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By Kelly M. Pyrek
Studies have indicated the contamination levels of devices such as mobile phones and tablets and observed that these potential reservoirs for microorganisms are not being cleaned and disinfected as they should be to prevent cross-transmission from the device to healthcare workers' hands, and finally, to the patient.
A casual online poll of ICT readers shows that 83 percent of survey respondents use their personal mobile technology devices within the hospital, and just 68 percent said they clean/decontaminate these devices regularly. Fifty-seven percent of respondents indicated they use a hospital-issued mobile technology device in the course of their workday; 56 percent report cleaning the device themselves, while 7 percent let someone else clean the device. (See the January/February 2019 print/digital issue of ICT for complete survey results.)
A lack of formal recommendations requires healthcare institutions to evaluate the issue and formulate strategies to address it. Manning, et al. (2013) emphasize that "It is imperative that infection prevention and control programs be actively engaged in providing healthcare worker (HCW) guidance and education in how to mitigate the risk of bacterial contamination of their mobile health devices (MHDs). Programs also have an important role in working together with healthcare providers to establish and implement organizational MHD policies and procedures."
As Manning, et al. (2013) explain further, "Whereas there is no evidence of a direct link between environmental pathogens on small portable electronic devices and the rate of HAIs, cross contamination among patients may occur via the hands of HCWs after they have touched contaminated devices. Multiple investigators have shown that HCW mobile devices provide a known reservoir of pathogenic bacteria, with the potential to undermine infection control efforts aimed at reducing bacterial cross contamination. This potential could be amplified further as HCWs begin to carry additional personal electronic devices such as MHDs without concurrently providing appropriate protocols on decontamination, especially at the point of acute care. This is an important concern given the mounting descriptive evidence of the rapid adoption of MHDs in the healthcare arena. If the trend continues, MHDs could quickly surpass the use of mobile phones and PDAs."
To better understand the threats and opportunities associated with mobile technology devices in the healthcare environment, ICT spoke with James Davis, MSN, RN, CCRN-K, HEM, CIC, FAPIC, senior infection prevention and patient safety analyst/consultant with ECRI Institute, and Amanda Sivek, PhD, senior project engineer, also with ECRI Institute.
ICT: What's your feel for the level of cleaning and disinfection of contaminated mobile technology in hospitals?
James Davis: At ECRI Institute, not only do we conduct research on site but we perform consultations with hospitals and our own members, so we do get out in the field. Variability exists in terms of how well people are cleaning and disinfecting these devices. Essentially, it's all about identifying the process that fits your institution -- did you identify the shared equipment? Have you identified the process of who owns it so there is no confusion when it comes time to move that equipment, either from patient to patient or when the equipment is no longer needed, like a ventilator? Who's going to clean it? And then how do you identify that equipment as being clean? For example, some facilities, when they assign a ventilator to a room, they assign the cleaning and decontamination of it to the respiratory staff because who knows that equipment better? Some facilities put a clean bag over that equipment and store it in the clean utility room until it is needed again. That process could vary depending on the complexity of the equipment; you can take it down to as simple as a blood pressure cuff that's moving around on a med/surg floor between patients if they don't have disposable cuffs. In that case, the nurse or nursing assistant would be responsible for cleaning and disinfecting it between patients. Policy will vary by equipment type but also how the equipment is used, who "owns" it.
Amanda Sivek: It's important that staff have appropriate workflow, including time considerations, for proper cleaning and disinfection. For instance, nursing assistants frequently go in and out of patients' rooms across a unit, and they need time to properly clean and disinfect equipment and spot check it before it enters the next patient's room.
ICT: Mobile technology consists of electronics that can be damaged in the cleaning and disinfection process; what do you advise healthcare professionals to look out for?
JD: There are ways to help clinicians do the right thing when it comes to mobile devices; we are always balancing how to clean and disinfect a particular device when it is not technically considered a medical device, like a smartphone or a tablet. When you talk to a manufacturer such as Apple, they say just use a damp cloth, but there are no instructions for use (IFU) for these devices in the healthcare setting. An ECRI engineer and I wrote an article that addressed this in lieu of formal recommendations. Some solutions are as simple as putting a smartphone or tablet into a Ziploc-type bag if you must bring it into an isolation room -- it's essentially PPE for your phone. When you are done in that room, remove it like a pair of gloves and throw it away, then and wipe your device off and wash your hands. People do use alcohol pads on their phone, but that can be problematic. The idea is to reduce contamination and limit whatever potential bioburden could get deposited on the mobile device by putting a layer between it and the environment. Recently I have seen some covers that people are using on their phones, but over time, disinfectants may degrade that cover; if that happens, they throw it out and buy a new cover. I think there needs to be ownership -- if it is your device, then you need to be responsible and do the right thing by diligently cleaning and disinfecting it.
AS: We at ECRI are very interested in infection-reduction technologies, and one of the technologies that I have evaluated are countertop UV-emitting disinfection devices. The way they work is they generate UV-C, which is not native to Earth, so when bacteria encounter it, they are damaged irreparably and cannot replicate. So, that effectively kills them. We looked at five models of these devices and I am currently evaluating a sixth device. It is important that, as Jim was saying, to properly protect your phone, because in the case of UV-C, it is known to degrade materials. Say you have a black phone and you expose it to UV-C just like any type of ultraviolet light; it will become grey over time, and white will become yellow over time. So, you must take proper precautions to protect your mobile devices and having a cover over your phone is key.
JD: UV-C is a disinfection technology, it's not a cleaning technology, so at some point you will still need to wipe down your phone or tablet before you put it in one of those disinfection devices. Whether you use a wipe containing a quat or a UVC-generating device, you must remember that there is a distinct difference between cleaning, which is removal of soil, and disinfection, which is killing bugs.
ICT: What risk do contaminated devices pose to patients?
JD: It's very hard to tie infections to particular devices. Some manufacturers claim you will reduce your HAI rates if you use XYZ in a patient room, but there are so many variables that come into play. You must consider how well that room and the objects in it were cleaned, whether some kind of wipe was used with a mechanical action in combination with a disinfectant, and then was UV-C used as an adjunct? Real-world scenarios are difficult because humans are involved here; one worker may do something a little differently that might make all the difference. When it comes to mobile devices like a phone or tablet, we are not putting it on a patient, for the most part. Having said that, given that apps are becoming much more mature and are able to sense and detect conditions of the human body, who knows what the future may hold. Currently I am not putting my personal phone on someone's skin; I am touching the patient and then touching my phone and then potentially touching the next patient -- but I should be doing hand hygiene, wearing gloves, and wiping off my phone and using a Ziploc bag if I am in an isolation room. The risk there probably isn't as significant as most people would assign to it. However, if we talk about a blood pressure cuff moving from patient to patient applied to their skin, that could be a vector, of course, and there have been studies to document that. Now, if a piece of equipment goes into a patient's mucous membrane, and it is used as a multiple-patient device like an ERCP scope and you don't clean and disinfect it properly, there is documented transmission of disease and potentially death. So, we must be specific about what devices we are talking about and where they fall according to the Spaulding classification and the relative risk assigned to these classifications.
ICT: How can barriers to compliance be broken so that healthcare personnel can always do the right thing?
JD: As we look at this, sounds simple but it's not. There is pressure for rapid bed turnover and if a piece of equipment is needed and it takes 25 minutes to do a good job, you must look at those human factors-related issues. Also, does the facility provide the right tools needed to do proper cleaning and disinfection? And are healthcare personnel using appropriate cleaning products and techniques for whatever was in that room last, whether it was CRE or C. diff, for example. I think it is multi-factorial. I've done some consults where facilities have conducted time studies where instead of turning things over in 25 minutes, it takes much longer when you clean and disinfect properly and thoroughly. I think people are realizing that disinfection is paramount, it's a mission-critical task around which processes and workflows should be arranged so that it is performed correctly. Institutions must make it easy for healthcare workers to do the right thing all of the time, not making it hard for them to do their jobs.
AS: I would like to expand on what Jim said by emphasizing that it is a team effort; it's everyone working together and always trying to do the right thing for the next patient. I was an artificial heart engineer and during training I remember we were expected to clean and disinfect our intra-aortic balloon pump consoles; our trainer told me always clean and disinfect it like your family member is going to be using it next. Our workflow was such that cleaning and disinfection was supported, so that I had the time to devote to proper technique. So, it's a team effort and it must be supported by executive leadership, with the understanding that your turnover time is increased because you must take the time to properly clean and disinfect the room and the items in it, so that the next patient is not put at risk.
ICT: What recommendations can you offer?
JD: The guidelines are there for instruction, but they are not prescriptive as far as what cleaning tool to use, or what type of disinfectant or UV light to use, and considerations such as wipe dry times, wet times and kill times. So, facilities must do their own assessments that are guideline-based but also conduct their own due diligence when introducing all these components to your cleaning and disinfection program. To reiterate, you have the human factors issue, you have the timing issue, you have the pathogen issue, you have the level at which the equipment is being used in the Spaulding classification -- you must figure it out for yourself by conducting your own study of local issues, but have the foundation in evidence-based practice, as you develop policies and procedures. I can't make a global recommendation because there are so many variables.
ICT: Can biomedical personnel assist clinicians with this issue?
JD: If you can't get your hands on IFUs, biomedical personnel can often assist you. They can also help you with your product evaluation and purchasing when it comes to technology or things such as covers for your technology. They can help make expert recommendations because they see the damage from disinfectants on plastics and can help advise on how to avoid the degradation issue. What they see coming to them is often broken and it's good to have their perspective.
AS: Biomedical personnel used to be involved in the procurement of medical devices and I don't know if that is still the case or not in many facilities, but these professionals can inform you about the life cycles of the products because they see them at all stages; take an infusion pump for example; they know when it needs maintenance, what is the expected life of the product, what's likely to fail on the device and the components needed, how to clean it, and the total costs involved.
Manning ML, Davis J, Sparnon E and Ballard RM. iPads, droids, and bugs: Infection prevention for mobile handheld devices at the point of care. Am J Infect Control. 41, No. 11 (2013):1073-10.
Pyrek KM. Mobile Technology Disinfection: Contaminated Devices Pose Threat to Patients. Infection Control Today. February 2017. Accessible at: https://www.infectioncontroltoday.com/transmission-prevention/mobile-technology-disinfection-contaminated-devices-pose-threat-patients