Abstract: Patients in the healthcare environment frequently contaminate surfaces and inanimate objects with their own transient and resident microorganisms. These microorganisms can be transmitted to other patients by healthcare worker hands, contaminated gloves, and handheld devices, resulting in healthcare associated infection (HAI).{1}

One category of handheld devices exponentially increasing and predicted to continue increasing in healthcare, is mobile electronics. {2 }Mobile electronic devices are being introduced into healthcare at a far greater pace than protocols are being developed to direct cleaning and disinfection.  According to a recent survey, there is great variability in the processes used and the frequency with which handheld mobile electronics are cleaned.{3}   Until professional guidelines are developed to address how and when to clean these devices, the process should be approached by healthcare facilities in a deliberate and standardized fashion, potentially as an extension of an existing hand hygiene program.

Overview: Handheld devices in healthcare today

Handheld electronic tablets are being used more frequently in hospitals in a variety of ways including for patients at appointment registration, to view lab results, to receive clinical education, for inpatient menu selection, and inpatient skyping with family.  Healthcare workers (HCW) and physicians use tablets to access medical records, to receive educational training, and for risk assessment and auditing activities.  

And of course both personal and business cell phones are ubiquitous in healthcare, and hospital based mobile phones are in wide use.  

Beyond electronic mobile devices, there are numerous additional handheld devices frequently used in healthcare including otoscopes, blood pressure cuffs, stethoscopes, glucometers, reflex hammers, pens, etc.  

Contamination of these devices, and the potential role in infection transmission has been reported in peer reviewed literature.{4,5} The patients at greatest risk of infection from environmentally transmitted pathogens are those with indwelling devices (e.g. bladder catheters or IVs), and post-operative patients, since the incision and devices can provide a portal of entry for the pathogens.{6}  Surveys and site visits by The Joint Commission (TJC) and CMS are now addressing cleaning of these devices, however, protocols for device cleaning have not yet been developed in many healthcare facilities.{7}

The Risk: Contaminated Handheld Electronic Mobile Devices and HAI

Environmentally transmitted pathogens including Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA) and Acinetobacter baumannii can cause HAI resulting in significant patient morbidity and mortality. These organisms, which can be transmitted by contaminated hands and devices, have been recovered on surfaces for as long as 4-5 months. {8} 

Numerous published studies conclude that contaminated handheld devices represent a great challenge in healthcare today.  A paper published in American Journal of Infection Control in 2015, reviewed thirty-nine studies from the previous 10 years focused on contamination of mobile phones in healthcare. A finding common to all of the studies was that healthcare worker cell phones are frequently contaminated with bacteria that can cause HAI. The conclusion of the author was that “use of mobile phones by healthcare workers increases the risk of repetitive cyclic contamination between the hands and face (e.g., nose, ears, and lips) and that this may contribute to transmission of microorganisms between patients, including multidrug resistant organisms”. {9}

The Challenge: Cleaning and Disinfection of Handheld Electronic Mobile Devices 

Mobile electronics in healthcare settings pose a unique challenge with regard to cleaning and disinfection, because they are frequently touched with healthcare worker hands (not always clean), with contaminated gloves, and are carried into multiple patient rooms and other potentially contaminated environments. Furthermore, the most common cleaning and disinfection solutions cannot be used on mobile electronics without causing damage.  Often the manufacturer instructions for use for these devices requires cleaning and disinfection with products that are not available or cannot produce a disinfection effect.  

The most common method of cleaning of these devices, germicidal wiping, is reported to be inconsistently effective. In a 2016 study, samples were taken from the cellphones of hospital staff entering the operating room of a university hospital center orthopedic surgery department. The majority (94%) of cell-phones were found to be contaminated prior to cleaning (wiping) and 75% were still contaminated after wiping. {10}  

Current Practices – A Survey 1

To gain a better understanding of current cleaning and disinfection practices for handheld devices and to identify opportunities to improve, a survey was sent to 1,125 Infection Prevention professionals (IPs) during the first quarter of 2017.  In addition to cleaning practices, questions were posed to the IPs regarding their perceptions of the potential impact on patient infection risk.  A total of 218 responses were received and some of the findings follow.  

• The majority of respondents reported no policy guiding cleaning/disinfection of mobile devices, hand hygiene before or after use of mobile devices, and not using mobile devices while wearing gloves;

• The most common types of mobile devices were: cell phones, followed by tablets and hospital based wireless phones;

• There was wide variability in the process for cleaning mobile devices, whether or not there was a written policy.  The most common process reported was use of a disinfectant solution or germicidal wipe. 

Innovation for mitigation of handheld electronic mobile device contamination

There have been a number of product innovations designed to reduce the contamination of electronic mobile devices. These include protective films and cases that enable cleaning the devices using effective disinfectant solutions without damaging them.  There are some protective films that report having an antimicrobial effect.  Additionally, there has been an expansion of UV disinfection technology, specifically for handheld electronic devices.  

There are three UV light wavelengths: UV-A, UV-B and UV-C.  The UV-C wavelength is the germicidal wavelength. UV-C acts by destroying the DNA within the microorganisms including bacteria and viruses. Consequently UV-C light has been in use for decades in healthcare, as a proven tool for disinfection of air, water and environmental surfaces and in reducing HAI of many types. {11,12}   

Recently this UV-C technology has been adapted to provide rapid high level disinfection of mobile electronic devices and other handheld instruments.  Laboratory testing of one of these novel UV systems has demonstrated a 6 log reduction of Mycobacterium spp. {13} Since they are small and portable they can be placed in multiple locations such as at the entrance to Neonatal ICU (NICU), in nursing stations, medication rooms and staff lounges.  

Some versions have associated software that enables tracking of individual phones and electronic tablets to ensure they are disinfected according to the frequency dictated by the hospital policy.  Another advantage of an automated device for disinfection of electronic mobile devices, is that the human factors associated with inadequate manual wiping are eliminated. 

Conclusions:

Based on peer reviewed studies and the recent survey of IPs, cleaning and disinfection of handheld electronic and other devices is a significant challenge in healthcare.  A deliberate and standardized approach is needed in order to support patient safety and reduced infection risk.  Additionally, since the devices can contribute to healthcare worker hand contamination, it may be logical to consider incorporating the routine cleaning and disinfection of these devices in an existing hand hygiene program.  

Authors: Sue Barnes, RN, CIC, FAPIC, Maureen Spencer, M.Ed, BSN, RN, CIC, FAPIC, Shannon Oriola, RN, BSN, CIC, FAPIC

References:

1. Burdsall, D. “Exploring inappropriate certified nursing assistant glove use in long term care”. American Journal of Infection Control 45 (2017) 940-5.

2. Wallask, S. “Mobility in hospitals is key to better healthcare”. Pulse. July 2017, Vol. 5, No. 4. 

3. Survey of 1,125 Infection Prevention professionals “Contaminated handheld devices and HAI”; 2017 DDG Associates LLC at Deniseagraham@gmail.com

4. Cohen HA, Amir J, Matalon A, Mayan R, Beni S, Barzilai A. “Stethoscopes and otoscopes--a potential vector of infection?” J Hosp Infect. 2001 Aug;48 Suppl A:S64-8.

5. Singh D, Kaur H, Gardner WG, Treen LB. “Bacterial contamination of hospital pagers”. Infect Control Hosp Epidemiol. 2002 May;23(5):274-6. 

6. Sydnor ERM, Perl TM. Hospital Epidemiology and Infection Control in Acute-Care Settings. Clinical Microbiology Reviews. 2011;24(1):141-173.

7. The Joint Commission Standards, Infection Control Chapter, IC.02.02.01 EPs 1-5 §482.42 A-0747: “The organization reduces the risk of infections associated with medical equipment, devices, and supplies”. 

8. Chemaly RF, Simmons S, Dale C, et al. The role of the healthcare environment in the spread of multidrug-resistant organisms: update on current best practices for containment. Therapeutic Advances in Infectious Disease. 2014;2(3-4):79-90.

9. Ulger, F. “Are healthcare workers' mobile phones a potential source of nosocomial infections? Review of the literature”. The Journal of Infection in Developing Countries. 2015; 29;9. 1046-53.  

10. Murgier J. et al. “Microbial flora on cell-phones in an orthopedic surgery room before and after decontamination. Orthop Traumatol Surg Res. 2016 Dec;102(8):1093-1096.

11. Anderson DJ, et al. “Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study.” Lancet. 2017 Feb 25;389(10071):805-814. 

12. Yang JH1, Wu UI1, Tai HM1, Sheng WH2.  “Effectiveness of an ultraviolet-C disinfection system for reduction of healthcare-associated pathogens”. J Microbiol Immunol Infect. 2017 Sep 18. pii: S1684-1182(17)30200-1. 

13. Burton, S. “Report for PhoneSoap Express on effectiveness of UV light on killing vegetative cells of Staphylococcus aureus,  Escherichia  coli,  Salmonella typhimurium, Klebsellia pneumoniae  and Mycobacterium smegmatis”. Richards Industrial Microbiology, INC. 2017.