Dr. Peter Papadakos, an anesthesiologist and critical care specialist at the University of Rochester Medical Center in New York, has become something of a crusader against mobile devices in hospitals.
A man well into middle age, Papadakos describes cell phone use as an addictive behavior and laments that at a recent lunch with his son at a waterfront restaurant, few in the room were taking in the view of anything but their small screens.
“I was probably one of the first people to bring this up and I’ve always been amazed how that occurred,” Papadakos said, but “I’m not the lone crier out there.”
Papadakos paints a terrifying portrait of mobile devices as an army of pocket-sized Trojan horses traveling in and out of the hospital and between rooms, spreading germs along the way.
Nurses and doctors might show a patient some lab results on an iPad, then touch the device later in the day without washing it first. They might also touch their phone before or after washing their hands between patients.
Hospital visitors can also contribute to the problem. They may have a friend or loved one in intensive care scroll through photos on a phone or tablet. When they leave the hospital, they may carry multiple-resistant staph bacteria on their touchscreen.
“There is some theory,” Papadakos said, that the two nurses who contracted Ebola in a Dallas hospital “got the virus from a contaminated surface.”
But if Papadakos is right, we would see it in the data on hospital-acquired infections — right?
Keeping Track of Infections
“It’s really hard most of the time to say why a patient got an infection because there’s so many things in the hospital and in the community that could contribute to that,” said Paul Anderson, who is part of the patient safety risk quality group at the ECRI Institute, which tracks risks in healthcare settings.
Nor would we necessarily see a spike in any one type of infection since the iPhone first put touchscreens in millions of pockets in 2007, according to Anderson.
“There are so many different initiatives going on to fight hospital-acquired infections. I don’t know that anybody has gone through those numbers to get to ‘is there or isn’t there?’” he said.
The Centers for Disease Control and Prevention data on hospital-acquired infections isn’t detailed enough to identify such a trend.
But there are a number of studies showing it’s possible for mobile devices to help spread bacteria and viruses.
One team of researchers recently swabbed the phones of orthopedic surgeons and medical residents as they entered the operating room and found that four of five devices had pathogenic bacteria on them.
After the phones were disinfected, 8 percent retained harmful bacteria, and a week later, 75 percent had again accumulated bacteria.
Another similar study took swab samples from portable electronic devices of 106 hospital workers. Every device housed bacteria, either on the device itself or on the cover.
Less than 10 percent of healthcare workers regularly sterilize their phones, a third study found.
Among patients’ phones tested in 2011, 84 percent were positive for microbial contamination, including 12 percent that were growing bacteria linked to hospital-acquired infections.
“There is no reason to believe that transmission by fomites, or inanimate objects, can't occur, at least if the transmission events happen quickly enough so that there is still viable virus. So, for example, if your hand comes into contact with contaminated body fluids of a patient with Ebola, then you touch a keyboard, and then someone else touches the keyboard and then rubs their eye, there’s no reason to believe that couldn't transmit,” said Dr. Daniel Bausch, M.P.H., an associate professor at the Tulane University School of Public Health and a consultant to the World Health Organization.
“But documenting that as a precise route of transmission would be very difficult,” Bausch added.
It may be hard to prove that a mobile device caused any one illness, and the numbers aren’t big enough to speak for themselves.
“But,” said Dr. Scott Kaar, an orthopedic surgeon in St. Louis, Missouri, co-author of the orthopedic cell phone and bacteria study, “if there’s a phone with staph on it, someone’s going to get staph.”
Why Is the Doctor on the Phone?
If mobile devices are a plausible source of infection, why do doctors use them?
Because mobile phones have largely replaced pagers, doctors need to have some sort of access to them. But there are currently no national rules covering the use of mobile devices in hospitals, even in operating rooms (ORs).
Surgeons scrub in before they operate and can’t touch anything non-sterile during the procedure. But surgeons aren’t alone in the OR. Anesthesiologists, technicians, and nurses are also on hand. Because these providers don’t generally touch the patient once surgery has begun, they aren’t subject to the same demanding hygienic protocol.
“The truth is, in the OR there’s two areas. There’s the sterile field, which is the operating field, and the rest of the room is sub-sterile. It’s cleaned in between surgeries and more thoroughly at the end of the day, but it’s not a truly sterile environment,” said Kaar.
Sometimes medical staff outside the operating field consult their phones to look up lab results or potential drug interactions that will help guide medical decisions for the patient.
“You could create a scenario where there’s a legitimate use,” Anderson said.
But where Anderson and Kaar see legitimate uses, Papadakos sees excuses. It’s almost always easier to access medical information through the hospital-networked computers in most ORs, he said.
“It’s a production to enter into HIPAA-protected records on the phone,” he said. “You’re just creating an excuse as to why you want to look at the phone.”
But one thing seems clear: Hospitals should require electronic devices to be cleaned or stashed into disposable sleeves made for that purpose. These bags don’t interfere with ease of use, researchers have found. And doctors should only access information relevant to the patient on the table.
The Joint Commission, a hospital accrediting body, considers cell phones "non-critical devices," that should be disinfected with wipes that won't ruin them.
"It would be up to the organization to develop a policy and procedure regarding care and frequency of cleaning. Personal mobile devices would be a separate issue. Organizations may develop their own policies and procedures around personal cell phone use while at work, but our standards do not require a policy," the commission said in a statement.
The trouble is that, like most of us, doctors sometimes use their phones when they shouldn’t.
“Just look around any work environment and people are staring at their phones. Healthcare is no different,” Papadakos said.
Studies back his claim. In one, nearly 80 percent of nurses acknowledged using their devices for nonprofessional activities while on duty.
Reasoned thinking would tell hospital staff to stay away from the phones while they’re caring for a patient. But reason doesn’t always prevail.
“In the beginning there was a certain attitude that we shouldn’t have to tell you not to do these things, but there’s some emerging literature that these devices are pretty addictive,” Anderson said. “If somebody develops a habit that every time their attention wavers, they pull out their phone and check Twitter, it can be pretty hard to break that habit.”
So why don’t hospital administrators enforce cell phone policies for medical staff? Papadakos answered with a rhetorical question: “They’re going to make up a policy banning the device that they’re staring at 24/7?”
When Helpful Reminders Aren’t so Helpful
Even clean or gloved, mobile devices can be dangerous in hospitals because they can distract doctors and nurses from their work.
In one widely publicized 2011 incident, a patient turned blue on the operating table while the anesthesiologist who was supposed to be monitoring her shared content on Facebook, the cardiologist who performed the surgery later told investigators. The patient died and the case is in court.
Few cases are so egregious, but distraction is widespread.
In a 2012 survey conducted by the trade magazine OR Manager, 41 percent of respondents said they’d witnessed distracted behavior.
In a survey of perfusionists, technicians who provide blood transfusions for patients during surgery, more than half said they’d seen medical personnel distracted by mobile devices in the OR. A significant percent also said they’d seen an adverse event take place as a result.
ECRI looked through all reported medical accidents and near misses in Pennsylvania between 2010 and 2011. There were slightly more than 1,000 problems blamed on distraction, and 40 reports of error specifically mentioned distractions from technologic devices.
A 2011 report published by the Agency for Healthcare Research and Quality recounted one incident in which a medical resident took out a mobile phone to discontinue an order for a patient’s medication.
The resident was distracted by an incoming personal text message and didn’t finish the cancellation. As a result, the patient continued to get the medication, causing blood to pool in the sac of the heart. The patient underwent emergency open-heart surgery to fix the problem.
Doctors and nurses, in other words, have their attention just as absorbed by their phones as the rest of us.
“Unless you’re going to frisk doctors and nurses when they come in, you’re never going to stop it,” Anderson said.
After Kaar did the research into the germs his phone could carry, he didn’t leave it at home, but he did start disinfecting it.
“I clean my phone now pretty regularly, maybe just for peace of mind, because even if one person got sick, and I knew that my cell phone was pretty dirty, I couldn’t live with myself,” he said.
Sanitizing wipes or sterile sleeves at the door of the OR could help remind other doctors to do the same, he thinks.
Hospitals can engineer cultural shifts with their technology policies, as well. Papadakos’s hospital provides work-only phones to medical personnel, who are asked to leave their own phones in a locker at the beginning of their shift to discourage personal use.
Some hospitals require doctors to consult via phone, rather than text message, to limit miscommunication.
Mobile phones bring a constellation of new challenges into healthcare, just as they bring a slew of new tools.
Anderson thinks it will boil down to more attention on the way the devices fit in with the work of the hospital.
“If the doctors are determined to use mobile devices, make it easy for them to do the stuff that’s legitimate and make it hard to do the stuff that’s not,” Anderson said.
Even something as seemingly unrelated as the layout of patients’ rooms can play a part, he said. Medical devices sometimes have USB ports that visitors will slap their phones into to charge them — potentially spreading viruses or causing someone to trip and fall.
As a New York City theatergoer who recently crashed the stage right before a live performance to squeeze some juice out of a power outlet made clear: People lose their sense of perspective when their digital access is threatened.
That’s why Papadakos maintains that mobile phone addiction has to be confronted head-on.
Identifying those with addictive attitudes toward their phones will help them realize that what might seem like harmless peeks at social media could be a real problem in a hospital.
“This is a unique environment. This is not the dinner table with grandma; this is life and death,” Papadakos said.
“I’m the first person to say technology is great, but what we have done is introduce a form of technology with no education behind it,” he added. “We need to start teaching tech-to-human interface. We need standardized education that’s introduced early in professional training.”