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Comprehensive Medical Careers Advice
Karen Hebert (BMJ Careers 12 April 0 Cool

paints a falsely glowing account of the present image of the white coat. Over the past 5 years, white coats have only represented either medical students approaching or eccentric professors (both of which are to be avoided). It was perhaps not only Alan Johnson, but the natural evolution of fashion which sounded its death knell. Being Bare Below elbows is good common sense being enforced and it is essentially not tres difficile to adhere to.
A recent audit at the North Middlesex Hospital found that 60% of junior doctors in the elderly care department were NOT naked below the elbows. By far the biggest offender was the reliable watch (58% of cases),[link widoczny dla zalogowanych], followed by long sleeves (25% of cases), nail varnish (
Karen Hebert (BMJ Careers 12 April 0 Cool

1 provides us with food for thought on the topic of hand hygiene. Should clinical staff ignore hospital policies designed to improve hand hygiene practices, just because they have not been shown to be effective in a double blind randomised controlled trial? Her investigation misses an important point namely our responsibility as individual clinicians in reducing risk to our patients.
Hebert does not offer her personal view on whether "bare below the elbows" is a worthwhile initiative, but quoting other clinical colleagues, the conclusion appears to be that there is little support for this in the medical profession due to the lack of clear evidence. Infection Control suffers greatly with respect to the lack of published evidence from controlled trials. Policy therefore also relies on common sense and principles applied from other related areas,[link widoczny dla zalogowanych], or from the findings of successful multi-intervention studies. However, much of what we practice in medicine today is not based on well-constructed randomised controlled trials, but rather historical approach and sound first principles. So why do we struggle with the cheap and cheerful policy that is "bare below the elbows"? One hundred and fifty years ago Semmelweiss found that the high incidence of peri-natal maternal deaths with fever reduced significantly after he adopted the practice of hand washing between leaving the post mortem room and attending a delivery. Are we to dismiss this seminal infection control study because he did not have the foresight to reproduce his findings in a formal crossover trial setting?
Thorough hand decontamination cannot be done properly while wearing wrist and hand jewellery. We are well aware that watches and stoned rings harbour many bacteria, which persist despite frequent handÂTM washing. Bacteria are very capable of migrating the short distance from wrist to fingers, and it is not necessary to wear a watch on the wrist to accurately take a pulse -- ask any nurse. There is, however,[link widoczny dla zalogowanych], evidence that the surface of plain metal rings when left in place can be effectively decontaminated with alcohol hand sanitizer2 hence their exemption from the "bare below the elbows".
It is accepted that targeting hand hygiene alone will not solve the Infection Control challenges faced in UK hospitals. High bed occupancy rates, lack of resources for cleaning, conflicting targets and widespread inappropriate antibiotic use must all be reviewed together, as we have done in this Trust. A significant effort by clinicians, other clinical staff and managers have reduced MRSA bacteraemia and C difficile diarrhoea cases significantly in this Trust in the last year: "Naked to the elbows" has been an important element of our programme. We all have responsibility for our own practice and hand hygiene is central to prevention of HCAI, even if the supporting evidence for each component is lacking. Influence of rings on the efficacy of hand sanitization and residual bacterial contamination. Infect Control Hosp Epidemiol. 2007; 28:351-3
Conflicting interests.
E. Darley is the DIPC for a large acute trust in England which introduced "Naked to the Elbows" in 2006, as one of many initiatives to address high rates of HCAI.
For each article of clothings we wear, they all portend to be carriers of infection? the shirt, trousers or skirts? Being naked from the elbow downwards won't solve the problem. in one of Atul Gawande's books he alluded to the fact,[link widoczny dla zalogowanych], that by repeated hand washing the infection rate dropped,[link widoczny dla zalogowanych], but it costed them quite some money, and he said the most difficult thing to get most of the health workers to do is to wash their hands.
there are other things that can help control spread of infection, in a hospital, which will be much more effective than banning the use of the traditional ward coats. examples of such things include, reducing patient population in the wards, making available more user freindly hand washing solutions and methods.
It is telling, and rather depressing, that the DoH seems to focus more on public perception than on factual evidence. The "drivers" are easily identified: By advocating bare forearms, blame for the desastrous infection control can be put on the "dirty doctors". This is cheap, indeed. The media can still their "feeding frenzy", any protest by medical professionals will just be another proof of who the guilty part is, and best of all, it doesn't cost a penny. It is also a strategy that completely avoids to look at a number of underlying issues that might be more painful and costly to deal with. These issues include widespread and inappropriate over- use of antibiotics contributing to growing bacterial resistance; laxitude in surface cleaning; inappropriate ban on the public bringing infectious agents into the hospital.
Permit me to elaborate: It takes great effort to provide and sutain good medical care with reduced antibiotica use, but it seems to be worthwhile [1].
The recent "deep clean" activities were amusing rather than amazing. For the first time ever in a British hospital, I saw side tables and bed frames being cleaned thoroughly. As a nursing intern during my medical school years, bedside tables were scrubbed between each and every patient. Beds (frames and mattresses) were sterilized between patients as a rule, not as a publicity activity. And the visiting public was asked to stay outside the wards if they felt that they,[link widoczny dla zalogowanych], or their offspring, might be transmitting an infectius disease (a cold, that is, or any pediatric infections). The ban on visitors below a certain age, say 12 years, was thought normal and appropriate but these days certainly might be considered ageist and politically incorrect.
But this is not about political correctness (read: hypocrisy). This is about improving public health, and when it comes to infection control, tough measures indeed may be necessary [2]. If, on the professionals' side, this means short sleeves and no wrist watches, so be it. But the politicians need to pay their dues, too. And that means funding of properly trained cleaners and cleaning services, sterilization units for beds and mattresses, and ideally provision of daily fresh protective professional clothing to doctors, nurses and allied health carers with the trusts taking care of the laundry logistics.
All this is expensive, tiresome and a lot of extra work. But to face epidemiological crisis and respond with a campaign to improve "public perception" is a shameful act at best, and fatal madness at worst.
Ref.:
1. MÃƒÂ¶lstad S,[link widoczny dla zalogowanych], et al. Sustained reduction of antibiotic use and low bacterial resistance: 10-year follow-up of the Swedish Strama programme. Lancet Infect Dis. 2008 Feb;8(2):125-32
2,[link widoczny dla zalogowanych]. SARS Investigation Team from DMERI; SGH. Strategies adopted and lessons learnt during the severe acute respiratory syndrome crisis in Singapore. Rev Med Virol,[link widoczny dla zalogowanych]. 2005 Jan-Feb;15(1):57-70.
That statement made by Alan Johnson,a politician, must have come as a shock for many senior clinicians who have been treating their patients for decades wearing long sleeved shirts, wrist watches and wedding rings!This profound, scientifically brilliant revelation, must have made them wonder'How many patients did I kill in the 60s,70s,80s and 90s?!'
On one hand we have the entire medical world, politicians and public imploring doctors to treat patients based on sound evidence base and on the other hand we have the UK,who is the leader for many good things in public health for many a country within and outside Europe,[link widoczny dla zalogowanych], coming out with such non-scientific policies.
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