ON ANY GIVEN DAY, the CDC estimates that 1 out of 25 hospitalized patients has a healthcare-associated infection (HAI).1 Up to 1.7 million HAIs occur annually in the United States, resulting in an annual financial loss of $6.5 billion.2 HAIs are responsible for approximately 75,000 deaths annually.1,3 Preventing HAIs is essential to keep hospitalized patients safe as well as to control costs.
Access to instant communication and information such as medical records and test results, coupled with the ability to share images quickly among providers, patients, and families, are important benefits of mobile device use. However, along with these benefits comes the risk of transmitting pathogens that may be contaminating the surfaces of cell phones and other mobile devices. The purpose of this review is to examine the current evidence to determine whether the use of mobile devices, particularly cell phones, increases the risk of HAIs and what hospitals and individual clinicians can do to minimize the potential for transmitting infection.
Hazards of healthcare
HAIs are infections that result from receiving treatment in a hospital or other healthcare facility. According to the CDC, types of HAIs include, but are not limited to, surgical site infections, central line-associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated pneumonia, Clostridium difficile infections, and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia.3,4
The Agency for Healthcare Research and Quality states that the average adjusted length of stay for hospitalized patients is 5 days; this increases to 24 days for patients who develop a HAI.5 The average cost of stay for a patient who develops a HAI increases by $43,000, resulting in an overall direct cost to the healthcare system ranging from $28 to $45 billion annually.5,6
The use of cell phones and other mobile devices has become a routine means of communication between nurses, healthcare providers (HCPs), and other clinicians.7 In addition, patients and their visitors handle their devices in patient rooms and throughout the facility. These devices are potential reservoirs for pathogenic microorganisms that can contaminate the user's hands. However, whether this contamination translates into higher rates of HAI is unclear.
Reviewing the evidence
The authors conducted a literature search to evaluate the current evidence about whether the use of mobile communication devices, specifically cell phones, increases the risk of HAIs in hospitals. The aim of this review was to answer a PICOT question (P = population; I = intervention; C = comparison; O = outcome; and T = time): “When healthcare providers (P) use mobile phones (I), does the risk of HAIs increase (O) during hospitalization (T)?” (Comparison [C] was not pertinent to this PICOT question.) The databases Academic Search Premier, Medline, and CINAHL were searched (2010 to present) using the following keywords: mobile device, cell phone, hospital, infection, and HAIs.
The evidence clearly demonstrates that cell phones are contaminated with various benign and pathogenic bacteria. In a pilot study conducted in a pediatric unit, researchers found that 95% of phones were colonized with bacteria and 5% contained pathogenic bacteria.8 This study is consistent with a systematic review by Ulger and colleagues that reviewed 39 individual research studies.9 All of the studies identified the proliferation of bacterial growth on devices, most commonly S. aureus (n = 26, 66.7%), followed by coagulase-negative staphylococci (n = 19, 48.7%).
Other studies have shown that in addition to natural skin flora, mobile devices supported growth of MRSA, Escherichia coli, Acinetobacter, Enterobacter, Klebsiella, and Pseudomonas. Some devices also tested positive for endemic viruses, including adenovirus, rotavirus, and bocavirus.10-12
The humidity/moisture and warmth of mobile devices present ideal conditions for pathogens to reproduce and contaminate the device user's hands and face.9 The mouth, ears, and nose, which are among the most highly contaminated areas of the body, come in close contact with mobile phones during ordinary use.13
Several authors have demonstrated that up to 90% of subjects' clean hands immediately became recontaminated with the same bacteria found on their phones once they touched the phones again.13,14 In a cross-sectional study in a 75-bed neonatal ICU, Beckstrom and colleagues found that all phones demonstrated bacterial contamination and that 90% of parents had the same bacteria on their hands as that found on their cell phones.14
Alcohol wipes, considered the gold standard in cleaning environmental surfaces such as phones, have been shown to reduce bacterial contamination of mobile devices by up to 79%.14,15 Researchers have shown that when phones are cleaned every 48 hours, bacterial growth is still present but pathogenic bacteria are absent, suggesting that daily alcohol cleaning may reduce the chances of transmitting pathogenic bacteria to clean hands.8
Although the evidence clearly demonstrates that mobile devices are contaminated with microorganisms, no published data directly link mobile device contamination with the development of HAIs. However, the evidence reveals an accumulation of red flags regarding the possibility of transmitting infections and jeopardizing patients' safety and health. Consequently, educating healthcare professionals regarding device contamination and cleaning guidelines is essential to prevent the spread of infection.
The evidence suggests that most healthcare professionals do not consider their mobile devices to be contaminated.16,17 In addition, studies have shown that most HCPs do not clean their phones frequently enough; several authors have found that phones are cleaned weekly at best.10,12
In surveys, most HCPs have reported that they do not clean their mobile devices on a regular basis.16,18,19 Foong found that only 31% of HCPs (n = 70) stated they cleaned their cell phones regularly; however, this did not decrease or eliminate bacterial growth, possibly suggesting that the phones were not being cleaned frequently enough.8 Similarly, Cantais and colleagues found that mobile phones used by pediatricians were contaminated by viruses that were circulating the week before the study began, despite the fact that half of the professionals stated that they cleaned their phones at least once a week.10
Healthcare facilities need to develop evidence-based guidelines that describe the frequency and cleaning agents to safely and effectively decontaminate phones. The CDC recommends “periodic” disinfection, but routine cleaning should be more clearly defined within hospital guidelines.
Strict hand hygiene before and after use of a mobile device in the clinical setting is almost universally indicated in the studies reviewed.15
The iPBundle advocated by Manning and colleagues is a bundle of common-sense recommendations: using waterproof, nonporous cell phone cases, disinfecting devices before and after patient/family contact using an approved disinfectant as directed by facility policy, setting an alarm on the mobile device to remind the user to disinfect the device at regular intervals (hourly or daily), and adhering to routine hand hygiene practices.20
Along with routine device cleaning, Ulger and colleagues suggest the following:9
- Use wireless earbuds or headphones and antibacterial device covers to minimize the need to touch devices.
- Use waterproof or washable mobile phones.
Take action to reduce risk
Mobile phones have become integral to communication in healthcare facilities. As technology continues to improve, clinicians will become ever more reliant on mobile devices, potentially increasing the risk of infection. A review of the evidence clearly shows that mobile devices are reservoirs of pathogenic microorganisms, and that contaminated devices quickly recontaminate sanitized hands.
Nurses are instrumental in protecting patient safety by developing policies and procedures and creating and implementing education programs designed to prevent the spread of infection. Nurses, HCPs, and infection prevention practitioners must partner to create surveillance programs to track infections to ensure that patients are protected from pathogens on contaminated mobile devices. Although this article focused on devices used by healthcare professionals in hospitals, guidelines and education should extend to patients and visitors as well.
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