Are Gloves Misused?

Personal Protective Equipment, particularly gloves, have been a hot topic of conversation over the last 12 months. We have seen headlines in the media stating that there is a national shortage of gloves, incorrect gloves being dispatched and more recently that the government has wasted ￡10 billion on overpriced PPE. One thing I often ask myself, is do people really understand the true reason that gloves should be worn in the battle to prevent the transmission of infection or are we wearing them out of habit and a false sense of security? If so, we are both wasting money unnecessarily and causing more environmental waste than we truly need to.

So, what is the history of glove use in healthcare?

Glove use was first introduced in the surgical field at John Hopkins Hospital, US, as far back as 1889 and resulted in a significant impact on the safety of surgery for both the patient and the healthcare professional (https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)00271-8.pdf). During surgical procedures glove wearing by the medical staff was observed to save lives.

In 1964, the first disposable sterile latex medical gloves were manufactured by the Ansell Rubber company and quickly became a staple addition to theatre staffs PPE. However, the use of non-sterile clinical gloves in healthcare settings did not become a mainstream practice until the mid-1980s as a measure to protect healthcare workers from exposure to blood-borne viruses in blood and bodily fluids. The US Centres for Disease Control and Prevention first recommended the use of gloves in response to managing the increasing incidence of HIV and Hepatitis B cases at the time (Centers for Disease Control (CDC). Update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. MMWR Morb Mortal Wkly Rep. 1988 Jun 24;37(24):377-82, 387-8. PMID: 2836717.)

Since then, further developments have been made to gloves. 2016 saw the removal of powered gloves due to research linking an increased risk of post-operative scars and inflammation when surgery was performed with powdered gloves. More recently a growing trend has developed to move away from the traditional rubber (latex) glove to non-latex materials, such as polyvinyl chloride and neoprene gloves, to reduce the number of latex associated allergies for both patients and healthcare professionals. Each type of glove has its own merits and drawbacks:

• Latex gloves – have a high efficacy in protecting against bloodstream infections and properties that maintain wearer dexterity. However, the proteins found within latex can increase the risk of allergies and contact dermatitis.
• Neoprene and nitrile gloves – have a similar efficacy to latex gloves in protecting against bloodstream infections. Nitrile gloves may also lead to sensitivity reactions.
• Vinyl gloves – these are the kindest to our hands and research suggests produce the least skin reactions but they are not as robust against Bloodstream infections as other gloves (Loveday HP et al (2014) epic3: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection; 86: S1, S1-S70.)

So, when should we be wearing gloves?

The World Health Organization (WHO) guidelines on hand hygiene recognise the potential for gloves to be over-used and provide guidance on when gloves are indicated and when they are not required (WHO, 2009). The WHO, 2009, states that gloves should be used when:

1.     there is a possibility that a Healthcare professional will come into contact with blood, body fluids, mucous membranes and non-intact skin; 

2.    or, if there is an indication of contact precautions, such as when the patient is known or suspected to be colonised or infected with a pathogen or during emergency epidemics and outbreaks.

Gloves should not be used when there is no exposure to blood or body fluids and no reason for contact precautions. (https://www.who.int/gpsc/5may/Glove_Use_Information_Leaflet.pdf)

The glove acts as a barrier between the healthcare professional’s skin and pathogens so the healthcare professional does not become directly infected by a pathogen. However, gloves do not stop the transmission of pathogens from one place or surface to another – this is the role of hand sanitisation, see previous article (https://www.dhirubhai.net/pulse/power-handwashing-helen-harland/). Gloves should never be used as an alternative to hand hygiene.

Unfortunately, it appears healthcare professionals do not always following the WHO guidance. Healthcare staff have been observed wearing gloves to talk to patients and when writing notes. Two independent studies have identified that gloves are used for procedures when they are not required 42% of the time (https://www.his.org.uk/2019/02052019-glove-awareness-week/)

But does it really matter if healthcare professionals wear gloves when they do not need them? From a safety perspective one would assume not directly, although studies have shown that healthcare professionals are less likely to wash their hands after patient contact if they wear gloves (Jain, S., Clezy, K., McLaws, M. Gloves: use for safety or overuse? Am J Infect Control, 2017; 45:1407-1410). This reduction in handwashing due to wearing gloves will likely result in increased rates of infection transmission, increasing the risk of healthcare associated infections for the patient. The same research also identified that patients often feel uncomfortable with inappropriate use of gloves for personal tasks. Therefore, the overuse of gloves not only can present a potential increased risk of infection to patients but also can make the patient feel uncomfortable at the same time.

Putting the safety consideration aside, if we look at the economic and environmental impact of glove overuse, especially in the current economic climate, I would argue yes it does matter. The NHS spends over ￡35 million a year on more than 1.5 billion boxes of examination gloves (https://www.his.org.uk/2019/02052019-glove-awareness-week/), if 45% of these gloves are not necessary that is a saving of ￡15.75 million. To date, no gloves worn in healthcare procedures are recyclable and nitrile gloves are non-biodegradable. The use of gloves where they are not indicated currently results in 675,000 gloves unnecessarily ending up in a landfill or being burned releasing avoidable hazardous materials into the environment. These are big numbers with significant impact on both the environment and our pockets – saving ￡15.75 million on unnecessary glove use could contribute to a good pay increase for frontline workers for instance.

So why do healthcare professionals wear gloves unnecessarily?

The answer to this question is very complex and linked to many different drivers and variables in human behaviour. However, several studies have revealed the following two main perceptions from healthcare professionals about why they choose to wear gloves.

1.     Wilson et al, 2017 found that healthcare professionals believe that gloves provide complete protection against all pathogens. The main driver for why someone will wear gloves they state is the emotional link to self-preservation (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5418898/)

2.    Healthcare workers also perceive the use of gloves as their professional responsibility and that patients want them to wear gloves, although as we have already discussed, this is often not the case (Jain, S., Clezy, K., McLaws, M. Gloves: use for safety or overuse? Am J Infect Control, 2017; 45:1407-1410)

The unnecessary overuse of gloves in healthcare is an issue that needs addressing not just for the economic savings or the benefit to the environment but also to improve outcomes and experience for our patients. Perceptions often held by healthcare professionals that lead to the overuse of gloves are often inaccurate and can adversely affect patient safety and comfort.

Where to start on such a mammoth task?

How do you put the genie back in a bottle? To quote Martin Luther King,

“you don’t have to see the whole staircase, just take the first step”.

The first step is to raise awareness of the important but also limited part gloves play in healthcare. When it is common knowledge amongst all healthcare professionals where glove use is appropriate and where it is not, then maybe we all can ask ourselves; do I need gloves for this task? According to research, almost half of the time, the answer will be no.