Hand Hygiene

Infection Control Today: Clinical Update

Coated Gloves May be Good for Infection Control as Well asDamaged Hands

By Barbara Stein, RN, BSN, CIC

Hospital clinical staff may be fullyaware of the importance of hand hygiene in controlling infection, but when theirhands are damaged by long hours in medical gloves, they may be reluctant tocomply with hand-hygiene guidelines. Constant use of hand scrubs andhand-washing products, coupled with extended wear of medical gloves that cantrap water and soap residue on hands, can lead to dry, chapped, red, sore skin.

Medical gloves are designed to be occlusive — impervious tobody fluids and hazardous substances — which helps protect both patients andclinicians from infection. Unfortunately, those same protective qualities putclinicians at greater risk of contact irritant dermatitis. In contrast to allergic dermatitis, which is an immunologicalresponse prompted by hyper-sensistivity to agents such as chemicals or latex,contact irritant dermatitis is the skin’s response to irritants. Whileallergic dermatitis may cause systemic conditions such as swollen eyelids orrespiratory distress, contact irritant dermatitis caused by medical glovesusually stops where glove contact ends. It may be chronic or acute (see Table1), and may be exacerbated by environmental conditions such as hot, aridatmospheres, age, and even emotional stress. In the worst cases, skin becomesopen and scaly, with sores, fissures and cracks that are unattractive anduncomfortable — and potentially dangerous.

Skin lesions put staff at greater risk of acquiring largernumbers of gram-negative bacteria, yeast, coagulase-positive staphylococci andother potentially pathogenic microorganisms. Damaged skin, therefore, alsoincreases the risk the patients will acquire infectious organisms.

Contact irritant dermatitis can be treated, but it isparticularly difficult for staff in departments such as surgery or emergency tomaintain healthy skin when they are required to wear gloves for most of theirshifts and to wash their hands between each patient and glove change.

A study of skin damage on the hands of nurses concluded thatefforts to improve skin condition should focus on improving products, rather than procedures.¹

One innovative option that hospitals are considering ismedical gloves coated with skin conditioners that provide protection while theyare being worn. The gloves are among the newer delivery systems being developedin part because of concerns surrounding infection control, employee health andmorale and patient safety.

The Products Standards Committee at Children’s Hospital ofThe King’s Daughters in Norfolk, Va., recently agreed to run trials on glovescoated with a protective formulation of provitamin B5, glycerin, gluconolactoneand chitisan that was created especially for healthcare workers.

Over the years, the hospital had changed from latex topowder-free to nitrile gloves, but at one point the surgery department alone wasstocking eight different kinds of gloves in an effort to accommodate everyone’sneeds. Even so, compromised skin was interfering with proper hand-hygieneprotocols and, in some cases, led to use of unapproved lotions and emollients,even though the hospital supplies compatible hand lotion.

While mass marketing has given some products the cache ofwonder drugs, some consumer cosmetic and skin-care products may result in someimprovement, but they may not be as efficacious as advertised. Additionally, some ingredients are incompatible with someantiseptics and some types of gloves. Worse, from the clinical point of view,over-the-counter hand-care products can be contaminated due to the type ofdispensing system used and may then harbor infectious microorganisms that thrivein the occlusive environment of medical gloves. In addition, consumer productsoften contain additives, some of which may prove incompatible with clinicalhand-hygiene products.

Recognizing the problem, the Centers for Disease Control andPrevention (CDC)’s “Guideline for Hand Hygiene in the Healthcare Setting”calls for hospitals to provide “efficacious hand hygiene products that havelow irritancy potential, particularly when these products are used multiple times per shift.”²

Approved moisturizers can help prevent dehydration, damage tolipid barrier properties and desquamation (excessive skin cell shedding), andcan also restore the water-holding capacity of the keratin layer. Severalcontrolled trials have demonstrated that regular use of hand lotions or creamshelps prevent and treat irritant contact dermatitis³ and there is biologicalevidence that emollients may help protect against cross-infection.

The question is, what constitutes effective protection?Glycerin has been shown to attract moisture into skin, maintain liquidcrystallinity of intracellular lipids and normalize desquamation (skinshedding). It moisturizes and plasticizes the stratum corneum, and is used in arange of living organisms to maintain the correct osmotic pressure in livingcells.

Gluconolactone is an alphahydroxyacid (AHA) that is lessirritating than other AHAs such as lactic and glycolic acid and is known tominimize flakiness. It is often used to treat photodamaged skin.

Chitosan, which is widely used in dressings for wound healing,is a carbohydrate that promotes regeneration of injured tissues. Used alone, itcan bind to skin or hair and act as a protective film. In composition with otherskin-care product ingredients, it can bind water and other molecules fordelivery, and increase skin’s moisture retention. Panthenol/provitamin ⁵, thealcohol form of pantothenic acid, more familiar as vitamin B5, can play animportant role in protecting aging skin when applied topically. This isparticularly relevant in nursing, where the majority of practicing nurses aremore than 40 and the average age of an operating room nurse is48.7.

Even the best skin-care product must be used regularly andproperly if it is to be effective, however, and many clinical personnel do notadequately protect their hands, even when they use the proper lotions or creams.

Children’s Hospital’s products standards committee membersagreed that the theory behind Esteem gloves with Neu-Thera™ seemed sound, andwere pleased to see results of extensive controlled, qualitative andquantitative studies overseen by a board-certified dermatologist at theCalifornia Skin Research Institute (see Table 2).

At the same time, they were reluctant to make unnecessarychanges in the personal protective apparel in which people develop proprietaryinterest. They did, however, agree to try on the gloves. After only a fewminutes they could feel a difference. The gloves’ coating left what felt likea protective layer on hands without feeling greasy or powdery.

That was enough to convince the committee that the gloves wereworth trying in several departments to determine whether staff would beresistant to a full-scale change, and also whether the gloves would justify therelatively minor additional expense involved.

The gloves were first tried in the operating room (OR), withfive staff members who had particularly troublesome hands. The positiveresponses from all five prompted a larger trial in the OR and, a short timelater, in other areas. The gloves were at each bedside in the pediatricintensive care unit and 70 other boxes were distributed to individuals in threeother nursing units.

The committee was not optimistic about the outcome, as glovetrials in the past had led to numerous complaints about fit, ease of donning,sweating and other problems. The results from this trial were different; within a day managers were hearing positive comments; within aweek they were seeing improved skin conditions and by the end of the month, 28of the 32 people who completed post-trial surveys said their hands feltmoisturized, smoother and less flaky.

Some of those whose hands had been in the poorest conditionasked that the new gloves be made a permanent addition to hospital supplies.

Outside the OR, testers were asked to rate the gloves for fit,durability, tactile sensitivity, ease of donning, and grip properties. Therewere no “poor” rankings in any category, and only two “acceptable”ratings — in different categories. Virtually all the rankings were “good”or “excellent.”

The response was so positive that the exam gloves now are usedhospital-lwide, and the surgical gloves are the primary product in the OR.

They were introduced with little fanfare. Mass e-mail,departmental newsletters and members of the product standards, education andnursing practice committees gave notice, but news of the gloves’ benefitsspread so rapidly by word of mouth that the customary extensive education wasunnecessary.

None of the resistance that the committee feared has surfaced,despite a common staff assumption that any change is made strictly to savemoney. Cost was considered, but hospital materials management personnel notethat choosing products based solely on cost can be a false economy. Not only canthe cost of even a few nosocomial infections match the budget for hand-hygieneproducts supplied for patient care areas, one severe infection can result inexpenses that exceed the budget for antiseptic agents. In addition, if staff won’tuse a product or it doesn’t work, any initial savings will be lost. Finally,quality products that improve employees’ health also improve morale, whichhelps reduce turnover.

It is too early for definitive conclusions to be drawn, but atChildren’s Hospital of The King’s Daughters the expectation is that coatedgloves will make the hospital safer both for employees (who after a month of usehad not reported allergic reactions) and patients by improving skin health and,as a result, hand-hygiene compliance. The gloves may also eliminate much of theneed for different types of gloves and decrease referrals to occupationalhealth. The hospital hopes that the need for lotions and the use of unapprovedpersonal lotions will decrease because of improved hand conditions. While nohospital should select coated medical gloves without reviewing the formulationand efficacy of the ingredients in the coating and examining the test data thatdemonstrates the benefits claimed by manufacturers, the experience at Children’sHospital of The King’s Daughters indicates that coated gloves are worthcareful evaluation by any facility.

Barbara Stein, RN, BSN, CIC, is director of infection controland a member of the Products Standards Committee at Children’s Hospital of The King’s Daughters, a 186-licensed-bed pediatric hospital inNorfolk, Va.

1. Heart Lung(r) 1997;26:404-12.

2. Boyce, J.M. and Pittet, D. Guidelines for hand hygiene inhealthcare settings: recommendations of the healthcare infection controlpractices advisory committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene TaskForce. Vol. 23, No. 12 Suppl. Infection Control andHospital Epidemiology, 2002.

3. Grove, G.L., et. al. Methods for evaluating changes in skincondition due to the effects of antimicrobial hand cleansers: two studiescomparing a new waterless chlorhexidine gluconate/ethanol emollient antisepticpreparation with a conventional water-applied product. AmJ Inf Con. 2001, Vol. 29, No. 6, 361-369.