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Should Doctors Go Bare Below the Elbow?

Should Doctors Go Bare Below the Elbow?


Is the bare bones approach for doctors a practical solution for infection control? The United Kingdom adopted an initiative that requires all health care workers to remain bare below the elbows, or BBE, as a way to prevent cross-contamination and lower the risk of healthcare-acquired infections, according to Queensland Health.

The goal is to remove objects able to harbor pathogens despite rigorous hand washing.

  • Bracelets
  • Wristwatches
  • Rings with stones or ridges
  • Long sleeved shirts

In addition, the initiative requires nails be short, clean and without polish. Staff must cover any breaks in the skin below the elbow due to cuts, abrasions or dermatitis. Some of the policies adopted, specifically the avoidance of long sleeves, are based on recommendations by the World Health Association. Evidence suggests that many skin organisms are transient such as:

  • Staphylococcus aureus, including MRSA
  • Gram-negative bacilli
  • Candida

Going bare below the elbows reduces the risk of pathogenic transfer and encourages better hand hygiene. Studies prove lab coats are common sources of contamination and that organisms persist on clothing for months. A survey of physicians found the 20 per of them had never even washed their lab coat.

The Ongoing Debate

Not everyone in the medical community supports this concept, but some facilities have opted to err on the side caution. The University of Iowa Hospitals will formally adopt a BBE policy as of January 2016.

Penn Medicine supports the flip side of that debate stating there is no clear evidence that a BBE policy works. Baring the forearms may come with its own hazards, too. At the very least, it has a psychological effect on patients.

A straw poll taken at the IDWeek 2015 conference in San Diego found that 58 percent of physicians in attendance agreed with Penn Medicine. Forty-two percent sided with the delegate for the University of Iowa Hospitals.

The biggest part of this debate centers around long sleeves. The forearms are hairy, so there may still transfer pathogens even without fabric. Lab coats are an iconic look for doctors, as well, one that patients identify with when seeing a physician.

As the representative from Iowa pointed out, facilities will only know if a below the elbows approach is effective in reducing HAIs if they try it. Analyzing the infection data before and after the policy change will give some indication of how well the initiative works in the U.S. The decision makers in the United Kingdom believe it has improved infection control for them.

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