It is almost hard now to imagine a world without the myriad of mobile computing devices. Tablets, netbooks, ultra thin laptops, and smartphones are putting a vast array of resources and limitless amounts of information in the palms of our hands. The use and impact of these digital devices have been the source of multiple questions directed to the American Society of PeriAnesthesia Nurses (ASPAN) Clinical Practice Committee (CPC). A commonly asked question is: “Does anyone have experience with iPads in a medical setting?” The question seems simple enough, but actually begs multiple questions about the integration and use of these devices by both patients and providers in the perianesthesia setting. The issues of infection control, privacy/security, device management, and the impact on nurse-patient interaction are explored in this column.
Let Us Have Lunch
Before examining how mobile devices and technologies might be used in health care, it is important to understand what they can do. Mobile devices and the software that runs them pull data from a variety of sources and repackage these data in new ways through the use of global positioning system (GPS), social networks, voice recognition, proximity readers, rich audio/video media, and Internet integration. Let us imagine a software application for a moment that helps us to decide where we want to have lunch based on the amount of time we have to eat and our food preference. The application could use the weather forecast, live traffic feeds, and our GPS location to pull a list of restaurants and menus from the Internet for us to review. Now imagine a similar application on a tablet or smartphone that could guide our patient care decision making or improve patient education or satisfaction. Nurses working with multiple outpatients in Phase II could readily receive call light alerts, laboratory value updates, and notification of prescription readiness via a mobile application, freeing them from stationary computers.
Mobile devices might also be used to improve and enhance the patient experience. On arrival to an ambulatory surgical center, patients could receive a tablet that provides the agency's Bill of Rights information or preoperative instructional videos automatically selected according to the listed surgical procedure. The same device might also alert the patient and their family to delays using real-time information from the surgical tracking software. How about improving satisfaction through offerings of magazines, books, and movies on this same device? Three-dimensional imaging, report generation using electronic health record (EHR) data, and portability of rich media are opening new doors for patient education, patient engagement with the health care experience, and the opportunity for nurses to improve care in a better way. These opportunities, however, must be weighed against new hazards that might accompany them.
GermPad
“We plan to use iPads in the PACU and would like infection control procedure ideas used by others. Patients will have hands-on contact with the devices. Any good ideas would be appreciated?” This question was posed to ASPAN's CPC and opens a big area of concern related to mobile devices. Reducing the risk for surgical site infections has recently received renewed focus owing to potential reimbursement consequences. Careful timing of antibiotics and aggressive warming measures are just a few of the interventions that have become commonplace in perianesthesia practice to reduce these risks. A number of studies have shown that many of the pieces of equipment we use in the surgical and perianesthesia environments, such as electrocardiogram cables, laryngoscope handles, and keyboards, may actually be vectors for the very infections we are working to control.
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Stethoscopes, for example, have been blamed for the spread of a variety of nosocomial infections, including hospital-acquired methicillin-resistant Staphylococcus aureus.3
The computer mouse and keyboard, even those keyboards with covers on them, have also been identified as sources of bacterial contamination in multiple studies.4
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Perianesthesia nurses often have to move rapidly between a number of patients, which may also imply moving from computer to computer and in the process, potentially transmitting infectious agents. These concerns prompt the question as to whether or not we want to introduce another portable piece of equipment into the care environment (ie, mobile devices) that might add more infection risk for the patient?How Dirty Is Your Device?
The question of mobile devices and computers as a source of disease transmission has been a hot topic since computers were introduced into the health care setting. Due to the long-time ban of mobile devices in most hospital settings, research exploring the relationship of these devices and infection risk has only recently developed. Tablets and similar devices are fairly new and research has yet to catch up, although a few early studies confirm the concerns that most providers have about introducing this new means of passing along hospital-acquired infections. Ulger et al
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cultured the phones of 200 health care workers and found that 94.5% of phones had some type of bacterial growth, with more than one-half of the strains demonstrating antibiotic resistance. An author commenting on the article concluded that it would, “… seem sensible to advise health professionals to use mobile phones as little as possible in patient areas.”9
Cleaning
The cleaning of cords, carts, and cables is often a ritual part of transferring a patient from one phase of care to another. There may be variations among providers, and even between agencies as to cleaning solution used, as well as the frequency and thoroughness in cleaning of patient care equipment. Consequently, there is potential for cross-contamination or “undercleaning” of surfaces and equipment, especially with questionable or inconsistent hand hygiene practices.
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Current cleaning of patient care equipment may reflect on how mobile devices might be handled. All the nooks and crannies of mobile devices (ie, USB ports, plug-in slots, and on/off switches) add to the challenge of ensuring that they stay “clean.” There is some evidence to suggest that cleaning of keyboards, even with water, is effective in removing most bacterial contaminants without destroying the equipment itself.11
The same might not be true, however, of more sensitive (and expensive) mobile device equipment that may not survive the dozens of cleanings per day that might be needed between patient or provider exposures. To date, little has been published on best practices or guidelines for cleaning mobile devices, although such guidelines and research findings have been published for computers and peripherals (keyboards and so on).4
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Practical Considerations of Mobile Devices
Mobile devices and computing technology may open new doors for providers and patient care, but they may come with a hefty set of practical considerations. Storage, battery life, maintenance, security, and protection are just a few of the pragmatic aspects that must go into decision making regarding these devices. Customization and purchasing of software, particularly for agencies that might create specialized patient or provider applications, can also quickly add to the price.
Mobile devices are notorious battery hogs and depending on use and means of signal access (wireless vs data network), they may need to be charged frequently or have replaceable batteries, if this is even an option. An array of other issues, such as screen brightness and applications being used, may also factor into battery life. The website CNET
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recently compared battery life with a video running continuously on most of the tablets that are currently on the market. They found a wide range of battery life. Popular devices such as Amazon's Kindle Fire (2012) had a battery life of approximately 4.6 hours, whereas an Apple iPad (fourth generation) ran for 13.1 hours. The charging and updating cords, space for storage, docking stations, and availability of extra devices or batteries add another dimension to their use and purchase prices.Franklin E, Blanco X. CNET tablet battery life results. Available at: http://reviews.cnet.com/8301-19736_7-20080768-251/cnet-tablet-battery-life-results/. Published November 16, 2012, and Updated 2012. Accessed November 19, 2012.
Many of the devices discussed are expensive and sought-after pieces of technology. It may be important to have a system for “check-in/check-out” and for securing these devices during off hours to prevent theft. Some agencies will outfit devices with “kill switches” or programs that disable the device if it is removed from the hospital. Some devices can be outfitted with radio frequency identification chips, which let you track their location within the hospital. Other products may have tracking chips and deactivation software already built in, but these features often have to be activated ahead of time (in other words, you cannot do it after it has been stolen or misplaced).
Having a device fall on the floor or in the sink may be just as disastrous as having one stolen. Replacement plans and maintenance options as well as the purchase of protective cases for the device may need to be factored into purchasing decisions.
Security and Confidentiality
Federal tracking of health care data security breaches, which began in 2009, has identified that almost 40% of cases involved mobile devices, hard drives, and laptops.
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Recent changes to the Health Information Portability and Accountability Act (HIPAA) and the final rules for the second stage of Meaningful Use (government incentive program for promoting use of EHRs) are illustrative of the impact that technology is having on the security of health care data and past episodes of data security breaches. Stage 2 of Meaningful Use has provided clarification regarding the encryption (coding of messages so that it cannot be easily understood without the decryption key) of mobile devices that might hold patient care data.15
The Meaningful Use rules for Stage 2 are intended to supplement or reinforce the HIPPA Privacy and Security Rules. Health care agencies are required to complete a security risk analysis, audit user activity, and ensure reasonable and appropriate encryption practices. There is a whole host of encryption standards and practices, which may better protect patient health care data that may be on mobile devices while new policies dictate reporting procedures in cases of security breaches.Gallagher LA. Psst! Stage 2 Meaningful Use Final Rule Impact to Privacy and Security. Available at: http://blog.himss.org/2012/09/19/psst-stage-2-meaningful-use-final-rule-impact-to-privacy-and-security/. Published September 19, 2012, and Updated 2012. Accessed November 20, 2012.
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Privacy issues beyond lost or stolen devices with patient data on them must also be considered alongside new threats such as the hacking of mobile devices. The hacking of devices is a sophisticated type of breach of patient privacy or data loss, although less technological concerns are arising as well. A family member or even a patient can easily and discretely take a photo of hospital staff or other patients with cameras on cell phones and tablets. Imagine how easy it would be in a cramped preoperative or postoperative environment for a family member or patient to accidentally or purposefully take a photo or video of another patient. Our care environments are progressively moving towards more family-friendly policies, which can increase the risk of these types of purposeful or accidental infringements on privacy. To complicate matters, these photos or videos could make the rounds on social media networks in a matter of seconds.
Technology as Disruption to the Nurse-Patient Dyad
One of the most important but often overlooked issues related to mobile devices pertains to the role of technology in the nurse-patient dyad. Technology as a potentially dehumanizing force is not a new issue, and was a hot topic in the late 1980s and early 1990s as the sophistication and use of patient care technologies was booming. Although the idea of maintaining “high tech and high touch” care is a familiar notion, it must be revisited in the face of a new breed of devices and technological innovations that may create even greater disruption.
My realization of how disruptive the computer and EHRs could be came when I was in the clinical setting with undergraduate nursing students. The students were often of traditional college age (19 to 21 years) and had grown up with technology, never really knowing a time without the Internet or cell phones. Often when they entered a patient's room their first or second action was to go to the computer keyboard. The students used the computer to get to know the patient but also as a means of collecting their thoughts. Their reliance and focus on the computer sometimes gave an impression of rudeness or distance, particularly to older patients. When asked about this, most students were not even aware of what they did or had a realization of the impact that their shift of attention to the computer might have on forming a therapeutic relationship with the patient. As the documentation burden grows for perianesthesia nurses, even those who are not of a more computer-savvy (dependent?) generation, the press to be at the computer early and often may be a necessary source of dissatisfaction and discomfort. Adding to this discomfort is the realization that perianesthesia nurses may have a wide range of abilities and knowledge when it comes to computer and informatics competence.
More time in front of the screen may be less comforting and more a result of not knowing where to find information or comfort with navigating the EHR. Either way, few nurses seem to argue that they want more time in front of a screen and less time directly engaged with their patients. Rozzano Locsin, a nurse researcher and theorist, proposed the theory of “technological competency as caring in nursing.” Locsin's
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book and several articles on the topic offer important insights as to how to reconcile the disruptive effect of technology. Locsin theorizes that our technological competence is actually a part of how we demonstrate caring as registered nurses. He posits that “machine technology can bring a patient closer to nurses because it enhances their knowledge of the person being cared for. Nonetheless, such technology may also widen the gap between a nurse and a patient because of an unconscious disregard for the patient as a person.”17
(p78) Locsin's work calls us to figure out how to best use technology to know as much as we can about the patient to provide safe care that is tailored to their individual needs and preferences.Access to information in the EHR or via a mobile device can provide us an opportunity to know the patient more holistically, but only if we embrace the importance of advancing our computer and information literacy. Technology can and must affirm the centrality of holistic patient knowing, rather than creating distance as it did in the case of my students, or frustration for experienced providers who consider electronic charting as a waste of time. Technology should not be a barrier to a nurse's progress toward knowing the patient but rather should serve as a means of building a therapeutic relationship. The vital question then becomes: how do we find the information we need in the compressed and hurried time frames of the perianesthesia environment while holding sacred therapeutic relationship building?
Best practices for using technology, computers, and mobile devices is a fairly new area of research, but is a concern with some level of urgency. Dr. Beth Strauss (Doctor of Nursing Practice Innovations lecture, October 2012, University of Minnesota) recently presented her findings related to the experience of patients when nurses communicate with them while using the EHR. Her research accentuates both the pitfalls and previously unspoken concerns about the potential role of technology in health care. Strauss' qualitative analysis of patient responses identified that computer charting can indeed deter a nurse's use of presence in the therapeutic relationship and may chip away at trust. Instead of being engaged with the patient and his or her family, the nurse's attention may shift to the computer or other technologies. Her recommendations included beginning the therapeutic interchange by addressing the patient's needs before going to the computer, explaining what is being entered into the computer, and the importance of improving the skill of nurses for better maintenance of the therapeutic relationship in light of growing technological demands. Her research accentuates the need to strike a balance between the pitfalls of this technology with its practical applications.
Conclusion
As nurses, we need to both understand and shape the design and application of mobile technologies to be successful in embracing all that mobile devices and technology might offer. We now readily have the ability to communicate with patients and families in a wide variety of mediums ranging from video chats to text messages. The data that were once filed in the basements of hospitals is now being made directly available to patients, families, and other health care providers. Rich media in the form of audio and video can be made portable for multiple devices and can bridge the divide of time and learning needs. I look forward to an ASPAN CPC question and research priority list that includes questions such as: Are postsurgical complications reduced with the use of patient care videos uploaded to a patient's mobile device as a standard part of discharge instructions? Like any disruptive innovation or technology, we must face the risks and rewards with a patient-centric attitude, intellectual curiosity, and positive deviancy from the status quo.
References
- The prevalence of visible and/or occult blood on anesthesia and monitoring equipment.AANA J. 2001; 69: 44-48
Wild D. ECG cables are common source of contaminants in OR. Infectious Disease Special Edition. December 2011:1.
- Stethoscopes as a source of hospital-acquired methicillin-resistant staphylococcus aureus.J Perianesth Nurs. 2012; 27: 82-87
- Computer equipment used in patient care within a multihospital system: Recommendations for cleaning and disinfection.Am J Infect Control. 2005; 33: 233-237
- Bacterial contamination of computer keyboards in a teaching hospital.Infect Control Hosp Epidemiol. 2003; 24: 302-303
- Computer keyboard and mouse as a reservoir of pathogens in an intensive care unit.J Clin Monit Comput. 2004; 18: 7-12
- Computer keyboards and the spread of MRSA.J Hosp Infect. 2006; 62: 390-392
- Are we aware how contaminated our mobile phones with nosocomial pathogens?.Ann Clin Microbiol Antimicrob. 2009; 8: 7
- Commentary: Ulger F et al. (2009). Are we aware how contaminated our mobile phones with nosocomial pathogens?.Nurs Crit Care. 2009; 14: 213-214
- Anaesthetists' role in computer keyboard contamination in an operating room.J Hosp Infect. 2008; 70: 148-153
- Bacterial contamination of keyboards: Efficacy and functional impact of disinfectants.Infect Control Hosp Epidemiol. 2006; 27: 372-377
- Basic microbiologic and infection control information to reduce the potential transmission of pathogens to patients via computer hardware.J Am Med Inform Assoc. 2002; 9: 500-508
Franklin E, Blanco X. CNET tablet battery life results. Available at: http://reviews.cnet.com/8301-19736_7-20080768-251/cnet-tablet-battery-life-results/. Published November 16, 2012, and Updated 2012. Accessed November 19, 2012.
- Medical Data Breaches Raising Alarm.Washington Post Health & Science, 2012 (Available at:) (Accessed November 20, 2012)
Gallagher LA. Psst! Stage 2 Meaningful Use Final Rule Impact to Privacy and Security. Available at: http://blog.himss.org/2012/09/19/psst-stage-2-meaningful-use-final-rule-impact-to-privacy-and-security/. Published September 19, 2012, and Updated 2012. Accessed November 20, 2012.
- HITECH security mandates for healthcare organizations.Healthc Financ Manage. 2011; 65: 118-122
- Technological Competency as Caring in Nursing: A Model for Practice.Sigma Theta Tau International, 2005
Biography
Matthew David Byrne, PhD, RN, CPAN, is Assistant Professor of Nursing, Saint Catherine University, Saint Paul, MN
Article info
Footnotes
Conflict of interest: None to report.
Identification
Copyright
© 2013 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.
