Mobile computers can bring both information and infection to the point of care.
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| Steven J. Davidson, M.D. | Gregg Malkary |
Mobile computing devices represent a patient safety conundrum. While they bring decision support, bar-code and RFID-assisted medication administration, and the latest patient data to the point of care, they also can serve as vehicles for germs and increase the potential for hospital-acquired infections.
A recent market research study of the current state of physician computer adoption in the United States found that 65 percent of physicians interviewed believe mobile computing devices pose infection control risks at the point of care due to poor physician hand-washing habits, multi-tasking at the bedside (simultaneously using a device while examining patients’ ears and eyes or listening to their heart and lungs) and ignorance of the potential risk. This represents a 160 percent increase from a January 2005 study in which only 25 percent of physicians interviewed believed mobile devices posed any form of risk.
Spotlight on Nosocomial Infections
Hospitals are under increasing pressure to prevent hospital-acquired infections, and anything that could be a carrier—a physician’s necktie, white coat and stethoscope, or a device used at the point of care—is under scrutiny. Stethoscopes often are contaminated with Staphylococcus aureus and other dangerous bacteria because caregivers seldom take the time to clean them in between seeing patients. The Committee to Reduce Infection Deaths, a not-for-profit education campaign that suggests lower-cost interventions, recommends that patients ask their physicians to wipe the stethoscope’s diaphragm with alcohol before use.
Similarly, a new dress code banning neckties, long sleeves and jewelry for physicians takes effect in British hospitals this month. The dress code, which also bans the traditional white coat, is being implemented to stop the spread of deadly hospital-borne infections, including Methicillin-resistant Staphylococcus aureus (MRSA).
While there is little data supporting the spread of disease through contaminated neckties or other clothing, both hospital- and community-acquired infections are much in the news these days. And where the news goes, politicians and regulators are sure to follow.
Infection control experts believe clinician hand decontamination with alcohol-based cleansers if no visible soiling is present or by hand washing when visible soiling is present must take place before and after touching a person, object or surface, and gloving and de-gloving are the most important factors in preventing the spread of microorganisms. The practice must be uniform and routine. The Joint Commission’s focus on reducing hospital-acquired infections has led to health care organizations installing alcohol-based cleanser dispensers at the entrance of patient rooms and in hallways.
Clinician hand-hygiene compliance has significantly improved during the past few years but physicians interviewed admit they sometimes forget to clean their hands between patient encounters. Other physicians believe the hand-washing process—which can take upwards of 30 seconds—can be an impediment to clinical workflow if the physician sees large volumes of patients. Introducing these practitioners to alcohol-based hand-cleaning agents may reduce resistance and blunt this argument.
Contaminated Computers
Mobile computing devices pose a risk at the point of care. A physician’s hands can be contaminated not only by touching a patient but also by touching contaminated surfaces such as these devices, smartphones, pagers and computer keyboards. Thus, a dirty mobile device becomes the vector of contamination as the physician moves from patient to patient and from the hospital into the community. Only hand decontamination can protect the practitioner, each patient and the community because the devices rarely can be decontaminated without damage.
In addition, most hospitals lack formal infection control policies for mobile devices. Standard hospital cleaning agents can damage the device casing, screen and internal electronics of a general purpose computer.
There are three ways to reduce the infection risk of mobile devices at the point of care:
Emphasize clinician hand-hygiene and gloving as appropriate: Health care organizations need to continue promoting clinician hand hygiene and hand decontamination. Public education is an important component of clinician hand-hygiene campaigns because until the practice becomes reliable and consistent, all prompts are valuable. Identification badge holders printed with “Ask me if I cleaned my hands” have been distributed at some hospitals. The reminder they provide—along with ready access to alcohol-based hand cleansers—increases compliance.
Infection control practitioners and hospital IT leaders must collaborate. Hospitals also need to better define roles, responsibilities and procedures for cleaning and maintaining all computing devices, especially input devices such as keyboards, computer mouses and trackballs, and mobile devices at point of care. IT leaders and clinicians should form a partnership in fighting the spread of infection via mobile devices.
Invest in mobile devices that can be easily cleaned: Hospitals should explore opportunities to invest in mobile computing devices that can be more easily cleaned and sanitized at point of care with standard commercial cleansers. These devices ideally would be water resistant and hermetically sealed to prevent the entry of microorganisms. One tablet computer vendor is advertising a “highly sealed, disinfectable chassis.” Washable keyboards and mouses, and submersible handheld devices also are available.
Physicians who have adopted mobile computing devices are not going to give them up any time soon, nor should we ask them to do so. The safety and quality benefits of IT at the bedside are too important. Still, even if these devices become easily cleaned, clinician hand-hygiene practices will remain at the center of infectious disease risk reduction. Simply exhorting clinicians to do better is not enough; patient, family and community education, perhaps cued by a badge holder with a message, ubiquitous alcohol-rub dispensers and the study of clinician workflows that support hand-hygiene practices will help us avoid the risk using powerful mobile devices for voice and data communication may pose.
Steven J. Davidson, M.D., M.B.A., FACEP, FACPE,is chairman, department of emergency medicine, Maimonides Medical Center, Brooklyn, N.Y. Gregg Malkary, M.S., is founder and managing director of Spyglass Consulting, Menlo Park, Calif.
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This article first appeared on January 9, 2008 in HHN's Magazine online site.
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