Love The Glove
It's pretty easy to hate on gloves. They're certainly annoying to put on and wear. Yet, much of what we do in medicine is difficult yet worth it, if what we do is effective. Now if we really could get hand hygiene compliance beyond 90%, I think a narrow focus on hand rub utilization would be OK. But, irrespective of what facilities are reporting, when you really look, their compliance is closer to 50% (if they're lucky). That's why I continue to (a) encourage investment in hand hygiene research and (b) recommend glove use in our infection control bundles.In a recent JAMA Pediatrics, David Kauffman and colleagues reported the results of a single-center RCT comparing mandatory glove use before all patient and IV catheter contacts vs hand hygiene alone. The study took place in the NICU during 2008-2011 and was funded by University of Virginia and Cardinal Health Foundation. The 120 enrolled infants (60 in each arm) needed to weigh less than 1000 g and/or have a gestational age less than 29 weeks and age less than 8 days old. The primary outcomes were infection in the bloodstream, urinary tract, or cerebrospinal fluid or necrotizing enterocolitis. Randomization was fairly effective; however, the glove use arm neonates were more likely to have a central line, require mechanical ventilation and receive TPN.
Their were several significant difference between the outcomes in the two groups. Neonates in the glove-use arm had lower rates of late-onset invasive infection or necrotizing enterocolitis (32% vs 45%, p=0.13), fewer Gram-positive BSIs (15% vs 32%, p=0.03) and fewer CLABSI (3.4 vs 9.4/1000 catheter days, p=0.01). Frankly, with such a small study, I'm surprised they found any significant differences. What would I recommend after reading this study? I would recommend (a) NIH/AHRQ/PCORI fund a follow-up multicenter study to validate these findings and (b) in the meantime, wear gloves when caring for pediatric patients based on this study and our earlier study in Pediatrics.
I agree that gloves are a good thing. I agree that the research shows that gloves have been shown to be as effective as Contact Precautions for the prevention of colonization and acquisition of some types of drug resistant bacteria. (Trick, et al., 2004; Bearman et al., 2007). But with the exception of Dr Bill Trick/Dr. Bob Weinstein's studies, most studies have been done in intensive care units where the patient load is probably at maximum 1-3 patients. (I’m now copying part of my prior blog entry about gloves) What about my area where people have to meet the needs of 12-30 people on an average shift?
ReplyDeleteWe throw up potential barriers by making it hard to even change gloves without performing what may be unnecessary hand hygiene in intra-sequence events during the sequence of patient care (Eveillard, 2011, Rock et al, 2013). I’m sure you have tried to get gloves on your hands when they are still wet from hand sanitizer. Darn nuisance, and not practical if you have a person that needs your hands on them this instant.
Add to that that we are required by OSHA to pound it into healthcare personnel (HCP) heads that they need to wear gloves to protect themselves from pathogens in blood and body fluids, and it makes it counter-intuitive to remove or change gloves after contamination. Fits right into a very apropos psychological theoretical framework developed by Maddux, Rogers, and Bandura (another Iowa grad!)
Protection Motivation Theory posits that when 1) something is perceived as noxious or a threat to self 2) when it is likely that the noxious, threatening event will happen, like exposure to blood and body fluids or drug resistant organsism 3) when there is an efficacious and readily available solution (gloves) that is easy to use (self-efficacy)- people will use them (Maddux & Rogers, 1983 plus Bandura, 1977, 1982). Most long term care facilities have a culture of almost universal glove use. I have a hard time getting them to take them off when they don’t need them, and this has been identified by the teams led by Girou, Loveday and Cookson, and Eveillard.
The focus of most infection prevention activities is on hand hygiene, but what good is hand hygiene if a person has gloves on the entire time? Proper glove use has not even really been established, but IMHO, if we could get people just to change gloves when they have touched a contaminated surface or item, and clean hands when soiled and between patients a lot of the problems relating to HAI and environmental contamination would go away. I will now again get off my soapbox and go back to writing my dissertation.