New York bill seeks physician dress code to cut infections

New York physicians may have to take off their neckties, jewelry, wristwatches and long-sleeved white coats when caring for patients if a bill under consideration in the state Legislature becomes law.

The bill, proposed in April in the state Senate, calls for a "hygienic dress code council" within the New York Health Dept. to consider advancing a ban on neckties and requiring physicians and other health professionals to adopt a "bare below the elbow" dress code in an effort to slash hospital-acquired infections.

"I'm not looking in any way to hurt anybody in health care," said Sen. Jeffrey D. Klein, the bill's sponsor. "This is something we have to take a good, hard look at."

New York would not be the first government body to weigh in on health professionals' attire. The United Kingdom's Dept. of Health in 2007 published guidelines advising against long-sleeved clothing, fake nails and jewelry. The guidance was slightly revised in 2010.

Yet the medical evidence does not support bans on neckties or long sleeves, infectious-disease experts said. "The hypothesis that uniforms/clothing could be a vehicle for the transmission of infections is not supported by existing evidence," said an August 2007 systematic review prepared for the U.K. Dept. of Health and published in the Journal of Hospital Infection.

Though studies have found that neckties and other clothing can be contaminated with bacteria, the link between contamination of clothing and infection of patients has not been established definitively, experts said.

The New York legislation "sort of verges on hysteria," said James L. Cook, MD, chief of the Section of Infectious Diseases, Immunology and International Medicine at the University of Illinois College of Medicine in Chicago. "You've got to decide. Do you want to use the evidence? ... There is nothing to suggest that anything you find on someone's article of clothing is likely to be transmitted to a patient."

The quest to entirely eliminate bacteria in health care settings is futile, said Patrick J. Brennan, MD, former president of the Society for Healthcare Epidemiology of America.

"If you swab the bare arms, you're going to get bacteria. It's not as though, by eliminating sleeves, you eliminate germs," said Dr. Brennan, chief medical officer of the University of Pennsylvania Health System. "The key thing to understand is that these environments are not sterile and are never going to be sterile. That goal is unattainable in a clinical setting. The real goal is to adhere to good hand hygiene, isolation practices, gloving, barrier precautions -- that's where we'd put our money."

Testing short sleeves

A handful of hospitals have reportedly adopted dress codes as part of a bundle of quality interventions, but experts said there have been no randomized controlled trials to test whether avoiding long sleeves and neckties prevent infections.

Meanwhile, an April 6 Journal of Hospital Medicine study cast some doubt on the no-sleeves policy. Fifty physicians at Denver Health Medical Center were asked to wear their usual white coats, and 50 other doctors wore freshly cleaned short-sleeved scrubs. After an eight-hour shift, tests of the clothing found no difference in the extent of bacterial contamination.

"Even if you put the clean uniform on -- unless you're going to change your clothes every few hours -- there's no data to support that these dress code measures are really effective," said Marisha Burden, MD, lead author of the study and an internist and hospitalist at Denver Health.

Neither the Medical Society of the State of New York nor the Greater New York Hospital Assn. has taken a position or offered any comment on the Senate bill. A 2010 report adopted by the American Medical Association said there is little evidence linking clothing to infection rates and called for further research before adopting restrictive dress codes.

If the bill, referred to the Senate Standing Committee on Health, becomes law, the state health department could pursue a coat-and-tie ban through regulation, Klein said. He stressed that physicians and other experts would have a role on the advisory council to determine whether to pursue a U.K.-style dress code.

"I'm an attorney, I'm not an MD," said Klein, a Democrat who represents the Bronx. "This is a simple and noninvasive approach to alleviating the infections that are taking place in hospitals and which are a serious problem -- not only in New York, but across the country."