Cleaning of Cell Phones in the Neonatal Intensive Care Unit

Problem: Mobile devices are known to harbor bacteria and viruses. Since these devices, including cell phones, are now more common in the neonatal intensive care unit (NICU), it can be postulated that thorough cleaning of these devices may help protect immunocompromised neonates. This project explored whether improvement can be achieved in the routine cleaning of cell phones among providers and families in the NICU, and whether a cleaning method using antibacterial wipes and UV-C light were effective. Methods: Participants included parents, visitors and health care workers entering or working in a community-based level three NICU in Orem, Utah. A survey assessing cleaning practices, attitudes and barriers to cell phone cleaning was developed. The survey was administered and culture swabs of cell phones were taken prior to educational intervention for the staff. Educational materials were developed, including a PowerPoint presentation and video of the correct cleaning procedure. These addressed knowledge deficits and barriers identified in the initial survey. Surveys were administered and swabs of cell phones were obtained again two weeks after the intervention was completed. Results: A total of 50 surveys and 15 swabs were obtained pre- and post-educational intervention. Comparison between surveys showed improvement in the number of people who had changed their cell phone cleaning habits 62% vs 84% (p=0.009), but not in the number who cleaned their cell phone daily 38% vs 44% (p=0.685). One hundred percent of cell phones swabbed prior to educational intervention had bacterial contamination, while only 67% showed bacterial contamination post intervention (p=0.042). Conclusion: Decreased bacterial contamination indicated that the cleaning procedure was effective. Although cleaning frequency was not improved by the educational intervention, bacterial load and pathogenic organisms were significantly reduced on cleaned cell phones. Instituting a comprehensive cell phone cleaning program may reduce infectious exposure to NICU patients.

Running head: CELL PHONE CLEANING Cleaning of Cell Phones in the Neonatal Intensive Care Unit Kari M. Wood The University of Utah College of Nursing In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice 1 CELL PHONE CLEANING IN THE NICU 2 Abstract Problem: Mobile devices are known to harbor bacteria and viruses. Since these devices, including cell phones, are now more common in the neonatal intensive care unit (NICU), it can be postulated that thorough cleaning of these devices may help protect immunocompromised neonates. This project explored whether improvement can be achieved in the routine cleaning of cell phones among providers and families in the NICU, and whether a cleaning method using antibacterial wipes and UV-C light were effective. Methods: Participants included parents, visitors and health care workers entering or working in a community-based level three NICU in Orem, Utah. A survey assessing cleaning practices, attitudes and barriers to cell phone cleaning was developed. The survey was administered and culture swabs of cell phones were taken prior to educational intervention for the staff. Educational materials were developed, including a PowerPoint presentation and video of the correct cleaning procedure. These addressed knowledge deficits and barriers identified in the initial survey. Surveys were administered and swabs of cell phones were obtained again two weeks after the intervention was completed. Results: A total of 50 surveys and 15 swabs were obtained pre- and post-educational intervention. Comparison between surveys showed improvement in the number of people who had changed their cell phone cleaning habits 62% vs 84% (p=0.009), but not in the number who cleaned their cell phone daily 38% vs 44% (p=0.685). One hundred percent of cell phones swabbed prior to educational intervention had bacterial contamination, while only 67% showed bacterial contamination post intervention (p=0.042). Conclusion: Decreased bacterial contamination indicated that the cleaning procedure was effective. Although cleaning frequency was not improved by the educational intervention, CELL PHONE CLEANING IN THE NICU bacterial load and pathogenic organisms were significantly reduced on cleaned cell phones. Instituting a comprehensive cell phone cleaning program may reduce infectious exposure to NICU patients. 3 CELL PHONE CLEANING IN THE NICU 4 Introduction Problem Description Nosocomial, or hospital acquired infection, is a term that causes clinicians in any specialty, sub-specialty or hospital department to take pause. It leads to additional care, morbidity and sometimes death. This is especially true in the neonatal population. Neonates are often already challenged by extremely long hospital stays, pulmonary inflammation, the need for prolonged indwelling and invasive lines, immature immune systems, poor reserves and heightened pro-inflammatory systems (Jiang et al., 2014; Zhao et al., 2008). Long stays in the intensive care unit expose them to multiple bacteria and viruses through contact with caregivers and during common procedures. Nosocomial infection significantly increases their morbidity and mortality rates (Chen et al., 2017; Green et al., 2015; Stoll et al., 2015; Zhang, Xie, He, Dong, & Lei, 2017). Neonatal intensive care units (NICUs) have been aware of these issues and have been trying to improve care and minimize nosocomial infection risk for years (Alcock, Liley, Cooke, & Gray, 2017; Chen et al., 2017). No single cause has yet been identified for this multifactorial problem and no single solution has been found. Clinicians have worked on hand-washing, skin care, central line education bundles, pneumonia/early extubation protocols, feeding protocols, etc.; this work has improved nosocomial infection rates, but has not eliminated nosocomial infection from the NICU. With neonatal intensive care patients, it is difficult to assess how much of their morbidity and mortality is related to their underlying prematurity and underlying diagnosis versus a newlyacquired nosocomial infection. Unfortunately, we know that nosocomial infections are more common in the most vulnerable and immature infants (Jiang et al., 2014). Several researchers have tried to differentiate what change in outcomes can be directly attributed to nosocomial CELL PHONE CLEANING IN THE NICU 5 infection in the hospitalized newborn (Green et al., 2015; Jiang et al., 2014; Wu et al., 2017). They have been able to link increased rates of meningitis, chronic pulmonary issues, increased length of stay and mortality to this disease (Green et al., 2015; Jiang et al., 2014; Lapcharoensap et al., 2017). Bizzaro et al. (2011) were even able to show that there are genetic predispositions that lead some infants to be more susceptible to nosocomial infection. The mortality rate with nosocomial infection has been cited to be between 29% and 66% (Jiang et al., 2014; Kumar et al., 2018). Increased level of illness, such as with nosocomial infection, raised risk ratios from 3.15 for intensive care in the NICU to 6.58 for patients who received high-dependency care in the NICU (Leighton, Cortina-Borja, Millar, Kempley, & Gilbert, 2012). Because many small and fragile infants go home on oxygen, it is hard to determine whether the oxygen need is related to nosocomial infection or chronic lung disease as a complication of prematurity. Undoubtedly, episodes of inflammation do not improve chronic lung disease and can only exacerbate it. Most neonates are discharged by their due date, so extensions over the due date may be attributable to nosocomial infection. In the neonatal population, it is hard to determine causal relationships with a single patient; so large studies are the only way to obtain good data (Kumar et al., 2018; Lapcharoensap et al., 2017; Zhang et al., 2017) Over the past several years, digital devices have become more ingrained in both medical and nursing practice. Most neonatal intensive care nurseries require charting, order entry and reference data to be in an electronic format. This has led to increasing numbers of providers carrying digital devices and/or cell phones. Families have also begun to carry their own digital devices and/or cell phones into hospital units, and to feel that they are essential to their care and vital for their families (Brady et al., 2011). CELL PHONE CLEANING IN THE NICU 6 Available Knowledge One of the new sources of bacterial load found in the NICU has been electronic devices (Beckstrom et al., 2013; Brady, Verran, Damani, & Gibb, 2009; Pillet et al., 2016; Tekerekoǧlu et al., 2011). Initially, it was felt that these devices were unlikely to be carriers of opportunistic bacteria, but that belief has been disproven. These digital devices can be a serious source of bacterial and viral contamination (Brady, Verran, Damani, & Gibb, 2009). In fact, digital devices have been shown to be contaminated with bacterium that are associated with nosocomial infections (Brady et al., 2009). This is especially concerning in the NICU because the premature infant is immunocompromised. Guidelines on cleaning these devices have been inconsistent and early studies suggested that good handwashing may be adequate to reduce transmission of organisms (Mark et al., 2014). However, Beckstrom, Cleman, Cassis-Ghavami, and Kamitsuka (2013) found that good hand hygiene and anti-microbial gel did not eliminate bacterial contamination of the cell phone in the NICU. Russotto et al. (2017) showed that current cleaning products used in the ICU do not properly clean inanimate objects. Given these findings, new and more effective methods of cleaning need to be identified and implemented. Neonatal intensive care units around the country are attempting to implement guidelines and protocols for the cleaning of electronic devices used in the NICU (Kirkby & Biggs, 2016; Tekerekoǧlu et al., 2011). Rationale Many NICU care practices are guided by habit or routine. The theory that guides this clinical process proposal is the Practice Theory, which describes how habits are formed. A habit can be defined as routine behavior that does not require motivation or even a specific choice CELL PHONE CLEANING IN THE NICU (Darnton, Verplanken, B, 2011). It is a way of reproducing the same behavior with each corresponding element, such as scrubbing upon entry to a medical unit. This theory started with Triandis' (1977) Theory of Interpersonal Behavior which appears to be one of the only theories that discusses habits and their formation in behavior change (Darnton, 2011). It is a theory that seeks to understand why we develop behaviors that require multiple steps, without significant decision making, in an everyday manner (Butts & Rich, 2018; Darnton, 2011). Practice theory explains how routines can become habits and how the behavior or habit becomes a common practice (Darnton, 2011). The theory is not individually focused, but rather, works on changing behavior through modifying environment and social behavior norms until the habit or practice takes place without specific individual motivation (Butts & Rich, 2018; Darnton, 2011). In essence, the environment can be adjusted to facilitate behavior change. This project focuses on creating a cleaner environment in the NICU by teaching health care workers and families to wipe down their cell phone at a cell phone cleaning station at or near scrub sink with sanitizing wipes and to place it into a sanitizing light box as soon as they enter the NICU, prior to starting their scrub. Families check into the front to gain access to the NICU. Both families and caregivers complete a lengthy handwashing as they enter the patient care area. Establishing an environment where everyone who enters the NICU performs this exact same routine and sees others do the same produces societal pressure which encourages normalization of the behavior (Butts & Rich, 2018; Darnton, 2011). Thus, the cell phone cleaning routine will become a habit. This means that the environment can be very conducive to encouraging the behavior, that the task can be easy to perform without significant one-on-one 7 CELL PHONE CLEANING IN THE NICU 8 education, and that the process is openly visible so that there are social norms to follow (Butts & Rich, 2018; Darnton, 2011). Specific Aims The purpose of this project is to improve the frequency of routine cleaning of cell phones among neonatal providers and families in a neonatal intensive care unit. While the project does not look at nosocomial infection rate, the hope is that this may lead to a decrease in fomite exposure and nosocomial infection in the NICU. Methods Context This intervention was performed in a community-based level three neonatal intensive care unit of 24 beds located in Orem, Utah. Admissions to the facility have minimal diversity. The majority of patients are Caucasian, of European descent and families belong to the predominant religion in the area. However, the presence of three large universities within 50 miles attracts more diverse patients and families. The majority of mothers who have infants in the NICU are over the age of 18, have received adequate prenatal care and have at least a high school education. There is a low rate of homeless families in the NICU and many families have social support structures in place. This NICU serves approximately 300 infant's per year. The NICU has a neonatology staff of two neonatologists, four full time neonatal nurse practitioners (NNPs) and 3 part time NNPs. The author is one of the full-time NNP's in this NICU, and is Master's Degree prepared. The NICU staff has approximately 60 nurses dedicated to the unit, 20 hospital wide respiratory therapists, 4 lactation consultants, one NICU dietitian and one neonatal occupational therapist. The unit provides clinical teaching for registered nurses, respiratory therapy and neonatal nurse practitioner students. CELL PHONE CLEANING IN THE NICU 9 To qualify for data collection, the participants must have a cell phone with them, be older than 18 years of age, be a parent of a NICU infant or a healthcare worker entering the NICU, and be willing to participate in the data collection. Participants must be entering the NICU during October 2018 and February 2019 when data collection will be occurring. Data will be collected for approximately 1-2 weeks both pre and post intervention. Exclusion criteria include: visitors or families who are in imminent need of transfer of their infant to a level 4 NICU; families who do not have a cell phone with them; or families who do not wish to participate. The health care providers and visitors who take the survey must meet the inclusion criteria and be willing to participate. Overall, this community follows most medical advice and are willing to make changes if they feel the changes will improve the life of their family members, a contextual factor which may impact the success of this intervention. This may not be representative of all NICU visitors in other communities. Intervention(s) To achieve the goal of improving the frequency of routine cleaning of cell phones among neonatal providers and families at a neonatal intensive care unit, the project had four objectives. The first was to assess the current frequency of cleaning of cell phones among health care providers and families at a local NICU. The second objective was to identify current evidence-based guidelines for frequency and modes of cleaning cell phones. The third objective was to develop and deliver education material addressing the knowledge deficits and barriers identified in the survey for staff and families. The fourth and final objective was to evaluate the frequency of cell phone cleaning after education. CELL PHONE CLEANING IN THE NICU 10 This intervention assessed cell phone cleaning and cell phone cleaning attitudes and skills among visitors and workers at the NICU. There was data collection prior to and after an educational intervention given to both health care providers and families. Data was collected for approximately 1-2 weeks both pre and post intervention. The data collection assessed knowledge and attitudes via survey and evaluated bacterial load on the cell phones with swabs of the cell. A survey was developed by the author to determine the current frequency of cell phone cleaning, attitudes toward cleaning, and cleaning knowledge of those who enter the NICU. The survey was given to health care workers, family and visitors as they enter the NICU. The preintervention survey was given prior to the set-up of a cleaning station and any educational interventions to teach visitors and health care providers the best way to clean their cell phones. The follow-up survey asked the same questions and was given three weeks after the cleaning station set-up and educational intervention. The second section of data collection was a swab of cell phones for bacterial load after entering the NICU, at patient bedsides. Swabs were collected from the cell phones at the patient bedside after entry to the NICU, labeled with date, time and NICU bed space or NICU bed space 26, if taken from a hospital employee's phone. Swabs were all collected by the investigator then walked to the laboratory for plating and incubation. Microbiology then assessed swabbed plates for bacterial load and reported findings to the investigator. The educational intervention developed was a power point presentation with a real-time demonstration of cell phone cleaning. The author developed the educational intervention, and the content addressed deficiencies in knowledge and attitudes identified by the survey and information obtained through literature review about the latest evidence-based practice in cleaning inanimate objects. It was reviewed by the medical director and the author's DNP project CELL PHONE CLEANING IN THE NICU 11 chair. The first educational intervention was started in small groups for each shift of the NICU on the 21st of January 2019. The intervention was then placed on the NICU mandatory computer education site with a due date of Feb 7, 2019 and included a demonstration of the cleaning technique and new cleaning station that was installed the day he first educational intervention was given. The second educational intervention was again a PowerPoint presentation discussing the importance of cell phone cleaning, with a video of the demonstration of proper cell phone cleaning. This second educational intervention was to be played on a monitor above the scrub sink for everyone to watch as they scrub into the NICU, but had not been implemented by the end of study. Study of the Intervention(s) The approach chosen to determine the impact of the intervention was change statistics. Survey data was compared prior to the educational intervention and then three weeks after the educational intervention. Bacterial colonization was also assessed prior to the educational intervention and then again three weeks after the intervention. The participants attending the educational intervention were counted and their completion of the education was recorded by the hospital's education department. The time spent on the educational intervention was also tracked. The author and content experts felt that by waiting the three weeks after the educational intervention, information collected could better be related to a change in culture toward cell phone cleaning in the NICU. There was no comparison group in this project. The two groups analyzed were those who entered prior to and then after the educational intervention was given. CELL PHONE CLEANING IN THE NICU 12 Prior to this project the author checked with the NICU director, hospital administration and the quality improvement director to make sure that there were no similar projects happening in the hospital that may have impacted this project's outcomes. Measures The survey chosen was not a published reliable tool, as the process and evaluation of cell phone cleaning is new to the NICU. The author developed the survey with the input of advisors and experts, including their content expert, chair and mentor. It was then checked for readability and measurability with a small test group of nurse practitioners who were completing their doctoral degree. A statistical mentor also suggested improvements in the tool to more accurately assess information given. A content expert on the project assisted the author with the statistical measures. The hospital administration was approached and agreed to fund this project. The hospital also approved the time needed to present the project and training to the hospital workers. In addition, the hospital donated the lab supplies and microbiology analysis. Administrative support for the project contributed to the study's success. The author routinely assessed the missing survey data and double-checked data entered into the spreadsheet to analyze the completeness of the survey data. Analysis Analysis was done pre and post educational intervention on survey data and cell phone swab data. Demographic and outcome variables were described using frequency distributions and appropriate summary statistics for central tendency and variability. A Fisher Exact Test (using an on-line calculator) was used to measure the change between pre-intervention frequency of cell phone cleaning and post-intervention frequency of cell phone cleaning and for categorical CELL PHONE CLEANING IN THE NICU 13 values. The Mann-Whitney U test was used to Likert scale variables. The author had statistical advice and analysis oversite from a statistical expert from the University of Utah, College of Nursing. Descriptive statistics were performed using Excel. A content analysis was conducted on the open-ended survey questions. The words were read word for word then coded. Next the coded data were categorized, organized and summarized. Ethical Considerations This quality improvement study, while done in the NICU, exclusively involved adult subjects and their cell phones. Therefore, none of the data or information was obtained from a protected group. Consent was obtained with voluntary involvement in the project. There was no incentive or deterrent to participation in this project. This study was determined to be non-human subjects research by the University of Utah Institutional Review Board and by Timpanogos Hospital Review. There were no conflicts of interest discovered or disclosed by any of the project team members. Results Intervention Steps and Process Measures and Outcomes Demographic data are presented (Appendix A). There were an equal number of completed pre- and post-surveys (n=50). There was no statistical difference found between the respondents who were family or visitors (36-38%) or who were healthcare workers (62-64%) between the pre- and post-surveys. Survey data are shown (Appendix B). There was also no difference between the pre- and post-surveys in the percentages of respondents who had never cleaned their cell phones (10% vs 2%). There was statistical improvement in the number of respondents who had changed their cleaning habits since coming to the NICU, the number who CELL PHONE CLEANING IN THE NICU 14 had been taught/told to clean their cell phone and the number who had been taught how to clean their cell phone after the educational intervention. The number of respondents who typically cleaned their cell phone daily did not significantly change pre and post intervention, neither did the number of respondents who cleaned their cell phone every time they entered the NICU, or the respondents who could correctly answer the best way to clean their cell phone. There was also no significant change in the rank sum score on the Likert scale for perception of bacterial load. Secondary analysis showed that the majority of health care workers already had the habit of cleaning their cell phones upon entry to the NICU both before and after the intervention (71% and 72%, respectively, NS). However, for families and visitors a statistical improvement was noted in the percentage who had cleaned their cell phones on entry to the NICU comparing pre and post-intervention (37% vs 83%, p=0.0069). Swab data can be viewed (Appendix C). Fifteen swabs were obtained pre-intervention and 15 swabs obtained post-intervention. There was a statistical difference between preintervention swabs which showed 100% bacterial colonization versus post-intervention swabs having 67% bacterial colonization after a 72-hour incubation period. There were also statistical differences found between pre-intervention swabs with 10 different organisms and a total of 35 isolates compared to 2 different organisms and a total of 17 isolates for post-intervention swabs. The level of bacterial load between pre-intervention swabs and post-intervention swabs with greater than a few organisms showed a statistically significant decrease (p=0.065) at a cutoff of 0.1, but not at alpha of 0.05. Bacteria specific isolates are noted (Table 3) on both pre and post intervention swabs. Post-intervention swabs had no pathogens recovered. CELL PHONE CLEANING IN THE NICU 15 Contextual Elements The investigator initially planned to give the educational intervention in a NICU staff meeting. However, the staff meeting date was changed to a date and time that the investigator was unable to attend. Steps were then made for the medical director to give the educational intervention at the staff meeting, however discussion of a requested case study lasted the duration of the meeting. New arrangements had to be made for delivery of the educational intervention. Because the educational intervention could not be given in a single day to all staff, teaching only during nursing shifts delayed the post-survey and swab analysis by approximately two weeks. The investigator presented the educational intervention in person to approximately 30% of the staff, until the PowerPoint, which included video, was provided as a mandatory online education module for staff for NICU staff. Unit census and level of parental involvement were different during the pre-intervention and post-intervention time periods. During the pre-intervention surveys, the NICU had fewer patients, but a greater number of families with longer lengths of stay. Surveys were of interest to both health care workers and families. During the post-intervention surveys, the NICU had increased census, but shorter lengths of stay. Both health care workers and families seemed to be more likely to say that they would consider completing the survey the next time they were in. However, in both time periods families and health care workers expressed interest in results and several of them requested that the swab result be made available to them. This request was denied as swabs were anonymously labeled and no structure was in place to discuss swab findings in a one-to-one manner. Health care workers had been present with the pre-intervention swabs and they often attempted to find out which day post-intervention swabs would be obtained. The investigator had to privately co-ordinate this with microbiology and make sure that CELL PHONE CLEANING IN THE NICU 16 both departments did not know which day swabs would be obtained. Swabs were all obtained in the same manner by the investigator and plated and analyzed by the microbiology department lead. Details about missing data Because surveys were anonymous, if the content was missing, data could not be requested. If data were written in that coincided with categories, but the answer was not circled, then it was coded to the corresponding category. If the investigator was not able to interpret the written response or it did not match any of the answers, then the answer for that question was left blank. Questions that were left blank were not used in analysis, but remaining survey questions were still used for the questions that were completed. Discussion Summary The purpose of this project was to improve the frequency of routine cleaning of cell phones among those who enter the NICU. This key measure was achieved for families and visitors, but not for health care workers. Health care workers appeared to not have been affected by the educational intervention as there was no difference in the number of participants who cleaned their cell phone daily or those who cleaned it every time they entered the NICU. However, it was a measure of success that all participants did change their cell phone cleaning habits and acknowledged they had been taught how to clean their cell phones. The eradication of pathogens and decreased bacterial load shown by cell phone swab cultures were confirmation that an appropriate and effective cleaning procedure had been identified. CELL PHONE CLEANING IN THE NICU 17 Interpretation The lack of daily cell phone cleaning and participants' inability to verbalize the correct cleaning process post-intervention may be due to several factors. The high rate of staff already cleaning their cell phone when entering made statistical improvement difficult. Most staff do not work every day and many visitors do not visit every day, so it is possible that the investigator had picked an unattainable measure for analysis. The video that was to play above the scrub sink to solidify the education while scrubbing had not been implemented by the hospital at the time of post-intervention analysis, which may have been a factor in the lack of retainment of the educational information. Kirkby & Biggs (2016) implemented a cleaning procedure with antibacterial wipes in a NICU in 2014 and found that they were able to drop contamination of cell phones from 100% to 72% in a convenience sample of 18 cell phones. These phones were swabbed, then cleaned then swabbed again. Unfortunately, they did not collect data about the bacteria noted on cell phones or if any isolates were pathogenic. They also collected their data prior to entry to the NICU instead of at the NICU bedside. They then implemented an education program and mandatory cell phone cleaning and with a series of random audits found that four months later there was 100% compliance with this new cleaning procedure. This was the pilot program that helped guide the current project's choice of cleaning procedure and the investigator was disappointed that the current program was not able to meet the 100% compliance reached by Kirkby and Biggs (2016). Tekerokoglu et, al. (2011) was able to obtain 200 swabs of health care workers, patients and visitors cell phones that were brought into to the hospital. They found approximately 2040% held pathogenic bacteria, with patient/visitor cell phones having a higher rate of pathogens CELL PHONE CLEANING IN THE NICU 18 than the phones of health care workers. They made recommendations for implementing a cell phone cleaning procedure and for consideration of new techniques, including UV light. This helped to guide the cleaning procedure chosen and analysis of bacteria and pathogens on swabs for the current project. The cleaning procedure and educational intervention chosen were both low cost and had little time impact on the NICU unit personnel. Previously the unit had been supplying antibacterial wipes and clear sleeves that cell phones could be placed in. They continued to supply the antibacterial wipes and purchased the UV light boxes for cleaning. The UV lights are not medical grade and low enough cost to be obtained with unit discretionary funds. Limitations This was a small quality improvement project in a single unit. The survey may not have adequately evaluated why the expected change to more frequent cell phone cleaning did not occur. A larger sample size of swabs may have been able to achieve statistically significant decrease in bacterial load at a level of 0.05. A mandatory cell phone cleaning area may have been able to achieve 100% compliance with cleaning upon entry to the NICU. It may be that in a larger unit with an increased number of swabs an evaluation of pathogen eradication from cell phones using UV light and antibacterial wipes would be feasible. Conclusions These results show that we were able to develop an effective cell phone cleaning procedure for the NICU, but were not able to impact frequency of cell phone cleaning in the hoped-for manner. It appeared to sustain awareness of the need for cell phone cleaning in the NICU but the educational intervention was not effective in improving the frequency of cell phone cleaning. Improving cell phone cleaning in the subset consisting of visitors and families CELL PHONE CLEANING IN THE NICU 19 upon entry was significant. The reduction in bacterial load, while not statistically significant, may be clinically significant. The reduction in pathogens on cell phones is both clinically and statistically significant. This cleaning procedure could easily be implemented in other areas of the hospital where patients are felt to be immunocompromised. If this cell phone cleaning procedure were to be implemented in a larger unit or in a collaborative group, a link between nosocomial infection and pathogens on cell phones may be found. Acknowledgements This investigator had help from many resources. Catherine Schultz, DNP, FNP-BC and project chair; Dale Gerstmann, MD and content expert; Sandy Ewell, MBA, BSN and mentor. Sandy Ewell also help to arrange to hospital support and funding of swabs. Heather Hutchison, BS, Microbiology MT, ASCP was my microbiology liaison and content expert. Their help has been immeasurable and appreciated. CELL PHONE CLEANING IN THE NICU 20 References Beckstrom, A. C., Cleman, P. E., Cassis-Ghavami, F. L., & Kamitsuka, M. D. (2013). Surveillance study of bacterial contamination of the parent's cell phone in the NICU and the effectiveness of an anti-microbial gel in reducing transmission to the hands. Journal of Perinatology, 33(12), 960-963. doi:10.1038/jp.2013.108 Brady, R. R., Verran, J., Damani, N. N., & Gibb, A. P. (2009). Review of mobile communication devices as potential reservoirs of nosocomial pathogens. Journal of Hospital Infections, 71(4), 295-300. doi:10.1016/j.jhin.2008.12.009 Chen, Y. C., Lin, C. F., Rehn, Y. F., Chen, J. C., Chen, P. Y., Chen, C. H., . . . Huang, F. L. (2017). Reduced nosocomial infection rate in a neonatal intensive care unit during a 4-year surveillance period. Journal of the Chinese Medical Association, 80(7), 427-431. doi:10.1016/j.jcma.2017.02.006 Darnton, A., Verplanken, B. (2011). Habits, Routines and Sustainable Lifestyles: A summary report to the Department for environment, food and rural affairs. Green, N., Johnson, A. P., Henderson, K. L., Muller-Pebody, B., Thelwall, S., Robotham, J. V., . . . Deeny, S. R. (2015). Quantifying the Burden of Hospital-Acquired Bloodstream Infection in Children in England by Estimating Excess Length of Hospital Stay and Mortality Using a Multistate Analysis of Linked, Routinely Collected Data. Journal of the Pediatric Infectious Diseases Society, 4, 305-312. doi:10.1093/jpids/piu073 Jiang, N., Wang, Y., Wang, Q., Li, H., Mai, J., & Lin, Z. (2014). [Clinical analysis of nosocomial infection and risk factors of extremely premature infants]. Chinese Journal of Pediatrics, 52(2), 137-141. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/24739727 CELL PHONE CLEANING IN THE NICU 21 Kirkby, S., & Biggs, C. (2016). Cell Phones in the Neonatal Intensive Care Unit: How to Eliminate Unwanted Germs. Advances in Neonatal Care, 16(6), 404-409. doi:10.1097/ANC.0000000000000328 Kumar, S., Shankar, B., Arya, S., Deb, M., & Chellani, H. (2018). Healthcare associated infections in neonatal intensive care unit and its correlation with environmental surveillance. Journal of Infection and Public Health, 11(2), 275-279. doi:10.1016/j.jiph.2017.08.005 Pillet, S., Berthelot, P., Gagneux-Brunon, A., Mory, O., Gay, C., Viallon, A., . . . BotelhoNevers, E. (2016). Contamination of healthcare workers' mobile phones by epidemic viruses. Clinical Microbiology and Infection, 22(5), 456.e1-6. doi:10.1016/j.cmi.2015.12.008 Stoll, B. J., Hansen, N. I., Bell, E. F., Walsh, M. C., Carlo, W. A., Shankaran, S., . . . Wyckoff, M. (2015). Trends in care practices, morbidity, and mortality of extremely preterm neonates, 1993-2012. The Journal of the American Medical Association, 314(10), 10391051. Retrieved from https://jamanetwork.com/journals/jama/fullarticle/2434683 Tekerekoǧlu, M. S., Duman, Y., Serindağ, A., Cuǧlan, S. S., Kaysadu, H., Tunc, E., & Yakupogullari, Y. (2011). Do mobile phones of patients, companions and visitors carry multidrug-resistant hospital pathogens. American Journal of Infection Control, 39(5), 379381. doi:10.1016/j.ajic.2010.10.026 Zhang, D. S., Xie, D. K., He, N., Dong, W. B., & Lei, X. P. (2017). [Pathogen distribution, risk factors, and outcomes of nosocomial infection in very premature infants]. Chinese Journal of Contemporary Pediatrics, 19(8), 866-871. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28774360 CELL PHONE CLEANING IN THE NICU 22 Zhao, J., Kim, K. D., Yang, X., Auh, S., Fu, Y.-X., & Tang, H. (2008). Hyper innate responses in neonates lead to increased morbidity and mortality after infection. Proceedings of the National Academy of Sciences, 105(21), 7528-7533. Retrieved from http://www.pnas.org/content/pnas/early/2008/05/16/0800152105.full.pdf CELL PHONE CLEANING IN THE NICU 23 CELL PHONE CLEANING IN THE NICU 24 Appendix B Descriptive Statistics: Pre-and Post-Education Survey Questions and Data Respondents who have cleaned their cell phone today Yes No How often respondents think of cleaning their cell phone Daily Weekly Monthly Yearly Never Missing Respondents typically clean their cell phone Daily Weekly Monthly Yearly Never Missing What respondents typically use to clean cell their phone Pant or shirt edge Wet Washcloth Screen cleaner wipe or spray Antibacterial wipe UV light None of the Above A combination of the above Missing Respondents that have changed cleaning habits since NICU Yes No Missing I have been told/taught to clean my cell phone in the NICU Yes No Pre-Education Survey (n=50) n (%) Post-Education Survey (n=50) n (%) p-value 27 (54%) 23 (46%) 38 (76%) 12 (24%) 0.035 25 15 4 0 6 0 (50%) (30%) (8%) (0%) (12%) (0%) 26 16 1 2 4 1 (53%) (33%) (2%) (4%) (8%) (0%) 0.842* 19 19 5 1 5 1 (38%) (38%) (10%) (2%) (10%) (2%) 22 16 9 2 1 0 (44%) (32%) (18%) (4%) (2%) (0%) 0.685* 5 2 4 13 1 3 21 1 (10%) (4%) (8%) (25%) (2%) (6%) (42%) (2% 4 4 4 11 2 0 24 1 (8%) (8%) (8%) (22%) (4%) (0%) (48%) (2%) 0.685* 31 (62%) 18 (36%) 1 (2%) 42 (84%) 6 (12%) 2 (4%) 0.009 28 (56%) 22 (44%) 41 (82%) 8 (16%) 0.004 CELL PHONE CLEANING IN THE NICU Missing Respondents who have been taught how to clean their phone in the NICU Yes No Missing I think about bacteria or viruses on my cell phone Yes No Missing How many bacteria/viruses people think are on their cell phone (Likert Scale, 0-5) Few - 0 1 2 3 4 Many - 5 Missing Reasons given for not cleaning cell phone upon NICU entry I do I don't want to I don't know how I don't have time I don't have materials I don't think it is important None of the above Missing Correct way to clean cell phone per participant written description Correct Partially Correct Wrong Missing * Fisher Exact test for line item versus rest of items in the question 25 0 (0%) 1 (2%) 21 (42%) 28 (56%) 1 (2%) 41 (82%) 8 (16%) 1 (2%) 0.0001 38 (76%) 10 (20%) 2 (4%) 44 (88%) 6 (12%) 0 (0%) 0.282 7 0 0 0 2 38 3 (14%) (0%) (0%) (0%) (4%) (76%) (6%) 3 0 2 3 3 33 6 (6%) (0%) (4%) (6%) (6%) (66%) (12%) 23 0 3 0 2 1 20 1 (46%) (0%) (6%) (0%) (4%) (2%) (40%) (2%) 27 0 1 2 1 1 16 2 (54%) (0%) (2%) (4%) (2%) (2%) (32%) (4%) 0.419* 6 30 10 4 (12%) (60%) (20%) (8%) 10 29 2 9 (20%) (58%) (4%) (18%) 0.048 0.614* CELL PHONE CLEANING IN THE NICU 26 Appendix C Characteristics of Culture Swabs Pre-Intervention Post-Intervention (n=15) n (%) (n=15) n (%) No growth 0 (0%) 5 (33%) Rare Bacteria 0 (0%) 0 (0%) Scant Bacteria 2 (13%) 2 (13%) Few Bacteria 4 (27%) 4 (27%) 1+ Bacteria 8 (53%) 4 (27%) 2+ Bacteria 1 (7%) 0 (0%) 3+ Bacteria 0 (0%) 0 (0%) 4+ Bacteria 0 (0%) 0 (0%) p-value Bacterial Growth Levels 0.0651 Bacterial Identification (NP, non-pathogenic) Coag Negative Staph (NP) 15/15 (100%) 9/15 (60%) 0.069 8/15 (53%) 8/15 (53%) 1.000 Group D Strep 1/15 (7%) 0/15 (0%) 1.000 Fungus 1/15 (7%) 0/15 (0%) 1.000 Lactobacillus (NP) 1/15 (7%) 0/15 (0%) 1.000 Bacillus Species 3/15 (20%) 0/15 (0%) 0.224 Haemophilus Species 2/15 (13%) 0/15 (0%) 0.480 Micrococcus Species 1/15 (7%) 0/15 (0%) 1.000 Staph Aureus 2/15 (13% 0/15 (0%) 0.480 Corynebacterium Species 1/15 (7%) 0/15 (0%) 1.000 7/15 (47%) 0/15 (0%) 0.028 15/15 (100%) 05/15 (33%) 0.042 Strep Veridans (NP) Swabs with One or More Pathogens Number of swabs with organisms CELL PHONE CLEANING IN THE NICU 1 Few or less vs. 1+ or more 27