by John A. Molinari, PhD
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A key component of the recommended infection- control precautions for health-care workers is the routine use of personal protective equipment [PPE] (e.g., gloves, masks, protective eyewear, and protective clothing).
In the case of protective clothing, the prescribed type and use of disposable gowns, laboratory coats, and clinic jackets were included in the Dec. 6, 1991, Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard. These regulations require sleeves to be long enough to protect the forearms when the gown is worn as PPE (i.e., when spattering and spraying of blood, saliva, or other potentially infectious material [OPIM] to the forearms is anticipated).
It does not have to be fluid-impervious to meet OSHA standards but must prevent contamination of skin and underlying clothing. Health-care providers should change protective clothing when it becomes visibly soiled, and as soon as feasible if it has been penetrated by blood or other potentially infectious fluids.
In addition, this protective garment should be removed before leaving areas of the dental health-care facility used for laboratory, instrument processing, or patient-care activities. OSHA prohibits home laundering of items considered to be PPE. The employer is required to launder or clean any reusable PPE contaminated with blood, saliva, or other infectious material. This can be done in the office or contracted through a commercial laundry service.
As an alternative, the office may choose to use disposable protective clothing. The 2003 Centers for Disease Control and Prevention infection-control guidelines for dentistry echo the OSHA regulations:
“Wear protective clothing (e.g., reusable or disposable gown, laboratory coat, or uniform) that covers personal clothing and skin (e.g., forearms) likely to be soiled with blood, saliva, or OPIM. Change protective clothing if visibly soiled; change immediately or as soon as feasible if penetrated by blood or other potentially infectious fluids.”
Although most of the discussion during the OSHA hearings focused on the necessity for long-sleeved, high-neck clinic attire to reduce potential exposure of skin to a patient's blood, a basic premise for the recommendation was related to the perception of cleanliness.
Many health-care workers and patients at that time viewed the presence of dried blood on a health professional's clinic jacket as an automatic — a possible source of HIV cross-infection or some other bloodborne pathogen. Fortunately, to date, no documented cases of bloodborne disease transmission have been traced to contaminated clinic attire.
Despite this apparent good news, it has been well established that a variety of microorganisms involved in many hospital-acquired (i.e., nosocomial) outbreaks can survive and live on inanimate surfaces, including contaminated clinic attire. Pathogenic viruses, such as influenza and SARS coronavirus, are able to survive for hours on environmental surfaces. They can be spread via surface-to-hand and hand-to-hand contact.
Other investigations have raised the prospect of clinic coats worn by health-care workers serving as vectors for microbial cross-contamination and possible cross-infection.
As an example, a recent study reported findings after testing clinic coats worn by health-care workers at a large teaching hospital. These were cultured and assessed for the presence of Staphylococcus aureus and enterococci. A significant percentage of the samples were found to be contaminated with Staphylococcus aureus, including isolates of methicillin-resistant S. aureus (MRSA). The investigators did not look at possible cross-infection to patients.
Despite that, the fact that these bacteria can be transmitted by either direct contact or through fomites — coupled with increasing incidence of antibiotic-resistant bacterial infections in hospitals — suggests that further investigation is warranted.
As more medical and dental facilities provide care to patients who are knowingly and unknowingly colonized with an increasing array of hardy, resistant bacteria and viruses, emerging data may cause us to reevaluate how an item as seemingly innocuous as a clinic jacket can affect the efficacy of our routine infection-control practices.
Dr. John A. Molinari is professor and chairman of the Department of Biomedical Sciences at the University of Detroit Mercy School of Dentistry. Contact him at firstname.lastname@example.org.