Finding the Glove Protection that Meets Your Needs
This article discusses glove selection and latex-free environments
By Rosaline Parson, RN, BSN, CEN, CCRN
Gloves first entered the healthcare scene in 1889 when an operating room nurse developed severe dermatitis from mercuric chloride, which was used as a cleansing agent. The Goodyear Rubber Co. made two pairs of thin rubber gloves with gauntlets to protect her hands. The prototype gloves worked so well that eventually the entire surgical team requested the gloves.
Over the past 10 years, the growth in latex use has been associated with universal precautions. The Bloodborne Pathogens Standard requires gloves to be worn when it is reasonable to anticipate hand contact may occur with blood, other potentially infectious materials, mucous membranes, non-intact skin, or contaminated items or surfaces, and when performing most vascular access procedures.1 In a recent clarification, OSHA has said that "gloves made of natural rubber latex (NRL) as well as synthetic materials have been cleared for marketing as medical gloves by the FDA and can be used effectively for barrier protection against bloodborne pathogens."2
With the advent of universal precautions to protect against HIV, hepatitis, and other viruses, the US glove market quickly reached 10 billion pairs annually. More than 200 types of gloves are available on the market with an overwhelming choice of materials, design, and cost.3 Recently, new glove challenges have arisen with the emergence of latex allergy among patients and health professionals. With the addition of burgeoning healthcare costs and lowered reimbursement, it's more important than ever that healthcare workers and materials managers know how to select the right glove.
Latex gloves are derived from a natural product of the rubber tree Hevea brasiliensis. Some of the proteins in natural rubber are essential for enhancing barrier protection, but a subset of those latex proteins are also allergens. Sensitization to NRL is caused by direct contact with latex gloves and antigens that become aerosolized by glove powders in the donning process.
Due to the occupational threat of HIV, Hepatitis B, and other infectious agents in the hospital environment, the Centers for Disease Control and Prevention (CDC) issued universal precautions in 1987 that emphasized the need for glove barrier protection. With healthcare workers wearing gloves more often, and for longer periods of time, incidents of skin reactions have increased dramatically. Although the prevalence of latex allergy in the general public is low (1% to 6%), the risk for healthcare workers becoming sensitized to latex ranges from 8% to 17%.
There are three types of reactions to latex gloves originating from three distinctly different physiological mechanisms: irritant contact dermatitis, allergic contact dermatitis (also called Type IV delayed hypersensitivity), and urticaria (also known as Type I immediate hypersensitivity or IgE/histamine-mediated allergy).
Irritant contact dermatitis is a direct injury to the skin cells followed by local inflammation. The first symptoms are generally redness and swelling with associated itching or burning. Continued contact results in lesion formations that often appear as dermal fissures. Chronic conditions are associated with dry, thickened skin, cracks, and papules (bumps). Causative agents include pH extremes, residual soaps and disinfectants, excessive glove chemicals, and insufficient leaching. Gloves worn too long without allowing the skin to air can result in hyperhydration, a condition rendering the skin susceptible to injury. Intracellular desiccation and surface abrasion caused by glove powder may initiate, aggravate, or amplify irritant reactions.
Allergic contact dermatitis (Type IV) is a cell-mediated allergic response to specific chemicals often referred to as contact sensitizers. The chemicals that are primarily present in most glove formulations are mercaptobenzothiazole (MBT), thiurams, and carbamates. Less frequently, individuals may develop a reaction to other glove chemicals such as antioxidants, colorants, and antimicrobials. Each time the skin is exposed to the specific antigenic chemicals, more cells are sensitized, increasing the intensity and area of the reaction. Because allergic contact dermatitis includes inflammatory mechanisms similar to those seen in irritant contact dermatitis, it is often difficult to distinguish between the two reactions. The process may be aided by remembering that irritation is confined to the area of glove contact while allergic contact dermatitis may extend beyond the border of the glove.
Immediate hypersensitivity (Type I) can occur in genetically predisposed individuals and may show no symptoms during the process of sensitization. Repeated exposure with the allergen amplifies the production of allergen specific IgE antibodies, which attach to increasing numbers of mast and basophil cells. When triggered by allergen contact, these cells release immunological mediators, such as histamine. The following symptoms may appear within minutes of exposure: local or systemic urticaria, hay fever-like symptoms, abdominal cramps, difficulty in breathing, rapid heart rate, blood pressure drop, and, potentially, anaphylactic shock. Examples of immediate Type I hypersensitivity reactions occur with penicillin and bee sting allergies. The allergens specific to gloves are proteins in the latex sap of Hevea brasiliensis (rubber tree). Individuals in high-risk occupational groups may be able to delay or avoid exposure by using gloves that are powder-free, low in protein allergens, and/or made from non-natural rubber latex materials.
No one glove material is impervious to all chemicals. The range of effects from these different chemicals can be broad. Some are immediate and obvious as the gloves literally dissolve. In others, the chemicals can degrade the barrier effectiveness, but the glove appears to remain intact. For example, polyvinyl chloride (PVC) is resistant to oxidation, acids, alkalis, fats, and some alcohol but not organic solvents. Nitrile is resistant to many chemicals and oil-based products. Chloroprene offers good resistance to chemicals, atmospheric degradation, oils, and fats. Polyurethane has no accelerators, residual odor, or taste. When chemicals are anticipated, workers need to know in detail the hazards and limits of exposure as described in the Material Safety Data Sheet as well as the manufacturing product information sheet.
The major role of examination gloves is to provide barrier protection against infectious agents and bodily fluids. Besides latex gloves, several additional examination glove types are available, including PVC, nitrile, and polyurethane.
Latex: NRL gloves remain the first choice of many healthcare workers: the gold standard of functionality, comfort, tactile sensitivity, and low cost against which all alternatives were judged. However, the increase in latex allergies has caused the non-latex glove market to expand exponentially.
Synthetics: The three major categories of synthetics are plastics, like polyvinyl chloride (PVC); elastomers, like nitrile and polychloroprene (copolymer plastics are used in non-medical settings, such as food handling); and polyurethane. Elastomers, neoprene, and copolymers of styrene butadiene rubber are more common in surgeon's gloves.
PVC remains the most widely used non-latex glove. PVC provides adequate barrier protection, especially for short-term procedures or general patient care. Furthermore PVC has a relatively low cost, is easily available, and avoids concerns regarding latex sensitivity.
Nitrile costs more than PVC, but it delivers more. Its barrier properties, fit, and function have been shown to be similar to latex. However, unlike PVC, the nitrile tends to stretch and relax with hand movement, which translates to a soft, comfortable, flexible fit even during extended wear and hand manipulation. The majority of nitrile gloves are powder-free with a polymer coating added for ease of donning.
Polyurethane is the most recent entry in the examination glove market, and its cost is comparable to nitrile. This propriety product does not contain NRL and is safe to use by individuals who are sensitive to the proteins that are found in NRL. No accelerators, like those found in nitrile, neoprene, chloroprene, and natural latex gloves or plasticizers found in vinyl gloves, are added to the polymer during manufacturing, consequently creating the first "clean" glove. This creation will virtually eliminate the potential for Type I and Type IV allergic reactions. Polyurethane offers outstanding touch sensitivity, protection, fit, and comfort unparalleled in a synthetic examination glove. Most importantly, this glove has no residual odor and/or taste for improved comfort for both patient and healthcare professional.
As with examination gloves, the major protective role of surgical gloves is against bloodborne and other pathogens. Focus on surgical gloves has been less than the low-cost examination glove. Primary reasons for this are the frequency and duration of use, the number of workers that use the product, and that surgeons require greater dexterity and tactile sensitivity. Sterile surgical gloves are available in NRL as well as the other synthetic gloves that are listed above, just at a higher cost.
Since gloves were introduced, the search has continued for a dry lubricant that would make donning easier, absorb perspiration, and avoid friction. Early agents, from club moss to talc, did all the above but contaminated the environment with particulate matter and caused post-operative complications. Today's surgical gloves use a USP-defined absorbable dusting powder: a chemically cross-linked cornstarch to which no more than 2% of magnesium oxide is mixed to prevent caking.
Cornstarch is the most common powder for both latex and synthetic examination gloves. Since exam gloves are not sterilized like surgical gloves, the cross-linking in the cornstarch particles does not break down and, thus, is far less absorbable than the powder on surgical gloves. The cross-linked cornstarch can abrade delicate tissues in the eye or internal ears and can affect the lungs, especially the underdeveloped respiratory pathways of premature babies and other at-risk patients. A powder-laden environment is also a potential source of respiratory problems and asthma-like attacks for healthcare workers.4 All environments including the surgical arena are at risk when powder is present.
Today, the primary concern of powder is the potential allergen, as in latex proteins or chemicals, used in NRL and synthetic glove manufacturing. These proteins attach themselves to the powder and are aerosolized on donning or removal. As a result of these concerns, several professional healthcare organizations have recommended that, in addition to discontinuing unnecessary use of latex gloves, healthcare institutions implement low-allergen and powder-free gloves whenever possible.
Hospitals are addressing these issues by implementing latex-safe zones through multidisciplinary committees. Responsibilities of this committee will include the coordination of system-wide efforts. Policy and procedures, standards of care, protocols, or guidelines will be formulated and reviewed through this central body of knowledge.
Some studies suggest that the typical hospital can save from 10 to 15% of total glove budget by managing usage correctly, choosing the appropriate gloves, and buying in bulk and from right vendors. In the past, one of the easiest ways to keep costs down was to use latex gloves. But a recent study from Emory University suggests that hospitals must address the rising costs related to patient and employee allergy reactions, especially allergens in NRL medical products.
Occupational latex allergy was first reported by US healthcare workers in 1992, and prevalence figures since then have varied from 8 to 17%. Sensitization to latex is caused by direct contact with latex and by latex antigens that become aerosolized with glove powders in the donning process. Phillips Goodrich and Sullivan completed a cost-analysis study comparing the costs of converting to a latex-safe environment vs. the status quo strategies in three different types of facilities in Georgia: a tertiary care hospital, a community hospital, and an outpatient internal medicine clinic.5 Each institution reported the type, quantity, and manufacturer of gloves purchased; the prices of the gloves were obtained from the manufacturers. The researchers then substituted the unit price for the comparable non-latex glove alternative to calculate the healthcare facilities' annual glove costs, if they created a latex-safe setting.
In this study, a latex-safe approach was more expensive for each facility when only glove costs were considered. However, this changed when potential disability costs were introduced into the financial decision. It was also noted, based on documented prevalence rates, that 8% of employees routinely exposed to latex gloves would develop IgE-mediated latex allergy, with 2.5% of this number also developing latex-related asthma. When calculating only the cost of diagnosis (not treatment) and using Georgia's workers' compensation benefits for RNs (the largest group of healthcare workers affected by latex allergy), it was found that only 1% or fewer of those at risk for latex allergy needed to become fully disabled, or fewer than 2% to become partially disabled for the latex-safe approach to be financially viable. The calculations did not include increased sick leave, decreased job productivity, and medical care costs for disabled employees, nor did they include costs of developing and implementing policies for avoiding latex use or in-service training. An additional study from Hopkins validated the hospital's conversion to synthetics as having minimal cost impact. This was related to volume purchasing and Group Purchasing Organization (GPO) contracting.6
Does changing latex policy work? Some supporters believe changes will minimize the risk for sensitization of predisposed healthcare workers. A study that was completed at Hopkins proved this belief. It proved that people that were already allergic to latex have shown a decrease in symptoms and serum IgE anti-latex levels once they are able to practice strict latex avoidance. Another study demonstrated symptoms ranging from rhinitis and conjunctivitis to asthma and anaphylaxis. Six months later these workers lost allergic skin and respiratory symptoms associated with latex product use when the environment was changed to latex-safe. At 15 months, the group had lost all detectable laboratory sensitivity as well.6
As the impact of latex allergy has become clearer, it is now recommended that individuals with latex allergy or workers whose tasks do not involve potential for bloodborne exposure reduce exposure to latex by using a synthetic glove alternative. If NRL gloves are chosen to be used in these circumstances, they are recommended to be low-allergen and non-powdered.6 In fact, the Food and Drug Administration (FDA) is considering reclassifying latex gloves from Class I to Class II medical devices. This would require more stringent reporting when allergic reactions occur. In September 1998, the FDA began requiring manufacturers to put allergy warnings on products or packing that contain latex. Some states recently considered banning or limiting the use of latex products.
NRL allergy is a serious medical problem for many patients and a devastating occupational disease for the healthcare provider. Since there is no treatment for latex allergy, except for complete avoidance, ways to decrease exposure must occur.P
Rosaline Parson, RN, BSN, CEN, CCRN, is vice president, Clinical Resources, Maxxim Medical, Inc. (Clearwater, Fla).
For a list of references, access the ICT Web site.
|Table 1: Risk Reduction Strategies
|Table 2: Types of Glove-Related Reactions
TYPE OF REACTION
IIrritant Contact Dermatitis
Localized reaction. Appears where there is glove-to-tissue contact. Burning, itchy, and dry, cracked skin is common.
Allergic Contact Dermatitis (Type IV)
Non-localized reaction can present beyond the area of direct tissue exposure. Swelling, pustules, and above symptoms are common. Symptoms are reoccurring.
Immediate Allergic Hypersensitivity (Type I)
Systemic allergic response to NRL protein allergens. Runny, itchy nose, watery eyes, and shortness of breath may be indicators. Can cause permanent disability and may be fatal in rare instances.
For a complete list of references click here