jbry the difference between physician lit review

Running head: THE DIFFERENCE IN STETHOSCOPE CONTAMINATION 1

The Difference Between Physician and

Nurse Stethoscope Contamination: A Literature Review

Jessica Bryan

Azusa Pacific University

Author Note

Jessica Bryan, Department of Nursing, Azusa Pacific University.

This paper was prepared for the Graduate Nursing Seminar 507, Scientific Writing course,

taught by Professor Corinne McNamara and reviewed by the Writing Center.

THE DIFFERENCE IN STETHOSCOPE CONTAMINATION 2

The Difference Between Physician and Nurse Stethoscope Contamination: A Literature Review

Concern over hospital-acquired infections (HAI's) has risen amongst healthcare providers

because of poor disinfection practice of stethoscopes. Pathogenic bacteria, such as Staphylococcus

aureus (S. aureus), Escherichia Coli (E. Coli), and Methicillin Resistant Staphylococcus aureus

(MRSA), have potential to transfer onto stethoscope surfaces once skin contact is established with

an infected patient and pose a severe threat to patients’ health. These kinds of pathogenic bacteria

are known to cause serious illness or death if the patient is immunocompromised, critical, or for

patients with compromised barriers, such as wounds, surgical sites, and ulcers (Whittington,

Whitlow, Hewson, Thomas, & Brett, 2009). Amongst healthcare workers in the hospital setting,

physicians and nurses more commonly use stethoscopes on a regular basis for assessing patients to

provide quality care. Both careers see multiple patients daily; however a physician would see

patients by the dozens during each shift. With the high volume of patient interaction, controlling

the rate of transmitting pathogens from stethoscope to patient is a concern for the prevention of

HAI's. Distinguishing if there is a difference in the severity of stethoscope contamination between

physicians or nurses will establish which workforce is more likely to pose the higher risk for

spreading harmful pathogens to patients, follow evidence based practice for disinfecting

techniques, and aide in the efforts to improve disinfecting practices in the hospital setting. Five

peer-reviewed articles will be discussed to identify if there is a difference and what can be

recommended to improve stethoscope-disinfecting practices in the hospital setting.

Summaries

Stethoscope Contamination Within the Units

The study performed by Whittington et al. (2009) concentrated on the care of patients’ within an

intensive care unit (ICU) of a hospital. This prospective cohort study asked 12 bedside nurses, 10

doctors, nine physical therapists, and two medical students questions on how often they clean their


stethoscopes. After questioning, a culture was taken from their personal stethoscopes with no

indication of when it was last cleaned. Surprisingly, results from the questionnaire revealed that

91% of nurses cleaned their stethoscopes after each use, 25% of doctors and medical students

sanitized daily or within the last month to six months with 17% reported of never cleaning their

personal stethoscopes. Sixty-seven percent of personal stethoscopes and 95% of ICU bedside

stethoscopes tested positive for pathogenic bacteria; 75% of that group was comprised of MRSA.

Unfortunately, one of the ICU bedside stethoscope’s earpieces tested positive for MRSA

indicating workers were being exposed to pathogens in an unexpected parallel.

Messina et al. (2013) conducted a cross over study within a teaching hospital in Italy that

collected cultures from 35 stethoscopes, 37 headsets, and 27 keyboards distributed among four

different units: first aide, emergency department, ICU, and cardiology. The study was done to

determine the effectiveness of decontamination techniques practiced by the medical staff within

these units. Results showed that keyboards contained the largest colonization of MRSA with

stethoscopes following. Cultures sampled before experimentation revealed stethoscopes harvested

staphylococcus spp. Escherichia Coli, coliform, and MRSA. A significant difference was found

between pre-intervention and post-intervention cleaning. Amongst the four hospital units, first

aide was discovered to be the most contaminated unit, and the ICU was found to be the least

contaminated. The researchers made no recommendations, but concern was stated for the growing

number of older and critical populations in hospitals, which requires strict decontamination

protocols for healthcare staff (Messina et al., 2013).

Tang, Worster, Srigely, and Main (2011) conducted the first study in Canadian

Emergency Departments (ED) to detect the proportion of medical staffs’ personal stethoscopes

that contained S. aureus bacteria or MRSA. Staff were asked consent to participate in the

questionnaire that inquired the frequency of stethoscope cleaning. Cultures were collected from


stethoscopes without knowledge of the last cleaning. This prospective observational cohort study

consisted of physicians and nurses from three different Canadian EDs. Of the 100 sampled

stethoscopes, 70 cultures had bacterial growth and 30 without growth. Fifty-four cultures

revealed growth of coagulase-negative staphylococcus, 30 cultivated gram-negative cocci and

bacilli, one with staphylococcus aureus, but no results of MRSA found. There was no significant

difference between the bacterial load between physicians and nurses. Reasons found for

inconsistent cleaning of stethoscopes were recorded as: 1) little time 2) lack of initiative and 3)

unavailable cleaning resources.

Contamination by Physicians Fingertips

The Longtin et al. (2014) study focused on the relationship between contamination of

physicans' hands during physical examinations and the transmission of pathogenic bacteria to

stethoscopes. Researchers implemented a prospective study design conducted in two parts. The

first phase examined the hands of a physician with gloves to assess the aerobic colony count

(ACC). The second phase selectively tested MRSA, which required the physician to perform the

physical assessment without gloves, however hand hygiene was allowed afterwards. A total of 489

cultures were collected from the examiners’: fingertips, thenar eminence, hypothenar, and hand

dorsum; two samples were cultured from the diaphragms of stethoscopes and one from the tubing

of each stethoscope following the physical examination. Cultures revealed that the fingertips of the

physician followed by a physical exam had a significant link to the colonization of bacteria on the

diaphragm of stethoscopes. Researchers concluded that the stethoscope should be handled as a

critical assessment tool, compared to the hand’s of the examiner. Researchers suggest further

studies to emphasize the location where bacterial contamination is more likely to originate from,

the patient or the physician.

Disinfection Education


Uneke et al. (2014) evaluated the effectiveness of an education program established in a

hospital in a Nigerian teaching hospital. The program focused on education the physicians and

nurses on proper sanitization of stethoscopes after each use. The study was performed in a pretest-

posttest design with qualitative and quantitative data. A questionnaire was utilized on the 202

healthcare workers to question about their current routine on stethoscope handling followed by 89

stethoscopes culture collections. Of the 202 workers, 39 were physicians and 163 were nurses.

Pretest results from the questionnaire revealed that 16.7% of physicians cleaned their stethoscope

regularly and 33.3% reported have never cleaned them (Uneke et al., 2014). Before the education

program was initiated, 78.5% of stethoscopes were contaminated with S. aureus and E. Coli.

Thirty-nine percent of nurses disinfected their equipment before and after each use. Posttest results

confirmed that the efforts of the stethoscope disinfection education program lowered

contamination rates by 55%. Results revealed that the efforts of the education training and

marketing strategies on stethoscope disinfection practice had a positive impact on the frequency of

cleaning stethoscopes.

Discussion

Similarities and Limitations

Amongst these studies, Messina et al. (2013), Uneke et al. (2014), and Whittington et al.

(2009) studies recognized a significant difference in the severity of pathogenic bacteria

contamination amongst stethoscopes between doctors and nurses. Uneke et al. (2014), Tang et al.

(2011), and Whittington et al. (2009) used questionnaires to gather data and responses showed the

majority of physicians did not clean their stethoscope once a day, but only once every one to six

months or never cleaned their stethoscope. However, the Uneke et al. (2014) and Whittington et

al. (2009) studies revealed that almost all the nurses who participated stated they sanitized their

stethoscope after each use. Moreover, both studies found the prevalence of stethoscope


contamination was problematic because the lack of reinforcement for practice. Due to the process

of the studies that used questionnaires, subjects were notified prior to data collection for

permission to participate. Furthermore, researchers had belief that participants tarnished the

integrity of the results for the submission of desirable answers and created a limitation to the

credibility of the results.

Differences and Limitations

The differentiations amongst all the studies discussed are found in the objectives and

location of experimentation, test subjects, and outcomes of the studies. The objective of the Uneke

et al. (2014) study was to establish the effectiveness of stethoscope disinfection education within

the hospital and reinforce the practice through visual aides posted in hospital rooms. The objective

of the Whittington et al. (2009) study was to find an occurrence of poor stethoscope cleaning with

contamination in an intensive care unit in a prospective cohort study approach. Whittington et al.

(2009) had no focus on the affect of stethoscope disinfecting education amongst healthcare

workers. However, the study did recognize the present status of stethoscope contamination on the

ICU unit.

While the studies by Messina et al. (2013), Uneke et al. (2014), and Whittington et al.

(2009) centered on the pathogen culture load, Longtin et al. (2014) concentrated solely on

physicians and the contamination transferred from their fingertips to the diaphragm of a

stethoscope following a physical assessment. According to this study, physicians had a significant

impact on the contamination of stethoscopes and transferred pathogenic bacteria with poor hand

hygiene practice. Location of experimentation varied amongst each study; between various

hospital units and regions around the world. For instance, Messina et al. (2013) concentrated on

the contamination of equipment with the first aide, emergency department, ICU, and cardiology

units of an Italian teaching hospital discovering that keyboards were more contaminated than


stethoscopes. Uneke et al. (2014) stethoscope disinfection education took place in a teaching

hospital in Nigeria and discovered use of visual reminders to sanitize stethoscopes were effective

in the hospital setting.

The Messina et al. (2013), Uneke et al. (2014), and Whittington et al. (2009) studies found

that physicians were more likely to harvest pathogenic bacteria on their stethoscopes compared to

nurses, therefore physicians were more of a threat to patients in spreading potential pathogens that

cause HAIs. However, Tang et al. (2011) found no significant difference in stethoscope

contamination between physicians and nurses.

Conclusion

Because stethoscope sanitation practice is revealed to be one of the most disregarded

practices, determining whether a physician or nurse is more likely to spread pathogenic bacteria to

patients through their stethoscopes can reinforce the need to improve this practice in the hospital

setting. This is key to understand when examining what risk each work force has on patients to

obtain a HAI. When patients are immunocompromised or exposed to external pathogens as a

result of open wounds, their chances of acquiring an infection increases immensely, ensuing

physicians to be held to a higher standard when using a stethoscope and coming into contact with

patients. While stethoscopes were proven to be viable vectors for pathogenic bacteria, such as, S.

aureus, E. coli, and MRSA, the majority of physicians who participated in the Messina et al.

(2013), Uneke et al. (2014), and Whittington et al. (2009) studies admitted in the questionnaires

they did not sanitize their stethoscope after each use. This holds physicians as a bigger risk than

nurses in the transmission of life-threatening pathogens to patients (Longtin et al., 2014).


References

Longtin, Y., Schneider, A., Tschopp, C., Renzi, G., Gayet-Ageron, A., Schrenzel, J., & Pittet, D.

(2014). Contamination of stethoscopes and physician’s hands after a physical examination.

Mayo Foundation of Medical Education and Research. 89(3), 291-299. doi:

http://dx.doi.org/10.1016/j.mayocp.2013.11.016

Messina, G., Ceriale, E., Lenzi, D., Burgassi, S., Azzolini, E., & Manzi, P. (2013) Environmental

contaminants in hospital settings and progress in disinfecting techniques. BioMed

Research, 2013, 1-8. doi:10.1155/2013/429780

Tang, P., Worster, A., Srigely, J., & Main, C. (2011). Examination of staphylococcal stethoscope

contamination in the emergency department (EXSSCITED Pilot Study). Canadian

Association of Emergency Physicians, 13(4), 239-244. doi:10.2310/8000.2011.110242

Uneke, C., Nduke, C., Nwakpu, K., Nnabu, R., Ugwuoru, N., & Prasopa-Plaizer, N. (2014).

Stethoscope disinfection campaign in Nigeria teaching hospital: Results of a before-and-

after study. The Journal of Infection in Developing Countries. 8(9), 86-93.

doi:10.3855/jidc.2696

Whittington, A., Whitlow, D., Hewson, C., Thomas, C., & Brett, J. (2009). Bacterial

contamination of stethoscopes on intensive care units. Journal of the Association of

Anaethetists of Great Britain and Ireland. 64, 620-624. doi:10.1111/j.1365-

2044.2009.05892.x

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