Any self-respecting germaphobe knows that cellphones are filthy. They pick up microscopic crud from toilet stalls, gym benches, tray tables, and pretty much every other surface they—or we—touch. But doctors and nurses know better. They keep their phones as clean as Donald Trump’s official medical record, right?
Don’t let the scrubs fool you. Doctors check their Twitter feeds (or more likely, their Vanguard funds) in the john just like the rest of us. But unlike us, medical professionals’ devices also pick up microbes from the health care environment. In fact, studies show that their phones are even nastier than those of people who don’t work in health care.
Hypochondriacs, consider this your trigger warning.
More than half of clinical personnel say they use a phone or tablet on the job, and for good reason. A cellphone is a handy—some would argue essential—tool for carrying out medical tasks like calculating drug dosages, running through preop checklists, reviewing skills videos, performing vision tests, and offering consultations on the fly. The problem is that 90 percent of health care personnel never clean their devices. In the course of a day’s work, a nurse or doctor’s phone can be splashed, splattered, or smeared with wound drainage, blood, or god-knows-what other bodily dreck. Handling the device can transfer bacteria to the ears, nostrils, and hands. And bacteria parked on a Galaxy S9 screen or a My Little Pony iPhone case can live for months. If the germs are lucky, they’ll get to cross-contaminate something the provider later touches—a nice fresh incision, a cozy catheter, or a warm ventilator tube, say. The result may be a health care–associated infection. Three percent of hospital patients per year in the United States will develop a health care–associated infection, and about 72,000 patients will die of one. Mobile devices are a known source of the agents that cause these infections.
Study after study has called for the development of comprehensive infection control guidelines for mobile phone use in health care settings. Yet a regulatory void continues to exist. Mobile devices aren’t even mentioned in the CDC’s most recent infection control guidelines, released when most of us were still using BlackBerrys. In lieu of device-specific advice, the CDC recommends correct hand hygiene procedures as the primary means of infection control. But overall compliance with such procedures in the health care setting is less than 40 percent.
Cross-contamination goes both ways, of course. Providers pick up pathogens—namely bacteria but also viral particles and fungal spores—during direct patient care or from bed rails, stethoscopes, ID badges, and other high-touch environmental surfaces. Soiled hands or exam gloves can then deposit bacteria and other pathogens on a phone and its case, or on the point-of-care tablets used to document medication administration and other routine activities. Mobile devices emit a gentle heat, incubating the germs in a sludge of oil, skin cells, and food remnants. Bacteria flourish in this rich slurry, tactfully known as “bioburden.” It might as well be the floor of a rest area off I-95.
Not all of these percolating pathogens are a menace. But a recent study of bacteria swabbed from cellphones used in intensive care units isolated 107 dangerous species of bacteria from 491 samples. That and similar research shows that Enterobacter and Staphylococcus—notorious bacterial bullies—are the two most common bugs parked on health care professionals’ phones. Enterobacter can cause any of the four health care–associated infections: surgical-site infection, ventilator-associated pneumonia, catheter-associated urinary tract infection (which can shut down the kidneys), or sepsis (a systemic infection sometimes called blood poisoning). Staph infections can manifest as beastly skin abscesses, pneumonia, or sepsis.
The organisms that cause health care–associated infections are opportunistic. In other words, they live all around us, chillaxing like bridge players at the Boca del Vista clubhouse. But when they spot their chance—a preemie with an IV line, a stroke patient on a ventilator—they hustle in like a busload of hangry snowbirds at the Pompano Park buffet. They ride in on visitors’ and patients’ own phones, too, and on devices in the pockets of security guards, lab techs, food-service workers, and other peripheral facility personnel. Some of these bacteria are resistant to methicillin and other antibiotics, making them especially dangerous to vulnerable immune systems.
Policymakers generally agree that the use of mobile devices in health care settings can’t and shouldn’t be banned. But there aren’t really any useful guidelines on how to handle the germ threat. The CDC recommends only that facilities address “multi-use electronic equipment” in their infection control policies and procedures. The substance of those directives is left up to each institution. But regulation remains virtually absent even in the operating room, where mobile device use would seem to merit the tightest restriction.
Recommendations often boil down to “Use your best judgment.” A statement issued by the American College of Surgeons in 2016, for instance, says only that surgeons should avoid the “undisciplined” use of mobile devices and that their use “must not compromise the integrity of the sterile field.” But common sense is not science, and practices that intuitively seem safe may not be. For example, taking a call during surgery by holding the phone with a sterile towel turns out to be about as effective in protecting sterility as wearing a lambskin condom is in preventing sexually transmitted infection. Bacteria can penetrate the surgical towel and contaminate the no-longer-sterile gloves beneath.
Statements like that issued by the ACS are aimed primarily at mitigating another threat posed by mobile devices: distraction. Seventy-eight percent of the health care professionals who participated in one study used mobile phones during clinical activities to text or email, shop, play games, post on social media, or catch up on the news. These brief breaks, some researchers argue, reduce fatigue, restore concentration, and increase productivity during busy shifts. But other evidence shows that interruptions, welcome or not, can degrade performance by disrupting flow and diverting focus away from patient care.
The Association of Operating Room Nurses addressed cellphones specifically in its 2014 Guidelines for Surgical Attire, but these mobile device recommendations got little attention in the subsequent brouhaha over bouffant caps vs. skullcaps. The AORN advised that phones and tablets be cleaned with a “low-level disinfectant according to the manufacturer’s instructions for use before and after being brought into the perioperative setting.” That’s tricky, though, since liquid disinfectants could seep inside the device and harm its electronics. Liquid detergents can also wear down the oleophobic (oil- and dirt-repellent) coating on the screen or phone. In fact, Apple recommends applying no cleaning products whatsoever to the iPhone.
Facilities that lack an effective mobile device infection-control strategy may jeopardize their accreditation status. But it’s tough to find a means of cleaning or disinfection that’s effective, affordable, convenient, and safe for both people and electronics. Comparative data are scarce, and results vary widely. A few things are clear: Wiping down a touchscreen with a clean microfiber cloth, 70 percent isopropyl alcohol wipes, or plain wet wipes does significantly reduce bacterial populations. Disinfection, however—that is, virtually eliminating pathogens—requires use of either a chemical disinfectant like hydrogen peroxide or an inactivation process such as application of microbicidal metals or ultraviolet light. Researchers and engineers have made promising strides in producing microbicidal materials, such as those that contain triclosan or quarternary ammonium phosphates, but a self-disinfecting phone is still science fiction.
Irradiation of mobile devices with ultraviolet light is not. This process virtually eliminates aerobic bacteria by thwarting its ability to replicate. “UV systems offer important benefits,” says Taylor Mann, CEO of CleanSlate UV, an Ontario-based company that markets a UV sanitizer device for health care settings. “But they do have some important limitations.” Key among them is that pathogens can be shielded by anything that blocks light, such as blood droplets, screen cracks, or Velcro closures on wallet cases. Bacteria also hide in the junction between the screen and the case—the germiest part of the phone. Research shows that cleaning a phone with a delicate-task wipe (a low-lint, nonabrasive wipe made of cellulose) reduces bacterial burden 55 to 70 percent. According to CleanSlate’s own testing, twice as much UV light is required to sanitize a device if it’s not wiped down first. Rather than instructing hurried users to preclean their phones before placing them in the chamber, however, the unit delivers the necessary additional UV output.
Another limitation of medical-grade UV stations is their cost: $4,000 to more than $10,000 per unit, which might strain the budget of a small facility. It’s difficult for budget administrators to compare systems, and aside from the price tag, it may not be clear what they are comparing. “Regulation hasn’t caught up yet,” Mann told me. “In the meantime, companies may make unsubstantiated claims or test their devices under conditions that don’t match real-world use.”
A UV system, then, is just one aspect of a comprehensive infection control strategy. To reduce the risk of health care–associated infections transmitted by mobile device cross-contamination, we need a multipronged approach similar to the one veterinary health has adopted. It would include infection control training for clinical staff and other employees, and perhaps information for visitors and patients themselves. The strategy would outline and monitor compliance with hand-hygiene procedures. It would offer clear, specific recommendations regarding when and where it’s appropriate and safe to use mobile devices in the health care setting. It would include detailed instructions for cleaning and disinfection of phones, tablets, and cases. And it would urge mobile device manufacturers to take into account the need for disinfection in design and materials engineering.
Mackenzie Richmond Hill Hospital, in Ontario, is working on such an approach. The facility has installed a UV sanitizer unit in the lobby, cleverly placed near the coffee bar so that staff and visitors can use it while they wait for a mocha frap or double espresso. Great news for germaphobes and caffeine freaks alike.