INFORMATION

INFORMATICS AND HEALTH

TECHNOLOGY

Mobile Devices in the PerianesthesiaEnvironment

Matthew David Byrne, PhD, RN, CPAN

IT IS ALMOST hard now to imagine a world with-

out the myriad of mobile computing devices. Tab-lets, netbooks, ultra thin laptops, and smartphones

are putting a vast array of resources and limitless

amounts of information in the palms of our hands.

Theuse and impact of thesedigital deviceshavebeen

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 experiencewith 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 tech-

nologies might be used in health care, it is impor-

tant to understand what they can do. Mobile

devices and the software that runs them pull datafrom a variety of sources and repackage these

data in new ways through the use of global posi-

tioning system (GPS), social networks, voice recog-

nition, proximity readers, rich audio/video media,

and Internet integration. Let us imagine a software

application for a moment that helps us to decide

wherewewant to have lunch based on the amount

of timewehave to eat and our foodpreference. Theapplication could use the weather forecast, live

MatthewDavid Byrne, PhD, RN, CPAN, is Assistant Professor

of Nursing, Saint Catherine University, Saint Paul, MN.

Conflict of interest: None to report.

Address correspondence to Matthew David Byrne, Saint

Catherine University, 2004 Randolph Avenue, Saint Paul,

MN 55105; e-mail address: matthewbyrnern@yahoo.com.

� 2013 by American Society of PeriAnesthesia Nurses

1089-9472/$36.00

http://dx.doi.org/10.1016/j.jopan.2012.11.006

26 Journ

traffic feeds, and our GPS location to pull a list of

restaurants and menus from the Internet for us toreview. Now imagine a similar application on a tab-

let or smartphone that could guide our patient care

decision making or improve patient education or

satisfaction. Nurses working with multiple outpa-

tients 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 surgi-

cal procedure. The same devicemight also alert thepatient and their family to delays using real-time

information from the surgical tracking software.

How about improving satisfaction through offer-

ings of magazines, books, and movies on this same

device? Three-dimensional imaging, report genera-

tion using electronic health record (EHR) data,

andportability of richmedia are openingnewdoors

for patient education, patient engagement with thehealth care experience, and the opportunity for

nurses to improve care in a better way. These op-

portunities, 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 de-

vices. 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. Re-ducing the risk for surgical site infections has re-

cently received renewed focus owing to potential

reimbursement consequences. Careful timing of

antibiotics and aggressive warming measures are

al of PeriAnesthesia Nursing, Vol 28, No 1 (February), 2013: pp 26-30

INFORMATICS 27

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 sur-

gical and perianesthesia environments, such aselectrocardiogram cables, laryngoscope handles,

and keyboards, may actually be vectors for the

very infections we are working to control.1,2

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 coverson them, have also been identified as sources of

bacterial contamination in multiple studies.4-7

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 anotherportable 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 thehealth care setting. Due to the long-time ban of

mobile devices in most hospital settings, research

exploring the relationship of these devices and in-

fection 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 newmeans of passing alonghospital-acquired infections. Ulger et al8 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 profes-

sionals to use mobile phones as little as possiblein 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 forcross-contamination or ‘‘undercleaning’’ of sur-

faces and equipment, especially with question-

able or inconsistent hand hygiene practices.10

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 effec-

tive in removing most bacterial contaminants

without destroying the equipment itself.11 The

same might not be true, however, of more sensi-

tive (and expensive) mobile device equipment

that may not survive the dozens of cleanings per

day that might be needed between patient or pro-vider 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).4,11,12

Practical Considerations of MobileDevices

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 prag-

matic aspects that must go into decision making

regarding these devices. Customization and pur-

chasing of software, particularly for agencies that

might create specialized patient or provider appli-

cations, can also quickly add to the price.

Mobile devices are notorious battery hogs anddepending 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

CNET13 recently compared battery lifewith a video

running continuously on most of the tablets thatare currently on the market. They found a wide

range of battery life. Popular devices such as

28 MATTHEW DAVID BYRNE

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 charg-

ing and updating cords, space for storage, docking

stations, and availability of extra devices or batter-ies add another dimension to their use and pur-

chase prices.

Many of the devices discussed are expensive and

sought-after pieces of technology. It may be impor-

tant to have a system for ‘‘check-in/check-out’’ and

for securing these devices during off hours to pre-

vent 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 hasbeen stolen or misplaced).

Having a device fall on the floor or in the sink may

be just as disastrous as having one stolen. Replace-

ment 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.14 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 se-

curity breaches. Stage 2 of Meaningful Use hasprovided clarification regarding the encryption

(coding of messages so that it cannot be easily un-

derstood 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 Se-

curity Rules. Health care agencies are required to

complete a security risk analysis, audit user activ-ity, and ensure reasonable and appropriate encryp-

tion practices. There is a whole host of encryption

standards and practices, which may better protect

patient health care data that may be on mobile de-

vices while new policies dictate reporting proce-

dures in cases of security breaches.16

Privacy issues beyond lost or stolen devices with

patient data on them must also be considered

alongside new threats such as the hacking of mo-

bile devices. The hacking of devices is a sophisti-

cated type of breach of patient privacy or data

loss, although less technological concerns are aris-

ing as well. A family member or even a patient can

easily and discretely take a photo of hospital staffor other patients with cameras on cell phones

and tablets. Imagine how easy it would be in

a cramped preoperative or postoperative environ-

ment for a family member or patient to acciden-

tally or purposefully take a photo or video of

another patient. Our care environments are pro-

gressively moving towards more family-friendly

policies, which can increase the risk of these typesof purposeful or accidental infringements on pri-

vacy. To complicate matters, these photos or

videos could make the rounds on social media net-

works 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. Tech-

nology as a potentially dehumanizing force is not

a new issue, and was a hot topic in the late1980s and early 1990s as the sophistication and

use of patient care technologies was booming. Al-

though the idea of maintaining ‘‘high tech and

high touch’’ care is a familiar notion, it must be re-

visited 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 camewhen 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 pa-

tient’s room their first or second action was togo to the computer keyboard. The students used

the computer to get to know the patient but also

INFORMATICS 29

as a means of collecting their thoughts. Their reli-

ance and focus on the computer sometimes gave

an impression of rudeness or distance, particularly

to older patients.When asked about this, most stu-

dents were not even aware of what they did or hada 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 dis-comfort. Adding to this discomfort is the realiza-

tion 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 com-

forting and more a result of not knowing where to

find information or comfort with navigating theEHR. 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’s17 book and several articles on

the topic offer important insights as to how to rec-

oncile the disruptive effect of technology. Locsintheorizes that our technological competence is ac-

tually a part of howwe demonstrate caring as regis-

tered nurses. He posits that ‘‘machine technology

can bring a patient closer to nurses because it en-

hances 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 per-son.’’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 em-brace the importance of advancing our computer

and information literacy. Technology can and

must affirm the centrality of holistic patient know-

ing, 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 framesof 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 Innova-

tions lecture, October 2012, University of Minne-sota) recently presented her findings related to

the experience of patients when nurses com-

municate with them while using the EHR. Her

research accentuates both the pitfalls and previ-

ously unspoken concerns about the potential role

of technology in health care. Strauss’ qualitative

analysis of patient responses identified that com-

puter charting can indeed deter a nurse’s use ofpresence 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 atten-

tion may shift to the computer or other technolo-

gies. Her recommendations included beginning

the therapeutic interchange by addressing the pa-

tient’s needs before going to the computer, explain-

ing what is being entered into the computer, andthe importance of improving the skill of nurses

for better maintenance of the therapeutic relation-

ship in light of growing technological demands.

Her research accentuates the need to strike a bal-

ance 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 de-

vices and technology might offer. We now readilyhave 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 bridgethe divide of time and learning needs. I look for-

ward to an ASPAN CPC question and research

30 MATTHEW DAVID BYRNE

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 in-

structions? Like any disruptive innovation or

technology, we must face the risks and rewards

with a patient-centric attitude, intellectual curios-

ity, and positive deviancy from the status quo.

References

1. Perry SM, MonaghanWP. The prevalence of visible and/or

occult blood on anesthesia and monitoring equipment. AANA J.

2001;69:44-48.

2. Wild D. ECG cables are common source of contami-

nants in OR. Infectious Disease Special Edition. December

2011:1.

3. Russell A, Secrest J, Schreeder C. Stethoscopes as a source

of hospital-acquired methicillin-resistant staphylococcus au-

reus. J Perianesth Nurs. 2012;27:82-87.

4. Neely AN, Weber JM, Daviau P, et al. Computer equipment

used in patient care within a multihospital system: Recommen-

dations for cleaning and disinfection.Am J Infect Control. 2005;

33:233-237.

5. Schultz M, Gill J, Zubairi S, Huber R, Gordin F. Bacterial

contamination of computer keyboards in a teaching hospital.

Infect Control Hosp Epidemiol. 2003;24:302-303.

6. Hartmann B, Benson M, Junger A, et al. Computer key-

board and mouse as a reservoir of pathogens in an intensive

care unit. J Clin Monit Comput. 2004;18:7-12.

7. Wilson APR, Hayman S, Folan P, et al. Computer keyboards

and the spread of MRSA. J Hosp Infect. 2006;62:390-392.

8. Ulger F, Esen S, Dilek A, Yanik K, Gunaydin M,

Leblebicioglu H. Are we aware how contaminated our mobile

phones with nosocomial pathogens? Ann Clin Microbiol Anti-

microb. 2009;8:7.

9. Gould D. Commentary: Ulger F et al. (2009). Are we aware

how contaminated our mobile phones with nosocomial patho-

gens? Nurs Crit Care. 2009;14:213-214.

10. Fukada T, Iwakiri H, Ozaki M. Anaesthetists’ role in com-

puter keyboard contamination in an operating room. J Hosp In-

fect. 2008;70:148-153.

11. Rutala WA, White MS, Gergen MF, Weber DJ. Bacterial

contamination of keyboards: Efficacy and functional impact of

disinfectants. Infect Control Hosp Epidemiol. 2006;27:372-377.

12. Neely AN, Sittig DF. Basic microbiologic and infection

control information to reduce the potential transmission of

pathogens to patients via computer hardware. J Am Med In-

form Assoc. 2002;9:500-508.

13. 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.

14. Schultz D. Medical Data Breaches Raising Alarm.

Washington Post Health & Science. 2012. Available at: http://

www.washingtonpost.com/national/health-science/medical-

data-breaches-raise-alarms/2012/06/02/gJQAVPWt9U_story.html.

Accessed November 20, 2012.

15. Gallagher LA. Psst! Stage 2 Meaningful Use Final Rule Im-

pact to Privacy and Security. Available at: http://blog.himss.org/

2012/09/19/psst-stage-2-meaningful-use-final-rule-impact-to-pri

vacy-and-security/. Published September 19, 2012, and Up-

dated 2012. Accessed November 20, 2012.

16. McMillan M. HITECH security mandates for healthcare

organizations. Healthc Financ Manage. 2011;65:118-122.

17. Locsin R. Technological Competency as Caring in Nurs-

ing: A Model for Practice. Sigma Theta Tau International; 2005.