Through Proper Hand Hygiene and Gloving
By Kelly M. Pyrek
By now, healthcare workers (HCWs) should know by heart the hand-hygiene drill further underscored in the Centers for Disease Control and Prevention (CDC)s 2002 Guideline for Hand Hygiene in the Healthcare Setting.1 The main principles are:
- If hands are visibly soiled or contaminated with blood or other bodily fluids, they should be washed with a non-antimicrobial or antimicrobial soap and water.
- If hands are not visibly soiled, an alcohol-based hand sanitizer should be used routinely for decontaminating the hands.
- Hands should be sanitized prior to patient contact; prior to donning sterile gloves when inserting a central venous catheter; prior to inserting urinary catheters, peripheral vascular catheters, or other invasive devices that do not require surgery.
- Hands should be washed after contact with a patients intact skin; after contact with a patients body fluids or excretions, mucous membranes, non-intact skin, and wound dressings; after removing gloves; before eating; and after using the restroom.
- The recommended hand-hygiene technique (outside of the OR) is: wet hands with water, apply soap, rub hands together for at least 15 seconds. Rinse and dry with a disposable towel. Use the towel to turn off the faucet. When using a handrub: apply the product to the palm of one hand, rub hands together and cover all surfaces until dry. Observe the volume needed as recommended by the products manufacturer.
No discussion of hand hygiene issues is complete without addressing a key component of infection prevention medical glove usage and most importantly, avoiding breaches of gloves barrier-protection abilities.
One of the greatest challenges to glove integrity is degradation, which is considered to be deleterious effects that sharp edges, fatigue, extreme temperatures, ozone, chemicals, oil or other substances can have on gloves physical properties. The obvious signs of glove degradation include loss of elasticity, brittleness, softening, tackiness, cracking, and growth or creep of the length of the fingers.2
It is essential for clinicians to recognize the early warning signs of glove degradation, says Wava Truscott, PhD, MBA, BS, director of scientific affairs and clinical education for Kimberly-Clark Health Care. The concern is if a clinician sees a finger (of a glove) growing, that they would think this kind of material is just one that stretches, and stays stretched, rather than recognizing that its really a breakdown of the double bond that holds together the components of a glove. As you break a double bond, it continues to stretch out, and I dont think some clinicians recognize this is a problem. Brittleness is probably a little easier for clinicians to recognize most instantly think breakdown if they feel the glove is getting brittle. Its a challenge to all clinicians; surgeons may notice glove degradation a little quicker because as the fingers of the glove grow, he or she may lose dexterity and sensitivity.
- Gloves barrier-protection capacity, as well as performance, can be compromised by everyday practices, such as:2
- Glove selection: Choosing the wrong size of glove can interfere with its performance and barrier protection; check for correct . t of glove length, . nger contour and thumb position. Also look for embedded debris that may weaken the glove.
- Donning technique: Avoid rips and tears by donning gloves correctly to avoid unnecessary stretching; make sure hands are dry before donning.
- Length of wear: Gloves should be changed frequently to reduce the potential for barrier compromise. Fatigue is exacerbated by rigorous manipulation, and exposure to certain chemicals.
- Storage conditions: Glove material can be degraded by extreme heat, light, moisture and ozone; they should be stored in a cool, dry place located away from light- and electricity-generating equipment such as X-ray machinery.
Truscott says HCWs must be vigilant about observing the signs of impending glove failure. One of the biggest concerns is wearing gloves for too long of a time period.
I dont believe clinicians truly are aware of the need to change their gloves frequently, she says. Theres a tendency to wear gloves for far too long. Evidence for the need to change gloves regularly has been published and has been presented at lectures, but there is still a need for continued education. For clinicians just on the floor in hospitals who are using exam gloves, you see them wearing them closer to 15 minutes at a time, so it probably isnt an issue. But there are many others, such as HCWs and housekeeping, who are wearing them much longer. Its an issue in the OR, too. During surgery it is very difficult; OR staff cant just remove their old gloves and put on new ones, as the sterile field can be compromised.
It is being recommended that clinicians double-glove in high-risk situations; they can remove the outer glove and put on another outer glove. After working a few hours in the OR, you become sweaty, and its challenging to remove gloves once the hand swells a bit and the gloves become sticky. Only taking off and replacing one outer glove is much easier.
Truscott adds that donning gloves improperly is a significant cause of glove degradation. Grabbing gloves too hard at the cuff with fingernails can be a problem. HCWs also grab gloves at the fingertips to pull them out of the box, thus contaminating them before they put them on. Although this is not a breach in barrier protection, it serves the same purpose of transferring organisms to the outside surface of the glove. The biggest insult to gloves are rings with sharp edges, as well as long or ragged fingernails; nails should not be more than a quarter-inch in length, and artificial nails, which are very rugged, place significant pressure in pounds per square inch at the tip of the glove. About 90 percent of breaches and breaks in vinyl gloves, for instance, occur at the fingertips; they also occur between the first finger and the thumb.
Like other aspects of hand hygiene, constant education in proper glove protocol is required, especially during times of HCW shortages. Its human nature to cut corners, Truscott says. Studies have identified that factors such as shortness of staff; non-availability or short-availability of soap and water, a sink, or handrub; or irritation of the hands all reduce HCWs abilities to perform good hand hygiene. Also, harried HCWs develop a false sense of security that wearing gloves solves all hand hygiene-related problems.
Its very frustrating to keep repeating the basics of hand hygiene, while we lose the finer points of decreasing infections, Truscott says. I was in nursing school ages ago, and hand hygiene was part of the basics, probably emphasized before anything else. Things may have changed, but when I look at the immense amount of research conducted on hand-washing, these basic principles are all over the place. There is talk about engineering controls such as an auditory signal we can incorporate in the healthcare setting to remind people to wash their hands or change their gloves. Whatever it is, something else needs to go into effect to increase compliance.
Truscott adds, The best way to address awareness of glove degradation is in-servicing HCWs, and helping them as much as possible to do their own tests perform their normal activities while wearing gloves, remove them, then fi ll the gloves with water to see if they leak. We can give them general guidelines, but in truth, everybody has different levels of rigorousness, different things they contact and different degrees of twisting and torque that may affect the length of time they should be wearing gloves.
Medical glove manufacturers and standards agencies are cognizant of the continuing need to improve the imperviousness quality of gloves, Truscott says. There are tests being developed to ensure manufacturers know before the gloves even go out into the fi eld that they can withstand the rigors of and various insults to the integrity of medical gloves. The American Society for Testing and Materials (ASTM) is developing new test methodologies for durability, as well as a test that addresses glove-material compatibility with various lotions and hand treatments that might be used in conjunction with gloves. A third ASTM standard under development would actually be a summary of all the different types of glove related ASTM tests, to help clinicians and manufacturers understand what type of test they would do when seeking specific kinds of information. Essentially it would serve as a guideline to the standards and test methods.
Currently, ASTM glove-testing methods include a water leak test (ASTM D5151), a thickness test (ASTM D3767), a tensile strength test (ASTM D412), an ultimate elongation test (ASTM D412), and a resistance to movement test (ASTM D412). The ASTM also has a test methodology which tests viral penetration; a liquid suspension of the challenge virus Phi X 174 is used to detect breakthrough and potential failure of the glove material.
Robert C. Klein, et al, of Rockefeller University conducted a study evaluating examination gloves barrier-protection capabilities, specifically for protection against viral particles.3 The researchers found, thin gloves manufactured from polyethylene or polyvinyl chloride (vinyl) are ineffective barriers, while gloves of thin latex are superior but not without failure This study highlights the need for caution on the part of those who rely upon examination gloves for protection from infectious agents as well as the need for establishing more adequate standards and testing procedures for their manufacture.
Although no chemical resistance requirement exists for standard medical gloves, some manufacturers choose to use the ASTM F739 method to evaluate the resistance of medical gloves to specifi c chemicals, including isopropyl alcohol, gluteraldehyde, and formalin. The popularity of alcohol-based handrubs has soared since late 2002, when the CDC released its revised hand-hygiene guidelines which embraced such products for their efficacy and time effiiency.
Alcohol-based handrubs are considered to be hand sanitizers that contain 60 percent to 95 percent ethanol or isopropanol. While no one disputes the value of alcohol-based products, there is concern among experts regarding proper usage especially related to glove barrier integrity. Several studies have cautioned that alcohol-based hand sanitizers must be allowed to dry completely, or else they may make gloves susceptible to rapid degradation.
The Klein study also indicated that latex gloves are rapidly permeated by 70 percent ethanol, which is commonly used as a disinfectant while gloves are worn. However, they remained effective barriers against virus penetration. The authors say that while there are no epidemiological data to substantiate that the microporosity of glove materials is responsible for occupationally acquired disease, clinicians should take care when selecting and using medical gloves and hand-hygiene products.
If HCWs are not letting alcohol-based hand sanitizers dry completely, they are not killing the bugs, and they are threatening the integrity of the material of their gloves, Truscott says. Studies have shown that some vinyl and polyurethane gloves are susceptible to breakdown when exposed to alcohol that has not been allowed to dry. Truscott is quick to add that there is no lingering degradation effect once the hands are dry. If HCWs use the hand sanitizers properly, they should be fine. I love the alcohol-based products; its just that people arent always using them properly.
Truscott adds that HCWs need to be aware of the potential for build-up while using hand sanitizers and wearing gloves. HCWs are supposed to scrub at the beginning of the day and then throughout the day, use hand sanitizers as long as there is no visible soiling. Lets pretend there is no visible soiling and a HCW has changed his/her gloves 10 times. Each time they have used an alcohol handrub just like they should, but one of the things people dont realize is by doing that, you now have 10 times the amount of chemicals being leached from the gloves as usual. Normally you would have rinsed those off each time you washed your hands. But now you are just using alcohol, which doesnt usually denature the chemicals, so you have 10 times the build-up of anything that could be an irritant. I dont know if its related, but we are seeing an increase in the Type IV and chemical allergic reactions to gloves as documented in a few studies published recently.
Truscott adds that HCWs should also beware of using hand lotions containing a significant percentage of petroleum-based oils known to deteriorate certain glove materials, such as natural rubber latex (NRL).
The CDC has advocated the use of oil-based lotions; while they are great for the skin, they are wonderful things at night or at lunch, not on a work shift. They will definitely work toward breaking down materials like NRL. A lot of lotions that are water-based or dont have a significant oil component are fine. If oil is the 12th ingredient in the products ingredient list, its probably no big deal; but lotions like Vaseline or Keri have high percentages of oil. Part of it is how much do you use, how much do you let seep into the skin before you don your gloves all those are variables that are difficult to control. People will call me and say, show me the information; they see the CDC guidelines that approve oil-based lotions, and theyre confused. Nitrile gloves, by the way, are resistant to the oil.
Truscott offers a few best practices to those trying to figure it all out. There has been emphasis on the need for hospitals to supply their HCWs with the right kinds of lotion and hand-hygiene products so that HCWs dont have to figure out whether they are compatible or not with gloves, and the HCWs should have these products in small, user-friendly sizes so they can keep it in their pockets or nearby. The thing to remember is not to refill them, because of the potential for contamination.