Barriers to Disinfection of Mobile Touch Screen Devices Amongst a Multidisciplinary Team in Intensive Care Units at a Tertiary Hospital

Introduction

Mobile touch screen devices (MTSDs), including smartphones and tablets, are commonly used in Intensive Care Units (ICUs). Their potential to act as a reservoir for multidrug-resistant (MDR) pathogenic bacteria may be under-appreciated by users, and knowledge of MTSD disinfection practices among Critical Care healthcare professionals (HCPs) remains limited [1,2]. The objective of this study was to determine the perceived barriers for disinfection of MTSDs amongst a multidisciplinary healthcare professional team working in the Division of Critical Care at a tertiary level hospital.

Methods

Setting and questionnaire

With no validated published questionnaire available at the time of study design, the research group consisting of microbiologists with backgrounds in infection prevention and control (IPC) together with a Critical Care specialist, constructed questions to establish the face validity of the instrument. Face-validity refers to a subjective measure to ensure that the contents are reasonable according to the opinion of experts in the field. The self-explanatory, quantitative and open-ended questionnaire was written in English and formulated to capture obstacles to the disinfection of MTSDs (Appendix A). This was a self-administered questionnaire, without prompting from a researcher. The questionnaire was administered to HCPs from six multidisciplinary ICUs at Groote Schuur Hospital (GSH) in Cape Town, South Africa (SA), comprising a total bed capacity of 43. GSH is a public tertiary establishment that is affiliated with the University of Cape Town as a teaching institution. Prior to enrolment (May 2019), a pilot study amongst senior specialists working in the ICU and IPC fields at GSH was conducted to ensure the adequacy of the questionnaire.

Eligibility and sample size

All HCPs in the ICU were eligible to participate, including both day and night shift personnel. Compared to the day shift personnel, the night shift staff complement is pared down and consists only of essential HCPs. Allied HCPs are available telephonically, and for emergency call out only, after hours. Data was collected between 01 June 2019 and 30 June 2019 and captured prospectively in real time. A sample size of sixty-three questionnaires was required, from an estimated workforce of 75 HCPs across the six ICUs. This sample size was based on a desired confidence interval of 95%, a 5% margin of error and an anticipated population variability of 50% with regards to answers provided [3]. Only 60 ICU HCPs consented to participation in the study. Five participants declined, citing concerns that participation may influence work responsibilities; three failed to explain their non-participation, and the remaining seven were not present during the convenience sampling method.

Survey sample size calculation formula:

• n—required sample size
• P—percentage occurrence of a state or condition
• E—percentage maximum error required
• Z—value corresponding to level of confidence required

Statistical analysis and ethics

Data were imported into Stata version 16.1 (StataCorp, USA) and Microsoft Excel (Microsoft Corporation, USA) for logistic regression analysis. Results were expressed as odds ratios (OR) with their confidence intervals (CI). Fisher’s exact test was used for small sample sizes. All tests were two-sided and a p-value ≤ 0.05 was deemed to be significant. The study was approved by the Human Research Ethics Committee, University of Cape Town (HREC REF: 345/2019) and the Department of Health, Western Cape Government, SA. Data were stored securely, password protected and only available to researchers.

Results

Sixty questionnaires were completed over a one-month period, comprising of 43 day shift and 17 night shift ICU personnel. The majority of participants were nurses 63% (38/60), followed by physicians 20% (12/60), dieticians 8% (5/60), physiotherapists 7% (4/60) and a pharmacist 2% (1/60). Only 28% of participants cleaned and disinfected their devices every time after use in the ICU. The reported deterrents to cleaning MTSDs included (Figure 1): a concern for device damage (48%), uncertainty of a correct cleaning procedure (40%) and the absence of a cleaning policy (40%). Half of the participating doctors (6/12) were concerned about the lack of a procedure guideline and cleaning policy (5/12) on MTDS disinfection. Amongst day staff (as compared to night staff) multitasking was cited as the main reason for not disinfecting MTSDs (33% vs. 6%; p = 0.046). The leading reasons in descending order of statistical significance amongst the night staff (as compared to day staff) were concern about device damage (71% vs. 40%; p = 0.045) and unawareness of MTSD spreading resistant microorganisms (29% vs. 7%; p = 0.035).

Perceived barriers to device cleaning between the different disciplines compared to all other HCPs (Figure 2) demonstrated that doctors were mostly concerned about a lack of time due to multitasking at the bedside (60% vs. 17%; OR = 7; 95%CI: 1.43–34.77; p = 0.006;). Compared to other HCPs: dieticians felt that device cleaning was unnecessary as there was no physical contact with patients or their surroundings (40% vs. 4%, OR = 17.6, 95%CI: 0.87–294.73; p = 0.031), nursing staff were concerned most about device damage (47% vs. 45%, OR = 1.2; 95%CI: 0.37–3.93; p = 0.793), physiotherapists had no knowledge of a cleaning policy (75% vs. 38%, OR = 5; 95%CI: 0.36–269.78; p = 0.292) and were concerned that the cleaning solution may damage the device (75% vs. 46%, OR = 3.5; 95%CI: 0.25–187.64; p-value = 0.345). Of concern from an IPC perspective is that 18% (7/38) of nurses and 20% (1/5) of dieticians were unaware that MTSDs can be a reservoir for pathogens in the ICU, whilst all doctors were cognizant of this fact. Twelve percent of the HCPs felt that senior personnel did not set a good example. This concern was amongst the junior doctors (4/12) and nurses (3/38).

Discussion

Numerous studies have focused on bacterial colonization of HCP phones, but few have investigated the reasons behind poor phone disinfection practices and the beliefs that hinder disinfection [4]. The principal reason for non-disinfection of devices has previously been attributed to lack of awareness. In contrast to previous studies, our survey showed that the major barrier to cleaning devices is the concern that disinfectants would damage devices (48%) [2].

An obstacle to the safe use of MTSDs in the hospital environment is the lack of manufacturers’ recommendations on cleaning of MTSDs, likely due to MTSDs being devised for use in the consumer market and not the healthcare setting [5]. Cleaning products such as alcohol, ammonia and abrasive wet agents are discouraged for cleaning, and may damage MTSDs when applied directly. Nevertheless, no phone damage related to disinfection has been reported in the literature to date [2].

Several creative solutions have been implemented alongside the Centers for Disease Control and Prevention guidelines to overcome these problems with varying degrees of success. These include the use of a waterproof or water-resistant barrier over the phone before decontamination, setting regular alarms on the MTSD to clean the phone, enforcing hand hygiene policies before and after device use, phone hygiene stations at entrances, visual reminder aids at strategic points and novel approaches such as ultraviolet phone sanitizers [2,5,6].

To our knowledge, there is no consensus recommendation or policy for the disinfection of MTSDs in hospitals. Our results emphasize a need, particularly amongst doctors, to establish and implement organizational procedures, guidelines, and policies on how to clean and disinfect MTSDs in the ICU and hospital setting. Of note, there are varying reasons between different disciplines, as well as between the day and night staff. A potential reason for this is the decreased staff complement at night. Multitasking was cited as a significant factor preventing disinfection amongst HCPs during the day (33%), especially doctors (60%, 6/12). Multitasking may be a result of the excessive workloads in high pressure environments with HCPs often facing many disruptions while performing singular tasks and thus having to re-focus attention elsewhere. The attending clinician may also consult with senior specialists via an MTSD to get patient advice. Some night shift HCPs (5/14 nurses) were unaware of MTSDs harboring resistant pathogens (29%). All doctors were mindful that MTSDs can be vectors for MDR-organisms in the ICU. In this study 12% of people felt that an example should be set by senior staff. Doctors should ideally raise awareness amongst nurses and the allied HCPs. Behavioral changes amongst staff may occur more quickly if there is early adoption of MTSD hygiene practices by senior personnel.

The study limitations included a design that relied on the integrity of participants to answer truthfully. HCPs, and their handling of MTSDs, were not directly observed and thus there were no objective measures of device cleaning.

In conclusion, different shifts (day and night) and disciplines in the ICU have varying reasons for not disinfecting devices, therefore, a multifaceted approach to overcoming all barriers to disinfection is necessary. Behavioral modification requires imparting knowledge, peer-to-peer role modelling, uninterrupted access to supplies, good leadership, and appointing stewards to champion the cause. Healthcare establishments must prioritize the development of disinfection guidelines to reduce the role of MTSDs as vectors to transmit pathogens especially in current circumstances where multidrug-resistant organisms are an escalating health threat. Future research should focus on exploring the possible link between device contamination and ICU related infections and the utility of disinfection processes to decrease contamination on MTSDs.