As a resident on rotation in New York City's public hospital system, Edgardo Olvera-Lopez, MD, said he was "shocked" at the filth on the white coats his colleagues were wearing while at their patients' bedsides. It was the same coats with the same stains day after day after day, he said.
"Rather than white coats, they looked more like brown coats," he told 鶹ý. The stains -- on the pockets, sleeves, around the neck, and on the elbows -- included some that looked like blood. "I don't know how many weeks or months they went without laundering, but it was definitely something I found disgusting and unprofessional."
So last July, Olvera-Lopez, now in his third year of internal medicine residency at Lincoln Hospital in the South Bronx, surveyed attending physicians and colleagues in graduate training within his department: How often, exactly, did they launder their white coats, and how?
The head of his department "was excited about the idea," Olvera-Lopez said, because he had trained in the U.K., where doctors are barred from wearing clothing that extend below the elbow because of concern about cross-patient infection.
The results, published in November , were not for the weak of stomach, Olvera-Lopez acknowledged.
More than 14 days
While the sample size was small with only 62 respondents (46% of those surveyed), 36% said they wore their white coats for 7-14 days before washing them and 21% said they wore them for more than 14 days before putting them through the laundry.
Only 14.8% washed their white coats after 3 days or less. The other 27.9% said they averaged 3-7 days between washings.
What's more, over half of the respondents said they only owned one white coat, and 29% owned just two.
And this was not the first study to document habits like this. was a convenience-sample survey of 160 healthcare professionals attending conferences, indicating a mean time between white-coat washings of 12.4 days (SD 1.1).
In 2014, the Society for Healthcare Epidemiology of America issued what it called an on frequency for laundering attire for doctors who work in non-operating room healthcare settings.
It reads: "Optimally, any apparel worn at the bedside that comes into contact with the patient or patient environment should be laundered after daily use. In our opinion, white coats worn during patient care should be laundered no less frequently than once a week and when visibly soiled."
And when the coats are laundered at home, they should be put through a hot-water wash cycle, ideally with bleach, followed by a cycle in the dryer, the guidance suggests.
Asked whether they knew about the SHEA recommendations for laundry frequency, 79% of the Olvera-Lopez's survey respondents said they were unaware those existed, and some of those who were aware weren't paying attention to them.
"Even some attending physicians said they didn't know about this, that the longer we wear them, the risk of hospital-acquired infections we are bringing to patients' rooms goes up. It was shocking to see the reaction from colleagues when I presented these results," Olvera-Lopez said.
And, 27.4% of respondents did not think the recommendation was reasonable and easy to follow.
What's the problem?
The problem, as the SHEA guidance mentions, is that there isn't much evidence of coat-to-patient disease transmission, although some experts said it's logical to assume it happens.
Gonzalo Bearman, MD, first author of the 2014 SHEA expert guidance statement and chair of infectious diseases at Virginia Commonwealth University, acknowledged the infrequency in which white coats and other long-sleeved garments worn by health professionals at the bedside are laundered. And, he said, it's also well known that those white coats worn at the bedside "are during the course of the day, no question." But the optimal laundering frequency is unknown.
"We aimed for something that was practical, to wash your long-sleeved garments (or white coats) once a week, or when visibly soiled. We also acknowledged that the impact of doing that on healthcare-associated infection outcomes remains unknown."
Infections might also be spread through hands washed inadequately or not at all, through interventional devices, through the inanimate environment, and through the patients' or the providers' own microbiome, Bearman said.
At his university in Richmond, the current practice is to move away from white coats altogether, through various ways to message "that your sleeves are potentially dirty." There are now team vests with the doctor's name that are now worn in lieu of a white coat. "It's short-sleeved, and it provides warmth when it's cold outside and it has pockets, which are important for healthcare providers."
But at many hospitals, including those in the University of California system, the white coat remains the mantle of a physician's expertise and authority, an honor they worked long and hard to earn the right to wear. "Pretty much everybody here wears one – that's the culture," said Robert Wachter, MD, chair of the Department of Medicine at the University of California San Francisco.
Some doctors note that they sometimes are worn in the toilet.
A need to come clean
Olvera-Lopez said he'd spoken with many colleagues in other health systems who told him they, too, see lax attitudes toward the white coat. "I think it happens throughout the nation, and even in other countries. And not just doctors, but respiratory therapists, social workers, anyone who wears a long-sleeved white coat."
"That's why there's a real need for education about this within the hospital," he said.
Robert McLean, MD, president of the American College of Physicians, said he wasn't surprised at the New York City survey results and agreed that more attention and research should focus on the topic of white coat cleanliness.
"It's probably something we do not pay enough attention to," he said.
"The badge of honor, the coat that we're wearing is potentially getting covered with stuff, bacteria as we touch our patients, whether we see it or not. There's pretty good data in the literature about ," even though the same tie isn't being worn every day like the white coat.
McLean added that the practice of white coats "being worn repeatedly for days on end is actually very real." The problem, however, is that he isn't aware of data showing that accumulating infectious substances are being transmitted from one patient to another and making them sick.
Those studies should be done, McLean said.
"I think we get nervous that, especially in hospitals, you may have more immunocompromised people and you don't want anybody spreading things. We wash our hands a lot for that reason, obviously. So why would we wash our hands and not wash our white coats?"