Portable electronic devices including mobile phones, pagers, tablets, laptop computers and workstations on wheels, are increasingly important tools for healthcare workers and support staff in healthcare facilities.
As PEDs are used within the environment of care (i.e. within the patient zone) by healthcare workers and/or patients, they represent complex environmental hygiene challenges. In fact, previous studies have demonstrated that they are frequently contaminated with pathogenic bacteria and potentially other pathogenic microorganisms which can be indirectly transmitted to a patient or co-worker.
PEDs should be considered additional non-critical surfaces in need of routine cleaning and disinfection. Yet, standards, guidelines and regulations for PEDs are conspicuously absent from the Centers for Disease Control and Prevention, Environmental Protection Agency, the Association for Professional in Infection Control and Health Canada guidance. Infection Prevention and Control Canada has the only guidance specifically for PEDs available to date.
It's important for the healthcare community to understand the key challenges associated with PEDs and consider practice recommendations.
Unique challenges of PEDs
Differing from most other patient care equipment in healthcare, PEDs are essentially an extension of the healthcare worker into the patient care environment.
For example, PEDs:
• Travel with healthcare workers in clinical areas and are used within the patient care environment
• Are moved between patients as the healthcare worker moves, and thus may be taken into patient rooms dozens of times each shift
• May be used for teaching or displaying testing results, creating the potential for both the worker and the patient to touch a device
• May be used unexpectedly, such as when a worker receives a page or phone call while delivering care, which causes the person to have unanticipated contact with the PED before proper hand hygiene can occur
Hand hygiene and environmental hygiene standard practices
The World Health Organization's current model for hand hygiene requires the healthcare worker to consider their physical location and/or expected/completed activities to determine when to perform hand hygiene.
The five moments include:
1. Prior to entering the patient zone: In a patient room, a one meter space around the patient has been arbitrarily defined as the patient zone and entry into this zone triggers a requirement for hand hygiene.
2. Prior to performing an aseptic procedure: While in the patient zone, anticipation of performing aseptic procedures (changing an IV bag, changing a bandage/dressing, etc.) triggers a requirement for hand hygiene.
3. After risk of body fluid exposure: While performing patient care, healthcare workers can be exposed to blood and body fluids, such as through changing a urine catheter bag, handling a bedpan, bathing/cleaning a patient or helping a patient back into bed after using a toilet or portable commode. Exposure to blood/body fluids triggers a requirement for hand hygiene.
4. After patient contact: Hand hygiene is necessary after performing patient care and then leaving the patient zone.
5. After contact with patient surroundings: Hand hygiene is also required after being in the patient zone and touching surfaces or equipment in the patient zone (but not directly touching the patient).
The current model for environmental hygiene (i.e. cleaning and disinfection) of non-critical surfaces (environmental surfaces and patient care equipment for contact with intact skin) requires the healthcare worker to consider the hygiene of the object and whether it is being moved out of the patient zone and potentially into another patient zone.
These recommendations include:
1. Perform low-level disinfection for non-critical patient care surfaces and equipment that touches intact skin.
2. Ensure that, at a minimum, non-critical patient care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly).
3. Disinfect (or clean) environmental surfaces on a regular basis (e.g. daily, three times per week) and when surfaces are visibly soiled.
4. If dedicated disposable devices are not available, disinfect non-critical patient care equipment after using it on a patient who is on contact precautions before using this equipment on another patient.
The infection prevention/epidemiological justification for these guidelines is to interrupt the chain of infection by preventing the direct and indirect contact transmission of pathogens. As healthcare workers' hands and environmental surfaces (including patient care equipment) can be part of the chain of contact transmission, interventions that remove soil and pathogen contamination would be justified from an infection prevention point of view.
Hand transfer of pathogens by a healthcare worker is generally considered the main route of environmental transmission. The specificity of the WHO model is meant to simplify the decision-making process for workers by enabling them to perform hand hygiene at appropriate times, thus interrupting the chain of transmission.
Because surface contamination is seen as a lower risk than hand contamination, this in theory justifies the current view that a lower level of hygiene is adequate to prevent transmission of pathogens. However, the WHO guidelines on hand hygiene (2009) note:
"During daily practice, healthcare workers' hands typically touch a continuous sequence of surfaces and substances including inanimate objects, patients' intact or non-intact skin, mucous membranes, food, waste, body fluids and the HCW's own body. With each hand-to-surface exposure, a bidirectional exchange of microorganisms between hands and the touched object occurs and the transient hand-carried flora is thus continually changing. In this manner, microorganisms can spread throughout a healthcare environment and between patients within a few hours."
This statement reflects a view that clean hands that touch contaminated surfaces (and patient care equipment) negate the benefit of clean hands. Said differently, attention to hand hygiene while not keeping surfaces clean is not likely to adequately protect patients.
Practice recommendations
There is still a matter of controversy around how hands and surfaces become contaminated with pathogens and how frequently hand and surface hygiene are needed to fully protect patients. Regardless, healthcare facilities should consider a set of best practices for PEDs, which may include:
1. Developing written protocols for the use, storage and hygiene of PEDs.
2. Ensuring all PEDs used in healthcare are appropriate for a healthcare environment. They should be easily cleanable, be able to withstand frequent disinfection from liquid disinfectants and have care instructions detailing how they are to be used and cared for in a healthcare environment.
If a PED cannot be disinfected with healthcare disinfectants, it must be used with a PED manufacturer-approved cover/skin that allows for proper cleaning and disinfection. The cover or skin should be changed/replaced per the manufacturer's guidance.
If the facility cleaning policy is to use a sporicide for cleaning patient rooms and equipment for patients with active Clostridium difficile, the PED must also be capable of withstanding disinfection with sporicidal disinfectants or be used with a disposable protective cover. If one of these guidelines isn't met, the PED should not be used in a room with a patient with active Clostridium difficile.
3. Handling PEDs with clean hands, and never with gloved hands. Hand hygiene should be performed prior to and after using a PED.
4. Following proper cleaning/disinfection. PEDs touched by the worker while in the patient zone (i.e. at the point of care) must be cleaned and disinfected with a hospital disinfectant (consistent with the PED manufacturers' care instructions) once the worker has left the patient zone. Proper cleaning/disinfection should also include the holders/brackets, or other devices designed to facilitate transport of the PED.
5. Developing facility protocols for PEDs on when to perform hand hygiene and cleaning/disinfection. Staff training on these protocols should be available in written format and documented as part of the training program.
The handling of PEDs in healthcare environments presents challenges for patient safety. However, the proposed set of practice recommendations can easily be combined with the WHO model for hand hygiene in order to reduce the opportunity for the transmission of pathogens.
Peter Teska is the an Infection Prevention Application Expert with Sealed Air's Diversey Care division, a leading provider of commercial cleaning, sanitation and hygiene solutions. He can be reached at peter.teska@sealediar.com.
Jim Gauthier is an Infection Preventionist and is the Senior Clinical Advisor with Sealed Air's Diversey Care division. He can be reached at james.gauthier@sealedair.com. For more information, visit www.sealedair.com.
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