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Focus on hand hygiene when using stethoscopes


November 1, 2017

Healthcare workers know to keep both hands clean. What about ‘the third hand’?

There were special contact precautions imposed on those caring for the patient in room 12. Doctors and nurses were required to don gowns and gloves before entering, as a sign on the door stated. When a physician in the University of Kansas Hospital’s family medicine progressive care unit stepped into room 12 the morning of October 26, 2016, he wore the PPE as required, but he jeopardized the facility’s infection control efforts in a subtler way—by bringing his stethoscope, a foreign object, into the room with him.

A federal inspector spotted the stethoscope dangling around the doctor’s neck when he entered and exited the room, then watched as the doctor began typing on a computer keyboard without using the hand hygiene gel container mounted on the wall just outside the patient’s room. A compliance officer confronted the physician, who then used the hand gel and explained that he hadn’t used his stethoscope inside the room, according to a summary of the inspector’s report obtained and published online by the Association of Health Care Journalists. A manager explained, however, that the stethoscope should not have been taken into an environment with any kind of isolation or contact precautions, regardless of whether it was used.

Do the details of that inspection sound familiar, even mundane? Could you picture this happening in your facility? If so, then you’re likely already aware that poor stethoscope hygiene practices are pervasive. The importance of hand hygiene is one of those topics that infection control specialists tend to spend a great deal of time reinforcing, for good reason; what often gets overlooked is how handheld tools, such as the stethoscope, can transmit pathogens just as easily and often as hands do.

“Stethoscopes are used repeatedly throughout the day and become contaminated after each patient expo-sure, so they must be treated as potential vectors of transmission,” said Linda Greene, RN, MPS, CIC, FAPIC, president of the Association for Professionals in Infection Control and Epidemiology (APIC), in a statement. “Failing to disinfect stethoscopes could constitute a serious patient safety issue similar to ig-noring hand hygiene.”

Although the CDC says reusable medical equipment must undergo disinfection between patients, research-ers have documented atrociously low rates of compliance. According to a report published in 2015 by the Journal of Hospital Medicine, trainees at three academic medical centers exhibited a stethoscope hygiene rate of just 4.6% for non-isolation rooms during an 11-month observation period. The authors on that report, having reviewed the relevant body of research, referred aptly to a stethoscope as “the third hand.”

Citation risk

For the doctor’s stethoscope misstep at the University of Kansas Hospital, the federal inspector wrote a report under the CMS Condition of Participation for infection control, tag A-0749, finding that the infection control officer “failed to assure an effective on-going infection control program that identified potential environmental infection control risks.”

Others, too, have been faulted for stethoscope inci-dents of their own under this tag. A registered respiratory therapist at Sparks Regional Medical Center in Fort Smith, Arkansas, used her stethoscope on one patient the afternoon of May 3, 2016, then used it about 15 minutes later on a second patient without disinfecting it in between, according to a federal inspector’s report.

“The failed practice promoted the spread of infection from cross contamination and had the potential to affect all patients admitted to the facility,” the inspector wrote.

When a staff member at Auburn (New York) Community Hospital was confronted April 20, 2016 for failing to clean the stethoscope before using it to auscultate a second patient, the staff member replied that they clean and disinfect stethoscopes between patients if a patient is on isolation—an explanation the inspector clearly found to be inadequate.

None of the three organizations mentioned above for citations under A-0749 responded to requests for comment on their plans for correction.

When an inspector issues a citation or a surveyor calls attention to a shortcoming, it’s not fun. But that em-barrassment is minimal compared to the headache healthcare-acquired infections can cause. The germs a stethoscope can transmit could give your patients more than the common cold. A study published in 2014 in the journal Mayo Clinic Proceedings found that the diaphragm of a doctor’s stethoscope is contaminated as much as, or even more than, the palm of the doctor’s dominant hand—and that it can carry methicillin-resistant Staphylococcus aureus (MRSA) from one patient to the next.

“By considering that stethoscopes are used repeatedly over the course of a day, come directly into contact with patients’ skin, and may harbor several thousands of bacteria (including MRSA) collected during a previous physical examination, we consider them as potentially significant vectors of transmission,” the researchers wrote. “Thus, failing to disinfect stethoscopes could constitute a serious patient safety issue akin to omitting hand hygiene. Hence, from infection control and patient safety perspectives, the stethoscope should be regarded as an extension of the physician’s hands and be disinfected after every patient contact. However, the optimal method of disinfection remains to be determined.”

Interventions menu

Those who recognize the infection risk stethoscopes pose have experimented with a variety of interven-tions designed to improve hygiene rates. The results have ranged from somewhat promising to, well, bleak.

Making it convenient. In a bid to improve stethoscope disinfection rates specifically among pediatric healthcare providers, a group of researchers in Boston tried out a two-part intervention. They posted visual reminders to disinfect stethoscopes between patients, and they provided easy access to the materials needed to do so. Their findings were published in 2013 by The Society for Healthcare Epidemiology of America’s Infection Control & Hospital Epidemiology journal.

“Baskets filled with alcohol prep pads and a sticker reminding providers to regularly disinfect stethoscopes were installed outside of patient rooms,” the re-searchers wrote. “Healthcare providers’ stethoscope disinfection behaviors were directly observed before and after the intervention.”
The researchers made 226 observations before their intervention and 261 afterward. They found that compliance with stethoscope hygiene guidelines increased from 34% to 59%, suggesting that the two-part project was effective—though more research is needed to assess the ultimate impact on patient infections.

“Providing stethoscope disinfection supplies and visi-ble reminders outside of patient rooms significantly increased stethoscope disinfection rates among physicians and nurses at a children’s hospital,” the re-searchers wrote in their abstract. “This simple intervention could be replicated at other healthcare facili-ties.”

Going back to the classroom. More recently, another group of researchers sought to improve stethoscope hygiene rates by implementing a brief educational tool. They used an 11-slide PowerPoint presentation to emphasize the importance of disinfecting stethoscopes and the fact that either alcohol swabs or hand sanitizer is acceptable. Their findings were published in July 2017 by APIC’s The American Journal of Infection Control.

“The brief, interactive PowerPoint presentations seemed to be well received by enthusiastic interns, residents, and attendings and generated discussion afterward,” the researchers wrote. “Our final slide ended with the sentence, ‘We may be monitoring intermittently’ because we believed the intervention might be taken more seriously if physicians were aware of this. When our final observations showed zero incidences of stethoscope hygiene for the same teams that had been educated, it was clear to us that our educational efforts and providing supplies was insufficient to change culture or habits.”

That’s right: When the researchers observed the cohort that had undergone their training intervention four weeks earlier, they didn’t find a single person doing stethoscope hygiene properly.

“Despite limitations,” the researchers added, “we think this highlights an important, but often overlooked infection control issue by discovering how rarely stethoscope hygiene is done and suggests that standard education may not be the answer.”

As an alternative, they suggested trying to increase accountability by designating one employee on each team to remind all members to keep their hands and stethoscopes safe and clean.

Buying stethoscope covers. What if there’s a way to give up entirely on obsessive stethoscope disinfection without abandoning infection control best practices? That’s a question physician Richard Ma, MD, asked himself while caring for patients at Saints Medical Center in Lowell, Massachusetts, because he saw how rarely doctors clean their stethoscopes.

“The truth of the matter is that people don’t do it,” Ma told The Boston Globe in 2010. “It’s never mentioned beyond medical school, and that’s where it stops.”

Ma answered his own question: He began using a latex glove as a barrier around the end of his stethoscope whenever he used it on a patient. The material was cumbersome and muffled the sound quality, but it gave him an idea, which Ma turned into disposable stethoscope covers he called StethGuardTM. The long plastic sleeves can be stored in rooms throughout a facility, just like disposable gloves.

Ma’s invention is now for sale by New Jersey-based Itus Healthcare, and a product evaluation published last year by the company suggests that StethGuard was found to be effective at reducing contamination.

“Furthermore, the use of the stethoscope covers revealed no appreciable reduction in audio quality of the stethoscope,” the product evaluation states. “The results of this study suggest stethoscope covers are an efficient means to prevent pathogen transmission.”

Buying stethoscope covers for your staff doesn’t guarantee that they will be used, of course—just as telling team members to disinfect their stethoscopes doesn’t guarantee they will follow through. The point is that researchers and experts agree stethoscope hygiene presents a significant opportunity for improvement in the fight against healthcare-acquired infections, so look for ways to drive the point home with your team.

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