Mo Med — NovDec 2010 LN ‘Change Language: Choose > The Necktie In Medicine...Professional Or A Double Windsor Fomite? sJonn F Eisendeis ‘Should Physicians be Banned from Wearing Neckties in Medical Venues? ‘The Necktie in Medicine... Professional or a Double Windsor Fomite? If the VENERABLE © necktie is hastily banned without proper evidence-based studies, what is next2All clothing, all pens, pencils, and stethoscopes have some bacterial load Nosocomial or health carerelated infections (HRI) are major concems for health care professionals and patients The latest estimates from the Centers for Disease Control and Prevention (CDC) state that HRI account for approximately 4.7 milion infections per year and 99,000 deaths per year1 This is a potential source for major morbidity and mortality 5 well as health care expenditures As of March 2009,the cost of HRI was estimated to be $37.5 billion to $45 billion after adjusting to 2007 dollars and using the Consumer Price Index (CPI) for all urban consumers. 2 ‘Since the time of Ignaz Semmelweis in 1847 and Joseph Lister in 1967 much time and energy has been expended to ecrease infections patients obtain from health care providers. There has been an increased emphasis placed on hand hygiene education for physicians, nurses, medical students, and other health care providers In recent years there has been investigation into items of apparel, such as neckties,white coats,and even pens as potential fomites for pathogens.In theory, such items could cary a bacterial load that may be delivered from a health care provider Inadvertently to a patient To combat this theoretical risk the United Kingdom has developed a “bare-below-theelbous* Gress policy within the past five years.3 ‘Studies have shown that bacteria such as methicilin-resistant Staphylococcus aureus (MRSA) have been isolated from Physicians’ and medical students'neckties.4 An adcitional study looked at neckties and pens as potential vectors and found that no important pathogenic bacteria had contaminated the pens or the ties.5 Additionally, it was discovered that bacteria that were present were very small in numbers and required enriched medium to produce large numbers.5 Currenty, itis uncertain if bacteria on neckties present a legitimate risk of HRI or if this risk is pure speculationAt the present time, the medical literature demonstrates that neckties are capable of carrying bacteria. The literature differs on whether the bacteria are pathogens, commensal bacteria or simply environmental contaminants. This has led toa division amongst physicians, some decreeing that the necktie should be banished from our professional attire and others defending its piace As an important part of the traditional medical mantle. ‘The potential risk posed by neckties begs a simple question, where does the theoretical risk end and legitimate risk begin?What about the bacterial load on exam tables. chairs. paper charts or computer keyboards in the clinics and on the wards? Or the risk potentially posed by pens in the office? It stands to reason that tne doorknobs kely have a substantal bacterial load. The take home message is that evidence should serve as 2 basis for actions that are taken for patient care and safety. Some believe that the necktie has become a scapegoat because it has the potential to cary bacteria and can potentially contact a patient Micnael Bell, MD, Associate Director for Infection Control at the Center for Disease Control and Prevention in Atlanta, has stated; “Its understandable to focus on a necktie,because it dangles, but all cotning nas Bacteria on it | dont think removing pieces of clothing is the answer."6 Dr. Bell raises a very important and valid pomnt and t seems unikely that the removal of 2 necitie is going to make any type of meaningful impact on iatrogenic infection rates, What is to be gained by banning necktes? There is no real evidence to validate such @ mandate. is truly ironic for such action to be hastily taken without evidence in the literature We are in the age of evidence-based medicine.if the VENERABLE” necktie is hastly banned without proper evidence based studies what is next?Wnere does it end?All clothing, all pens, pencils. eyegiasses. and stethoscopes have some bacterial load Il fs impossib for aseptic technique to be economicaly maintained outsice tne OR wiinout signifeantly discupting the physielanpatient ynamic. (One important aspect to consider when discussing banning physician's neckties due to a theoretical and thus far unproven fear is the impact that this might have upon the physician-patient relationship Recent study found that had Increased confidence trust in physicians in traditional professional dress consisting of a white coat and necktie for men and white coat and professional dress for women.7 This was found to be true regardless of patient gender or ethnicity or the gender or ethnicity of the physician.7 ‘The basis of all patient-physician dynamics is trustA patient trusts their Physician with potentially sensitive Information The patient irusis the surgeon to complete the appropriate procedure to a level of siandarG of care One: can argue that trust is the lynchpin of the physician-patient relationship. physician should take the time to present him or herseff in a professional mannerif a necktie helps establish trust then a case can be made that all male physicians should wear tes.For some the necktie is a potential vector. For others, including the authors, it is seen as an essential piece of professional dress of physicians Currently in the Iterature there is no evidence fo support the claim that neckties serve ‘as vectors for pathogen delivery.it seems the necktie has become an innocent scapegoat as pressure mounts to decrease HA'siIt is much more important to emphasize hand washing and other evidence based infection contro! interventions. We conclude with this “Cravat Caveat": without an evidence based medicine approach to nosocomial infections, we are susceptible to impulsive and inappropriate fiats such as proscribing neckties, References 1. Ceniers for Disease Control and Prevention Estimates of Healthcare-Related Infections, March 12 2010.Http:/lww.cde.govincidod/dhapiha.himl 2. Scott RD. The Direct Medical Costs of Healthcare-Related Infections in U.S. Hospitals and the Benefits of Prevention, March 2009. Hittp:!iwww.Cdc.govincided/dhapmai. hil. 3. Dancer $J.Pants, policies, and paranoiaJ Hosp infect 2010; 74: 10-15. 4. Nurkin S, Urban C, Mangini E, Mariano N, etAl.'s the Clinicians’ Necklie 2 Potential Fomite for Hospital Acquired Infections?in Abstracts of the 104th General Meeting of the American Society for Microbiology 2004. New Orieans, Louisiana, 2004: p204. 5. Pisipati S, Bassett 0, Pearce | Do neckties and pens act as vectors of hospitabacquired infections7BJU Int. 2008 Jun; 103(12): 1604-5. 6 Smin R_ Nothing to sneeze at: doctors’ neckties seen as flu risk. The Wal-Stret Journal November 20 2009 Http //online WS) convaricie/SB125859205137 154753. nimI?7KEYWORDS=necktle