Does glove use increase the risk of infection?

Introduction

Over the past two decades gloves have become a routine part of healthcare delivery, and are often used with little consideration for whether it is appropriate in a given situation or the potential hazards associated with their use. While hand hygiene is acknowledged and promoted as a fundamental aspect of infection prevention practice, how the use of gloves may affect compliance with hand hygiene is rarely discussed.

Hands and infection transmission

Numerous studies have shown the role of hands as a vehicle for transmitting infection between patients in healthcare settings (World Health Organization, 2009). Micro-organisms are picked up on hands by touch and, as they are not adapted to survive in the arid micro-environment of the skin, these transient organisms are readily transferred to the next object touched by the hands (Hoffman and Wilson, 1994). Touching any person or non-sterile object is likely to result in the transfer of micro-organisms to the hands, but some surfaces are more contaminated than others and the numbers of organisms transferred from these is likely to be much greater (Mackintosh and Hoffman, 1984). These transient micro-organisms are easily removed from the skin surface by washing or destroyed by contact with alcohol hand rubs (WHO, 2009).

Indications for glove use

Before the mid-1980s, non-sterile examination or clinical gloves were primarily recommended for use with patients under isolation precautions (Garner and Simmons, 1983). However, after the identification of the HIV and evidence that transmission occurred as a result of exposure to infected blood, the Centers for Disease Control in the US recommended the use of “protective barriers to prevent exposure to blood, body fluids containing visible blood”, together with other high-risk fluids such as cerebrospinal and amniotic fluids (CDC, 1988; 1987).

The advice acknowledged the difficulty in identifying those carrying blood-borne viruses and specified the need to apply the precautions in the care of all patients; as a result they were described as “universal precautions” (UPs) (Siegel et al, 2007). UPs also emphasised the importance of risk assessment, with the type of protective barrier(s) selected being appropriate for the procedure performed and the type of exposure anticipated. The principles of risk assessment are summarised in Box 1.

Subsequently, CDC guidance on UPs was extended to take account of the fact that potentially infectious micro-organisms are present in “moist body sites or substances”; the use of protective barriers for any direct contact with blood, body fluids (BBF), mucous membranes and non-intact skin became widely recommended (Wilson and Breedon, 1990; CDC, 1988; Lynch et al, 1987).

The primary purpose of this approach was to reduce the risks to patients of cross-transmission of micro-organisms via health professionals’ hands by minimising soiling in situations where gross contamination of the skin was likely (Jackson and Lynch, 1991). Patients are far more vulnerable to infection caused by pathogens acquired on the hands than the staff who care for them, because the organisms can enter their tissues via invasive devices and lesions. In addition, underlying illness, co-morbidities and treatments diminish their ability to fight infection (Wilson, 2006). The use of gloves to protect health professionals from micro-organisms harboured by their patients is therefore a secondary benefit (Jackson and Lynch, 1991). Table 1 gives examples of procedures where the use of gloves is indicated.

Gloves should be applied immediately before contact with a patient’s BBF, mucous membranes or non-intact skin; this ensures that other micro-organisms are not acquired on the gloves and transferred to susceptible sites on the patient. Likewise, gloves should be removed immediately after the procedure to ensure that contamination is not transferred to other items or patients (Royal College of Nursing, 2012; Jackson and Lynch, 1991). The concept that protective equipment should be used where direct contact with BBF, non-intact skin or mucous membranes is anticipated has now been incorporated into guidance on “standard precautions” (Loveday et al, 2014a). These are a set of principles designed to be used in the care of all patients to minimise the risk of transmission of pathogens (and therefore infection) to patients and staff (Siegel et al, 2007; Wilson, 2006).

Glove use and hand hygiene practice

Hand decontamination is considered the mainstay of practice to prevent transmission of infection between patients and from patients to staff. As such, it is the focus of considerable audit activity to measure and monitor staff compliance (WHO, 2009). Audits of hand hygiene are frequently based on the framework of “My Five Moments For Hand Hygiene” (5MHH) (Sax et al, 2007), which promotes five key indications for hand hygiene:

• Moment 1: Before patient contact;
• Moment 2: Before an aseptic task;
• Moment 3: After BBF exposure;
• Moment 4: After patient contact;
• Moment 5: After contact with patients’ surroundings.

In the original concept of 5MHH, glove use was acknowledged but it was anticipated that gloves would be used as a “second skin” in some situations, for example to protect wearers from exposure to BBF or to protect a susceptible site such as a wound. Glove use was not expected to affect the points at which hand hygiene should be performed (Sax et al, 2007).

Evidence from practice suggests the use of gloves has extended far beyond the type of indications listed in Table 1, and that they are commonly used inappropriately (Loveday et al, 2014b; Fuller et al, 2011; Pittet et al, 1999). In observations of over 7,000 moments for hand hygiene, Fuller et al (2011) found gloves were used in 26% (n = 1,983) of occasions. Gloves were worn for 17% of the observations where the risk of contact with moist body substances was minimal and so the use of gloves was inappropriate, but in 21% of occasions where the risk of contact with BBF was high gloves were not used.

There is also evidence that the way gloves are used can breach 5MHH. A recent study in a large acute teaching NHS trust focused on how gloves were used in a clinical setting and the extent to which their use may contribute to cross transmission of micro-organisms between patients. The risk of contamination was defined by non-compliance with one or more of the 5MHH; out of a total of 163 episodes of care involving glove use, a risk of cross contamination was observed in 60 (37%) (Loveday et al, 2014b). The most common point of risk was Moment 4, (after contact with the patient) followed by Moment 3 (after contact with BBF). However, an additional point of cross contamination was before contact with the patient (Moment 1), as gloves were commonly put on outside patients’ rooms or at glove dispensers in bays rather than at the bedside. As a result, curtains and other equipment were touched with gloved hands before patient contact.

In addition, even inside the “patient zone” (the intact skin of a patient, together with the immediate surroundings where his or her microbial flora will be colonised) health professionals often touched a large number of items with gloved hands before patient contact - in 7% of episodes more than 10 items were touched. The study also found widespread inappropriate use of gloves - in 58% of episodes where gloves were used, their use was unnecessary. This practice was observed across all groups of health professionals (Loveday et al, 2014b).

There is clear evidence that gloves become contaminated with micro-organisms during use and transfer these to other surfaces touched (Moore et al, 2013). Contaminated gloves have been implicated in outbreaks of infection and micro-organisms have been recovered from gloves after use, even after the wearer has tried to remove contamination by using alcohol hand rub (Girou et al, 2004; Patterson et al, 1991). Rather than aiding infection prevention, when put on too soon or taken off too late, gloves may facilitate the transmission of micro-organisms from the environment to the patient and between patients (Girou et al, 2004, Pittet et al, 1999).

Audit of glove use behaviour

5MHH has become the standard approach to both education and audit of hand hygiene behaviour but, as the use of gloves is not integrated into this framework, the significance of glove use may go unrecognised. While 5MHH suggests gloves should not replace or alter the performance of hand hygiene, the extension of their use into a broad set of activities that do not involve exposure to BBF means triggers for their removal are not obvious.

As the inappropriate use of gloves is widespread, it is possible that when hand hygiene practice is audited by peers, they do not recognise lack of compliance with 5MHH when it is linked to glove use, for example, the contravention of Moment 1 when gloves are put on before entering the patient zone. A recent study described an audit tool based on 5MHH that was specifically designed to capture audit data on glove use behaviour and identify key points in the delivery of care associated with a risk of transmission (Wilson et al, in press). Such data may be useful in providing systematic evidence about the risks of inappropriate glove use that can be used to help change staff behaviour.

Drivers of glove use behaviour

Educational strategies are unlikely to be effective unless the drivers of glove use are more clearly understood. Loveday et al (2014b) undertook qualitative interviews with staff to elicit the factors that influence health professionals’ decisions to wear gloves. Thematic analysis identified two main drivers of glove-use behaviour:

• Emotion;
• Socialisation.

In terms of emotion, the rationale for glove use was participants’ desire for a barrier to protect themselves and their families from a perceived threat of infection and a response to a sense of “disgust” about contact with people/patients who are not considered to be clean (Box 2). The influence of socialisation reflected expectations of their organisation, peers and patients, and indicated that participants commonly learn their glove use behaviour from watching colleagues or were driven to use gloves because they were challenged to do so by others.

Participants also saw gloves as a way to save time and avoid the need for hand hygiene, and considered that hospital policy on gloves contradicted their perception of infection control practice. Gloves were also justified as something that patients expected as a demonstration of high standards of hygiene or as a physical barrier, although participants acknowledged that it might negatively impact on their relationship with patients. There is currently no evidence on patients’ views on glove use; this is an important area for further research (Loveday et al, 2014b).

The role of disgust in hygienic behaviour in different countries has been described as an innate mechanism for defence against infection (Curtis, 2007). The work of Whitby et al (2007; 2006) suggested that feelings of disgust towards “dirt and germs” are important drivers for hand hygiene behaviour in healthcare settings and that these attitudes are established early in life and become a form of ritualised behaviour to protect the self from infection (Whitby et al, 2007). However, there is evidence that an assessment of the risk of exposure to “dirt” rather than infection is the key driver, and that perception of dirt is highly contextual, encompassing much more than BBF - examples include washing water contaminated by “body debris” and fingers that may have had contact with faeces; health professionals are also strongly influenced by value judgements made about patients and their standard of cleanliness (Jackson and Griffiths, 2014).

Perceptions of dirt also seem to be moderated by familiarity and are applied differently to adults and children, even though both may be incontinent (Jackson and Griffiths, 2014), and precautions may be relaxed if the patient is “known” or is perceived to be clean. Health professionals’ focus on the protection of self from dirt, rather than on the risk of infection may therefore lead to behaviour that increases the risk of transmitting micro-organisms between patients, such as the observed conduct in relation to the use of gloves.

These studies show the importance of addressing underlying motivators of glove use if behaviour is to be modified. It is possible the strong messages in recent years about the risks of infection in healthcare settings may have increased health professionals’ perceived need to protect themselves and contributed to gloves being seen as an essential part of this protection.

Approaches that provoke emotions of disgust have been proposed as a means of improving hand hygiene behaviour (Porzig-Drummond et al, 2009). However, the emerging evidence about glove use suggests this could be a high-risk strategy as it is likely to increase the triggers for using gloves and decrease the focus on the critical points for glove removal and hand hygiene. Education and training of the multidisciplinary team to address the lack of knowledge, the irrational beliefs and the inaccurate perceptions of risk is needed but may not be enough to counteract these emotions (Prieto and McLeod Clark, 2005).

Conclusion

Recent achievements in the UK relating to reducing infections caused by MRSA and C difficile are impressive but represent a very small part of the problem of healthcare-associated infection (Johnson et al, 2012; Health Protection Agency, 2011). As well as the endemic problems of healthcare-associated pneumonia, surgical site and urinary tract infections, there are now new threats in the form of increasing cases of severe infections caused by Gram-negative pathogens such as E coli and Klebsiella pneumoniae, and a rapid rise in strains that are highly resistant to antimicrobial agents (Chief Medical Officer, 2011; Wilson et al, 2011). The highest standards of practice in relation to the prevention of HCAIs therefore continue to be paramount in assuring patient safety.

The emerging evidence of excessive and inappropriate glove use in healthcare settings and associated risks of cross-contamination indicates the need to challenge health professionals’ perceptions of risk, the role of gloves in preventing HCAIs and hazards associated with their misuse.

It is likely that many of the factors that have been successful in improving compliance with hand hygiene, such as using cues to action and influencing system change at an institutional level, will be relevant to improving glove use behaviour. However, educational approaches that address the motivators of this behaviour are essential if change in practice is to be effective and sustained.