Choice of Reusables vs. Disposables Depends on Utilization, Surgical Procedure
By Kelly M. Pyrek
Nowhere is the debate over disposables vs. reusables seemingly greater than within personal protective equipment (PPE) choices such as gowns and drapes. Disposable items are single-use and nonwoven, while reusable items are multiple-use and woven. The most important criteria is the degree of barrier properties inherent in the item, meaning that only gowns and drapes that are impervious to fluids and contaminants through a protective mechanism of a reinforced film, membrane or coating, according to Barbara J. Gruendemann, RN, MS, FAAN, CNOR and Sandra Stonehocker Mangum, RN, MN, CNOR, authors of Infection Prevention in Surgical Settings. These items must meet standards established by the American Society for Testing Materials (ASTM), the Association for the Advancement of Medical Instrumentation (AAMI) and the Association of periOperative Registered Nurses (AORN). Manufacturers of gowns and drapes must verify that their fabrics provide "protective barriers against microorganisms, particulates and fluids, and that they can maintain their ability to withstand potential tears, punctures, stains and abrasions."1
Gowns and drapes are the frontline defense against the transmission of infectious bodily fluids and organic matter, so the health and safety of the surgical team is paramount in making PPE choices. Gown materials in particular "must meet the requirements of different types of invasive surgical procedures (dependent on length of procedure, amount of expected blood loss, area of body entered and risk to surgical team members), with no compromise to aseptic technique," Gruendemann and Mangum write.2
It is estimated that nearly 80 percent of U.S. hospitals use disposable drapes and gowns, and of the 20 percent that use reusable items, many are using high-tech synthetic materials designed to extend fabric longevity and boost barrier properties.3 Grundemann and Mangum acknowledge that choosing between reusables and disposables is no easy task, given the advantages and disadvantages of each system.
Overall, patient-care delivery, protection of staff and waste management considerations must be balanced. They write, "Although the materials have advanced, handling of reusable gowns and drapes soiled with body fluids remains problematic because they must be treated as potentially infectious materials. Single-use products, on the other hand, are more convenient because of their ready availability, guarantee of consistent barrier quality and performance and ease of disposal. Although single-use products add to landfills and consume more energy and materials to produce than reusables, the cleaning of reusables consumes water and chemicals, and adds pollutants to both water and air."4
According to Gruendemann and Mangum, the most used disposable gown and drape materials are constructed from a spunlace, wet-laid wood pulp and polyester fiber blend, and a spun-bonded, meltblown polyethylene, with both having polyethylene film laminated beneath the nonwoven fabric in critical areas. Reusable gowns are usually made from densely woven fabric; pima cotton that has a 270- to 280-thread count per square inch is an acceptable textile, as is a tightly woven, 100 percent polyester gown.
Gruendemann and Mangum say that a reusable gown should be able to withstand approximately 75 launderings and sterilization cycles before deterioration of the finish is detectable. They must be removed from use when they no longer provide an effective barrier. Disposable gowns and drapes should not be resterilized and reused unless manufacturers have provided sufficient reprocessing instructions.
Gruendemann and Mangum suggest that clinicians, infection control practitioners and materials managers consider the following points when evaluating both reusable and disposable systems:
- Are the materials compatible with infection control issues including barrier properties, effectiveness of protecting against occupational exposures to blood and body fluids, ability to meet aseptic handling qualities, and ability to meet professional standards?
- Can aseptic technique be adhered to by opening the fewest number of packages possible in a timely fashion?
- Are the products comfortable and do they meet the needs of nurses and surgeons?
- Are custom packs available to reduce waste?
- Do the products have inherent design features that enhance usage?
- Do the products meet the requirements of different procedures?
- Is there a satisfactory cost/benefit ratio?
- Are there high loss and damage rates?
"Choosing between single-use and reusable gowns and drapes is a complex exercise," Gruendemann and Mangum say. "When making decisions, it is most important to balance the considerations of barrier properties and effectiveness, safety for patients and personnel, infection prevention issues and the environment. Decision makers in healthcare facilities must continually evaluate priorities, ask questions and then decide which products are best for each situation and each facility."5
Numerous studies and papers have examined the properties and effectiveness of reusables and disposables. An early study at the Institute for Environmental Research at Kansas State University tested the liquid and microbial barrier properties of reusable and disposable gowns and studied the effects of laundering and sterilization on the barrier efficacy of reusable gowns by means of the splash test, blood resistance test, viral resistance test and physical distress test. 6 Results showed that single-layer regular gowns and double-layer fabric reinforced gowns offer different degrees of liquid resistance; specifically, they show some resistance to splashes and pooling of liquids on the surface. Gowns that have been reinforced with films, coatings and membranes are generally liquid-proof (resisting visible penetration of synthetic blood under pressure). Some of the gowns also were found to be viral resistant. The study concluded that hospitals should provide liquid-proof gowns that also offer microbial resistance for use in high-risk situations in which optimum prevention of exposure is required.
In a study conducted by the School of Chemical Engineering at Georgia Institute of Technology it was demonstrated that prolonged contact with blood alters surgical gowns' permeability traits7. In the study, a pressing-leaning simulator was used to quantify changes in fabric permeability to blood after surgical gowns were pre-wetted with anti-coagulated or coagulating blood. Five gowns were tested by placing them in contact with blood for one hour before the application of external pressure; it increased permeability for two gowns and did not alter permeability for one gown. The study concluded, "Increased fabric permeability results in an increased risk of skin contact with liquid-borne pathogens, and that a major criterion in the design and selection of a gown should be its ability to resist blood penetration for prolonged periods."