It’s time for medical students to hang up their lanyards, a safer alternative is available, says Antonia Round

The lanyard is a familiar part of a UK medical student’s clinical persona. Swinging from around our necks, it accompanies us on the morning commute, to every patient on the ward round, to lunch, to the bathroom, and back to our homes. In some ways this marks a progressive step forward: lanyards provide a clear identifier that ensure patients know who is looking after them. They are now ubiquitous in many trusts across healthcare professions⁠—but have we overlooked the risks? 

Infection control is a prominent feature of clinical practice: every ward has prominent hand-washing reminders, gloves and aprons, and hand-gel at every bed. In recent years, neckties were identified as a potential threat to infection control: they are rarely laundered, have been shown to be colonised by pathogens, and offer no benefit to patients. In 2007 the Department of Health recommended that neckties should not be worn during any form of patient contact surely this reasoning applies to lanyards too? [1] 

Limited evidence

An Australian study involving 59 clinical ward staff took samples from lanyards and identification badges, finding that 27 lanyards were contaminated with pathogenic bacteria. [2] Lanyards had ten times the bacterial load per surface area unit than the identity badges they were connected to. Another study with 108 healthcare workers found that 87% of lanyards cultured primarily skin flora, but 6% grew pathogenic and faecal bacteria. [3] As a bacterial reservoir, lanyards could pose a threat to other measures of infection control, providing a source for clean hands and equipment to be re-contaminated.

Historically, methods of infection control have not always been fully supported by research prior to recommendation. “Bare below the elbows” guidance was particularly controversial for its limited research support; highlighting that some recommendations are based on limited findings with sensible reasoning. [5]

To my knowledge, no study has yet investigated if lanyards are associated with transmission of microbes, actual infection, or patient outcomes. What we do know is that good hand hygiene reduces risk of transmission of infections, and contaminated lanyards (which hands frequently touch) could threaten this. [4]

What should change?

Lanyards are rarely, if ever, cleaned: perhaps this presents a solution. In a study where only 16% of lanyards had ever been washed, those cleaned recently had lower bacterial counts, with bacterial count increasing by 1.5 CFU/cm2 (colony forming units) each month after cleaning. [3] A project investigating contamination of identity badges and lanyards in theatres found 25% were colonised with potentially pathogenic bacteria; cleaning with sanitising wipes removed all identified pathogens. [6] However, molecular analysis has shown that nasal carriers of Staphylococcus aureus often carried the same strain on their lanyard. [7] This suggests that lanyards could be rapidly re-contaminated by the wearer’s nasal flora after laundering.

Clip-on identity badges may be a better solution, with significantly less bacterial colonisation than lanyards. [2] Whilst nasal contamination from the wearer is still possible, a fixed position on the upper chest minimises contact with the clinical environment. Further away from the wearer’s hands than a lanyard, a clip-on badge makes hand re-contamination more difficult. Like lanyards, clip-on badges retain the benefits of readable identification and the potential to be adapted with colours to emphasise roles. 

While a link to infection transmission has not yet been investigated with lanyards, it is known that they carry pathogenic bacteria. In the clinical environment where patients have entrusted staff to their care, we are knowingly exposing them to a potential risk. Clip-on identity badges fulfil the same purpose with less threat to infection control: it’s time to wave goodbye to lanyards.

Antonia Round is a third year medical student at the University of Leicester.
Twitter: @RoundAntonia
Competing interests: Antonia is a student ambassador for the Royal Society of Tropical Medicine and Hygiene. This is an unpaid voluntary position.

References

[1] Jacob G. Uniforms and Workwear: An evidence base for developing local policy [Internet]. London: UK Department of Health. 2007. Available from: https://webarchive.nationalarchives.gov.uk/20130220145219/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_078435.pdf [Accessed 18th March 2019]
[2] Kotsanas D, Scott C, Gillespie EE, Korman TM, Stuart RL. What’s hanging around your neck? Pathogenic bacteria on identity badges and lanyards. Med J Aust. 2008;188(1): 5-8.
[3] Pepper T, Hicks G, Glass S, Philpott-Howard J. Bacterial contamination of fabric and metal-bead identity card lanyards: A cross-sectional study. J Infect Public Health. 2014;7(6): 542-6.
[4] Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. Journal of Hospital Infection. 2009;73(4): 305-15.
[5] Burger A, Wijewardena C, Clayson S, Greatorex RA. Bare below elbows: Does this policy affect handwashing efficacy and reduce bacterial colonisation? Ann R Coll Surg Engl. 2011;93(1): 13-16.
[6] Lobaz S, Diddee R, Collins J, White D. Pathogenic colonisation of hospital badges and neck lanyards in the anaesthetic/theatre environment [Internet]. Available from: https://www.mwe.co.uk/modules/downloadable_files/assets/lobaz-et-al-2012-pathogenic-colonisation-of-hospital-badges–neck-lanyards-in-theatre.pdf [Accessed 18th March 2019]
[7] Murphy CM, Di Ruscio F, Lynskey M, Collins J, McCullough E, Cosgrave R, et al. Identification badge lanyards as infection control risk: a cross-sectional observation study with epidemiological analysis. J Hosp Infect. 2017;96(1): 63-66.