A cluster, randomised trial involving 13 US hospital units and including some 3 800 healthcare providers, found that a direct-gloving strategy led to improved adherence and was found to be as safe as the current practice of hand hygiene before donning non-sterile gloves.
The researchers found that adherence to expected practice was greater among the units asked to directly glove without hand hygiene compared with the units asked to clean hands before donning gloves (87% vs 41%, P<0.001), reported Dr Kerri Thom, MS, of the University of Maryland School of Medicine, and colleagues.
This held true even when controlling for baseline hand hygiene rates, unit type, and universal gloving policies (risk ratio [RR] 1.76, 95% CI 1.58-1.97), they wrote in JAMA Network Open.
Glove use was also higher in the direct-gloving units than the hand hygiene units when entering into contact precautions rooms (87% vs 67%, P=0.008).
Pathogens were identified in 4% of samples obtained from the direct-gloving units, with a mean total bacterial colony count of 16.3 colony-forming units (CFUs), while 2% of samples obtained in usual-practice units had pathogens identified, with a mean of 9.5 CFUs.
“Many infection control practices like hand hygiene and glove-wearing are a time burden for busy healthcare workers,” co-author Eli Perencevich, MD, MS, of the University of Iowa Carver College of Medicine, told MedPage Today.
“Particularly burdensome is the recommendation to clean your hands with soap and water or alcohol hand rub before putting on gloves, as you have to wait a minute or more for your hands to dry before gloving up.
“If guidelines are adjusted to allow healthcare workers to skip hand hygiene before putting on gloves, time would be saved and hospital safety could be improved.”
A previous randomised trial also showed no difference in glove contamination when non-sterile gloves are donned directly, compared with after performing hand hygiene.
Current guidelines from the Society for Healthcare Epidemiology of America (SHEA) recommend that healthcare personnel wash hands or use alcohol-based sanitiser and wear gloves. SHEA acknowledged that efficacy may be an issue, as just 7% of healthcare personnel effectively clean the entire surface of their hands.
Still, said Suraj Saggar, DO, of Holy Name Medical Centre, the findings of this study are probably less relevant now since the data were collected before the Covid-19 pandemic.
“However, hand hygiene is extremely important, so I would say any study that can show a way to increase compliance without compromising efficacy is welcomed,” he said.
Perencevich acknowledged that as the study was conducted before the pandemic, the data may not apply to practices during and after, especially if infection control practices at hospitals have changed.
This cluster randomised clinical trial was conducted at four academic centres from January 2016 until November 2017. In total, the trial involved 3 790 healthcare providers from 13 hospital units.
Thom and colleagues assigned each participating unit to either continue usual glove practices or use a direct-gloving approach.
They observed baseline rates for six months before initiating the intervention in six randomly selected units, which included one emergency department, one haemodialysis unit, one paediatrics unit, and three intensive care units.
The researchers used a standardised hand hygiene data collection tool at each site to capture hand hygiene and glove use during room entry and exit.
The direct-gloving strategy was associated with greater detection of pathogenic bacteria (adjusted incidence RR 10.18, 95% CI 2.13-44.94) on gloves in the emergency department and reduced colony counts in paediatrics units (adjusted incidence RR 0.34, 95% CI 0.19-0.63), with no change in either total colony count (RR 0.87, 95% CI 0.60-1.25 for intensive care units and RR 0.59, 95% CI 0.31-1.10 for the haemodialysis unit) or presence of pathogenic bacteria (RR 0.93, 95% CI 0.40-2.14 for adult intensive care units and RR 0.55, 95% CI 0.15-2.04 for the haemodialysis unit) in the other units.
The authors said a rigorous approach to evidenced-based guidelines would be needed to increase acceptance and adherence to hand hygiene and glove use in hospitals. A limitation was that the study did not apply to surgical settings where healthcare personnel must wear sterile gloves.
Study details
Direct gloving vs hand hygiene before donning gloves in adherence to hospital infection control practices
Kerri Thom, Clare Rock, Gwen Robinson, et al.
Published in JAMA Network Open on 26 October 2023
Key Points
Question Does a strategy of direct gloving compared with performing hand hygiene before donning non-sterile gloves influence adherence to infection prevention practices among health care personnel?
Findings This mixed-method, multicentre, cluster randomised trial including 3790 health care personnel across 13 hospital units of 4 academic centres demonstrated a statistically significant 46% increase in adherence to a direct-gloving strategy vs usual care of hand hygiene before donning gloves (87% vs 41% adherence).
Meaning These results suggest that a policy endorsing direct gloving may increase adherence to expected infection prevention practices and overall glove use in many hospital settings.
Abstract
Importance
Current guidelines require hand hygiene before donning non-sterile gloves, but evidence to support this requirement is lacking.
Objective
To evaluate the effectiveness of a direct-gloving policy on adherence to infection prevention practices in a hospital setting.
Design, Setting, and Participants
This mixed-method, multicentre, cluster randomised clinical trial was conducted at 4 academic centres from January 1, 2016, to November 30, 2017. Data analysis was completed April 25, 2019. Participants were 3790 health care personnel (HCP) across 13 hospital units.
Intervention
Hospital units were randomly assigned to direct gloving, with hand hygiene not required before donning gloves (intervention), or to usual care (hand hygiene before donning non-sterile gloves).
Main Outcomes and Measures
The primary outcome was adherence to the expected practice at room entry and exit. A random sample of HCPs’ gloved hands were imprinted on agar plates at entry to contact precautions rooms. The intention-to-treat approach was followed, and all analyses were conducted at the level of the participating unit. Primary and secondary outcomes between treatment groups were assessed using generalised estimating equations with an unstructured working correlation matrix to adjust for clustering; multivariate analysis using generalised estimating equations was conducted to adjust for covariates, including baseline adherence.
Results
In total, 13 hospital units participated in the trial, and 3790 HCP were observed. Adherence to expected practice was greater in the 6 units with the direct-gloving intervention than in the 7 usual care units (1297 of 1491 [87%] vs 954 of 2299 [41%]; P < .001) even when controlling for baseline hand hygiene rates, unit type, and universal gloving policies (risk ratio [RR], 1.76; 95% CI, 1.58-1.97). Glove use on entry to contact precautions rooms was also higher in the direct-gloving units (1297 of 1491 [87%] vs 1530 of 2299 [67%]; P = .008. The intervention had no effect on hand hygiene adherence measured at entry to non–contact precautions rooms (951 of 1315 [72%] for usual care vs 1111 of 1688 [66%] for direct gloving; RR, 1.00 [95% CI, 0.91-1.10]) or at room exit (1587 of 1897 [84%] for usual care vs 1525 of 1785 [85%] for direct gloving; RR, 0.98 [95% CI, 0.91-1.07]). The intervention was associated with increased total bacteria colony counts (adjusted incidence RR, 7.13; 95% CI, 3.95-12.85) and greater detection of pathogenic bacteria (adjusted incidence RR, 10.18; 95% CI, 2.13-44.94) on gloves in the emergency department and reduced colony counts in paediatrics units (adjusted incidence RR, 0.34; 95% CI, 0.19-0.63), with no change in either total colony count (RR, 0.87 [95% CI, 0.60 to 1.25] for adult intensive care unit; RR, 0.59 [95% CI, 0.31-1.10] for haemodialysis unit) or presence of pathogenic bacteria (RR, 0.93 [95% CI, 0.40-2.14] for adult intensive care unit; RR, 0.55 [95% CI, 0.15-2.04] for haemodialysis unit) in the other units.
Conclusions and Relevance
Current guidelines require hand hygiene before donning non-sterile gloves, but evidence to support this requirement is lacking. The findings from this cluster randomized clinical trial indicate that a direct-gloving strategy without prior hand hygiene should be considered by health care facilities.
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