Epidemiol. 2014 Feb;35(2):107-21. PubMed: PM24442071

16. The Society for Healthcare Epidemiology of America (SHEA). Infectious diseases experts issue guidance on healthcare personnel attire [Internet]. Arlington (VA): SHEA; 2014 Jan 20. [cited 2015 Aug 12]. Available from: http://www.shea- online.org/View/ArticleId/250/Infectious-Diseases-Experts-Issue-Guidance-on-Healthcare- Personnel-Attire.aspx

17. Guidance on uniforms and work wear [Internet]. London: Royal College of Nursing; 2013. [cited 2015 Aug 12]. Available from: http://www.rcn.org.uk/__data/assets/pdf_file/0010/78652/002724.pdf See: Minimum organizational standards, page 7

Review Articles

18. Cowperthwaite L, Holm RL. Guideline implementation: Surgical attire. AORN J. 2015 Feb;101(2):188-94. PubMed: PM25645036

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19. Mitchell A, Spencer M, Edmiston C, Jr. Role of healthcare apparel and other healthcare textiles in the transmission of pathogens: a review of the literature. J Hosp Infect. 2015 Aug;90(4):285-92. PubMed: PM25935701

Additional References

20. Dean E. Laundering uniforms at less than 60 degrees C may increase risk of HCAIs. Nurs Stand. 2015 Feb 20;29(25):11. PubMed: PM25690194

21. Spruce L. Back to basics: surgical attire and cleanliness. AORN J. 2014 Jan;99(1):138-46. PubMed: PM24369978

22. Deadly ties and the rise of multi-drug resistant infections: a case for a new health care practitioner hygenic dress code [Internet]. New York: New York State Senate; 2011 May. [cited 2015 Aug 12]. Available from: http://www.nysenate.gov/files/pdfs/DirtyTieFINAL_1.pdf

23. Heisel W. The California Endowment Health Journalism Fellowships. Reporting on health [Internet]. Alhambra (CA): University of Southern California. Hospital dress code could be a test case for tracking infections; 2011 Jul 15 [cited 2015 Aug 12]. Available from: http://www.reportingonhealth.org/node/11359

24. Schattner E. What should doctors wear? Even lab coats could spread disease. The Atlantic [Internet]. 2011 Nov 7 [cited 2015 Aug 12]. Available from: http://www.theatlantic.com/health/archive/2011/11/what-should-doctors-wear-even-lab- coats-could-spread-disease/247987/

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