To William S Halsted we owe a great deal, anesthesia, hospital charts, the hospital resident and last but not least, the rubber glove as we know it today. While it is said he developed the first gloves to protect the hands of fair Caroline, his wife to be, he was no doubt the first to see some of gloves many challenges. In both food and healthcare environments gloves can be a double edged sword, both protecting and contaminating, reducing exposures and producing exposures. This blog post will explore the glove risk paradigm in food and healthcare settings.
False Claims and Not
Gloves are personal protective equipment meant to protect workers from exposures to hazardous chemicals or harmful microorganisms associated with patient or raw food. At the same time they perform the function of protecting patient or ready-to-eat food from potential pathogens residing on the hands of the wearer. Whether it be food safety manager or infection control practitioner, neither will object to the claim that gloves can too easily provide a false sense of security to the wearer. Failure to change gloves at proper frequency in both environments is recognized to be at least as common a problem as lack of hand hygiene (HH). The two are inexplicably linked and often times considered partners in crime. When worn correctly in healthcare environments gloves have consistently helped reduce hospital associated infection rates. This despite the fact that in food and healthcare the most commonly used gloves are not sterile but protected for the most part by the reality or claim of “…only biological contaminates being harmless microbial species”. Yet to have any benefit they must be worn, and it is amazing how many foodborne illness outbreaks that have occurred where a sick food worker will have claimed to have worn their gloves when we know they probably didn’t even wash their hands. Here as in many other instances, either one of which (HH or glove use) would have prevented the outbreak from occuring. Public health experts have debated claims of glove superiority verses hand hygiene since Halstead's time, but fortunately we have reached a more evolved mental construct that places the two as interdependent components that can together effectively deal with the continuum of microbial exposure and chemical insult.
When gloves are chosen and worn properly they come in handy at significantly reducing the risk of pathogen transmission. When misused or abused and finger sized fragments end up in food, it is fortunate and planned that they come in so many cheerful colors. And indeed color coding is a strategy used for food operations to delineate raw food handling from cooked food handling processes and used similarly in healthcare to denote protection against different threats or exposures. Further in healthcare, color change gloves provide indication of puncture not to protect patient but the wearer. And lest we think puncture and break is rare, gloves are now made where pieces can be detected by automatic food detection systems that are in all respects colorblind.
Like soap or sanitizer usage, compliance can be monitored by glove usage figures that will indicate how long workers are wearing gloves and how frequently they are being changed. This is an important management function as many have observed food workers who are preparing food, pick up debris off the floor, handle money or scratch their head with nary a thought of changing their gloves. The equivalent actions also occur in healthcare, although on a less frequent basis. And what about washing or sanitizing hands before gloves are put on or after they are taken off. This is compliance of a different nature where food and healthcare worker (HCW) often miss the mark. With respect to hand hygiene compliance, if it were only so easy in healthcare as in food safety where health department inspectors can tell immediately upon walking into a facility if food workers are in compliance by the gloves they wear. Talk about a false sense of security, fortunately a good inspector knows also to look in the trash can to see if glove changes are taking place. Some have estimated that in these food settings when glove use is implemented, hand washing decreases by 50 %. What about double gloving as done by surgeons, still no substitute for hand washing as most puncture go unnoticed. Double gloving is rarely used by food workers where dexterity suffers and hands can cramp. To get the most from a glove whether adorned in cheerful colors or not, fingernails need to be trimmed and rings should be removed to reduce the chance of glove puncture. Ring removal in both food and healthcare environments is always a good idea anyway as increased hand counts are associated with these bangles. They cause difficulties in adequately washing or sanitizing hands and it is always a bad day when you loose rings in food or patient procedure.
Proof of the Pudding
Each glove type has its own profile with respect to use range, chemical exposure profile, puncture frequency prior to and during use, comfort level and dermal compatibility. Reusable gloves of many types are used in food processing plants where fortunately foods are cooked and workers hands need protection from sharp objects or the food handled. These gloves like hands need to be clean, food ready and able to be sanitized. The negatives regarding glove potential for abuse and innate shortcomings in food environments has been debated for the last 15 years. In studies where workers wore gloves or went bare handed for the same tasks, hands were found to be cleaner. Likewise it appears that gloves not only have higher levels of contamination than bare hands but transfer more of this contamination than do hands. That said, outbreaks attributed to contaminated hands far out numbers outbreaks attributed to contaminated gloves. The same could be said in healthcare environments where glove use and abuse go hand-in-hand. Contaminated gloves have been identified as causing a significant number of healthcare associated infection outbreaks yet they are effectively used to the tune of billions of pairs a year protecting patient and HCW alike. They are especially important in fighting C. difficile associated disease (CDAD). Part of the risk paradigm is that hands are hands and we really care about how dirty they get just as monkeys in the wild wipe their hands off on leaves and tree bark. But put gloves on workers and expose them to soil insults than all caution is thrown to the wind and contamination limits are pushed.
And what goes on inside that priestly glove as the hand moves around with its newly minted surrogate skin? While our palms and finger pads lack sebaceous glands and hair (a good thing), they contain 400 to 500 sweat glands per square centimeter. Thanks to our gloves, all the moisture created by thousands of sweat glands is trapped where oxygen levels plumet and skin maceration creates high microbial counts. The richest microbial flora on the hand is the nail region. Glove occlusion decreases the generation time and increases contamination from what ever was on the hand or under the fingernails before the gloves were donned. Removal of gloves at this stage without effective hand hygiene presents several hazards; 1) moist hands transfer more microbial contamination to surfaces than dry hands, 2) skin fissures can occur as a result of hyperhydration 3) that can be aggravated by allergic contact dermatitis (ACD) instigated by potential food, facility or glove allergen and 4) now that the skin barrier integrity is damaged, ACD triggered, colonization becomes increasingly more probable.
Breach of Integrity and Re-establishment
Glove changing frequency is important to reduce the risk of puncture leading to a gusher, where a liquid bridge of microbial contamination can flow from the hands to contact surfaces, food or patient. Change frequency is going to be determined by contamination build-up, strength limitations of glove type and how they are used. Factors favoring puncture such as touching sharp surfaces or extended use often cause damage to glove thumb and forefinger tips that can result in measurements of 20,000 bacteria escaping within seconds in what can only be described as a true potpourri.
In leading up to the 2002 introduction of hand sanitizer use in healthcare facilities and less reliance on hand washing, international advisory groups noted skin irritation from prolonged glove use as another factor requiring a paradigm shift. Just as with over washing, harsh chemical exposure or using water too hot for hands, it was recognized that skin lipid barrier can be completely lost with long bouts of glove use. Hand washing with mild soap and use of hand lotion or hand sanitizer containing a good emollient package will begin to repair or restore barrier function loss. When it comes to mitigating contamination risks in food or healthcare venues, gloves can be part of the problem or play a major role in the solution. Ultimately it is up to management to wisely select the best combination of glove and hand hygiene products or procedures to match the specific challenges encountered.
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