Skip to main content

Keeping PPE barriers in COVID-19 wards while doing proper auscultation

Abstract

The emerging COVID-19 pandemic poses many difficulties to medical professionals. One of them is the need to use personal protective equipment (PPE) in order to protect themselves and their families, while not compromising their care. Physical examination is one of the cornerstones of medical assessment but parts of it are nearly impossible to do while wearing protective equipment. In this brief report we demonstrate a novel wireless stethoscope and its use for treating suspected and proven COVID-19 patients, as a representative to other infectious diseases.

Background

The emerging Coronavirus disease 2019 (COVID-19) poses a serious risk for medical personnel infection, which may in turn cause nosocomial spread and endanger staff ability to provide patient care [1]. SARS-CoV-2, the causative agent of COVID-19, is transmitted mainly through droplets and contact [2]. The World Health Organization (WHO) recommends that medical staff use appropriate precautions, including personal protective equipment (PPE) and use of disposable or dedicated medical equipment; PPE used in high-risk settings include face mask or respirator, disposable gloves, face shield, and in many medical centers including our own, waterproof coveralls [3].

Physical examination is a cornerstone of medical assessment, and heart and lung auscultation is one of its inherent core skills [4]. A full physical examination is required when assessing newly admitted patients and is also required for ongoing assessment of the respiratory and cardiac condition of hospitalized patients in COVID-19 wards, for example to rapidly identify life threatening complications such as pneumothorax or non-endotracheal intubation.

However, stethoscope use causes breaches of PPE since placement of earbuds requires breaking coverall protection, and stethoscope removal and placing in COVID-19 wards while not in use can lead to contamination of staff. Recently, a commentary suggested that stethoscopes should be abandoned favoring ultrasound due to those infection/contamination risks [5].

When faced with this conundrum, we found that physicians in our hospital were routinely breaking infection control guidelines to provide the best care for their patients. Here, we describe our risk-minimizing approach in examining suspected and confirmed COVID-19 patients combining adequate infection control and proper stethoscope use.

Methods

We employed a prototype wireless stethoscope system which allows the physician to auscultate patients without the need of earpiece insertion and PPE disruption, as an example to the concept of using an electronic stethoscope to maintain PPE protocols. The equipment, manufactured by Digital Global Systems (Japan), was originally developed for telemedicine and teaching purposes. It includes a wireless stethoscope-microphone with dedicated modes for high-pitched lung sounds or low-pitched heart sounds. The system is comprised of the stethoscope standalone head itself and a wireless receiver which can be connected either to a cell phone or to a headset. To facilitate physician acceptance and to minimize device interaction, we added a commercial portable waterproof speaker to allow safe auscultation without breaking PPE use protocols (Fig. 1). All parts can be disinfected between patients with 70% alcohol wipes. The system has a possibility of connecting a smartphone to the receiver unit to record and transmit findings, but to simplify system operation, we did not include it at this stage.

Fig. 1
figure1

The wireless stethoscope (right), allowing different auscultation modes represented by the heart and lungs icons, the receiver unit (left) with different connections available for remote transmission of auscultation data, and the speaker cable (top) that allows the physician to hear heart and lung sounds without breaking PPE protocols

As a pilot, we introduced two devices, one to the Emergency Department area dedicated to suspected COVID-19 patients, and the second to a COVID-19 ward. Medical staff was instructed on operating and cleaning the unit.

Medical staff reactions observed in discussions with the authors, using narrative speech only, and were highly positive. The system provided audio quality superior to the dedicated disposable stethoscopes that were in use in the emergency department and in COVID-19 wards, and was easy to operate. Original sound samples can be heard in the Appendix, Patients’ consent was obtained before publication.

Discussion

The COVID-19 outbreak is changing many longstanding practices, and medical staff must balance protecting themselves and providing good medical care [6]. Here, we present a technological approach that can help resolve one such conflict without compromising either best patient care or staff safety. This approach also promotes medical staff confidence in hospital protection protocols and enables them to use and apply medical skills in which they commonly practice; the use of similar device was demonstrated by Edelman and Weber several years ago [4] but is still not considered common practice. We have described the use of an electronic stethoscope in COVID-19 wards, to test this concept in its most practical environment; obviously the performance of this device and several similar devices should be compared and evaluated before recommending a specific product for routine use. Such electronic stethoscopes have multiple advantages beyond preserving PPE guidelines, including superior audio quality, the ability to transmit findings for consultation, and minimizing the number of medical staff exposed to patients. The fact that these devices are easily disinfected and can be transferred between patients permits the use of a small number of devices per ward. Obviously, the use of such devices may be applied to other infections control settings, facilitating better control of hospital acquired infections. In case of remote operation the physician should have an access to live video feed of the patient, as done in COVID-19 wards. The use of such technological solutions and continued search for approaches that mitigate the risks and difficulties of tackling the COVID-19 pandemic, while allowing healthcare professionals to practice the best standard of medicine, will facilitate better care for these patients. “Is there any thing whereof it may be said, See, this is new? It hath been already of old time, which was before us” [7].

Availability of data and materials

Not applicable.

Abbreviations

COVID-19:

Coronavirus disease 2019

WHO:

World Health Organization

PPE:

personal protective equipment

References

  1. 1.

    Chang D, Xu H, Rebaza A, Sharma L, Dela Cruz CS. Protecting health-care workers from subclinical coronavirus infection. Lancet Respir Med. 2020;8(3):e13. https://doi.org/10.1016/S2213-2600(20)30066-7.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Modes of transmission of virus causing COVID-19 : implications for IPC precaution recommendations. World Health Organization Scientific Brief https://www.who.int/publications-detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations published: March 29, 2020 Accessed 2 May 2020.

  3. 3.

    Global Infection Prevention and Control Network. Infection prevention and control during health care when COVID-19 is suspected. World Health Organization https://apps.who.int/iris/rest/bitstreams/1272420/retrieve published: May 19 2020 Accessed 2 May 2020.

  4. 4.

    Edelman ER, Weber BN. Tenuous tether. N Engl J Med. 2015;373(23):2199–201. https://doi.org/10.1056/NEJMp1509265.

    Article  PubMed  Google Scholar 

  5. 5.

    Buonsenso D, Pata D, Chiaretti A. COVID-19 outbreak: less stethoscope, more ultrasound. Lancet Respir Med. 2020;8(5):e27. https://doi.org/10.1016/S2213-2600(20)30120-X.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Adams JG, Walls RM. Supporting the health care workforce during the COVID-19 global epidemic [published online ahead of print, 2020 mar 12]. JAMA. 2020. https://doi.org/10.1001/jama.2020.3972.

  7. 7.

    Ecclesiastes 1:10, The Holy Bible, King James Version.

Download references

Funding

Partially funded by the Hadassah Medical Center intrenal COVID-19 fund.

Author information

Affiliations

Authors

Contributions

RNP, YO, TN, TS – Conception and design. YR and AN – design and data acquisition, ES and SL – draft and technical advice, YO and RNP – revisions. All authors have approved the submitted version.All authors read and approved the final manuscript.

Corresponding author

Correspondence to Yonatan Oster.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Patients’ consent was obtained before publication.

Competing interests

Dr. T.N is the CEO of Digital Global Systems, Inc. manufacturer of the described prototype device. All other authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1.

Sound 1 – sitting patient, mid lung: Coarse crackles are noted both in inspiratory and expiratory phase as well as squawk at inspiratory phase.

Additional file 2.

Sound 2 – sitting patient, base of the lung: late inspiratory crackles (fine crackles).

Additional file 3.

Sound 3 – Recovery phase - sitting patient, base of the lung: normal alveolar breathing.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Seidel, ., Luski, S., Ribak, Y. et al. Keeping PPE barriers in COVID-19 wards while doing proper auscultation. Antimicrob Resist Infect Control 9, 196 (2020). https://doi.org/10.1186/s13756-020-00854-y

Download citation

Keywords

  • Auscultation
  • Stethoscope
  • Physical examination
  • COVID-19
  • Personal protective equipment (PPE)
\