Doctors sound off -- loudly -- about wearing scrubs on the street

Thanks so much for this thoughtful, and tangible series that seems to have hit a nerve with quite a few. I should clarify that in recent years I've spent more time as a patient than as a practicing physician. That said, from my patient's perspective these articles are terrific, and needed -

The author replies:

First and foremost, I am pleased to witness the copious and highly varied responses that my piece has generated, some quite passionate.  As I said, “dialogue is almost always a signpost on the road to quality improvement.”  One of my goals is simply to get this issue under the microscope.  Let me offer a few comments in response to some of the more common, contrary threads among your replies.

Some posts have belittled the scrub issue because there is no direct proof that wearing contaminated scrubs in public can be established as the proximate cause of superbug infection in the community.  Anticipating this sentiment from a few readers, I stated, “the use of hospital-exposed scrubs in public has never been proven as the direct cause of a single infection.”  Clearly, 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 caution, 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. 

In so doing, it helps to look at what has been proven.  Superbug infections, some fatal, are on the rise among people in the community who have not entered hospitals.  (See http://www.biomedcentral.com/1741-7015/6/2 for example).  And hospital scrubs taken from hospital worksites are frequently colonized with these organisms, though one physician’s comment incorrectly suggests otherwise.  Does it really require complete proof to connect these dots?  There are surely other fomites to blame, but clothing does cover a substantial portion of our bodies, and changing clothes takes mere seconds.  We are not talking about cumbersome “hazmat” suits; we are discussing changing in and out of what amount to a pair of pajamas.  Is that really a draconian measure?

Furthermore, we are also addressing what has become policy at many institutions, yet some respondents have trivialized the need for compliance.  This lack of respect for decisions that are made consensually by the greater medical community and the very institutions that make our practices possible is unprofessional and irresponsible.  And as one respondent opined, this in itself undermines the respect of those who depend on us for healthcare services.

Other respondents have cited other examples of potentially controllable superbug fomites, suggesting that lack of their control is reason to trivialize the scrub concern.  Instead, why not address these other concerns as well.  Neckties, as one post mentioned, have been addressed elsewhere as inappropriate, and should not be worn in the hospital.  In fact, many support a “nothing below the elbow” dress code, which also makes sense.  White hospital gowns, aka labcoats have been amply proven to be filthy and infrequently washed.  In my last place of practice, dozens of them hung on common coat racks, in physical contact with one another.  These garments, often used to cover up scrubs, are probably worse than scrubs, many going months or years between cleanings.  Yes, shoes are another concern.  A pair of shoes should be devoted exclusively to the hospital, and remain there at the end of each day; this is common practice among my surgical and anesthesia colleagues. 

Can we sterilize ourselves before and after our daily commute or eliminate the transmission of infection among ourselves?  Of course not, but why do nothing because we cannot do everything. Yet some respondents have trivialized my concern because it is incomplete and imperfect.  Healthcare workers that direct their efforts toward what can be provided perfectly will have short workdays.  Again, let us respect what we don’t fully understand.  For those few among you who demand proof, why not respect the wellbeing of others by insisting on that same level of certainty to support your contrary position?

-David C. Martin, M.D.

Very interesting. My concern though is the opposite. I'd be more worried about a medical professional sitting on a filthy subway seat then treating patients in the same scrubs. I'd be more concerned about what he or she will pick up from the bus or subway rather than what they'll leave behind.

I have never seen a nurse or doctor overseas wearing scrubs after work.

I saw a nurse in Phoenix, AZ, who lived in an apartment next door, was taking her garbage out and touched the dumpster with her hands and clothes while throwing her garbage bag away.

So, my question is: how much bacteria she got on her clothes?

And another question, if you were a patient with a weak immune system, any bacteria brought in the hospital from outside could be dangerous or lethal.

What if that nurse was going to help during your surgery wearing the same scrubs. Are not hospitals, and especially surgical rooms, supposed to have everything sterile in them?

Scrubs are more evidently worn in the hospital setting, but most physicians wear everyday clothes, not scrubs, and go to restaurants, etc. with those very clothes. Are we suggesting everyone change clothes before going to the supermarket on the way home or eating dinner after work at the hospital? After all, shouldn't those clothes be just as likely to carry the resistant organisms as scrubs?

As a microbiologist/university faculty member who instructs nurses and pre-docs, i can't say enough about how important this discussion is. With the continued rise of antibiotic resistant bacteria as well as incidence of HAIs ( some that are now out in the community) the medical community must recognize that past practices shoild be looked at closely and changed if necessary. Contrary to one of the posts, the organisms can and do remain viable on clothing. Its in the literature. When i move from lab to hallways or classroooms, i always remove my lab coat and wash my hands. This takes little time and eliminates any potential of bringing pathogens into an environment outside of the lab. Physicians and nurses----you are part of the transmission chain re. HAIs. My expectation would be that you should embrace any recommendation that could make your patients or the public less likely to contact pathogens.

As a nursing student I have noticed this practice and was amazed that it goes on in hospital knowing that scrubs and lab coats are covered with pathogens. I recently read a comment from a number of nurses on a site about this subject and a mojority oif comments were stating that wearing your own scubs is your wright and that it takes your independance of freedom away. Also things were said like "germs are germs", i really dont understand this way of thinking as we know as health care workers that some germs " pathogens" are the reason why some of these people are in the hospital in the first place. And we as health care providers, working in close contact with these clients who have sickess from pathogens can lead to spreading these (HAI'S) out into the public. This is why i think that all health care workers who reside or work in the hospital; wether you work as a nurse or a cleaner you should doff and dawn scrubs at work. As the author states, if we know that scrubs are not clean, and there are articles and endless journals that state this, why do we continue to think we cannot spread this out to the public? It should be hospital policy that no person should be able to wear scrubs to or from work, as to try and maintain a steril environment.

Not all healthcare workers are exposed to pathogens. In my work, I am exposed to no more pathogens than a person on a bus. I work with psychiatric and neurology outpatients with no more transmissible disease than anyone else. I don't even have much physical contact with them. I travel to several sites during the day, and I don't have a place or the time to change out of my scrubs between visits or before lunch. I sometimes have up to 2 hours drive before I return home, and I stop to get dinner on the way. We should leave it to the discretion of the professional to determine if they are carrying any biohazards on them. It's an individual responsibility.

Worth reading article.

A few thousand years ago, people were worried that bathing too often was unhealthy. Now, we use sanitizer, antibacterial soap, inject ourselves with vaccines and take antibiotics. We clean, disinfect and sterilize, and yet, we have super bugs. Bacteria have mutated into more extremely virulent forms.
While I don't doubt that perhaps scrubs may carry bacteria, more likely objects are pens, phones, money, and the most common of all, human hands.
In addition, where more precautions need to be taken is inside the hospital. People's immune systems are already compromised by illness. Doctors, nurses, orderlies and other hospital staff transfer all kinds of bugs without even realizing it.
Gloves don't keep you from transferring disease. You can transfer disease on your gloves. If you touch something after you wash and sanitize tour hands, you can transmit disease from it.

It makes you look like a pompous slob.

I worked at a hospital where L&D nurses carried on the bottom of their shoes infection into the newborn nursery, where 3 babies died and several became ill. Following the same jahco/aorn/cms rules for the OR, dedicated clean shoes to be kept at work, shoe covers if you left L&D, that are disposed when you return, and clean hospital scrubs are the only attire allowed. No employee was to every enter the building in scrubs/shoes from outside the facility, its grounds for immedate termination