Bare below the elbows

Thank you for your interest in our article.1 We are grateful for the recognition that we have tried to contribute a little evidence to what is essentially a policy introduced with little evidential basis. In fact the paper published by the government in 2007 actually stated that doctors should continue to dress in a manner that reflected the respect shown by the public for their profession. Henderson et al showed that the public would prefer doctors to wear traditional attire and indeed white coats in the outpatient setting.2 While your correspondence contains valid observations, you pose questions that simply need answering. The first statement that the reason for the policy ‘may in fact be the risk of transmission of pathogens from clothing and jewellery to patients’ has been addressed recently by a paper by Burden et al that showed that the wearing of long-sleeved white coats did not expose patients to greater risk of cross-contamination.3 Your second point regarding alcohol rubs ignores the fact that organisms such as Clostridium difficile (C diff) and norovirus are better addressed by hand washing. Our research was undertaken in 2009 and we deliberately addressed the issue of hand washing, as clearly described in the title of the paper. Alcohol rubs and pre-admission screening for methicillin-resistant Staphylococcus aureus (MRSA) had significantly reduced MRSA infections in our hospital but sadly C diff infections remained a challenge. Your observation that low yields of MRSA ‘may indicate an insensitive sampling method’ could be countered by the possibility that the preventative measures described may equally have produced the results obtained. Similarly, your hypothesis that the wide range of colony counts ‘supports the possibility that sampling and culture methods were too inaccurate’ is one that needs proving. We used accepted sampling and culture techniques under the direction and assistance of a consultant bacteriologist and a senior laboratory technician. Thirdly, your hypothesis that there was bias due to ‘not bare’ participants performing well in hand washing and that specialty distribution created bias also needs proving. We undertook the study with no forewarning and without informing participants of the details of the study. All participants had received prior hand washing instruction by our trust and no examples of extra care being taken were observed. As stated in the paper, there were insufficient numbers to allow comparisons between specialties, an opportunity for others to provide some evidence. We are grateful for the acknowledgement of the many difficulties in resolving the plethora of unanswered questions around the ‘bare below the elbows’ policy and would draw your attention to our discussion and conclusions. We clearly acknowledge the importance of hand washing but advocate caution in claiming a causal relationship between numbers of commensal colonies and hospital acquired infection (HAI). However, if we have provoked interest and stimulated further research, we have achieved something. In the 21st century the profession should practise evidence-based medicine and where no evidence exists it should attempt to provide it before acceding to directives with little or no supporting evidence. Such behaviour allows those responsible to ignore other important causes of HAIs such as antibiotic misuse, bed density, bed occupancy and standards of hospital cleanliness, for which there is evidence of a causal relationship with HAIs. We hope that Ms Griffin and colleagues will feel sufficiently motivated to put their hypotheses to the test and provide evidence that will either support or refute our findings.