To the Editor—The increasing risk of pathogen transmission within the hospital setting continues to be a challenge for hospital infection prevention programs striving to reduce hospital-acquired infections. While healthcare providers’ hands and medical devices are widely accepted sources of pathogen transmission, recent studies indicate that healthcare attire could potentially contribute to transmission as well.Reference Butler, Major, Bearman and Edmond ¹ In the United Kingdom, the practice of bare below the elbows (BBE) has been adopted to decrease the potential risk of cross transmission between healthcare attire and patients.Reference Haun, Hooper-Lane and Safdar ² Furthermore, experts from the Society for Healthcare Epidemiology of America suggest BBE in the inpatient setting as an infection prevention adjunct based on biological plausibility.Reference Bearman, Bryant and Leekha ³

At Virginia Commonwealth University Health System (VCUHS), BBE is recommended in the inpatient setting to facilitate hand hygiene and to limit cross transmission of pathogens via contaminated apparel. BBE requires all healthcare providers to wear short sleeves and to avoid wristwatches, bracelets, neckties, or white coats at the bedside. Although BBE has been an infection prevention recommendation since January 2009 at VCUHS, compliance assessment began in May 2014. We explored the correlation between BBE compliance and average monthly climate temperature.

This study was performed at an 865-bed, urban, academic medical center with 8 intensive care units and 25 non–intensive care units. In May 2014, trained hand-hygiene observers began measuring BBE compliance among healthcare providers. Healthcare providers were considered compliant with BBE if they wore short sleeves or rolled up their sleeves and avoided wearing wristwatches, bracelets, neckties, and white coats during patient encounters in the inpatient setting. Compliance was recorded as presence or absence of BBE at the bedside, but specific reasons for noncompliance were not documented. We compared monthly BBE compliance to the average local monthly climate temperatures from May 2014 through September 2015. Temperatures were obtained from an online weather source (www.accuweather.com). The relationship between BBE compliance and local climate temperatures was assessed using a correlation analysis software (SAS version 9.4, SAS Institute, Cary, NC).

Over the 16-month study period, 46,832 patient encounters were observed in the inpatient setting. The overall compliance for BBE was 68% (monthly range, 55%–72%). BBE compliance varied by provider type. Nurses had an average BBE compliance of 70%, and physicians averaged 49% BBE compliance. Figure 1 depicts BBE compliance and monthly average climate temperatures. Monthly climate temperature and BBE compliance were highly correlated (r=0.89), with compliance decreasing as seasonal temperature decreased. Inpatient ambient temperatures are maintained between 21.1°C and 23.9°C (70–75°F) year-round at VCUHS.

FIGURE 1 Bare Below the Elbow Compliance and Average Climate Temperature

A strong correlation between BBE compliance and monthly climate temperature suggests that BBE compliance decreases during colder months when healthcare workers tend to wear long sleeves. To our knowledge, this is the first report documenting variation in BBE practice based on seasonality. Barriers to BBE adoption were studied by Pellerin et al.Reference Pellerin, Bearman, Sorah, Sanogo, Stevens and Edmond ⁴ Although the majority of survey respondents in this study felt that white coats probably played a role in pathogen cross transmission and that the absence of a white coat had little impact on professionalism and self-esteem, the ongoing use of white coats by providers was driven by the need for pockets for storage.Reference Pellerin, Bearman, Sorah, Sanogo, Stevens and Edmond ⁴ In our institution, white coats for physicians and surgeons have since been supplanted by lined, black, logoed nylon vests that can be easily wiped down. In addition, the vests fit snugly so that they do not contact the patient when performing an exam, and they provide warmth.

Hospitals advocating BBE as an infection prevention adjunct should be mindful of potential seasonal variation in compliance and should encourage all healthcare workers to practice BBE year-round. Adequate storage areas for removable outerwear is an important facilitator for maximal BBE adherence. In addition, availability of compliant garments, such as vests, will further sustain adoption of BBE practice. Staff reminders may facilitate ongoing compliance despite seasonal transitions. Finally, indoor ambient temperature must be optimized and maintained at a comfortable range to promote BBE practice during all seasons.

We add to the body of literature on the implementation of BBE as an infection prevention adjunct and report seasonal variation in BBE adoption. All BBE compliance assessments were completed by trained members of the institution’s hand-hygiene monitoring program. The limitations of this study include the lack of detail regarding reasons for observed BBE noncompliance; this could have been due to the presence of long sleeves, bracelets, or watches below the elbow. However, the only component of BBE expected to change with temperature was sleeve length. Compliance with BBE by gender was not collected, thereby limiting the ability to discern attire differences between males and females in response to changing seasonal temperatures. In addition, the study was performed at a single healthcare system and the results may not be generalizable; specifically, compliance may differ by climate and geography.

Bare below the elbows is a simple, low-cost intervention to decrease the risk of bacterial transmission in inpatient units. Adoptability of BBE varies based on seasonal variation. Healthcare worker comfort should be considered in policies recommending BBE, optimal alternate attire options to ensure comfort must be provided, and indoor ambient temperatures must be optimized to promote this practice.