Clinician’s Smart Phones in the Emergency Department: Functional or Fomite?

Nicholas Billings,Khatija Zahiruddin, Kelly McDonough, Victoria Leytin

Abstract

Smart phone usage in the Emergency Department offers many benefits to clinicians such asallowing easy access to clinical literature, medical decision-making tools to aid in diagnosis anddosage calculators. As a result, smart phone usage has become commonplace in many hospitals. However, while helping to enhance patient care, smart phones could also be serving as a vector to spread dangerous bacteria from one patient to another and this undermines most infectious disease protocols that hospitals have in place.

Smart phones belonging to Attending Physicians, Resident Physicians, Physician Assistants and Nurse Practitioners (n=60) at two community hospitals’ emergency department were tested for pathogenic bacteria with a specific interest inMethicillin Resistant Staphylococcus Aureus (MRSA), Extended spectrum beta-lactamase producingEnterobacteriaceae(ESBL) andVancomycin Resistant Enterococcus (VRE). The providers were also asked to complete a survey regarding their frequency of smart phone use, how they perceived the risk,and how often they cleanedtheir smart phones. Only 4 of 60 cell phones grew any significant, non-environmental, bacteria. Our study demonstrates that there is little risk in allowing use of smart phones to accentuate patient care and reduces the concern that smart phones spread disease is unwarrantedwhen presumably other hygiene standards are followed.

We hypothesized that although physicians wash their hands in between patient encounters; the smart phones they use are not being cleaned as often and are able to act as fomites for the spread of pathogens to our vulnerable patient populations. After swabbing the smart phones of healthcare clinicians for pathogenic bacteria, we found that smart phones, in fact, do not appear to function as fomites.

Introduction

Health care associated infections (HCAIs) are infections that patients acquire while receiving medical care. According to the CDC, 1 in 20 hospitalized patients will contract a health care associated infection. HCAIs are a burden to the health care system as well as to patients seeking medical care as they increase length of hospital stay, morbidity and mortality. Prevention of HCAIs is a public health issue and hospitals have implemented numerous tactics for preventing such infection such as requiring hand washing before and after patient contact, the use of isolation gowns, and frequent cleaning of patient care equipment such asstethoscopes and sphygmomanometers. However, little attention has been given to the use of smart phones in the health care setting and their role as potential vectors for infection.

Smart phones are increasingly present in the health care environment. They provide faster and more efficient communication among clinicians and provide a means of easily accessing medical information. Because clinicians use their smart phones while providing patient care, these devices may be contaminated with microorganisms, which can then be transferred between patients and clinicians, potentially contributing to HCAIs. According to a review done by Brady et al. (2009), between 9-25% of mobile communication devices are contaminated with pathogenic bacteria.This potential transmissionmay be negatively impacting infection control measures and is an area where the scope of the problem as well as recommendations regarding the use and appropriate cleaning of smart phones in the hospital setting is lacking.

Research Hypothesis

Our hypothesis is that the majority of the health care providers do not clean their cell phones adequately or at adequate intervalsand thus the majority of practitioner smart phones may be contaminated with drug resistant bacteria. We assume that the majority of swabbed screens will culture positive for MRSA, ESBL or VRE. Because most smart phones now are touch screens, we hypothesize that we are not only carrying bacteria on our screens but also recolonizing our hands every time we use our phones. This may contribute to potentially spreading infections to our patient populations.

Material and Methods

The Investigational Review Board (IRB) committees of Kent Hospital and Saint Anne’s Hospital approved the study protocol. A cross-sectional prospective study was conducted at Kent hospital in Rhode Island, and Saint Anne’s Hospital in Massachusetts, community hospitals between the months of 1/2014-4/2014, and 4/2015-5/2015 respectively. The study group is comprised of practitioners in both Emergency Departments; specifically Attending Physicians, Resident Physicians, Physician Assistants, and Nurse Practitioners. Practitioners were only chosen if they utilized their smartphones in the Emergency department for patient care or for personal use while working clinically. Practitioners were not previously made aware that their phone would be swabbed and were not permitted to clean their phone prior to the swab, which was done during their shifts in the Emergency Department.

Samples were gathered in a consistent fashion with the investigator wearing clean gloves while cultures were obtained. BBLTM Aerobic culture swab and transport medium were used. After a drop of normal saline was placed on the screen cover, a sterile cotton tip was used to swab all parts of the smart phone including the speaker, the plastic components of the covers, and the earpiece. The cottonswab was placed in the accompanying transport medium in the tube set. The culture was then transported to the hospital laboratory within 2 hours where they were processed on McConkey’s agar at 37oC. Normal environmental flora was differentiated from S.aureus, Enterococci and Enterobacteriaceae, which were then further discriminated into methicillin resistant S.aureus, vancomycin resistant Enterococci and extended spectrum beta-lactamase producingEnterobacteriaceae.

Results

Out of 60 mobile devices swabbed, only four tested positive for pathogenic bacteria: one tested positive for MRSA, another tested positive for Staphylococusaureus (not MRSA) andEnterococcus faecalis, and two tested positive for Staphylococcusaureus(not MRSA). Four mobile devices demonstrated no bacterial growth. This translates into a 0.06% contamination rate across all mobile devices tested.

A review of data obtained from surveys completed by the owners of each smart phone revealed a majority of practitioners utilize their mobile devices three or more times during a shift. Their frequency of use appears to correlate to the number of medical applications they have on their smart phones: the more applications they have, the more frequently they use their Smart phones (r= 0.50). However, it does not appear that frequency of use correlates to a practitioners perceived need to use their smart phone in order to function at full capacity (r= -0.10).Most respondents felt they either did not need their smart phones to function at full capacity or would adjust if they were not able to use them.

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Most respondents indicated that they rarely, if ever, cleaned their smart phones and most were undecided if the use of smart phones in the Emergency Department contributed to the spread of disease. Nonetheless, most would clean their phones if cleaning stations were available.

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Discussion

Emergency departments in general are considered unclean with the thought being that the ER is too busy to maintain hand washing protocol and the practice to “pump in and pump out” antibacterial hand sanitizer. Infection control has become the hospital’s prophylactic strike against developing an infection with isolation protocols becoming prevalent. Physicians also are increasingly using their smart phones within the ED, not only to communicate with colleagues but also during patient encounters as the use of paper PDAs and the paper “peripheral brain” is going out of favor due to smart phone apps such as UpToDate and Epocrates.

Fomites and surfaces in health care are known to aid in transmission of pathogens. HCAIs are increasingly worrisome when multi-drug resistant bacteria are involved. Our institutions’ infection control guidelines recommend routine disinfection of patient surfaces and every time a patient is switched out from a room in the ED, the room and bed are cleaned with antibacterial spray and soap. The same courtesy is not provided to the healthcare professional’s smart phone however, which are often used inside and out of the patient’s room. Studies have found that more than half the time, even surfaces, which have been cleaned, are re-contaminated within minutes. This study suggests that this may be unnecessary concernregarding the smart phone.

In their study based out of a dental hospital in India, Walia,et. al. (2014) found that health care practitioners who had consistent and direct contact with patients grew more pathogenic bacteria on their mobile devices than people who had less contact with patients. In comparison to this study, which only tested practitioners with direct patient contact in the Emergency department, there is firm contradicting information. We attest that a practitioner’s smart phonewithin an ERmay not need to be cataloged as a fomite.This may be due to recent emphasis placed on hand washing in the health-care setting and its importance in the prevention of the spread of health care associated infections. If clinician’s are frequently hand washing and using hand sanitizers, then they are less likely to transmit bacteria from their hands to their smart phones and, ultimately, to their patients.

These results do contradict our original hypothesis that a majority of mobile devices tested would likely be contaminated with one of more pathogenic bacteria. There are several hypotheses that could explain these results. They may represent a false negative due to insufficient swabbing techniques: perhaps the swabs were not moistened adequately or the surface area that was swabbed was not sufficient. Our sample size of n=60 may be small resulting in limited data for analysis and the results are from one Emergency Department.

Conclusion

HCAIs contribute to lengthy hospital stays, increased spending of health care dollars and increased morbidity and mortality. Smart phones used in the clinical setting may be mistakenly thought of as significant vectors for the spread of nosocomial bacteria. Scant research has been done on this topic and a review of the literature reveals that most studies almost unanimously state that mobile phones are vectors for disease. This was not the result experienced at Kent Hospital and Saint Anne’s Hospitals’ Emergency Departments. There are many reasons why the results were so dissimilar to results of studies done elsewhere. Kent and Saint Anne’s, in conjunction with the Infectious Disease department, has widely implemented strict hand washing protocol with anonymous infection control monitors, whose job it is to report non-compliance,within the last two years.Also, Isolation protocol in the ER places any patient ever tested positive for MRSA, Pseudomonas, VRE or ESBL under strict isolation with gowning and gloving even at the Emergency Department level. These interventions may make these Emergency Departments fall outside the norm of the normal ED experience.This research may be made more thorough by perhaps comparing the data between inpatient providers and outpatient providers.

Bibliography

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Appendix 1: Questionnaire For Cell Phone Study

  1. How often do you use your smart phone/PDA while at work to access information to help your decision making process/ investigate correct dosages for medications?
  1. Never
  2. Infrequently
  3. Once a Shift
  4. Twice a Shift
  5. 3 or more times a shift
  1. How often do you disinfect your phone after using it at work?
  2. Never
  3. Dry wipe infrequently
  4. Disinfect Infrequently
  5. Dry wipe after every shift
  6. Disinfect after every shift
  7. Dry wipe after every use
  8. Disinfect after every use
  1. How many medical applications do you have installed on your smart phone/ PDA?
  2. 1
  3. 2
  4. 3-5
  5. 6-10
  6. 10+
  1. Do you feel that it is possible to function to your full potential in your capacity as a practitioner without your smart phone?
  2. No, I would not function at the same level
  3. I would likely buy books to replace the apps
  4. It would be difficult, but I would adjust
  5. Yes, I don’t need a smart phone to make decisions
  1. If there were cell phone cleaning stations set up around the ER, would you utilize them to disinfect your smart phone/ PDA?
  2. I would not use them
  3. I would use them infrequently
  4. I would use them frequently
  1. Do you feel cell phones/ PDAs used by care givers in the ER contribute to spreading diseases to the patient population?
  2. No
  3. Maybe
  4. Yes
  1. What is your function in the ER?
  2. Physician
  3. Physician Assistant
  4. Nurse Practitioner
  5. Nurse
  6. Other: Please specify

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