DUAL DISINFECTION Think of stethoscopes as part of a hand hygiene bundle. When one's disinfected, the other should be, too.

You're delighted when you see your anesthesia providers vigorously scrubbing their hands for a full 15 seconds. You can be confident that those all-too-common vectors of disease are now spotless. But how many pathogens are still clinging to the stethoscopes hanging from their necks? Or to the stethoscope in recovery — the one that's about to contact the skin of your next patient?

As healthcare providers, we're frequently reminded of the importance of hand hygiene. But we hear relatively little about the dangers posed by the bacteria that hitch rides on stethoscopes. The issue apparently barely registers a blip in the minds of most providers. At least, that is, if a recent study is representative. The study, published in the American Journal of Infection Control, involved 2 hospitalists who served as secret shoppers at an academic teaching hospital (osmag.net/no9ddz). They set out to covertly record incidents of stethoscope hygiene carried out by med students, residents and attending physicians, as they moved from patient to patient over a period of one week. The observers documented 169 opportunities for stethoscope disinfection. The students and physicians batted zero.

That's right. Not one of the 169 opportunities was seized. And making it even more surprising, 41 of those opportunities occurred after the residents and physicians were shown a PowerPoint presentation about stethoscope hygiene — a presentation that concluded with the sentence, "We may be monitoring intermittently." The observers emphasized to the study subjects that both alcohol swabs and hand sanitizers, which were readily available outside patient rooms, were acceptable and generally equivalent means of disinfecting stethoscopes.

The usual suspects
How big a deal is this? This was a relatively small study, but we know from previous studies that many of the microorganisms that live on patients' skin can adhere to inanimate objects. That's well supported in the literature. Studies have found Staphylococcus aureus, Pseudomonas aeruginosa, Clostridium difficile and vancomycin-resistant enterococci, among other potential pathogens, living on stethoscopes (osmag.net/jjec7j and osmag.net/7xqpyk). Stethoscope contamination after one patient exam has been shown to be comparable to the contamination on a physician's dominant hand.

Nurses, surgeons and anesthesia providers all use stethoscopes routinely, but how often are they being wiped down or otherwise disinfected? Even if facility-provided stethoscopes are confined to single rooms or bays, and cleaned regularly, physicians may prefer to use their own better-quality scopes.

One well-established point that the study underscores is that education in the absence of other interventions isn't enough. To change behavior, you need a feedback loop and reinforcement. Behavior is a lot more likely to change when an observer says, Hey, I just noticed that you went into that patient's room and you didn't wipe down your stethoscope first. Remember, we talked about that. The guilty party might be defensive, but he or she is a lot more likely to remember next time.

Hand hygiene bundle
Admittedly, we can be overwhelmed by the constant myriad demands associated with preventing infections. Potential pathogens, it would seem, are everywhere. It may help if, instead of looking at all these interventions as individual acts, we think of the stethoscope as part of the hand hygiene bundle: It's one of the things, along with my hands, that touched my patient, and that's something I need to address before going to my next patient.

In health care, as we all know, we can become very automated. And the more automated we get, the less mindful we are. We need to pursue medical mindfulness, to say, I'm going to see the next patient, am I taking anything into this room that could potentially contaminate that patient or cause harm?

Three important questions
It's really very easy to low-level disinfect a stethoscope. As the study points out, it can be done with either alcohol wipes or hand sanitizer. The diaphragm is clearly the most important part, but it takes just a few seconds to wipe the stem and tubing, as well. Typically, the scope will dry before you reach the next patient. It's just something you have to get into the habit of doing. Like wearing seat belts. Eventually it becomes second nature.

We all know that the bugs associated with healthcare-associated infections are getting increasingly determined and resilient. When it comes to actions that help us fight back, there are 3 simple questions we need to ask ourselves: Does it take a long time, is it hard to do and is it a patient safety issue?

With stethoscopes, the answers are, it doesn't, it's not, and yes, it is. OSM