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Wednesday Mar 18, 2015

Is Your Stethoscope Making Patients Sick?

An interesting conversation on an AAFP message board recently was sparked by a tale of a physician who was cited during a nursing home inspection for not cleaning a stethoscope between patients. It raises an intriguing question: How many of us are actually taking that step to prevent the transmission of disease?

In a 2012 study(www.ajicjournal.org) published in the American Journal of Infection Control, less than one-fourth of the 1,400 health care workers surveyed at a pediatric hospital said they cleaned their stethoscopes after each use. Lack of time and access to disinfectant were cited as barriers, but are either of those excuses reasonable?

As clinicians, we come in contact with multiple pathogenic organisms every day, increasing the potential for spread of disease. We often think of our hands or our mucus as doing the dirty work of transmission, but a study published last year in Mayo Clinic Proceedings(www.sciencedirect.com) pointed out stethoscopes are another possible source of contamination.In the study, three physicians performed exams on 83 patients using stethoscopes in a standardized manner. Several iterations were performed, including a gloved versus ungloved comparison, and all participants disinfected their hands before the exams. The physicians conducted routine head-to-toe exams on hospitalized patients, including heart and lung exams, so this should have been fairly representative of the routine contact we have with patients in a hospital setting.

After completing the regimen of exams, the physicians’ gloves, hands and stethoscopes were all swabbed for culture. Results were mostly as expected. In a nutshell, the stethoscopes, especially near the bell, were contaminated at a level similar to the hands or gloves.

Most contamination was found near the fingertips, but the diaphragm of the stethoscope held on to bacteria nearly as well. This finding, while not conclusive of infection transmission by stethoscope, definitely casts doubts on how well hand-washing alone can cover all of the myriad pathogens we encounter at the bedside.

With the number of devices used in medical applications growing, we need more research into methods and best practices for disinfecting the environment as well as our skin.

Anecdotally, the hospital where I trained disallowed white coats in the ICUs as an infection control measure. The reason? Many clinicians don’t routinely disinfect white coats, if they even wash them at all.

Last year, the Society for Healthcare Epidemiology of America(www.jstor.org) (SHEA) suggested that clinicians consider a "bare below the elbows" approach, meaning short sleeves, no watches and no jewelry. For facilities that do encourage (or require) clinicians to wear white coats, SHEA recommended that physicians should own more than one white coat and have access to an on-site laundry. It also was recommended that facilities provide a place for physicians to hang their coats before patient contact.

The same SHEA guidance pointed out that neckties, which also have recently been eschewed by many organizations, also are a problem. In fact, multiple studies have shown that up to 70 percent of physicians admitted to not cleaning their ties -- ever.

The core issue -- and what the authors allude to in the discussion of the stethoscope article -- is transmission of pathogens. Is contamination of clothing or instruments significantly affecting the transmission of infectious agents to other individuals? We need more studies to look at the absolute risk of transmission from fomites in order to better gauge the level of appropriate concern.

Disinfecting every object would be extremely expensive. Proving that those surfaces are truly germ-free would be even more so. Once the risk is established, then it becomes much more cost-effective to look at decontamination strategies for nearly all of the equipment we use, from our stethoscopes and otoscopes to ink pens and computers.

Meanwhile, judicious use of standard precautions and alcohol swabs and hand washes likely will keep contamination to a minimum. Most stethoscopes can be washed with soap and water or alcohol-based cleaners. I tend to keep a few alcohol swabs in my pocket just for the stethoscope and otoscope. Computer keyboards are trickier, but it’s a simple matter to wash your hands before touching the keyboard or mouse. Wipe down phones, reflex hammers, calipers, etc., after any possible contamination.

Common sense cleaning can cut out a lot of risk.

The Mayo study doesn’t say we need to autoclave our stethoscopes. Instead, it points out that there are tens, if not hundreds, of possibly contaminated objects in physicians’ offices and hospitals that need further evaluation. We have a responsibility to our patients to provide a safe environment, especially as it pertains to infectious organisms.

Gerry Tolbert, M.D., is a board-certified family physician who practices in northern Kentucky. A lifelong technophile, his interests include the intersection of medicine and technology. You can follow him on Twitter @DrTolbert.<

Posted at 09:37AM Mar 18, 2015 by Gerry Tolbert, M.D.

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