Bare below the elbows: safe or silly?

This is an example of a failure to examine the evidence base.

Many hospitals have imposed a bare below the elbows policy as a result of research showing that cuffs, jewellery, watches and neckties can carry bugs. Bugs can infect patients. Ergo, all of the above, which could cause patients to become infected, must be banned.

When the Department of Health appeared to endorse such a policy (and some Trusts have been quite hysterical in imposing it, with ward sisters screaming at offending staff like little Hitlers). London’s Royal College of Surgeons tried to commission a “for and against” pair of articles. It printed a pair – but both were against, as the journal’s editor was unable to find anyone who would write in favour. The reason was simple. While there is good evidence that ties etc can harbour bugs there is no evidence at all that anyone has been infected thereby[1]. Now I am no Luddite and am the first to remind students about Semmelweis (who? they say) but I cannot endorse a policy for which there is no evidence of benefit and which is founded on myth, supposition and unreasonable extrapolation. I would have conformed when there was some evidence (the Black Swan principle does not pass me by). I used my common sense – something that seem to have been bred out of many in authority – and stripped down appropriately on the ITU and ensured my tie did not dangle in an infected bedsore.

The corollary of this is that if managers insist you conform to a stupid policy then you cannot trust their judgement. People do not have isolated blind spots, and if they cannot take in and understand a scientific analysis of one thing it is almost certain that they will display the same failing in others.

Another infection issue raises the risk versus benefit question. For decades we have used skin prep swabs which come in little paper packets and are very cheap. Suddenly I found that they had disappeared, to be replaced with some fancy ampoules (of three different sizes) which took up cubic feet of storage space and were very fiddly to use (indeed I found it impossible to break the smallest ones without the tube splitting at the back and spreading a slightly tacky antiseptic over my fingers, not to mention driving sharp glass splinters into them). On enquiry I was told that the evidence base for their superiority was unquestionable. However where the old swabs cost about £2.50 per 100 the new ones cost upwards of £30 per 100.

In fact the risk of infection from a no-touch technique joint injection is almost zero, but one feels obliged to spread some sort of muck on the patient just in case, so you can say you have done it. If this new delivery system was to be used in phlebotomy services the NHS would be bust in months.

Actually… in “The Times (9th June 2015) it was reported that some of the damp wipes not only failed to kill the bugs, but spread them about…

[1] This has actually been properly researched. See Willis-Owen CA, Subramanian P, Kumari P, Houlihan-Burne D. Effects of ‘bare below the elbows’ policy on hand contamination of 92 hospital doctors in a district general hospital. Journal of Hospital Infection; 75: 116-119.  Result? BBTE is a waste of time


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