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 Table of Contents  
Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 53-58

Stethoscope hygiene and barriers among physicians – A cross-sectional study from National Guard Health Affairs in Dammam, Saudi Arabia

1 Department of Family Medicine, Imam Abdulrahman Bin-Faisal National Guard Health Affairs, Dammam, Saudi Arabia
2 Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
3 Al-Faisal University, College of Medicine, Riyadh, Saudi Arabia

Date of Submission17-Jul-2019
Date of Acceptance06-Sep-2019
Date of Web Publication20-Dec-2019

Correspondence Address:
Dr. Wajid Syed
Department of Clinical Pharmacy, King Saud University, Riyadh 11451
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpsic.jpsic_19_19

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Objectives: This study aims to evaluate the stethoscope hygiene Disinfection practice and barriers among National Guard Health Affairs physicians in Dammam, Saudi Arabia.
Methods: A paper-based cross sectional prospective study was conducted among physicians practicing at the Imam Abdurrahman Al-Faisal Hospital over a period of 3 months from October to December 2018. We assessed the frequency and method of disinfection, perception of contamination, and barriers to disinfection.
Results: Ninety-three respondents completed the survey. The results of the study found that Isopropyl alcohol 70% or an alcohol swab was the most common disinfecting agent, reported by 77 (82.8%) of respondents. The majority of the respondents 33 (35.5%) were spend 5-10 seconds to disinfect the stethoscope, 24 (25.8%) were <5 seconds, 12 (12.9%) were never disinfect stethoscope. Half of the respondents 51 (54%) were disinfect stethoscope after every use, 10 (10.8%) were disinfect multiples times per week, while 6 (6.5%) were disinfect stethoscope. The most common reported barriers to cleaning stethoscopes were forgetfulness/laziness 42 (45.2%), lack of time 30 (32.3%), or lack of knowledge regarding the best disinfectant 21 (22.6%).
Conclusion: This study found that the vast majority of respondents reported cleaning of stethoscope using a suitable method of their choice. Increasing physicians' access to appropriate disinfectants and providing visual reminders in health care facilities may improve stethoscope disinfection practices.

Keywords: Health care-associated infections, stethoscope, compliance and barriers, National Guard Health Affairs, Saudi Arabia

How to cite this article:
Al Saleh S, Al Rammah AA, Syed W, Al Duhailan R, Kattan S, Al-Mana F. Stethoscope hygiene and barriers among physicians – A cross-sectional study from National Guard Health Affairs in Dammam, Saudi Arabia. J Patient Saf Infect Control 2019;7:53-8

How to cite this URL:
Al Saleh S, Al Rammah AA, Syed W, Al Duhailan R, Kattan S, Al-Mana F. Stethoscope hygiene and barriers among physicians – A cross-sectional study from National Guard Health Affairs in Dammam, Saudi Arabia. J Patient Saf Infect Control [serial online] 2019 [cited 2020 Dec 4];7:53-8. Available from: https://www.jpsiconline.com/text.asp?2019/7/2/53/273732

  Introduction Top

Health care-associated infections (HCAIs) also most commonly known as “nosocomial” or “hospital” infections have a considerable impact on morbidity and mortality among hospitalized patients.[1] In 2008, the Centers for Disease Control and Prevention (CDC) reported a 7% prevalence of HCAIs in European countries, of which 32% were preventable.[2] There is a growing body of evidence concerning the global burden of harm caused by HCAIs, which comes to an estimated cost of 1 billion Pounds per year in the United Kingdom.[2] For primary prevention, it is of utmost importance to identify the potential vectors that may play a role in the transmission of HCAIs.[3]

A large number of previous studies have reported that health care workers' hands are one of the main routes of the transmission of HCAIs.[4],[5] However, there are little published data supporting the fact that non-critical medical equipment (NCME) such as stethoscopes, blood pressure cuffs, electronic thermometers, latex gloves, masks, pens, and white coats play vital role in the transmission of HCAIs.[3],[6],[7],[8] A stethoscope is an instrument commonly used in clinical practice. Certain existing studies reported that the contamination level of stethoscopes is substantial after a single physical examination and is comparable to the contamination of parts of the physicians' dominant hand.[4],[8] Several studies have also investigated stethoscopes as a potential vector of microorganisms, while other studies have investigated the microbial contamination of stethoscope.[6],[7],[9],[10],[11],[12] The majority of stethoscopes investigated were contaminated with gram positive organisms, primarily of the staphylococcus species. The presence of multi-drug resistant organisms such as Methicillin-resistant Staphylococcus aureus Scientific Name Search  (MRSA) and vancomycin resistant enterococci have also been reported. The mean rate of stethoscope contamination across 28 existing studies were 85.1% (range: 47-100)[2] Although NCME such as stethoscopes are frequently reported as vectors for transmitting organisms, researchers in one study argued that the role of these elements in HCAIs is unclear.[2]

To maintain the required quality and safety standard in health care practice, stethoscopes should be properly disinfected and cleaned after every use. Recent studies found that alcohol pads have improved a previously suboptimal standard of disinfection worldwide. There was no optimum disinfecting methods.[2], but recent studies found that the use of alcohol pads is the current gold standard method for stethoscope disinfection worldwide.[2],[6] Findings from several studies on the disinfection of stethoscopes documented very poor rates of compliance among health care workers.[6],[5] This suggests that many health care workers may not be aware of current required practice stating that NCME (including stethoscopes) should be disinfected after every contact with a patient.[4] A survey conducted with 150 health care workers showed that 48% of respondents disinfect their stethoscope daily or weekly, 37% monthly, and that 7% practiced stethoscope hygiene annually or never.[5]

However, a report published in 2015 by the journal of hospital medicine stated that the observed trainees at three academic medical centers exhibited stethoscope hygiene at a rate of only 4.6% for non-isolation rooms. The authors of this report referred to the stethoscope as the third hand.[5] This observation raised the question whether doctors' perception concerning stethoscope cleaning and disinfection affect their practice. This was also studied in 2012 and it was found that of the 1491 respondents that completed the survey, 76% believed that stethoscopes can transmit infection, whereas only 24% of them disinfected their stethoscopes after every patient contact .[13] Participants were also asked to identify potential barriers to stethoscope hygiene. Among the participants, 52% identified the lack of access to disinfection materials were the top barrier to stethoscope hygiene. Health care workers also cited other additional barriers, such as a lack of time, a lack of reminders (visual or from colleagues), and concern about stethoscope damage as obstacles to disinfection.[13] An intervention done among pediatrics health care workers showed that improving the accessibility to stethoscope disinfecting materials encourages compliance to stethoscope hygiene.[4] Considering all these aspects, training, education, and reinforcing the need to use alcohol based disinfectants with health care workers are inexpensive but very effective methods to improve their compliance.[3],[9]

Promoting infection prevention and control in health care settings is crucial. To the best of our knowledge, no studies have been published related to the evaluation of disinfection practice and barriers of stethoscope hygiene in hospitals in Saudi Arabia. Our research focuses on this important issue to optimize medical education and to attain optimal competence, thereby improving in-hospital patient safety. Therefore, the main objective of this study is to evaluate stethoscope hygiene, disinfection practice and the barriers among National Guard Health Affairs physicians in Dammam, Saudi Arabia.

  Methods Top

A cross-sectional prospective study was conducted at the Imam Abdurrahman Al-Faisal Hospital, which is located in the Eastern province of Saudi Arabia. The study as conducted over a period of 3 months from October to December 2018. The hospital was officially opened on October 14, 2002 and is strategically located between Dammam, Al Khobar, and Dhahran; the three cities with the highest population and significance in the eastern region. The hospital has 112 beds, an intensive care unit (ICU) with six beds, and a neonatal intensive care unit of five beds, four operating theatres, and four delivery rooms. Different units were chosen to account for the heterogeneity of hospital departments and staff. Each unit has different sittings. For our data collection, we included physicians working in National Guard health affairs in Dammam, Saudi Arabia. These physicians include consultants, specialists, registrars, and trainees (residents and interns). Physicians with low stethoscope usage and physicians from the departments of dermatology, anesthesia, dentistry, ophthalmology, psychiatry, and radiology were excluded from the study. A simple random selection was carried out (all the available physicians were nominated one by one).

A pilot study was conducted at PHCC of Imam Abdurrahman Al-Faisal Hospital in Dammam and the PHCC in Alkhobar, under supervision of the investigator for the purpose of evaluating the response of the subject, measuring the validity of the questionnaire, testing the study tools; and choosing the best manner to collect the data. The pilot study, completed in 1 weeks, involved 12 subjects. All the necessary additions or changes in the study tools were made. The results of the pilot study are not included in the main research report of the study. Cronbach alpha, used as a measure of reliability, was 67.0%.

The paper-based questionnaire was developed through a broad literature review.[6],[9],[13] To determine physicians' practices concerning stethoscope disinfection, we created 9 items for the anonymous validated questionnaire, consisting of two sections. The first Section addresses the respondent's personal information, including gender, age, marital status, department, and position. The last section consists of multiple choice questions concerning the frequency of disinfecting the stethoscope, time spent and methods used to disinfect the stethoscope, and barrier(s) concerning cleaning the stethoscope. The barriers include lack of time, forgetfulness/laziness, lack of knowledge regarding the best disinfectant, lack of access to disinfectants, concerns about damaging the stethoscope, and sharing of a stethoscope.

The Sample size was calculated using Raosoft calculator with 95% Confidence level at a Maximum error allowed 5%, so the total target population was 120 physicians so that the required response rate was 50% (recommended). All targeted physicians will be included in this study.[14] Data collection was carried out by the principal investigator through personal interviews with the respondents. The completed questionnaire was revised immediately after the interview. All of the questionnaires were collected during physicians' on duty time during 2017-2018. Regarding informed consent, the objectives of the study and the content of the questionnaire were explained to the respondents in detail prior to the completion of the questionnaire, after which consent to participate in the study was obtained. Participants were given adequate time to consider their participation.

The data collected were computerized using SPSS version 23. The computerized data were then tested for reliability. Frequency tables were created to explore the findings (frequencies, percentage, measures of central tendency, and dispersion). A cross tabulation was done to determine the relationship between predictors and outcomes using suitable statistical tests at a 95% confidence level, P < 0.05. Ethical approval for this study was obtained from the King Abdullah international medical research center (KAIMRC). All the participants were appropriately informed that the survey responses would be treated anonymously and confidentially.

  Results Top

A total of 120 physicians responded to the survey, of those 27 questionnaire was incompletely answered by responded, so we excluded incomplete questionnaire from the study. Ninety three physicians from different departments and specialties responded completely to the study. Their average age was 38.02 ± 9.6 years. Among the respondents, 56 (60.2%) were male and 37 (39.8%) were female, while 73 (78.8%) were married and 17 (18.3%) were single. Twenty-nine percent of respondents were residents, 23 (24.7%) were specialists, 19 (20.4%) were registrars, 21 (22.6%) were consultants, and 2 (2.1) were interns. Of the respondents, 57 (67.3%) practiced in medical departments, 15 (16.1%) in surgical departments, 11 (11.8%) in the emergency room, and 8 (8.6%) in the ICU. The demographic details of the respondents are provided in [Table 1].
Table 1: Demographic and Compliance concerning stethoscope disinfection (n=93)

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Fifty-four percent of respondents reported disinfecting their stethoscopes after every use, while 6.5% (n = 6) never disinfected their stethoscopes. [Figure 1] displays the frequency of disinfection practice of respondents. A good majority—92.5% (N = 86)—of respondents reported cleaning their stethoscopes using a suitable method, but 6.5% (N = 6) of respondents never cleaned their stethoscope. Of the 93 respondents, 54.8% (N = 51) reported that they disinfected their stethoscopes after every use. Thirty-three percent of respondents spent five to ten seconds at a time cleaning the stethoscope, while 12.9% (N = 12) of them did not spend any time on disinfecting their stethoscope [Table 2].
Figure 1: Frequency of disinfection practice in respondents

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Table 2: Frequency of disinfecting the stethoscope

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Alcohol swab or isopropyl alcohol 70% (82.8%) was the most commonly found disinfecting agent among the study subjects, but 6.5% of them never used any agent to clean or disinfect the stethoscope, see [Table 2].

The most common barrier concerning the disinfecting or cleaning of stethoscopes among physicians of the Imam Abdurrahman Al-Faisal Hospital were reported to be forgetfulness/laziness 42 (45.2%), lack of time 30 (32.3%), lack of knowledge regarding the best disinfectant 21 (22.6%), sharing of stethoscopes 12 (12.9%), concern for damaging the stethoscope 6 (6.5%), and unspecified reasons 21 (22.6%), see [Figure 2].
Figure 2: Details of the barriers to stethoscope disinfection practice

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  Discussion Top

Prevalence of HCAIs is a significant and challenging issue for health care facilities worldwide. Previously published studies have reported that health care workers including physicians and medical devices such as stethoscopes are associated with HCAIs [6],[15], with contaminated hands and devices being a major source of infection transference to patients.[16],[17] This study evaluated stethoscope hygiene associated with HCAIs among physicians of Imam Abdurrahman Al-Faisal Hospital and found more than half of the study respondents (54%) disinfect their stethoscopes after every use. This finding points to a low level of disinfection practice among the physicians. However, previous studies have revealed that only 24% of their respondents disinfect their stethoscopes after every use.[13] This low level of disinfection practice among physicians was reported to be associated with a number of obstacles including lack of time after use or forgetfulness as well as other perceived barriers, such as the availability of disinfectants or a lack knowledge. The lack of knowledge can also refer to different levels of knowledge concerning infection transmission or personal beliefs concerning the vulnerability of particular patient populations.[18]

It has been reported that the most significant source of nosocomial infection is infected patients and that the most common mode of transmission is the passing of pathogens through the hands of health care workers during direct physical contact with patients [16]. Hand hygiene play a significant role in the control and prevention of HCAIs or nosocomial infections, before and after patient contact. A large number of studies have revealed that the use of methylated spirit swabs led to lower contamination or a significant reduction in infection.[6],[13],[16],[19] The findings of this study shows that most physicians use Alcohol swabs or isopropyl alcohol 80% as a disinfecting agent, which is comparable to earlier published studies.[6],[9],[19]

There is large number of reports suggested that Alcohol swabs or isopropyl alcohol is an effective disinfecting agent for controlling the spread of microorganisms and hospital contamination.[19],[20],[21],[22],[23] Furthermore, a large part of the stethoscope the diaphragm has relatively a wide surface area that comes into direct contact with the patient. Therefore, there is a higher chance of bacterial contamination from this part than from other parts of the stethoscope. Using 70% isopropyl alcohol to wipe the stethoscope regularly leads to a reduced chance of contamination. Hence, it is always advisable to provide health care workers with alcohol swabs or isopropyl alcohol as a disinfecting agent. These materials are effective for disinfecting stethoscopes but also act as great option for hand hygiene compliance among health workers.[9] Moreover, waterless alcohol gel or hand rub has recently become an uncompromising expectation for health care workers.[17]

The results of this study revealed that the most common barriers to frequent disinfection practice include forgetfulness/laziness (45.2%), lack of time (32.3%), and lack of knowledge regarding the best disinfectant (22.6%). This finding confirms similar findings of previous studies, which also reported barriers such as lack of time, lack of knowledge, and a lack of visual reminders.[13] our findings clearly suggest the need to address the barriers that are limiting physicians in the practice of disinfection, as the need for prevention of HCAIs cannot be overstated. A large number of existing studies have indicated lower rates of contamination among physicians who practice disinfection after touching every patient.[6],[9],[13]

There is a huge number of reports that show that non-disinfected stethoscopes were found to carry different bacteria, such as staphylococcus aureus[9],[19],[24],[25],[26], micrococcus and coagulase negative staphylococci (CONS)[6], methicillin-resistant S aureus, and clostridium difficile.[27] However, studies have also reported that stethoscopes that are cleaned once a week or month carry gram negative bacilli. Among those that were isolated, some are pathogenic and have developed a resistance to antibiotics [6], which is a serious issue in the health care sector concerning the prevention of infection transmission from health care workers to patients.

The outcome of this study clearly suggests that there is an urgent need to inform and update physicians and health care workers concerning the importance of regular stethoscope disinfection for the prevention of HCAIs, which cannot be exaggerated. Previous studies have reported that training through education, reminders of disinfection [27],[15], and educational/promotional campaigns [15],[20],[21],[22],[28],[29] for physicians concerning strategies to prevent HCAIs can greatly improve compliance to appropriate disinfection practice among health care workers.

  Conclusion Top

In conclusion, this study reports that the majority of physicians of Imam Abdurrahman Al-Faisal Hospital indicate that only a small minority of the physicians never disinfect their stethoscope. The reported barriers for disinfecting stethoscopes were forgetfulness/laziness, lack of time, lack of knowledge regarding the best disinfectant, the sharing of stethoscopes, and concern about damaging one's stethoscope. There are simple interventions that could address these issues, which include making disinfecting agents available outside every patient room and providing posters and other visual reminders. Implementing these measures may improve stethoscope disinfection practices in health care facilities.

Financial support and sponsorship

The authors received no financial support for the research or preparation of this article.

Conflicts of interest

There are no potential conflicts of interest concerning the research, authorship, and/or publication of this article.

  References Top

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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