Infection Prevention

October 1, 2004

Infection Prevention Through Proper Hand Hygiene and Gloving

Infection Prevention
Through Proper Hand Hygiene and Gloving

By Kelly M. Pyrek

By now, healthcare workers (HCWs) should know byheart the hand-hygiene drill further underscored in the Centers for DiseaseControl and Prevention (CDC)s 2002 Guideline for Hand Hygiene in theHealthcare 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 orantimicrobial soap and water.

  • If hands are not visibly soiled, an alcohol-based handsanitizer should be used routinely for decontaminating the hands.

  • Hands should be sanitized prior to patient contact; priorto donning sterile gloves when inserting a central venous catheter; prior toinserting urinary catheters, peripheral vascular catheters, or other invasivedevices 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, mucousmembranes, non-intact skin, and wound dressings; after removing gloves; beforeeating; 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 atleast 15 seconds. Rinse and dry with a disposable towel. Use the towel to turnoff 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 neededas recommended by the products manufacturer.

No discussion of hand hygiene issues is complete withoutaddressing a key component of infection prevention medical glove usage and most importantly, avoiding breaches of gloves barrier-protectionabilities.

One of the greatest challenges to glove integrity isdegradation, which is considered to be deleterious effects that sharp edges,fatigue, extreme temperatures, ozone, chemicals, oil or other substances canhave on gloves physical properties. The obvious signs of glove degradationinclude loss of elasticity, brittleness, softening, tackiness, cracking, andgrowth or creep of the length of the fingers.2

It is essential for clinicians to recognize the early warningsigns of glove degradation, says Wava Truscott, PhD, MBA, BS, director ofscientific affairs and clinical education for Kimberly-Clark Health Care. Theconcern is if a clinician sees a finger (of a glove) growing, that they wouldthink this kind of material is just one that stretches, and stays stretched,rather than recognizing that its really a breakdown of the double bond thatholds together the components of a glove. As you break a double bond, itcontinues to stretch out, and I dont think some clinicians recognize this isa problem. Brittleness is probably a little easier for clinicians to recognize most instantly think breakdown if they feel the glove is gettingbrittle. Its a challenge to all clinicians; surgeons may noticeglove degradation a little quicker because as the fingers of the glove grow, heor 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 barrierprotection; check for correct . t of glove length, . nger contour and thumbposition. Also look for embedded debris that may weaken the glove.

  • Donning technique: Avoid rips and tears by donning glovescorrectly to avoid unnecessary stretching; make sure hands are dry beforedonning.

  • Length of wear: Gloves should be changed frequently toreduce the potential for barrier compromise. Fatigue is exacerbated by rigorousmanipulation, and exposure to certain chemicals.

  • Storage conditions: Glove material can be degraded byextreme heat, light, moisture and ozone; they should be stored in a cool, dryplace located away from light- and electricity-generating equipment such asX-ray machinery.

Truscott says HCWs must be vigilant about observing the signsof impending glove failure. One of the biggest concerns is wearing gloves for too long ofa time period.

I dont believe clinicians truly are aware of the need tochange their gloves frequently, she says. Theres a tendency to wear gloves for far toolong. Evidence for the need to change gloves regularly has been published andhas been presented at lectures, but there is still a need for continuededucation. For clinicians just on the floor in hospitals who are using examgloves, you see them wearing them closer to 15 minutes at a time, so it probablyisnt an issue. But there are many others, such as HCWs and housekeeping, whoare wearing them much longer. Its an issue in the OR, too. During surgery it is very difficult; OR staff cant justremove their old gloves and put on new ones, as the sterile field can becompromised.

It is being recommended that clinicians double-glove inhigh-risk situations; they can remove the outer glove and put on another outerglove. After working a few hours in the OR, you become sweaty, and itschallenging to remove gloves once the hand swells a bit and the gloves becomesticky. Only taking off and replacing one outer glove is much easier.

Truscott adds that donning gloves improperly is a significantcause of glove degradation. Grabbing gloves too hard at the cuff with fingernails canbe a problem. HCWs also grab gloves at the fingertips to pull them out of thebox, thus contaminating them before they put them on. Although this is not abreach in barrier protection, it serves the same purpose of transferringorganisms to the outside surface of the glove. The biggest insult to gloves arerings with sharp edges, as well as long or ragged fingernails; nails should notbe more than a quarter-inch in length, and artificial nails, which are veryrugged, place significant pressure in pounds per square inch at the tip of theglove. About 90 percent of breaches and breaks in vinyl gloves, for instance,occur at the fingertips; they also occur between the first finger and thethumb.

Like other aspects of hand hygiene, constant education inproper glove protocol is required, especially during times of HCW shortages. Its human nature to cut corners, Truscott says. Studieshave identified that factors such as shortness of staff; non-availability orshort-availability of soap and water, a sink, or handrub; or irritation of thehands all reduce HCWs abilities to perform good hand hygiene. Also, harried HCWs develop a false sense of security thatwearing gloves solves all hand hygiene-related problems.

Its very frustrating to keep repeating the basics ofhand hygiene, while we lose the finer points of decreasing infections, Truscott says. I was in nursing school ages ago, and handhygiene was part of the basics, probably emphasized before anything else. Thingsmay have changed, but when I look at the immense amount of research conducted onhand-washing, these basic principles are all over the place. There is talk aboutengineering controls such as an auditory signal we can incorporate inthe healthcare setting to remind people to wash their hands or change theirgloves. Whatever it is, something else needs to go into effect to increasecompliance.

Truscott adds, The best way to address awareness of glovedegradation is in-servicing HCWs, and helping them as much as possible to do their own tests perform their normalactivities while wearing gloves, remove them, then fi ll the gloves with waterto see if they leak. We can give them general guidelines, but in truth,everybody has different levels of rigorousness, different things they contactand different degrees of twisting and torque that may affect the length of timethey should be wearing gloves.

Medical glove manufacturers and standards agencies arecognizant of the continuing need to improve the imperviousness quality ofgloves, Truscott says. There are tests being developed to ensuremanufacturers know before the gloves even go out into the fi eld thatthey can withstand the rigors of and various insults to the integrity of medicalgloves. The American Society for Testing and Materials (ASTM) is developing newtest methodologies for durability, as well as a test that addressesglove-material compatibility with various lotions and hand treatments that mightbe used in conjunction with gloves. A third ASTM standard under developmentwould actually be a summary of all the different types of glove related ASTMtests, to help clinicians and manufacturers understand what type of test theywould do when seeking specific kinds of information. Essentially it would serveas a guideline to the standards and test methods.

Currently, ASTM glove-testing methods include a water leaktest (ASTM D5151), a thickness test (ASTM D3767), a tensile strength test (ASTMD412), an ultimate elongation test (ASTM D412), and a resistance to movementtest (ASTM D412). The ASTM also has a test methodology which tests viralpenetration; a liquid suspension of the challenge virus Phi X 174 is usedto detect breakthrough and potential failure of the glove material.

Robert C. Klein, et al, of Rockefeller University conducted astudy evaluating examination gloves barrier-protection capabilities, specifically for protection against viral particles.3 The researchers found, thingloves manufactured from polyethylene or polyvinyl chloride (vinyl) areineffective barriers, while gloves of thin latex are superior but not withoutfailure This study highlights the need for caution on the part of those whorely upon examination gloves for protection from infectious agents as well asthe need for establishing more adequate standards and testing procedures fortheir manufacture.

Although no chemical resistance requirement exists forstandard medical gloves, some manufacturers choose to use the ASTM F739 methodto evaluate the resistance of medical gloves to specifi c chemicals, includingisopropyl alcohol, gluteraldehyde, and formalin. The popularity of alcohol-basedhandrubs has soared since late 2002, when the CDC released its revisedhand-hygiene guidelines which embraced such products for their efficacy andtime effiiency.

Alcohol-based handrubs are considered to be hand sanitizersthat contain 60 percent to 95 percent ethanol or isopropanol. While no onedisputes the value of alcohol-based products, there is concern among expertsregarding proper usage especially related to glove barrier integrity.Several studies have cautioned that alcohol-based hand sanitizers must beallowed to dry completely, or else they may make gloves susceptible to rapiddegradation.

The Klein study also indicated that latex gloves arerapidly permeated by 70 percent ethanol, which is commonly used as adisinfectant while gloves are worn. However, they remained effective barriers against viruspenetration. The authors say that while there are no epidemiological data tosubstantiate that the microporosity of glove materials is responsible foroccupationally acquired disease, clinicians should take care when selecting andusing medical gloves and hand-hygiene products.

If HCWs are not letting alcohol-based hand sanitizers drycompletely, they are not killing the bugs, and they are threatening theintegrity of the material of their gloves,Truscott says. Studies have shown that somevinyl and polyurethane gloves are susceptible to breakdown when exposed toalcohol that has not been allowed to dry. Truscott is quick to add that thereis no lingering degradation effect once the hands are dry. If HCWs use thehand sanitizers properly, they should be fine. I love the alcohol-basedproducts; its just that people arent always using them properly.

Truscott adds that HCWs need to be aware of the potential forbuild-up while using hand sanitizers and wearing gloves. HCWs are supposed toscrub at the beginning of the day and then throughout the day, use handsanitizers as long as there is no visible soiling. Lets pretend there is no visible soiling and a HCW haschanged his/her gloves 10 times. Each time they have used an alcohol handrubjust like they should, but one of the things people dont realize is by doingthat, you now have 10 times the amount of chemicals being leached from thegloves as usual. Normally you would have rinsed those off each time you washedyour hands. But now you are just using alcohol, which doesnt usually denaturethe chemicals, so you have 10 times the build-up of anything that could be anirritant. I dont know if its related, but we are seeing an increase in theType IV and chemical allergic reactions to gloves as documented in a few studiespublished recently.

Truscott adds that HCWs should also beware of using handlotions containing a significant percentage of petroleum-based oils known todeteriorate certain glove materials, such as natural rubber latex (NRL).

The CDC has advocated the use of oil-based lotions; whilethey are great for the skin, they are wonderful things at night or at lunch, noton a work shift. They will definitely work toward breaking down materials likeNRL. A lot of lotions that are water-based or dont have a significant oilcomponent are fine. If oil is the 12th ingredient in the products ingredientlist, its probably no big deal; but lotions like Vaseline or Keri have highpercentages of oil. Part of it is how much do you use, how much do you let seepinto the skin before you don your gloves all those are variables that aredifficult to control. People will call me and say, show me the information;they see the CDC guidelines that approve oil-based lotions, and theyreconfused. 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 supplytheir HCWs with the right kinds of lotion and hand-hygiene products so that HCWsdont have to figure out whether they are compatible or not with gloves, andthe HCWs should have these products in small, user-friendly sizes so they cankeep it in their pockets or nearby. The thing to remember is not to refillthem, because of the potential for contamination.