UNIVERSITI KUALA LUMPUR ROYAL COLLEGE OF MEDICINE PERAK

(UniKL RCMP)

STUDENT RESEARCH PROJECT (2022/2023) PROPOSAL

Bacteriological Assessment of Stethoscopes Used Among Medical Students in

a Medical University

PROTOCOL 1, VOLUME 1, 10 MARCH 2023.

PRINCIPAL RESEARCHER

NANDHINI PALANIYAPPAN, UniKL RCMP

CO PRINCIPAL RESEARCHER

DR. KHOO KIM KEA, UniKL RCMP

RESEARCHERS

A.P. DATO’ DR. JEYASEELAN A/L P. NACHIAPPAN, UniKL RCMP & PROF. DR. ABDUL KARIM
RUSS HASSAN, UniKL RCMP & MADAM MASITAH BINTI ISMAIL, UniKL RCMP & DR. CHEW ENG
LAI, HOSPITAL RAJA PERMAISURI BAINUN PERAK & DR. HAEMA SHUNMUGARAJOO,
HOSPITAL RAJA PERMAISURI BAINUN PERAK & VAISHNEVI R SUNDARAM, UniKL RCMP &
HANISSA BT ZAHIDI, UniKL RCMP & AMIRA FARZANA BT MOHAMED ZAINI, UniKL RCMP &
INTAN AZUREEN BT HAMRAN, UniKL RCMP & NUR MAISARAH BT NOORZAID, UniKL RCMP

SPONSOR: UniKL RCMP

 TABLE OF CONTENTS

1. Introduction 3
1.1. Background of Research Problem 3
1.2. Problem Statement 5
1.3. Research Questions 6
1.4. Rationale or Significance of Study 6
1.5. Research Objectives and Hypothesis 6
1.5.1. General Objective 6
1.5.2. Specific Objectives 7
1.5.3. Null Hypothesis 7
2. Literature Review 8
3. Material and Method 11
3.1. Overview of the Study 11
3.2. Study Design 11
3.3. Study and Target Population 11
3.4. Sample Size, Sampling Method and Sampling Frame 12
3.5. Inclusion and Exclusion Criteria 12
3.6. Variables Definition 14
3.7. Method of Data Collection and Technique 16
3.8. Ethical Consideration 23
3.9. Data Management 23
4. Publication Policy 24
4.1 Plan of Data Entry and Analysis 24
5 Work Plan and Budget 26
6 Results 31
7 References 35
8 Appendices 38
8.1 Appendix A 38
8.2 Appendix B 42
8.3 Appendix C 43
8.4 Appendix D 45
1
8.5 Appendix E 46

2
 1. Introduction

1.1. Background of Research Problem

It is estimated that, at any one time, more than 1.4 million people worldwide are suffering from

infections acquired in hospitals, known as nosocomial infections.1,2 Healthcare-associated

infections occur worldwide and affect both developed and developing countries. Infections are

considered nosocomial when they become clinically evident during hospitalisation. Many

pathogens can be transmitted on the hands, which is a major reason that all healthcare workers

must wash their hands before and after seeing each patient.

Transmission of infections on contaminated medical devices is also possible and outbreaks of

hospital-acquired infections have been linked to fomites such as stethoscopes, electronic

thermometers, blood pressure cuffs, latex gloves, masks, neckties, pens, badges and lanyards, and

white coats. Fomites carry many bacteria and are responsible for hospital acquired infections. 3

However, for this research we are particularly looking at the stethoscope.

Stethoscopes have been reported to be potential vectors for nosocomial infections in various parts

of the world.4 Even though stethoscopes may harbour regular skin flora such as coagulase-negative

staphylococci, they may also harbour pathogens. Following contact with infected skin, pathogens

such as antibiotic resistant microorganisms can attach and establish themselves on the diaphragms

of stethoscopes, thus can subsequently be transferred to other patients if the stethoscope is not

disinfected.

The use of 70% isopropyl alcohol is found to be more effective in reducing contamination of

stethoscopes as well as medical equipment than other agents like detergent.5

3
The aim of the present study is to determine current stethoscope hygiene habits among medical

students and correlate this with a number of factors likely to influence cleaning frequency. From

this, it is hoped that factors inhibiting stethoscope cleaning can be identified and used for future

targeted interventions to improve cleanliness in the clinical environment.

4
 1.2. Problem Statement

We live in an era of increased efforts aimed at preventing healthcare-associated infections. Most

institutions have dedicated significant resources to improving compliance with hand-hygiene and

have developed rigorous protocols for the prevention of catheter-associated infections or surgical

site interventions. In contrast, stethoscope cleaning has received relatively little attention, despite

its frequent use in clinical practice.6 In our research, we sought to characterise healthcare workers’

beliefs and practices related to stethoscope cleaning within a clinical or educational setting.

To combat this, daily cleaning of stethoscopes has been shown to reduce the microbial load but

most of the time, stethoscopes are rarely disinfected by healthcare providers. Studies have shown

that medical students might not be committed to the routine cleaning process of the stethoscope

diaphragm even though it could decrease the bacterial load7. It occurs mainly when medical

students conduct successive examinations during hospital rounds or in complicated situations.

This low prevalence of stethoscope disinfection could usually be a result of a lack of readily

available equipment or supplies for disinfection. Other possible explanations include lack of time,

the difficulty of the task and the absence of a clear reminder to clean the stethoscope. Hence,

maintaining a hygienic stethoscope diaphragm is essential to prevent cross-transmission of

nosocomial infections from patient to patient.

Furthermore, there is no standardised practice in cleaning stethoscopes between patients but there

is a standard guideline in cleaning stethoscopes such as wiping your stethoscopes with 70%

5
isopropyl alcohol solution and not to use hand sanitizer as a cleaning agent as there are additives

that may damage parts of the stethoscope.8

Hence, our study is to determine the most effective cleaning method and cleaning agents to reduce

the microbial load on the diaphragm of stethoscopes.

1.3. Research Questions

These are the research questions to be answered:

I. Are stethoscopes a potential source of nosocomial infection transmission?

II. Does the cleaning method using 70% isopropyl alcohol significantly reduce the microbial

load?

III. Do different cleaning techniques affect the microbial load?

1.4. Rationale or Significance of Study

Cleaning stethoscopes with alcohol swab containing 70% isopropyl alcohol reduces the microbial

load before and in between examining patients

1.5. Research Objectives and Hypothesis

1.5.1. General Objective

● To evaluate the effectiveness and practices of medical stethoscopes cleaning by

medical students in UniKL RCMP.

6
 1.5.2. Specific Objectives

● To determine the effectiveness of 70% isopropyl alcohol as disinfectant in reducing

microbial load on medical stethoscopes before and in between patient examinations.

● To evaluate the stethoscope hygiene practices of medical students in UniKL RCMP.

● To evaluate the stethoscope cleaning practices of study respondents

● To assess the stethoscope cleaning methods practiced by medical students in UniKL

RCMP.

1.5.3. Null Hypothesis

● There is no reduction in the microbial load on the diaphragm of the stethoscopes after

cleaning the stethoscopes with 70% isopropyl alcohol.

● There are poor stethoscope hygiene practices among medical students.

● There is no reduction in the microbial load resulting from the use of various stethoscope

cleaning methods.

7
 2. Literature Review

The World Health Organisation (WHO) defines a healthcare-associated infection (HCAI)

as an infection occurring in a patient in a hospital or other healthcare facility, in whom the infection

was not present or incubating at the time of admission.9 HCAIs are caused by bacteria, fungi or

viruses through various sources including person-to-person contact via the hands of healthcare

providers and visitors, personal equipment, airborne transmission, environmental contamination

and colonised hospital staff.10 A survey conducted by the WHO in 55 hospitals across 14 countries

revealed an average of 8.7% hospitalised patients from HCAIs.11

A stethoscope, as the universal tool of the medical profession, is frequently used for the

cardiopulmonary assessment of the patient. It is used by medical practitioners, students, and health

workers. Therefore, it has been recognised as a potential vector for bacterial transmission because

it is used in direct contact with different kinds of patients daily. 13 A contaminated stethoscope

diaphragm can potentially transmit pathogenic organisms from one patient to another because the

auscultation procedure involves several minutes of contact with the patients’ intact skin, which

provides enough opportunities for pathogen transfer.14 Thus, the stethoscope can be considered as

one of the sources of HCAIs, also known as nosocomial infections.

However, stethoscope cleaning has received relatively little attention, despite its frequent

use in clinical practice. A survey regarding stethoscope cleaning frequency was done by Bansal

and his co-workers of 62 healthcare personnels. The results showed that six individuals cleaned

their stethoscopes less than once a week, six cleaned their stethoscopes every 1 to 4 weeks, two

cleaned their stethoscopes every 5 to 8 weeks, and 15 cleaned their stethoscopes after more than 8
8
weeks. The majority of healthcare providers who responded, 33 (53.22%), had never cleaned their

stethoscopes. Most notably, none of them would clean their stethoscopes after examining each

patient.12

A study done by Muniz et al found that 76% of 3208 healthcare providers at the Children’s

Hospital Boston acknowledged that infection transmission might occur via a stethoscope.

However, only 769 (24%) of them cleaned their stethoscopes after each usage. There are many

reasons behind the low prevalence of stethoscope disinfection, which include a lack of readily

available equipment or supplies for disinfection, a lack of time, the difficulty of the task, and the

absence of a clear reminder to clean the stethoscope.15

Since the original finding of stethoscopes contaminated with staphylococci, there are

actually a lot more potential pathogenic organisms discovered on the stethoscope diaphragm

surface.16 This includes methicillin-sensitive and methicillin-resistant Staphylococcus aureus,

Escherichia coli, vancomycin-resistant Enterococcus, Pseudomonas aeruginosa and Clostridiodes

difficile.14,17 According to a study conducted in the Department of Paediatrics of Kasturba Medical

College and Hospital, the largest microorganism colony found on a stethoscope diaphragm was of

coagulase-negative staphylococci (41.86%), followed by coagulase-positive staphylococci, E.

coli, Klebsiella species, Enterococci species, Acinetobacter species, and Candida albicans.18

The evidence suggests that 70% isopropyl alcohol is partially effective in stethoscope

disinfection19. Another study into several kinds of disinfectants have shown the efficiency of

alcohol-based cleaners. The effectiveness of antiseptic soap, ethyl alcohol, and propyl alcohol was

investigated. The pollution of the membranes was reduced by cleaning with three different

9
disinfectants; however, the antiseptic soap was the least effective and the disinfectant based on

propyl alcohol was the most effective.20

Another study found that alcohol wipes were superior to alcohol-based hand rubs for single

cleansing, probably because of the cotton pledgets mechanical impact.21

The Centres for Disease Control and Prevention (CDC) recommends cleaning stethoscope

surfaces with a disinfectant to reduce antimicrobial action and stop the transmission of healthcare-

associated infections. A stethoscope should also be disassembled, the diaphragms removed from

the chest piece, all surfaces cleaned with a 70% isopropyl alcohol solution, and then all parts dried

before reassembly.22 These steps are also listed in the Littmann website on stethoscope cleaning.

However, there are no specific guidelines for practitioners on how to clean their stethoscopes in

between patients.

10
3. Material and Method

3.1. Overview of the Study

This section describes the type of study design that was selected, and the methods

involved required to answer the research questions. The design was selected to

assess the reduction in microbial load on the stethoscope diaphragm pre- and post-

cleaning with 70% alcohol swab(s), and to evaluate the stethoscope cleaning

practice among study respondents. Methods in obtaining samples are discussed

further, along with the techniques in data collection and plan for data analysis.

3.2. Study Design

This is a cross-sectional and descriptive study. Data collection will be done via

questionnaires, stethoscope imprinting samples pre- and post- cleaning with 70%

alcohol swab(s) onto culture media and observation of stethoscope cleaning

techniques done by study respondents.

3.3. Study and Target Population

All medical students in their clinical years (Years 3,4,5) available in UniKL Royal

College of Medicine Perak (RCMP) at the time of and data collection. The data

collection will be done at the foyer of the main building and foyer of the academic

building of UniKL RCMP from 8am to 5pm from 15/05/2023 to 01/06/2023.

11
3.4. Sample Size, Sampling Method and Sampling Frame

Through OpenEpi.com, we managed to estimate a sample size of 376 medical

students in clinical years for this study with a confidence level of 95% with an

anticipated 50% reduction in bacterial CFU after cleaning with 70% isopropyl

alcohol and confidence limits of +/- 5%. The anticipated reduction was set at 50%

as it is a pilot study. Convenience sampling method will be used to approach the

medical students to participate in this study in which the inclusion and exclusion

criteria will be applied. The sample size is calculated using the following formula:

N = population size

z = z-score

e = margin of error

p = standard of deviation

3.5. Inclusion and Exclusion Criteria

3.5.1. Inclusion criteria

● All Year 3 to 5 MBBS students in UniKL RCMP based in Ipoh

3.5.2. Exclusion criteria

● Researchers

12
● RCMP medical students who do not give consent

● RCMP medical students who do not have stethoscopes

13
3.6. Variables Definition

Variable Operational definition Scale of measurement

1. Sociodemographic

Academic year Participants state their Year 3, Year 4, Year 5

current academic year in

MBBS under demographic

details in the questionnaire

2. Stethoscope cleaning practice among study respondents

Have you ever cleaned your Participants state if they Yes, No

stethoscope? clean their stethoscope

If yes, how many times? Participants state how Before/after every use, at

frequent they clean their least once a day, Every 1-4

stethoscopes weeks, Every 5-8 weeks,

After more than 8 weeks

Agents used for stethoscope Participants state type of Alcohol swab, Alcohol-

cleaning during typical agents used for stethoscope based hand disinfectant,

patient care day cleaning during typical Alcohol swab and alcohol-

patient care day based hand disinfectant,

Others

14
When was the last time you Participants state the last Never, <6 months ago, >6

removed the diaphragm and time the diaphragm is months ago

rim to be properly cleaned? removed to be properly

cleaned

After cleaning, do you wait Participants state the Yes, No

for the stethoscope duration of time for alcohol

diaphragm to dry? swab to dry before using

the stethoscope

How do you determine the Participants state how they Feel using hand, visual

stethoscope to be dry? determine the stethoscopes assessment, Wait for less

to be dry after the alcohol than 30 seconds, Wait for

swab 30 seconds or more, Others

3. Observation of Method of Cleaning

Number of alcohol swabs Researchers observe how 1, 2, More than 2

used many alcohol swabs used

by participants to clean

their stethoscopes

Timing Researchers observe how <2 secs, 2-5 secs, 5-10 secs,

long participants clean their >10 secs

stethoscopes with the

alcohol swab(s)

15
 Motion Researchers observe the Circular, side to side,

motion used by respondents twisting, others

to clean their stethoscopes’

diaphragm

Parts of stethoscope cleaned Researchers observe the Diaphragm, rim, bell,

parts of stethoscope tubing, earpiece

cleaned by the respondents

3.7. Method of Data Collection and Technique

The data will be collected from the study population in UniKL RCMP from 15th May 2023

to 1st June 2023 via questionnaire, laboratory sampling techniques and observation

checklist.

Phase 1: Training of researchers

6 researchers (4th year medical students) will be trained by university microbiologists on:

i. Imprinting stethoscope diaphragm onto culture medium. The culture medium used is

nutrient agar

ii. Reading colony counts

iii. The correct technique of culture medium transportation to and fro the university’s

microbiology laboratory and the foyers of the main and academic buildings

16
Phase 2: Pre-testing

Before the commencement of the study, a trial run will be done by the researchers to

perform the questionnaire, laboratory sample collection and observation of stethoscope

cleaning methods on 5 samples.

Phase 3: Study commencement

3 groups consisting of 2 researchers each are formed. The duo will be stationed at various

places at the foyer of the main and academic buildings and student lounge of UniKL

RCMP.

i. Researchers will identify and approach potential study respondents. Researchers

will explain accordingly using the study respondents’ information sheet, on the aim of the

study, assurance of confidentiality, benefits of the study for evaluation and data collection

purposes. Consent is then obtained. Each respondent is assigned a unique study

identification (ID) number (eg. 001. 001, 003) for use in the questionnaire, checklist and

petri dishes.

ii. Session with respondents is divided into 3 parts which are:

A. Questionnaire on stethoscope cleaning practice among study respondents

Researcher 1 will conduct a face-to-face interview using a questionnaire tool titled

‘Questionnaire on the Stethoscope Cleaning Practice among Study Respondents’

from Questions 1(a) to Question 2(c).

17
 B. Imprinting of stethoscope diaphragm onto nutrient agar (which is the culture

medium on the petri dish) before and after stethoscope cleaning.

Researcher 2 will hold the stethoscope’s bell and imprint the stethoscope diaphragm

onto the nutrient agar labelled according to their unique ID number (e.g.: 001 A,

002A) while taking care to prevent the stethoscope’s stem and tubing from touching

the nutrient agar. The stethoscope is then returned to the respondent. Respondent

will then clean the stethoscope.

After the cleaning, the stethoscope will be passed to Researcher 2 again who will

then hold the stethoscope’s bell and imprint the cleaned stethoscope diaphragm

onto the nutrient agar labelled according to the unique ID number (e.g.: 001B, 002B)

while taking care to prevent the stethoscope’s stem and tubing from touching the

nutrient agar. This imprint is carried out at least 30 seconds after the cleaning of the

stethoscope to allow the stethoscope surfaces to air dry.

C. Observation on the stethoscope cleaning methods by study respondents

Researcher 1 will conduct the observation on the stethoscope cleaning methods by

the study respondents using an observational checklist tool called ‘Checklist on the

Stethoscope Cleaning Methods’.

After cleaning the stethoscope, Researcher 1 will then proceed to complete the

Questionnaire on the Stethoscope Cleaning Practice among Study Respondents

from Questions 2(d) to 2(f) with the study respondent.

iii. All the samples collected on the culture medium will be transported back to the

university’s microbiology laboratory in a large storage container within the same day and

18
incubated for 24 hours. The next day, after incubation, colony counting and identification

of organisms will be done by the 6 researchers (4th year medical students). Colony

counting will be done using a colony counter in the university laboratory. Identification of

the microbes will be done on 70 culture medium (post-cleaning stethoscope samples) and

the results will then be tabulated.

The following tools and equipment will be used in this study:

1. Master data collection form will have information of the medical student’s study

ID number (refer Appendix A).

2. Patient information sheet and written consent form contain information on the aim

of the study, assurance of confidentiality, and benefits of the study (refer Appendix

B).

3. Questionnaire on the Stethoscope Cleaning Practice among Study Respondents

(Refer Appendix C)

This questionnaire will be used for evaluation and data collection purposes. It is

prepared in the English Language and consists of 2 sections, namely:

● Q1 covers the sociodemographic data of the respondents

● Q2 addresses on the stethoscope cleaning practice among study respondents

○ Questions (a) to (c) are adapted and modified from Ghumman, G.

W., Ahmad, N., Pop-Vicas, A., & Iftikhar, S. (2018). Stethoscope

cleaning during patient care. Rhode Island Medical Journal, 101(4),

18-2023

○ Questions (d) to (f) are self-developed

4. Checklist on Stethoscope Cleaning Methods (Refer Appendix D)

19
 The observation checklist developed and filled by the researchers will be used for

the stethoscope cleaning techniques of the study respondents. Researchers will

observe the methods of cleaning the stethoscope by the respondents according to

the number of alcohol swabs used, duration (in seconds), motion (using the alcohol

swabs), and parts of the stethoscope cleaning (to put in sequence if more than 1 part

is cleaned).

5. Laboratory microbial data, (Refer Appendix E) will be used by the researchers to

enter the data on reduction of microbial load on the stethoscope diaphragm surface

after cleaning with 70% isopropyl alcohol and also the data on the presence of

gram-positive, gram-negative organisms and the results of the catalase, coagulase

test, and the oxidase test.

6. The materials needed for this study are as such:

● 150 culture plates (2 plates for 1 stethoscope diaphragm)

● 150 nutrient agars (main culture medium)

● Gram-staining set and slide

● 1 set of catalase, coagulase, and oxidase

● 50 mannitol salt agars (MSA) for gram-positive culture

○ Used for coagulase test to differentiate S. aureus (positive) from

other coagulase-negative species

● 50 Mueller-Hinton agar (MHA) and Mueller-Hinton broth (MH broth) for

coagulase-positive samples

○ Used for cefoxitin sensitivity test to detect methicillin-resistant S.

aureus (MRSA)

20
● 2 alcohol swabs (100s)

● 2 bunsen burners

● 2 parafilm

● 6 stopwatches

21
Figure 1: Methodology flow chart diagram

22
3.8. Ethical Consideration

Ethical clearance for the study will be obtained from the Medical Research and Ethics

Committee (MREC) of RCMP prior to conducting the study. The study will be conducted

after formal institutional approval is obtained from the dean of RCMP. Participation will

be voluntary and written consent will be obtained from each respondent. Participants can

withdraw from the study anytime without giving any reasons.

Participants will not be given any forms of rewards or incentives for participating in the

study. Participants will be given access to their information pertaining to this study or they

study data upon request when deemed appropriate and reasonable.

3.9. Data Management

All data collected and responses obtained from the questionnaire will be kept confidential

from any public domain and no identifiers collected. Password protected computers will

be used to store digitised data and data in papers will be stored in a locked cabinet. The

master data collection sheet containing the information of the respondents and samples will

be kept for a duration of 3 years after the study ends, and consequently destroyed afterwards

via paper shredding and complete wipe out from the researchers’ computer. The subject

information sheet is a separate document from the questionnaire to avoid identification of

the respondents. Each respondent is given a unique study ID number (eg: 001, 002) to aid

in data analysis.

23
 4. Publication Policy

Results and data presented in the study report will not identify any individual participant. The

study data will be analysed collectively in groups. There will be no identifiable data available in

any publication or research finding presentations pertaining to this study. Approvals from relevant

authorities will be obtained prior to any presentation or publication of the data deriving from this

study.

4.1 Plan of Data Entry and Analysis

All statistical analysis will be analysed using Statistical Package for the Social Sciences

(SPSS) build 1.0. 0.1275. Categorical variables will be analysed using Chi Square Test.

All categorical data including the stethoscope cleaning practices and the methods of

cleaning among study respondents will be expressed as descriptive statistics.

For the laboratory samples, the average percentage of reduction of colony-forming units

(CFU) is calculated using the formulae below, where n=67 (sample size):

Average CFU in pre-alcohol swab sample

𝛴 𝐶𝐹𝑈 𝑖𝑛 𝑝𝑟𝑒−𝑎𝑙𝑐𝑜ℎ𝑜𝑙 𝑠𝑤𝑎𝑏 𝑠𝑎𝑚𝑝𝑙𝑒𝑠

=
𝑛

Average CFU in post-alcohol swab sample

𝛴 𝐶𝐹𝑈 𝑖𝑛 𝑝𝑜𝑠𝑡−𝑎𝑙𝑐𝑜ℎ𝑜𝑙 𝑠𝑤𝑎𝑏 𝑠𝑎𝑚𝑝𝑙𝑒𝑠

=
𝑛

Average reduction in CFU

𝛴 𝐶𝐹𝑈 𝑖𝑛 𝑝𝑟𝑒−𝑎𝑙𝑐𝑜ℎ𝑜𝑙 𝑠𝑤𝑎𝑏 𝑠𝑎𝑚𝑝𝑙𝑒𝑠 − 𝛴 𝐶𝐹𝑈 𝑖𝑛 𝑝𝑜𝑠𝑡−𝑎𝑙𝑐𝑜ℎ𝑜𝑙 𝑠𝑤𝑎𝑏 𝑠𝑎𝑚𝑝𝑙𝑒𝑠

= 𝑛

24
Average percentage of reduction in CFU

𝐴𝑣𝑒𝑟𝑎𝑔𝑒 𝑟𝑒𝑑𝑢𝑐𝑡𝑖𝑜𝑛 𝑖𝑛 𝐶𝐹𝑈

= x 100%
𝐴𝑣𝑒𝑟𝑎𝑔𝑒 𝐶𝐹𝑈 𝑖𝑛 𝑝𝑟𝑒−𝑎𝑙𝑐𝑜ℎ𝑜𝑙 𝑠𝑤𝑎𝑏 𝑠𝑎𝑚𝑝𝑙𝑒

CFU reduction of more than or equal to 50% will be categorised as ‘more sanitary

stethoscope’, whereas less than 50% will be ‘less sanitary stethoscope’.

25
 Commented [1]: Do we need?
5 Work Plan and Budget

Gantt Chart

Period March 2023 April 2023 May 2023 June 2023

Week Week Week

Tasks : 1 2 3 4 1 2 3 4 1 2

X X
Brainstorming

research idea

X X
Objective

development

X X
Research

proposal

development

X X
Questionnaire

development

X X
Research

26
proposal

development

X X
Questionnaire

development

X
Proposal

presentation

X X
Proposal

improvement

for NMRR

registration

X
Proposal

submission for

MREC

approval

X
Pre-testing for

questionnaire

X X X X X
MREC

approval

27
 X X X X X
Obtaining

permission

from relevant

authority for

use of venue

Students in other rotations

X X X
Data collection

X X
Data Analysis

X
Study report

preparation

28
Budget Commented [2]: Do we need?

Item Quantity Cost (RM)

A4 paper 150 sheets 10

Printing and photostat 550 sheets 55

-Master data collection

form

-Informed consent form

-Questionnaire

-Observation checklist

-Proposal

Binding 2 sets 10

Stationeries - 20

Alcohol swabs (100s) 2

1200 (Provided by RCMP

Culture plate 150
teaching laboratory)
Nutrient agar 150

Gram-staining set and slide -

Catalase 70 sets

Coagulase -

Oxidase — Bactident (50 3

29
strips)

Mannitol salt agar (MSA) 50

Mueller-Hinton agar 50

(MHA)

Mueller-Hinton broth (MH 50

broth)

Bunsen burner 2

Parafilm 2

Total 1295

30
6 Results

Table 1: Sociodemographic data of study respondents

Academic Year Frequency Percentage of frequency (%)

Year 3 30 43

Year 4 27 39

Year 5 13 19

Table 2: Data on reduction of microbial load on the stethoscope diaphragm surface before
cleaning and in between examining patients by cleaning with 70% isopropyl alcohol

Sample CFU count (pre) CFU count (post) Reduction of CFU (%)

Table 3: Stethoscope Cleaning Practice among Study Respondents

Item Frequency Percentage of

frequency (%)

Have you ever cleaned your stethoscope?

Yes 47 67

No 24 34

Frequency of cleaning stethoscope

Before/after every use 6 9

31
 At least once a day 0 0

Every 1 to 4 weeks 22 31

Every 5 to 8 weeks 7 10

After more than 8 weeks 13 19

Agents used for stethoscope cleaning

Alcohol swab only 26 37

Alcohol-based hand disinfectant only 12 17

Alcohol swab and alcohol-based hand 5 7

disinfectant

Others 4 6

When was the last time you removed the diaphragm and rim to be properly cleaned?

Never 31 44

<6 months ago 3 4

> 6 months ago 13 19

Do you wait for the stethoscope to dry?

Yes 34 49

No 14 20

How do you determine the stethoscope to be dry?

Feel using hand 16 23

Visual assessment 17 24

Wait for less than 30 seconds 7 10

Wait for 30 seconds or more 7 10

Others 0 0

32
Table 4: Data on Stethoscope Cleaning Methods (Observational Checklist)

Item Frequency Percentage of

frequency (%)

Number of alcohol swabs used

1 64 91

2 4 6

More than 2 2 3

Timing of cleaning (in seconds)

<2 10 14

2-5 18 26

5-10 21 30

>10 21 30

Motion used during cleaning

Circular 63 90

Side-to-side 6 9

Twisting 1 1

Others 0 0

Parts of stethoscope cleaned

Diaphragm 67 96

Rim 42 60

Bell 55 79

Tubing 28 40

Earpiece 33 47

33
Table 5: Difference in CFU percentage between academic years of medical students

No. Academic Year CFU (%) Difference in

percentage
(%)

1. Year 3

2. Year 4

3. Year 5

Table 6: Difference in CFU percentage based on cleaning techniques

No. Technique Reduction in

CFU (%)

1. Circular

2. Side-to-side

3. Twisting

4. Others

34
7 References

1. Tikhomirov E. (1987). WHO programme for the control of hospital infections.

Chemioterapia : international journal of the Mediterranean Society of Chemotherapy,

6(3), 148–151.

2. Vincent J. L. (2003). Nosocomial infections in adult intensive-care units. Lancet (London,

England), 361(9374), 2068–2077. https://doi.org/10.1016/S0140-6736(03)13644-6

3. Weldegebreal F, Admassu D, Meaza D, Asfaw M. (2019) Non-critical healthcare tools as

a potential source of healthcare-acquired bacterial infections in eastern Ethiopia: A

hospital-based cross-sectional study. SAGE Open Med. 2;7:2050312118822627. doi:

10.1177/2050312118822627. PMID: 30693084; PMCID: PMC6317151.

4. Young IJB, Luz S, Lone N (2019) A systematic review of natural language processing for

classification tasks in the field of incident reporting and adverse event analysis,

International Journal of Medical Informatics, Volume 132, 103971, ISSN 1386-5056.

https://doi.org/10.1016/j.ijmedinf.2019.103971

5. Waghorn, D., Wan, W.Y., Greaves, C.D., Whittome, N., Bosley, H., & Cantrill, S. (2005).

Stethoscopes: a study of contamination and the effectiveness of disinfection procedures.

British Journal of Infection Control, 6, 15 - 17.

6. Ghumman, G. W., Ahmad, N., Pop-Vicas, A., & Iftikhar, S. (2018). Stethoscope cleaning

during patient care. Rhode Island Medical Journal, 101(4), 18-20.

7. Boulée D, Kalra S, Haddock A, Johnson TD, Peacock WF. (2018) Contemporary

stethoscope cleaning practices: What we haven't learned in 150 years. Am J Infect Control.

47(3):238-242. doi: 10.1016/j.ajic.2018.08.005. Epub 2018 Nov 2. PMID: 30396696.

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8. United States. Littmann Stethoscopes. (n.d.). Retrieved March 6, 2023, from

https://www.littmann.com/3M/en_US/littmann-stethoscopes/my-stethoscope/using-your-

stethoscope/care/

9. World Health Organization. (2002) Prevention of hospital-acquired infections: A practical

guide. 2nd edition. Geneva: WHO.

10. Gastmeier P, Stamm-Balderjahn S, Hansen S, Nitzschke-Tiemann F, Zuschneid I,

Groneberg K and Ruden H. (2005) How outbreaks can contribute to prevention of

nosocomial infection: analysis of 1,022 outbreaks. Infect Control Hosp Epidemiol 26: 357–

361.

11. World Health Organization. (2010) The burden of health care-associated infection

worldwide. Geneva: WHO.

12. Bansal, A.; Sarath, R.S.; Bhan, B.D.; Gupta, K.; Purwar, S. (2019) To assess the

stethoscope cleaning practices, microbial load and efficacy of cleaning stethoscopes with

alcohol-based disinfectant in a tertiary care hospital. J. Infect. Prev: 46-50.

13. Bukharie, H.A.; Al-Zahrani, H.; Rubaish, A.M.; Abdulmohsen, M.F. (2004) Bacterial

contamination of stethoscopes. J. Fam. Community Med.:11, 31–33.

14. O’Flaherty, N.; Fenelon, L. The stethoscope and healthcare-associated infection: A snake

in the grass or innocent bystander? (2015) J. Hosp. Infect: 91, 1–7.

15. Muniz, J.; Sethi, R.K.V.; Zaghi, J.; Ziniel, S.I.; Sandora, T.J. Predictors of stethoscope

disinfection among pediatric health care providers (2012 Am. J. Infect. Control: 40, 922–

925.

16. Gerken, Anne; Cavanagh, S.; Winner, H.I. (1972). Infection Hazard from Stethoscopes in

Hospital. The Lancet, 299(7762), 1214–1215.

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17. Peacock, W.F.; Kalra, S.; Vasudevan, R.S.; Torriani, F. (2021) Aseptic Stethoscope

Barriers Prevent C difficile Transmission In Vitro. Mayo Clin. Proc. Innov. Qual.: 5, 103–

108

18. Sengupta, S.; Sirkar, A.; Shivananda, P.G. (2000) Stethoscopes and nosocomial infection.

Indian J. Pediatrics: 67, 197–199. Available online:

https://link.springer.com/article/10.1007/BF02723663?msclkid=2b88a55ad01711eca5ad4

2d78a7fd3b0#citeas (accessed on 31 March 2022).

19. Parmar, RC, Valvi, CC, Sira, P, et al. (2004) A prospective, randomised, double-blind

study of comparative efficacy of immediate versus daily cleaning of stethoscope using 66%

ethyl alcohol. Indian J Med Sci: 58, 423–430

20. Nunez S, Moreno A, Green K, Villar J. (2000) The stethoscope in the emergency

department: a vector of infection? Epidemiol Infect. 124(2):233–7. doi:

10.1017/s0950268800003563

21. Mehta AK, Halvosa JS, Gould CV, Steinberg JP. (2010) Efficacy of alcohol-based hand

rubs in the disinfection of stethoscopes. Infect Control Hosp Epidemiol. 31(8):870–2.

https://doi.org/10. 1086/655437.

22. Centers for Disease CaP. Guideline for disinfection and sterilisation in healthcare facilities.

2008.

23. Ghumman, G. W., Ahmad, N., Pop-Vicas, A., & Iftikhar, S. (2018). Stethoscope cleaning

during patient care. Rhode Island Medical Journal, 101(4), 18-20

37
8 Appendices

8.1 Appendix A

PARTICIPANT INFORMATION SHEET

(For adult subjects)

1. Title of study: Stethoscope Cleaning Practice among Study Participants

2. Name of investigator and institution:

• Nandhini Palaniyappan (UniKL RCMP)

• Dr. Khoo Kim Kea (UniKL RCMP)

• A.P. Dato’ Dr. Jeyaseelan A/L P. Nachiappan (UniKL RCMP)

• Prof. Dr. Abdul Karim Russ Hassan (UniKL RCMP)

• Madam Masitah Binti Ismail (UniKL RCMP)

• Dr. Chew Eng Lai (Hospital Raja Permaisuri Bainun Perak)

• Dr. Haema Shunmugarajoo (Hospital Raja Permaisuri Bainun Perak)

• Vaishnevi R Sundaram (UniKL RCMP)

• Hanissa Binti Zahidi (UniKL RCMP)

• Amira Farzana Binti Mohamed Zaini (UniKL RCMP)

• Intan Azureen Binti Hamran (UniKL RCMP)

• Nur Maisarah Binti Noorzaid (UniKL RCMP)

3. Name of sponsor: No external funding

4. Introduction:

It is important that you understand why the research is being done and what it will involve. Please take your

time to read through and consider this information carefully before you decide if you are willing to
38
participate. Ask the study staff if anything is unclear or if you would like more information. After you are

properly satisfied that you understand this study, and that you wish to participate, you must sign this

informed consent form.

Your participation in this study is voluntary. You do not have to be in this study if you do not want to. You

may also refuse to answer any questions you do not want to answer. If you volunteer to be in this study,

you may withdraw from it at any time. If you withdraw, any data collected from you up to your withdrawal

will still be used for the study. Your refusal to participate or withdrawal will not affect any medical or

health benefits to which you are otherwise entitled.

This study has been approved by the Medical Research and Ethics Committee, RCMP

5. What is the purpose of the study?

The purpose of this study is to determine the reduction of microbial load on the stethoscope’s diaphragm

surface pre- and in-between examining patients. This research is necessary to improve the understanding

of stethoscope hygiene.

This research will be conducted for a duration of 10 days (15/05/2023 till 24/05/2023). The expected

number of participants is 67 individuals.

6. What are my responsibilities when taking part in this study?

It is important that you answer all of the questions asked by the study staff honestly and completely which

will take about 10 minutes of your time.

39
You will be interviewed by any one of the researchers listed previously. The interview form contains 2

sections which will enquire about your sociodemographic data and stethoscope cleaning practices.

We will also imprint the diaphragm of your stethoscope onto a nutrient agar plate, before and after cleaning

with 70% isopropyl alcohol that will grow any potential microbes.

7. What are the potential risks and side effects of being in this study?

Participation in this study will not affect up in any ways, and the risk is minimal. You are free to decline to

answer any of the questions that you feel uncomfortable with.

8. What are the benefits of being in this study?

There may or may not be any benefits to you. Information obtained from this study will help assess if there

is a benefit from practising stethoscope cleaning pre and in between patients.

9. Who is funding the research?

This study does not receive any external funding. You will not be paid for participating in this study.

10. Will my information be kept private?

All your information obtained in this study will be kept and handled in a confidential manner, in accordance

with applicable laws and/or regulations. When publishing or presenting the study results, your identity will

not be revealed without your expressed consent. Individuals involved in this study, qualified monitors and

40
auditors, and governmental or regulatory authorities may inspect the study data, where appropriate and

necessary. Your personal information and study findings will be provided to you upon request.

11. Who should I call if I have questions?

If you have any questions about the study or if you think you have a study related injury and you want

information about this study, please contact the study researchers, Nandhini Palaniyappan at telephone

number 012-621 7045 or Amira Farzana Binti Mohamed Zaini at telephone number 019-657 0188.

If you have any questions about your rights as a participant in this study, please contact: The Secretary,

Medical Research & Ethics Committee, RCMP.

41
 8.2 Appendix B

INFORMED CONSENT FORM

Title of Study: Stethoscope Cleaning Practice Among Study Participants

By signing below I confirm the following:

• I have been given oral and written information for the above study and have read and understood

the information given.

• I have had sufficient time to consider participation in the study and have had the opportunity to ask

questions and all my questions have been answered satisfactorily.

• I understand that my participation is voluntary and I can at any time free withdraw from the study

without giving a reason and this will in no way affect my future treatment. I am not taking part in any other

research study at this time. I understand the risks and benefits, and I freely give my informed consent to

participate under the conditions stated. I understand that I must follow the study doctor’s (investigator’s)

instructions related to my participation in the study.

• I will receive a copy of this subject information/informed consent form signed and dated to bring

home.

Subject:
Signature: I/C number:
Name: Date:

Investigator conducting informed consent:

Signature: I/C number:
Name: Date:

Impartial witness:
Signature: I/C number:
Name: Date:

42
 8.3 Appendix C

Questionnaire on the Stethoscope Cleaning Practice among Study

Respondents

ID: _______________________________

SOCIODEMOGRAPHIC DATA

a) Academic year

(1) Year 3

(2) Year 4

(3) Year 5

1. STETHOSCOPE CLEANING PRACTICE

a) Have you ever cleaned your stethoscope?

(1) Yes (2) No

43
 THIS SECTION IS ONLY FOR THOSE WHO ANSWERED ‘YES’ IN 2(B).

b) If yes, how many times?

(1) Before/after every use (4) Every 5 to 8 weeks

(2) At least once a day (5) After more than 8 weeks

(3) Every 1 to 4 weeks

c) Agents used for stethoscope cleaning during typical patient care day?

(1) Alcohol swab only

(2) Alcohol-based hand sanitisers only

(3) Alcohol swab and alcohol-based hand sanitisers

(4) Others (please specify): ___________________

d) When was the last time you removed the diaphragm and rim to be properly cleaned?

(1) Never (3) > 6 months ago

(2) <6 months ago

e) Do you wait for the stethoscope to dry after using the disinfectant?

(1) Yes (2) No

f) How do you determine the stethoscope to be dry?

(1) Feel using hand (4) Wait for 30 seconds or more

(2) Visual assessment (5) Other (please specify):

_______________________________
(3) Wait for less than 30 seconds

44
 8.4 Appendix D

Checklist on the Stethoscope Cleaning Methods - Observation Checklist

METHOD OF CLEANING

1. Number of alcohol swabs used:

(1) 1 (2) 2 (3) > 2

2. Timing (in seconds):

(1) < 2 (3) 5 - 10

(2) 2 - 5 (4) > 10

3. Motion:

(1) Circular (4) Others (please specify):

_________________________
(2) Side to side

(3) Twisting

4. Parts of stethoscope cleaned

Parts of stethoscope Yes No

(1) Diaphragm

(2) Rim

(3) Bell

(4) Tubing

(5) Earpiece

45
 8.5 Appendix E

Laboratory Microbial Data Collection Form

46
47