Gloves: How Do the Pieces of the Puzzle Fit Together?
By Peter B. Graves, RN, BSN, CNOR
How do healthcare workers (HCWs) choose a glove barrier material today? More specifically, how do HCWs select gloves that can be used for so many different tasks? There are often numerous considerations when selecting the appropriate glove.
A History Lesson
In 1983, the Centers for Disease Control and Prevention (CDC) issued a guideline to all healthcare providers entitled "Acquired Immunodeficiency Syndrome (AIDS): Precautions for Health-Care Workers and Allied Professionals."1 While universal precautions were discussed as early as 1983, the momentum for this program did not begin until 1985, with implementation hitting full stride in 1987.
The primary goal of the CDC's universal precautions program was to "minimize the risk of parental exposure to potentially infective materials."2 When the CDC issued its recommendations, federal organizations such as OSHA and others issued parallel recommendations to protect workers and other individuals.3
Jumping forward from 1988, HCWs can see in hindsight that universal precautions created several problems for the healthcare industry. First, manufacturers were required to meet the huge demand for gloves created by these new recommendations. Because of the increasing number of gloves used every year, (FDA estimated about 22 billion in 19994) and perhaps because of higher than average irritant and/or allergen levels for some gloves during years of high glove demand, an increase in work-related illnesses involving gloves has been reported. These occupationally acquired ailments are well described in the literature as:
- Non-allergic contact dermatitis,
- Type IV - allergic contact dermatitis
- Type I - Natural Rubber Latex Allergy (NRLA)
Occupational asthma also has begun to surface as an issue HCWs will need to deal with in the coming years as it relates to permissible exposure levels (PELS).5 The role of USP absorbable dusting powders used in some glove production, as well as the potential link to latex hypersensitivity is being studied by government agencies.6 With these new personal protective equipment (PPE) issues surfacing, OSHA released its updated Bloodborne Pathogen Standards7 that address both the problems associated with preventing pathogen exposure and NRLA control and enforcement issues.
The Right Glove for the Right Job
Armed with OSHA's bloodborne pathogen standards, recommendations from the CDC and the National Institute of Occupational Safety and Health (NIOSH), guidelines from national organizations, and information supplied by support groups and legislatures, how does one determine what is the correct level of protection needed for a task?
First and foremost, one must recognize that different glove requirements exist for high-risk uses vs. uses that historically have little or no risk of exposures (table 1). A committee should be assembled from each institution to determine the level of protection required for each task (table 2). Once these tasks are identified, gloves that meet both the wearer's and the patient's concerns should be chosen. Though cost concerns are omnipresent in today's healthcare environment, clinical issues must be considered along with cost-related issues.
Personal Protective Equipment Standards
Development of the protective glove standards in an institution should address a wide array of issues. Some employees may be exposed to blood and body fluids, while others may be exposed to extremely hot or cold environments, electrical hazards, cuts, and abrasions, just to name some of the potential hazards within a healthcare facility. An individual may need more than one specific type of protection depending upon the task.
Conducting literature searches will help design your facility's PPE program. There are several hospitals that have completed such a task and have published their data on the Internet. This would help any institution in the initial phases of developing a PPE program.8
Fifteen years ago, HCWs had essentially two choices of medical glove materials--latex or vinyl. Today, with the development of new synthetics, HCWs have a much wider array of materials from which to choose. When one analyzes each type of material, it becomes obvious that institutions must re-think how they provide optimal barrier protection. Table 3 illustrates that each material has benefits and weaknesses and it is important that healthcare institutions review the available data on different materials to determine which is best able to meet the barrier protection needs of their facility.
While we have used PPE for years, let us review the strengths and weaknesses of each material:
Natural Rubber Latex (NRL)
Roughly 97% of all surgeon's gloves and 65% of all exam gloves9 are made from natural rubber latex. Natural rubber latex has been considered the gold standard since the late 1890s. Latex gloves were first introduced as a protective barrier between the wearer and the harsh chemicals used to soak instruments or cleanse the skin of surgical patients.
The pros of natural rubber latex are: Excellent barrier protection; highly elastic; low cost; produced from a renewable resource (H. brasiliensus tree).
The cons are: Should not be worn by those individuals allergic to natural rubber latex proteins; not recommended for use with certain chemicals (Table 3).
Vinyl (Polyvinyl Chloride/PVC)
Vinyl has been around for many years. It was first produced as a 'latex-alternative' material, but unfortunately it has had significantly high in-use failure rates,10, 11 as high as 68%.7 While we continue to see new vinyl blends coming to market, these designer-blended vinyl gloves offer increased elasticity and comfort without addressing the high in-use failure rates. Vinyl is not being used as a surgical glove material due its perceived poor fit and feel and high end use failure rates.12 Additionally, vinyl gloves should not be worn for more than 30 minutes.13
The pros for vinyl are: Alternative for those allergic to natural rubber latex; suitable for food service and other areas with low-risk tasks; not subject to light or ozone degradation.
The cons are: Low tensile strength; stiff material; relatively high-end in-use failure rate; not recommended for handling cytotoxic drugs.14,15
Neoprene is a material that was developed in 193117 as a substitute for natural rubber latex. It has characteristics similar to natural rubber latex such as strength, puncture resistance, fit, and feel. In medical gloves, neoprene is primarily used in surgical gloves.
The pros of neoprene are: Alternative for use by those allergic to natural rubber latex; excellent chemical barrier; provides good barrier protection; less permeable to alcohol than natural rubber latex and vinyl.18
The cons are: Some neoprene formulations are slightly less elastic than natural rubber latex; more expensive than natural rubber latex.
Neoprene and the other synthetics often undergo manufacturing methods similar to those used for natural rubber latex. As such, glove manufacturers may add many of the same rubber chemicals that are used in the manufacturing of natural rubber latex gloves. These rubber chemicals may elicit a Type IV reaction in those individuals already sensitized to them. Therefore, it is important to verify the amount and types of chemicals used to manufacture the gloves.19
Nitrile (carboxylated butadiene-acrylonitrile)
Nitrile is a polymer of carboxylated butadiene and acrylonitrile.20 This material also was developed as the result of a latex shortage during WWII, but was not commercially available until 1969. The most common use of nitrile is for examination gloves.
The pros of nitrile are: Alternative for those allergic to natural rubber latex; resistant to hydrocarbons (oil & benzene);21 durable (more puncture resistant).
The cons are: May be subject to ozone degradation; tears easily once breached.
Styrene (Butadiene Rubber (SBR))
This material is a copolymer of styrene and butadiene and does not require accelerators.22 It is ozone sensitive, and therefore requires the addition of antioxidants. When antioxidants are added, the potential always exists for Type IV contact dermatitis reactions to occur on the wearer's skin if users are sensitive to a chemical used in the glove's production.23
The pro of SBR is: Alternative for use by those allergic to natural rubber latex.
The cons of SBR are: Low ozone tolerance, will degrade without antioxidants; lower elasticity than latex; disintegrates upon contact with uncured bone cement (table 3).
Styrene Ethylene Butadiene Styrene (SEBS)
SEBS is a block polymer of styrene, ethylene, butadiene, and styrene. It is used in the manufacture of both examination and surgical gloves. The SEBS material does not require the use of rubber chemicals or antioxidants.24 This material has a noticeable and strong odor, particularly after the product has been sterilized, thus making one suspect that a softener has been used.25
The pros of SEBS are: Alternative for use by those allergic to natural rubber latex; resistant to ozone.
The cons of SEBS are: Strong odor from suspected softeners; low tensile strength; disintegrates upon contact with uncured bone cement (table 3).
As mentioned in both the SBR and SEBS materials, contact with uncured bone cement is not advised. SBR and SEBS are chemically alike because they are composed of short chain polymers. When you introduce methylmethcrylate (bone cement) to the equation, the methylmethcrylate catalyst is a short chain polymer solvent. Thus, rapid breakdown of the material is likely. When using methylmethcrylate, gloves made of either of these materials should be avoided.26
Polyurethane is composed of polymeric methylene diphenyl diisocyanate.27 This material is very expensive in comparison to natural rubber latex.
The pro of polyurethane is: Alternative for use by those allergic to natural rubber latex.
The cons of polyurethane are: Can be slippery when wet; some polyurethanes may dissolve in common alcohols (ethyl & isopropyl).28
Caution should be taken when using polyurethane gloves with certain sutures packaged in alcohol.
Polyisoprene is a new synthetic glove material that is structurally similar to natural rubber latex, but without the allergenic proteins. It is composed of polyisoprene molecules, the same building blocks found in natural rubber latex
The pro of polyisoprene is: Alternative for use by those allergic to natural rubber latex.
The con of polyisoprene is: More expensive than natural rubber latex.
So, with the data available to evaluate each material, it is important to determine if the appropriate glove is being used in your healthcare facility. From an infection control standpoint, it is imperative to find out what glove is being worn within your institution. For example, assume that one uses a SEBS glove (not compatible with uncured bone cement) during a total hip procedure on a patient who is allergic to natural rubber latex. You are told the surgeon uses bone cement to secure the implant. Does this not increase the risk for a catastrophic glove failure? The potential glove failure event may put the wearer at risk for direct exposure to blood and body fluids and place the patient at risk for acquiring an infection? This catastrophic scenario can be avoided by becoming informed and proactive.
Peter B. Graves, RN, BSN, CNOR is a clinical nurse consultant for Regent Medical in Norcross, Ga.
|"Gloves: How do the Pieces of the Puzzle Fit
By Peter B. Graves, RN, BSN, CNOR
1. Acquired Immunodeficiency Syndrome (AIDS): Precautions for HealthCare Workers and Allied Professionals. MMWR. Sept. 2, 1983;32(34);450-1.
3. Background of bloodborne pathogen standard. www.oshaslc.gov/OshDoc/interp_data/119921026.html.
4. Federal Register: July 30, 1999: Vol. 64, No. 146, Proposed rules, page 41720.
5. PELS update. www.osha.gov/oshinfo/priorioties/pel/html6. National Occupational Research Agenda (NORA). Occupational Asthma and Chronic Obstructive Pulmonary Disease. www.cdc.gov/niosh/psacops/html.
7. OSHA guide for Healthcare Facilities. January 1999 update.
8. University of Toronto. Protective glove standard. January 1999.
9. IMS Health. Quarter 4, 2000.
10. Leakakos, T. All gloves are not created equal. Surgical Services Management. July, 1999; Vol. 5, No. 7:29-32.
11. Korniewicz, D., et al. Leakage of virus through used vinyl and examination gloves. Journal of Clinical Microbiology. April 28, 1990;787-788.
12. Muto, M.G., et al. Glove leakage rates as a function of latex content and brand. Arch Surg. August 2000, Vol 135:982-985.
13. Burt, S. What you need to know about latex allergy. Nursing Management. August 1999;20-26.
14. Roley, R. Glove use and safety issues in the laboratory. American Laboratory News. June 1996.
15. Laidlaw, JL, et al. Permeability of latex and polyvinyl chloride gloves to 20 antineoplastic drugs. AM J Hosp Pharm. 1984;41:2618-23.
16. Neoprene is a registered trademark of Dupont Dow Elastomers.
17. Zimmerman, C. Gloves in medical and nursing settings. Part 2: Materials and their properties. Legal Aspects.
18. Leakakos, T. All gloves are not created equal. Surgical Services Management. July, 1999; Vol. 5, No. 7:29-32.
19. Kanerva, L., Estlander, T., and Jolanki, R. Occupational allergic contact dermatitis caused by thiourea compounds. Contact Dermatitis. Oct. 31, 1994:(4):242-8.
20. Welker, J. and Mcdowell, C. Nitrile emerges as a solution, not just as an alternative. Infection Control Today. March 1999.
22. Lecture. Alternative materials for medical gloves. Muenster, Germany. June 23, 1996.
26. Hinsch, M. Selecting Surgical gloves. SSM. April 2000.
27. Rubber & Plastic News. August 14, 2000. Page 8.
28. Hinsch, M. Selecting surgical gloves. SSM. April 2000; Vol. 6, No. 4:36-41.
29. Association of periOperative Registered Nurses. Standards and Recommended Practices (2001). 283-285.
30. Beezhold, D. and Sussman, G. Determining the allergenic potential of latex gloves, SSM. Feb. 1997; Vol. 3, No. 2:35-41.