Infection Control Today: Clinical Update

Coated Gloves May be Good for Infection Control as Well as Damaged Hands

By Barbara Stein, RN, BSN, CIC

Hospital clinical staff may be fully aware of the importance of hand hygiene in controlling infection, but when their hands are damaged by long hours in medical gloves, they may be reluctant to comply with hand-hygiene guidelines. Constant use of hand scrubs and hand-washing products, coupled with extended wear of medical gloves that can trap water and soap residue on hands, can lead to dry, chapped, red, sore skin.

Medical gloves are designed to be occlusive impervious to body fluids and hazardous substances which helps protect both patients and clinicians from infection. Unfortunately, those same protective qualities put clinicians at greater risk of contact irritant dermatitis. In contrast to allergic dermatitis, which is an immunological response prompted by hyper-sensistivity to agents such as chemicals or latex, contact irritant dermatitis is the skins response to irritants. While allergic dermatitis may cause systemic conditions such as swollen eyelids or respiratory distress, contact irritant dermatitis caused by medical gloves usually stops where glove contact ends. It may be chronic or acute (see Table 1), and may be exacerbated by environmental conditions such as hot, arid atmospheres, age, and even emotional stress. In the worst cases, skin becomes open and scaly, with sores, fissures and cracks that are unattractive and uncomfortable and potentially dangerous.

Skin lesions put staff at greater risk of acquiring larger numbers of gram-negative bacteria, yeast, coagulase-positive staphylococci and other potentially pathogenic microorganisms. Damaged skin, therefore, also increases the risk the patients will acquire infectious organisms.

Contact irritant dermatitis can be treated, but it is particularly difficult for staff in departments such as surgery or emergency to maintain healthy skin when they are required to wear gloves for most of their shifts and to wash their hands between each patient and glove change.

A study of skin damage on the hands of nurses concluded that efforts to improve skin condition should focus on improving products, rather than procedures.1

One innovative option that hospitals are considering is medical gloves coated with skin conditioners that provide protection while they are being worn. The gloves are among the newer delivery systems being developed in part because of concerns surrounding infection control, employee health and morale and patient safety.

The Products Standards Committee at Childrens Hospital of The Kings Daughters in Norfolk, Va., recently agreed to run trials on gloves coated with a protective formulation of provitamin B5, glycerin, gluconolactone and chitisan that was created especially for healthcare workers.

Over the years, the hospital had changed from latex to powder-free to nitrile gloves, but at one point the surgery department alone was stocking eight different kinds of gloves in an effort to accommodate everyones needs. Even so, compromised skin was interfering with proper hand-hygiene protocols and, in some cases, led to use of unapproved lotions and emollients, even though the hospital supplies compatible hand lotion.

While mass marketing has given some products the cache of wonder drugs, some consumer cosmetic and skin-care products may result in some improvement, but they may not be as efficacious as advertised. Additionally, some ingredients are incompatible with some antiseptics and some types of gloves. Worse, from the clinical point of view, over-the-counter hand-care products can be contaminated due to the type of dispensing system used and may then harbor infectious microorganisms that thrive in the occlusive environment of medical gloves. In addition, consumer products often contain additives, some of which may prove incompatible with clinical hand-hygiene products.

Recognizing the problem, the Centers for Disease Control and Prevention (CDC)s Guideline for Hand Hygiene in the Healthcare Setting calls for hospitals to provide efficacious hand hygiene products that have low irritancy potential, particularly when these products are used multiple times per shift.2

Approved moisturizers can help prevent dehydration, damage to lipid barrier properties and desquamation (excessive skin cell shedding), and can also restore the water-holding capacity of the keratin layer. Several controlled trials have demonstrated that regular use of hand lotions or creams helps prevent and treat irritant contact dermatitis3 and there is biological evidence that emollients may help protect against cross-infection.

The question is, what constitutes effective protection? Glycerin has been shown to attract moisture into skin, maintain liquid crystallinity of intracellular lipids and normalize desquamation (skin shedding). It moisturizes and plasticizes the stratum corneum, and is used in a range of living organisms to maintain the correct osmotic pressure in living cells.

Gluconolactone is an alphahydroxyacid (AHA) that is less irritating than other AHAs such as lactic and glycolic acid and is known to minimize flakiness. It is often used to treat photodamaged skin.

Chitosan, which is widely used in dressings for wound healing, is a carbohydrate that promotes regeneration of injured tissues. Used alone, it can bind to skin or hair and act as a protective film. In composition with other skin-care product ingredients, it can bind water and other molecules for delivery, and increase skins moisture retention. Panthenol/provitamin 5, the alcohol form of pantothenic acid, more familiar as vitamin B5, can play an important role in protecting aging skin when applied topically. This is particularly relevant in nursing, where the majority of practicing nurses are more than 40 and the average age of an operating room nurse is 48.7.

Even the best skin-care product must be used regularly and properly if it is to be effective, however, and many clinical personnel do not adequately protect their hands, even when they use the proper lotions or creams.

Childrens Hospitals products standards committee members agreed that the theory behind Esteem gloves with Neu-Thera seemed sound, and were pleased to see results of extensive controlled, qualitative and quantitative studies overseen by a board-certified dermatologist at the California Skin Research Institute (see Table 2).

At the same time, they were reluctant to make unnecessary changes in the personal protective apparel in which people develop proprietary interest. They did, however, agree to try on the gloves. After only a few minutes they could feel a difference. The gloves coating left what felt like a protective layer on hands without feeling greasy or powdery.

That was enough to convince the committee that the gloves were worth trying in several departments to determine whether staff would be resistant to a full-scale change, and also whether the gloves would justify the relatively minor additional expense involved.

The gloves were first tried in the operating room (OR), with five staff members who had particularly troublesome hands. The positive responses from all five prompted a larger trial in the OR and, a short time later, in other areas. The gloves were at each bedside in the pediatric intensive care unit and 70 other boxes were distributed to individuals in three other nursing units.

The committee was not optimistic about the outcome, as glove trials in the past had led to numerous complaints about fit, ease of donning, sweating and other problems. The results from this trial were different; within a day managers were hearing positive comments; within a week they were seeing improved skin conditions and by the end of the month, 28 of the 32 people who completed post-trial surveys said their hands felt moisturized, smoother and less flaky.

Some of those whose hands had been in the poorest condition asked that the new gloves be made a permanent addition to hospital supplies.

Outside the OR, testers were asked to rate the gloves for fit, durability, tactile sensitivity, ease of donning, and grip properties. There were no poor rankings in any category, and only two acceptable ratings in different categories. Virtually all the rankings were good or excellent.

The response was so positive that the exam gloves now are used hospital-lwide, and the surgical gloves are the primary product in the OR.

They were introduced with little fanfare. Mass e-mail, departmental newsletters and members of the product standards, education and nursing practice committees gave notice, but news of the gloves benefits spread so rapidly by word of mouth that the customary extensive education was unnecessary.

None of the resistance that the committee feared has surfaced, despite a common staff assumption that any change is made strictly to save money. Cost was considered, but hospital materials management personnel note that choosing products based solely on cost can be a false economy. Not only can the cost of even a few nosocomial infections match the budget for hand-hygiene products supplied for patient care areas, one severe infection can result in expenses that exceed the budget for antiseptic agents. In addition, if staff wont use a product or it doesnt work, any initial savings will be lost. Finally, quality products that improve employees health also improve morale, which helps reduce turnover.

It is too early for definitive conclusions to be drawn, but at Childrens Hospital of The Kings Daughters the expectation is that coated gloves will make the hospital safer both for employees (who after a month of use had not reported allergic reactions) and patients by improving skin health and, as a result, hand-hygiene compliance. The gloves may also eliminate much of the need for different types of gloves and decrease referrals to occupational health. The hospital hopes that the need for lotions and the use of unapproved personal lotions will decrease because of improved hand conditions. While no hospital should select coated medical gloves without reviewing the formulation and efficacy of the ingredients in the coating and examining the test data that demonstrates the benefits claimed by manufacturers, the experience at Childrens Hospital of The Kings Daughters indicates that coated gloves are worth careful evaluation by any facility.

Barbara Stein, RN, BSN, CIC, is director of infection control and a member of the Products Standards Committee at Childrens Hospital of The Kings Daughters, a 186-licensed-bed pediatric hospital in Norfolk, Va.


References:

1. Heart Lung(r) 1997;26:404-12.

2. Boyce, J.M. and Pittet, D. Guidelines for hand hygiene in healthcare settings: recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Vol. 23, No. 12 Suppl. Infection Control and Hospital Epidemiology, 2002.

3. Grove, G.L., et. al. Methods for evaluating changes in skin condition due to the effects of antimicrobial hand cleansers: two studies comparing a new waterless chlorhexidine gluconate/ethanol emollient antiseptic preparation with a conventional water-applied product. Am J Inf Con. 2001, Vol. 29, No. 6, 361-369.

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