Abstract

This study examines pathogen contamination of healthcare providers’ mobile phones and its potential role in pathogen transmission at the main hospital in the Al Baha area, Saudi Arabia. Mobile phones of 166 healthcare providers were swabbed and the swabs were cultured. Healthcare providers completed a questionnaire at the same time to investigate their phone use and cleaning methods at work. The results showed that a total of 23% (38/166) of the swabbed mobile phones were contaminated by clinicians making up >52% (87/166) of the study population. It was found that neither the brand nor the type of screen protector used increased the susceptibility of phone contamination (p>0.05). Approximately 77% (128/166) of those surveyed claimed they believed mobile phone cleaning was important. Moreover, 91% (151/166) confirmed that they performed hand hygiene before and after seeing a patient. Pathogenic bacteria were cultured from 13.2% (5/38) of the contaminated phones. A minority of the study participants admitted that they neither cleaned their phones nor believed doing so was necessary. Therefore, if such ideologies exist, they could present a transmission risk to patients. Hence, all healthcare providers should practice frequent mobile phone cleaning when they are at work, and these methods should be included in infection control policies and procedures in hospitals.

1. Introduction

Mobile phones are useful in healthcare settings, particularly for healthcare providers in hospitals. However, the literature on mobile phone use in healthcare, especially during daily hospital activities, is limited. As the spread of multidrug-resistant bacteria has increased, so has the concern about mobile phone contamination in medical settings, especially in critical care units, such as operating rooms, intensive care units, and burn units. ^{1, 2}

Smartphone innovation enables healthcare providers to facilitate instant communication, take and transfer photographs, search for medication requests, and provide opportunities for clinicians and patients to discuss information. Their use may also limit medical errors and help diagnosis. Study findings illustrate the positive effects of mobile phones on patient care ³ as over 80% of healthcare providers use phones in the workplace between three and twenty times per day. ⁴

Hand hygiene is a simple practice that healthcare providers can apply in any hospital. It is necessary because mobile phone contamination is possible, especially when no routine cleaning protocol is in place. ^{5, 6} Studies have found that in a hospital setting, items including stethoscopes, bed rails, entryway handles, and thermometers, which are touched multiple times, can become contaminated with pathogenic bacteria. ^{7, 8} Most items can be decontaminated as part of routine cleaning and disinfection policies in hospitals. However, the cleaning of mobile phones is often not included in such policies. Studies in Saudi Arabia regarding bacterial pathogen contamination of mobile phones used by healthcare providers are limited. This study addresses this gap and examines bacterial contamination of healthcare providers’ mobile phones in a hospital setting and the potential risk of transmission this contamination may present to patients.

2. Material & Methods

This study was conducted at the main general hospital (350 beds) in the Al Baha area of southwest Saudi Arabia. It was introduced to the staff upon their arrival during their morning duties. Out of 1,375 clinical staff members working at the hospital, 166 volunteered to contribute. Only staff who had time to participate and agreed verbally to be part of the study joined in. The data were collected for a one-week period in June 2018. No personal information was collected or used (e.g., names, initials, or hospital ID numbers). Therefore, there was no need for any ethical committee approval for this study.

An in-house questionnaire was used to collect data from healthcare providers, including demographic characteristics such as age, gender, nationality, years of experience and frequency of in-hospital mobile phone use (see Appendix 1). The questionnaire also included questions on mobile phone hygiene practices, namely, cleaning methods used and frequency of cleaning/disinfection. All healthcare provider participants were randomly chosen and participated voluntarily in the study. The questionnaire took approximately three minutes for each participant to fill out.

While healthcare providers completed the questionnaire, their phones were swabbed with saline-moisturized sterile swabs. The same swab was used to collect samples from the front screen, the sides, and the back of the phone. To prevent indirect contamination, the data collectors used an alcoholic sanitizer to disinfect their hands and wore medical gloves while performing the sampling. Each collected sample was labelled with a unique identification number and placed in the transport medium. The samples were then transferred to the laboratory for culture and sensitivity tests within four hours of sampling. All swabs were cultured on blood and MacConkey agar plates. They were incubated for 48 hours at 37°C. Plates with no growth were recorded as negative results. Those with any growth were further examined using routine microbiological methods. Sensitivity to antibiotics was reported based on the pathogens identified.

Results for categorical variables were presented as numbers and percentages. Chi-squared (χ2) tests were used to test for differences between the categorical data. Fisher’s exact tests were used when chi-squared tests were inapplicable. SPSS (Statistical Package for Social Sciences) 21.0 software was used to perform all statistical analysis. Statistical significance was set at a p-value<0.05.

3. Results

The study population consisted of 59% male (98/166) and 41% female (67/166) respondents ranging in age from 20 to 50+ years (see Table 1).

Out of the 166 mobile phones sampled, 23% (38/166) had evidence of bacterial contamination, including four strains of staphylococcus: Staph. epidermidis (79%), Staph. aureus (2.6%), Staph. capitis (2.6%), and Staph. spp (2.6%). Aeromonas salmonicida (2.6%), Pseudomonas alcaligenes (2.6%), Klebsiella pneumonia (2.6%), Acinetobacter haemolyticus (2.6%), and Enterobacter cloacae (2.6%) were also found. Five isolates (13.2%, 5/38) were considered pathogenic and are known to cause hospital infections. None of the identified isolates were considered multidrug-resistant bacteria (see Table 2).

Different types of healthcare providers, including doctors, nurses, technicians, pharmacists, and office workers, were included in the study, and their years of experience spanned the following ranges: 0–5 years, 6-10 years, 11–15 years, and >15 years. Healthcare providers from the emergency, surgery, infection control, medicine, pediatrics, intensive care, radiology, and clinical pathology departments were included. Notably, department and years of experience did not contribute significantly to differences in the degree of phone contamination. Phones belonging to younger male healthcare providers were more prone to bacterial contamination than those belonging to female ones and older workers (>40 years of age), but the differences were not statistically significant (p-values>0.05) (see Table 3).

Neither the mobile phone brand nor the type of screen protector used affected susceptibility to contamination (see Table 4).

A greater part of the study population (97%, 162/166) admitted to using mobile phones in the hospital during duty hours. Most (77%) were aware of the importance of phone cleaning in general and particularly when seeing patients, but it was unclear whether they cleaned their phones on a regular basis or not (see Table 5).

Around (91%, 151/166) of respondents reported that they performed hand hygiene before and after seeing a patient and applied the five moments of hand hygiene. Of the five phones found to be contaminated with pathogenic bacteria, two were owned by healthcare providers who did not clean their phones or think doing so was necessary (see Table 6).

4. Discussion

In this study, almost one-quarter (23%) of phones belonging to healthcare providers working in the main hospital of the Al Baha area were contaminated with bacteria. Most of the isolated species were not commonly associated with clinical infections, but some were involved in severe infections as found in other studies. ^{9, 10} Slightly over one-half of the study population comprised of clinicians (52%) whose mobile phones were more likely to be contaminated with a significant number of pathogenic bacteria. S. epidermidis, which was isolated in this study, is involved in varying clinical exposure outcomes, such as severe infection in immunocompromised patients (e.g., biofilm-associated infections in intensive care units). ^{1, 6, 11}

A lack of hand hygiene among clinicians during the study period is likely to have contributed to phone contamination with skin flora. Phones belonging to males and younger healthcare providers were more susceptible to bacterial contamination than those belonging to female ones and workers >40 years of age. However, the differences were statistically insignificant (p-values>0.05). Inconsistently, most healthcare providers indicated that they performed hand hygiene with 91% claiming to clean their hands before and after seeing patients and following the five moments of hand hygiene.

Phones belonging to healthcare providers are associated with a risk of bacterial transmission that may cause severe infection. ^{12, 13, 14} The low degree of contamination of mobile phones may indicate good compliance in hand hygiene at this hospital. This is in contrast to an earlier study, that found a higher rate of mobile phone contamination. ¹⁵ Of note, monitoring of hand hygiene compliance is a part of the monthly quality control protocol followed by infection control team members at this hospital; however, outlining and discussing this data is beyond the aims of this study.

Regarding the work characteristics of the study group, doctors with less experience or who worked in surgery, the emergency room, pediatrics wards, and medical wards were more likely to have phones contaminated with bacterial colonies compared with healthcare providers from other wards. However, these differences were not statistically significant (p-values>0.05). Although most of the study population used their phones in the hospital, almost all were aware of the importance of phone cleaning when seeing patients. Unfortunately, this knowledge appears to have been insufficient to encourage the required commitment to consistent mobile phone cleaning.

The identified risk variables, phone brand and type of cover used, were not significantly associated with a higher or lower presence of bacteria. The phones were manufactured by popular mobile phone production companies both worldwide and in Saudi Arabia. Apple and Samsung phones represented about 80% of the phones used in this study, followed by other brands. Approximately 80% of healthcare providers used screen protectors and two-thirds used phone covers. However, when these variables were examined, no significant differences were found (p-values>0.05).

The results of this study are consistent with the results of most studies in the region. ^{12, 16, 17} Compared with stationary phones, mobile phones have a higher chance of contamination with pathogenic bacteria in hospital settings. ^{11, 12, 18} In some critical departments, such as the intensive care unit (ICU), the risk of mobile phone contamination with resistant bacteria such as E. coli is higher than in other departments. ¹⁷ However, this study does not examine this correlation, as the sampling was performed randomly across hospital wards and the sample size was insufficient for inter-ward comparisons. Some researchers have emphasized that healthcare providers’ mobile phones can easily become contaminated with pathogenic bacteria and can serve as a potential source of major transmission between staff and patients. ^{12, 17, 19} The results of this study are consistent with this conclusion as well. The chances of finding non-pathogenic bacteria or skin contaminants are likely comparable to the chance of finding pathogenic bacteria, and all can cause infection in immunocompromised patients. ²⁰

Approximately 77% of participating healthcare staff responded that cleaning mobile phones frequently is important. However, routine phone cleaning, meaning cleaning with alcohol-based sanitizers within 48 hours prior to the study, was not performed regularly among all study participants. This might explain the finding of non-pathogenic bacteria such as skin flora, as daily wiping with alcohol could have reduced the possibility for bacteria to be present. Although a high percentage of participating staff indicated that they knew phone cleaning was important, determining the actual number of staff who consistently did so was difficult. This question should be examined in future studies.

No evidence-based guidelines exist for the use of mobile phones in healthcare facilities. ^{2, 12, 21} The findings of this study contribute to the findings of other studies, indicating that mobile phones operate as a vehicle for the transmission of organisms between patients and healthcare providers. ^{16, 19, 22} Almost two-thirds of participants used alcohol-based wipes, which can thoroughly decontaminate mobile phones for safe use in healthcare facilities. Given that these phones play important roles in modern healthcare facilities, procedures to decontaminate mobile phones with alcohol-based wipes while adhering to other infection control procedures (e.g., hand washing) should be developed and implemented.

5. Conclusion

Healthcare providers phones were examined in this study. Some of the bacteria found were pathogenic and can be transmitted to patients and cause severe infection. This indicates the need for a more comprehensive approach to reduce the transmission of pathogenic bacteria via mobile phones within healthcare settings. In addition to regular hand washing, wiping mobile phones with alcohol-based sanitizers could reduce the degree of pathogen contamination. This study also revealed that some clinicians do not understand the importance of phone disinfection before and after contact with patients. Healthcare providers must be made more aware that mobile phones should be disinfected regularly to reduce the risk of transmission of pathogenic bacteria. They should also practice frequent mobile phone cleaning, and this should be enforced through infection control policies and procedures in all hospitals.

This study has some limitations. The findings demonstrate mobile phone contamination with different bacteria, but the incidence of contamination was not determined to a high degree of accuracy because participation in the study was optional. The rate of phone contamination among staff may therefore be greater than has been found, especially among healthcare providers in constant contact with patients. Also, the phones of staff who have more contact with severely ill patients (e.g., in the ICU) might have a higher degree of contamination than those of staff in other wards or departments with patients in less critical conditions. Although the study has found the presence of bacteria that can cause life-threating infections, examining the clinical significance of these findings is beyond the aim of the study. Finally, the findings reflect the behavior of staff in a single hospital. A study of more hospitals in the region would be needed to express a comprehensive conclusion regarding the use of mobile phones by healthcare providers.

Statement of Competing Interests

The authors have no competing interests.

Acknowledgements

We would like to thank all the healthcare providers who contributed in this study.

References

Appendix 1

Mobile Phone Study Questionnaire

Swab code number:

Gender

Male

Female

Age (years)

20–30

31–40

41–50

>50

Experience (years)

≤5

6–10

11–15

>15

Job Classification

Doctor

Nurse

Technician

Pharmacist

Office worker

Other

Department

Emergency

Surgery

Infection Control

Paediatrics

Intensive Care Unit

Radiology

Laboratory Medicine

Other

Do you use your mobile phone in the hospital?

Yes

No

Do you clean your mobile phone?

Yes

No

Sometimes

Never

If yes, what do you clean it with?

Alcohol swab

Dry tissue

Wet tissue

Other

If yes, how often do you clean it?

Once a day

Once a week

Once every two weeks

Don’t know

If yes, do you consider cleaning your mobile phone important?

Yes

No

Maybe

Don’t know

Do you think it’s important to clean your mobile phone after seeing a patient?

Yes

No

Maybe

Don’t know

What type of mobile phone do you have?

Apple

Samsung

Huawei

Nokia

Sony

Other

Do you use a screen protector?

Yes

No

If yes, what kind of screen protector do you use?

Nano

Glass

Other

Don’t know

Do you use a phone cover?

Yes

No

Do you think you are a hand hygiene supporter?

Yes

No

If yes, how often do you clean/disinfect your hands?

After seeing a patient

Before seeing a patient

As necessary

According to the five moments of hand hygiene

Before and after seeing a patient

Upon arriving at work

Upon leaving work