Processes: Optimisation and Solutions

Hand hygiene: “You have to use gloves correctly if you want to prevent infections.”

Along with hygienic hand disinfection, medical gloves are an essential measure for infection control – if used correctly. Hygiene expert Dr Günter Kampf explains when and why gloves should be worn.

The WHO “Glove Use Pyramid” recommends when gloves should be worn and when not. Is there any uncertainty about this in practice?

Dr Günter Kampf: The upper part of the pyramid concerns the wearing of sterile gloves. There is no confusion about this in practice, as these processes are established and standardised. However, the situation is different with regard to non-sterile examination gloves*. People are still somewhat uncertain about when gloves should be worn, when not, and – above all – when they should be taken off. Although hospitals have hygiene plans, employees do not always follow the recommended guidelines. Instead, they often adopt the behaviour of their supervisors or follow their own instincts. Once certain behaviours become familiar and an established part of a routine, such habits are very difficult to change again. You need to increase awareness and provide practical training to improve behaviours and establish new patterns.

As recommended in the WHO’s Glove Use Information Leaflet gloves must be worn according to STANDARD and CONTACT precautions. The pyramid details various clinical examples in which gloves are not necessary, and others in which disposable or sterile gloves are indicated. Hand hygiene should be performed when necessary regardless of glove use.

In short: When should examination gloves be worn – and when not?

Kampf: There are classic indications for wearing disposable examination gloves, and users voluntarily and willingly do so in such situations – namely, when contact with blood, stool, urine or wound exudate is likely. Healthcare staff is also often advised to wear disposable gloves when treating patients infected with multi-resistant microorganisms. In both cases, the guidelines are generally observed, because healthcare professionals want to protect themselves as well as the patients. However, employees tend to wear gloves even when it is not necessary, or they leave them on when an indication is no longer present. According to a study, only one third of all worn gloves are used according to the indication. This is critical for two reasons: First, excessive wearing of gloves can be harmful to the skin health of users. Second, it impairs compliance to hand disinfection. Various studies have shown that wearing gloves correlates with a lower compliance of hand disinfection. And in the end, this harms patients1.

Do gloves offer the user full protection from contamination of their hands and the associated risk of infection?

Kampf: It is quite well documented that gloves do not provide full protection. Wearing disposable gloves keeps the majority of microorganisms away from the hands, but a certain percentage of bacteria can be found there despite the gloves. There are two possible explanations. Firstly, gloves are not completely impermeable because microorganisms can reach the skin of the user through microperforations in the gloves, which may be present in a certain percentage through the manufacturing process2. Secondly, employees can contaminate their hands with anything on the outside of the gloves if they are not removed skilfully3.

What role does hand disinfection play in this context?

Kampf: It is always recommended to disinfect your hands after taking off medical gloves. Since not all microorganisms can be kept away from the skin by wearing gloves, it is essential to disinfect your hands. I would like to illustrate this with the following example: Often HCPs have to perform several tasks on a patient. If, for example, gloves have to be put on for the second activity, the caregiver should ideally disinfect his hands at the beginning, carry out the first activity, disinfect his hands again, put on the gloves, carry out the second activity, take off the gloves, disinfect his hands and only then carry out the third activity. Such a procedure would comply with the recommendations, because the gloves are worn only for the one situation in which they are necessary. However, when treating patients with certain infections, gloves – or a complete set of personal protective equipment – must be worn right at the outset of treatment. Perhaps the best-known example was when years ago in Hamburg, Ebola patients were treated. If several activities, including aseptic ones, have to be carried out on such patients, gloved hands might be disinfected.

What rules should users follow when wearing gloves so as not to compromise their skin health?

Kampf: For me, the most important rule is to know which indications require gloves to be worn and which do not. Knowing this contributes to reducing improper use. If gloves are only put on for the time the indication is present, and are then taken off immediately when the indication is no longer present, the total duration of wearing gloves over the working day will certainly be shorter. This is helpful for skin health. It is also necessary for healthcare staff to be aware that they have to disinfect their hands after taking off the gloves. Furthermore, hands should always be dry when putting on gloves. No water or disinfectant should be left on the hands.

How can defining and establishing procedures for carrying out specific activities help?

Kampf: Standard operating procedures (SOPs), in other words, defined sequences of individual steps, can be very helpful. When SOPs are implemented in practice, patients are optimally protected. An observational study for the placement of venous catheters was carried out at the University Hospital Hamburg Eppendorf in 2013. The researchers found that the compliance of hand disinfection before aseptic activity – immediately before the placement of the peripheral venous catheter, for example–was almost zero. The reason: The employees put on their gloves right as they were beginning their work, although it was not necessary at that time. After that, however, they neither disinfected their hands nor their gloved hands. An established procedure is therefore very important to make it clear to users when they have to put on gloves and when hand disinfection is necessary. This probably involves changes to the routine as a whole, but even seemingly small adjustments will help to improve patient safety. When processes are properly learned and applied, they become routine. Then you can perform almost any activity blindfolded – and you do it right.

Putting on gloves: The WHO recommends precise procedures Using the correct technique to put on and take off gloves is crucial. The WHO recommends precise procedures that explain where to touch the glove, how to put on the first glove and then the second glove. A good technique for taking off gloves is also necessary to avoid contaminating the hands. “If I reach into the glove dispenser carelessly, it is very likely that the gloves will be contaminated even before patient treatment,” explains Kampf.

Link to infographic: Technique for donning and removing non-sterile examination gloves.

Independent specialist for hygiene and environmental medicine Dr Günter Kampf advises hospitals, physicians’ practices, producers of medical products and disinfectants on questions of hospital and practice hygiene. He has published numerous articles in international trade specialised journals. Kampf is adjunct Professor of Hygiene and Environmental Medicine at the University of Greifswald.

Further Information

  1. Disinfection of gloved hands for multiple activities with indicated glove use on the same patient., Kampf G. & Lemmen S., The Journal of Hospital Infection

  2. Perforation rates for nonsterile examination gloves in routine dermatologic procedures, Kupres K., Rasmussen S.E., Albertini J.G., Dermatologic surgery: official publication for American Society for Dermatologic Surgery

  3. Assessment of Self-Contamination During Removal of Personal Protective Equipment for Ebola Patient Care, Infection control and hospital epidemiology

*commercial communication

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