Achieving The Triple–Aim With Our Third Hand

By Dr. Alpesh N. Amin

Hand hygiene is a proven safety practice in health care. Unfortunately, hand hygiene is underperformed on a routine basis, leading to the transmission of pathogens and spread of infection from patient to patient. Similarly, stethoscopes – the clinician’s third hand – pose the risk of carrying pathogens and spreading infection from patient to patient. Like hands, stethoscopes can be effectively decolonized using alcohol. Yet, despite effective means to decolonize stethoscopes, our study in the Journal of Hospital Medicine showed only 16% of physicians or student trainees employed stethoscope hygiene prior to patient contact.¹ In non-isolation rooms, the issue was exacerbated – we found only 4% of patients received care involving stethoscope hygiene.¹

As patients are alarmingly exposed to unclean stethoscopes, stethoscope transmission of pathogens from patient to patient can undermine the efforts of hand hygiene programs. Effectively promoting hand and “third hand” hygiene best practices could reduce infection rates. In turn, infection control can decrease healthcare costs (including reducing antibiotic use and complications) while improving the patient experience – cornerstones of the Institute for Healthcare Improvement’s “Triple Aim”.

An easy to use and fail-safe method that improves stethoscope hygiene could help facilitate achieving the Triple Aim.

1. Jenkins IH, et al. Low Rates of Stethoscope Hygiene. J. Hosp. Med 2015;7;457-458. 

Alpesh N. Amin is Professor of Medicine at the School of Medicine, Chair of the Department of Medicine, and Executive Director for the Hospitalist Program at the University of California, Irvine.  He specializes in hospital, internal and perioperative medicine with research interests including patient care and quality improvement in the acute setting.

Third Hand Vector series spotlights the clinician’s third hand and the risks that contaminated stethoscopes pose to clinicians, patients and healthcare systems. The series features leading experts in infection control, patient care and quality measures raising awareness of the importance of aseptic barriers in reducing transmission of infectious diseases.

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Protect Your Patient

By Cynthia Cadwell, RN, ANP-BC, CNS

In the 1840s, Ignaz Semmelweis proved that handwashing reduced death in childbirth. Providers have since strived to prevent cross contamination, including the use of environmental sanitization between patients. The point of ‘care’ is to apply life-saving science while doing no harm. Yet, insidious infections occur and can be potentially lethal, particularly in the immunocompromised patients, even among meticulous providers.

Despite the abundance of studies showing the need for cleaning frequently touched items such as cell phones, keyboards, patient care areas and other items to prevent the cross contamination, it is difficult to ensure compliance. Providers know the importance of cleaning their stethoscope before use on a patient. However, when observing stethoscope hygiene in practice, busy providers who see multiple patients in a fast-paced environment frequently forget… because humans can and will make errors!¹

Effective quality techniques are exemplified by routine, simple methods implemented in standard workflows. Best practices are those that are easily applied by multiple staff without work-arounds.²  Technologies to help eliminate human error are the most effective – ensuring providers do the right thing, each and every time. Hand sanitizer and gloves immediately visible at the entrance of patient rooms enhance routine use. Adding a touch-free stethoscope barrier dispenser in these locations will decrease stethoscope contamination. Goal: “Do No Harm.” 

1. Institute of Medicine (US) Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, editors. Washington (DC): National Academies Press (US); 2000.

2. Crossing the Quality Chasm: A New Health System for the 21st Century. Institute of Medicine (US) Committee on Quality of Health Care in America. Washington (DC): National Academies Press (US); 2001.

Cynthia Cadwell, Principal Consultant at Cadwell Consulting, is a Nurse Practitioner with over 25 years of clinical and biotech experience focused on lean initiatives and quality improvement for patient care and healthcare systems.  As an RN, CNS, CPHQ, and Clinical Educator, her clinical experience spans SNF/PAC, advanced wound care, occupational health, critical care and cardiovascular disease.

Third Hand Vector series spotlights the clinician’s third hand and the risks that contaminated stethoscopes pose to clinicians, patients and healthcare systems. The series features leading experts in infection control, patient care and quality measures raising awareness of the importance of aseptic barriers in reducing transmission of infectious diseases.

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Stethoscope Contamination: What We Haven’t Learned in 150 Years

By W. Frank Peacock, IV, MD, FACEP, FACC, FESC

Standard of Care?

If you ask a doctor “How often do you clean your stethoscope?” you will likely hear “Oh, in about 30-40% of patient encounters.” If you would then ask “In those 30-40% of encounters, how do you clean your stethoscope?” they will commonly respond “I rub it with an alcohol swab.”

Unfortunately, self-reporting is not very accurate. And although everyone knows that the stethoscope is a strong vector for the transmission of disease, no one wants to admit they do something wrong all day long.

We recently published an observational study in the American Journal of Infection Control. The purpose of this important study was to uncover the facts about real-life stethoscope hygiene. For this investigation, we surreptitiously watched 400 patient-practitioner interactions (the staff didn’t know they were being observed) in high-risk hospital environments like the ER, ICU, and labor and delivery. No (zero) stethoscope hygiene was performed before the patient encounter in 82% of examinations.¹ A disgusting finding. And, even when stethoscope cleaning was performed, the quality almost never met the Centers for Disease Control (CDC) cleaning guidelines. In fact, stethoscopes were cleaned consistent with CDC guidance only 4% of the time.¹

Unfortunately, the apparent standard of care is to rub dirty contaminated stethoscopes on our patients.  This is because there has never – not in 150 years – been a system that efficiently and reliably provides a clean stethoscope while preserving its function.  This is not a call for a large investment in stethoscope washing, as others have shown that even guideline-compliant stethoscope washing is not effective at eliminating pathogens.  Rather, a disposable, aseptic barrier system for stethoscope diaphragms, one that completely prevents pathogen transmission, presents a strong opportunity for the medical community to improve patient safety.²

1. Boulée D, Kalra S, Haddock A, et al. Contemporary stethoscope cleaning practices: What we haven’t learned in 150 years.Am J Infect Control. 2018 Nov 2 Published online 2018 Nov 2.

2. Vasudevan R, Shin JH, Chopyk J, et al. Aseptic Barriers Allow a Clean Contact for Contaminated Stethoscope Diaphragms. Mayo Clin Proc Innov Qual Outcomes. 2020;4(1):21–30. 

W. Frank Peacock IV, MD, FACEP, FACC, FESC is a Professor of Emergency Medicine and Vice Chair for Research in the department of Emergency Medicine at Baylor College of Medicine, in Houston, Texas. With >600 publications, he is a two-time winner of the Best Research Paper of the Year Award from the American College of Emergency Physicians, and he was the 2019 recipient of the Ray Bahr Award for Excellence from the American College of Cardiology.  Finally, he is the founder of Comprehensive Research Associates, LLC, and Emergencies in Medicine, LLC.

Third Hand Vector series spotlights the clinician’s third hand and the risks that contaminated stethoscopes pose to clinicians, patients and healthcare systems. The series features leading experts in infection control, patient care and quality measures raising awareness of the importance of aseptic barriers in reducing transmission of infectious diseases.

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HAI MORTALITY: 
Equal to an Airplane Crash with No Survivors, Every Day

By Sandra Sieck, RN

In the U.S., nearly 100,000 people die each year from healthcare-associated infections¹ (HAIs)—infections acquired in a hospital or health care facility unrelated to whatever health issue took the patient there in the first place.

This is equivalent to a large commercial airliner falling out of the sky with no survivors, each and every day.

Roughly 1.7 million HAIs occur annually in acute-care hospitals¹, which result in total costs (direct, indirect and non-medical) estimated at up to $147 billion². Dramatic efforts are employed to improve hand hygiene in hospitals, and the effort has demonstrated a favorable impact.

Despite these efforts, HAI rates remain unacceptably high. One gap in our hygiene protocols, which could be contributing to the problem is hygiene for “the clinician’s third hand,” the stethoscope. Several recent studies have demonstrated that stethoscopes are highly contaminated, yet are cleaned between patients less than 10% of the time. Furthermore, even when stethoscopes are cleaned, the contamination level is reduced but not eliminated.

A validated aseptic barrier system could rapidly and effectively resolve the risks posed by stethoscope contamination. Imagine the impact on mortality and costs if a stethoscope barrier system were to be introduced into our hospital infection control procedures.

1. Patient Care Link. Healthcare-Acquired Infections. https://patientcarelink.org/improving-patient-care/healthcare-acquired-infections-hais/, accessed May 11, 2020.

2. Marchetti A, Rossiter R. Economic burden of healthcare-associated infection in US acute care hospitals: societal perspective. J Med Econ. 2013;16(12):1399‐1404.

Sandra Sieck, a registered nurse and healthcare business analyst, is the owner of Sieck Healthcare Consulting, specializing in healthcare business development, aligning hospital and physician services and public policy evaluation and strategies.

Third Hand Vector series spotlights the clinician’s third hand and the risks that contaminated stethoscopes pose to clinicians, patients and healthcare systems. The series features leading experts in infection control, patient care and quality measures raising awareness of the importance of aseptic barriers in reducing transmission of infectious diseases.

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Infection Control and the Clinician’s Third Hand – a Long Standing Problem

By Stuart B. Kipper, MD

My stethoscope, even more than my white coat, instantly identifies me as a physician. Without a word spoken, it establishes an immediate bond of trust between me and my patient.

Yet, while stethoscopes continue to serve as a ubiquitous and cornerstone tool for all healthcare professionals, its constant contact and use during our daily patient interactions is NOT without a significant risk. Just like a clinician’s hands, stethoscopes can, and DO, harbor dangerous contaminants and organisms. Unlike our two hands, there is no easy, rapid, or effective way to clean our ‘third hand’.

For nearly every device or surface that comes in contact with a patient – hands, thermometers, otoscopes, tongue depressors, culture swabs, needles, and even exam tables – there is a cover or disposable system that reduces or eliminates transmission of disease. Stethoscopes have been left exposed and vulnerable. Disposable stethoscopes have limited utility, provide poor quality, high expense, and offer no effective solution to reducing their spread of infection. Mitigation efforts, such as alcohol wipes, destroy acoustic performance, are tedious endeavors, time consuming, and often forgotten. Placing a glove over the scope’s diaphragm is cumbersome and falls short of the goal we seek – protecting our patient.

Stethoscope hygiene for the clinician’s ‘third hand’ would be resolved if there existed a rapid, easy to use, and cost-effective means to provide an aseptic barrier to cover the stethoscope’s diaphragm.

In the wake of a consistent series of studies in the medical literature¹, the New England Journal of Medicine Journal Watch joined a growing body of medical leaders and thinkers calling for stethoscope hygiene to be elevated to the level of hand hygiene in clinical care². With infectious diseases like COVID-19, S. aureus, C. difficile, MRSA, and so many other pathogens, it is finally time for the stethoscope, the clinician’s ‘third hand’, to take center stage as a target for improving infection control and better protecting our patients while adhering to our commitment to DO NO HARM.

1. Knecht VR, McGinniss JE, Shankar HM, et al. Molecular analysis of bacterial contamination on stethoscopes in an intensive care unit. Infection Control & Hospital Epidemiology. 2019;40(2):171-177.

2. Ellison III, RT. NEJM Journal Watch Infectious Diseases, January 7, 2019. https://www.jwatch.org/na48156/2019/01/07/stethoscope-contamination, Apr 22, 2020.

Stuart Kipper, a Board Certified physician in Internal Medicine, is owner of Stuart B. Kipper, MD and Associates in Encinitas, California and is affiliated with the Scripps Hospital System in San Diego, California.

Third Hand Vector series spotlights the clinician’s third hand and the risks that contaminated stethoscopes pose to clinicians, patients and healthcare systems. The series features leading experts in infection control, patient care and quality measures raising awareness of the importance of aseptic barriers in reducing transmission of infectious diseases.

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