The need for gloves to achieve asepsis is a given in modern healthcare. However, allergy to the natural rubber latex (NRL) proteins used in their manufacture emerged as an occupational disease in the 1980s (Royal College of Physicians (RCP), 2008). Unfortunately, the powder used to increase the ease of donning only exacerbates this problem because the protein powder reacts with the latex in the glove (RCP, 2008). While lower-protein gloves are now widely used and powder-free gloves are commonplace in healthcare settings in the UK, glove use has risen exponentially to provide protection from occupational exposure to blood-borne viruses (RCP, 2008).
There is evidence that the introduction of a latex-free glove policy would not only reduce latex sensitisation (Allmers et al, 1998) among staff, but also assure clinical outcomes, improve quality of life (Power et al, 2010) and provide a cost-effective solution (Phillips et al, 1999; Henry et al, 2020). The author is a long-time user of standard latex gloves (except in cases of allergy); however, his personal experience of having evaluated a high-quality brand of latex-free gloves supports the rationale presented within this article for the consideration of a new latex-free glove policy within NHS departments and trusts.
Why switch to latex-free?
NRL is extensively used in the manufacture of medical gloves, but is also used in catheters, elasticised bandages and wound dressings (Health and Safety Executive (HSE), 2020). NRL is a milky fluid derived from the Hevea brasiliensis tree, which contains proteins that can lead to skin irritations and allergic reactions in staff and patients (RCP, 2008). It is important that staff and patients are safeguarded from skin reactions and respiratory issues linked to the use of NRL single-use gloves (HSE, 2020). The types of reactions are listed below:
Although infection prevention guidelines (epic3) specify that alternatives to NRL gloves must be available on account of patient, carer and healthcare worker sensitivity (Loveday et al, 2014), alternatives have typically been associated with reduced dexterity, comfort and durability, as well as higher cost (Henry et al, 2020). Their use has therefore been limited to cases of allergy (Henry et al, 2020). Encouragingly, newer more durable non-latex alternatives are now available that provide equal dexterity and comfort to latex gloves, but without their associated risk of allergen and sensitivity (Henry et al, 2020).
A new latex-free
The author has routinely used latex gloves for the last 35 years and until recently, his experience supported the inferior assessment of non-latex gloves as being prone to tearing and not contouring as well as standard latex gloves. However, at the request of Cardinal Health, the author was asked to test their PI Micro latex-free gloves for five consecutive plastic surgery cases. He found that they performed just as well as latex gloves in terms of their feel, comfort and grip. The author was able to remove the gloves with reasonable ease and experienced no redness or irritation of his skin.
The author was also reassured in terms of the gloves' safety during surgery and their ability to support good clinical outcomes. The author carried out one scar revision with direct closure; one scar revision with local flap closure; one contracture release with a local flap; one excision of lesion with application of a split-thickness skin graft; and one wound debridement with subsequent application of negative-pressure wound therapy. During these procedures, the author did not experience any issues with the gloves ripping, which was something he experienced with an alternative brand of latex-free gloves used within his trust for cases of allergy.
Benefits of making the switch
A latex-free-only glove policy would prevent staff and patient morbidity, such as latex-induced asthma, rhinitis and more severe cases of anaphylaxis (UNISON, 2004; RCP, 2008; HSE, 2020). Skin conditions are also associated with issues related to self-image, and can negatively impact relationships, whether professional interactions with patients, or intimate or social relationships. Latex allergies also result in staff absenteeism and loss of productivity (Kalboussi et al, 2019). A more serious reaction can even lead to long-term respiratory problems, and can force staff to give up careers they love (UNISON, 2004).
The potential cost savings associated with a proposed switch from NRL to latex-free gloves are considerable in terms of treating patients with allergic reactions, risk of litigation, staff absence and disability, and resources to test for allergies and decontaminate clinical settings (Phillips et al, 1999; Henry et al, 2020).
In a cost analysis in Georgia, USA, Phillips et al (1999) concluded that even though latex-free gloves cost more, healthcare institutions would benefit financially from becoming latex-safe on account of cost savings from staff disability, even where disability levels are low. UNISON has also made clear the strict liability of employers to ensure their workforce is protected, having awarded a nurse £354,000 in compensation after she developed a skin irritation and respiratory problems, followed by a life-threatening allergy to powdered latex gloves (UNISON, 2004). While it could be argued that latex-free gloves can be used in cases of allergy, while powder-free low-protein NRL gloves can be used for colleagues, making the switch to latex-free-only would save resources allocated to risk-assessing staff and patients for latex sensitisation to use. Furthermore, in 2018, a group of NHS hospitals saved £400,000 by switching to a single brand of surgical gloves (Knapton, 2018).
Why now?
The RCP concluded in 2008 that the evidence did not justify a ban on NRL gloves and much of the guidance recommended powder-free low-protein latex, as latex-free gloves were found to have higher failure rates and lower user satisfaction (RCP, 2008). However, there are now new alternatives to NRL gloves that are durable and comfortable, and also safeguard staff and patients from latex sensitisation (Henry et al, 2020). Trusts are increasingly taking a proactive approach to protecting staff and patients from latex sensitisation by minimising their latex use as much as possible.
The Isle of Wight NHS Trust (2018) advocates non-latex glove (both sterile and non-sterile) use only unless risk-assessed and agreed with occupational health, health and safety or infection prevention and control departments. In cases where risk assessment determines the need to use latex gloves, only powder-free, low-protein NRL gloves are used, and hands must be washed after removal (Isle of Wight NHS Trust, 2018). At Portsmouth Hospitals NHS Trust (2019), the HSE carried out an inspection and concluded that there are very few clinical areas where continued use of latex is justified. The Trust policy therefore states that the glove of choice used should be latex-free and in cases where there latex is clinically required, this must be justified with a risk assessment (Portsmouth Hospitals NHS Trust, 2019).
Change management
All healthcare providers have a role in ensuring effective change (Barrow et al, 2020). A plan or proposal for a latex-free policy should make explicit its viability, be clear about its objectives, consider what resources will be needed, and review less tangible factors such as buy-in from the team (Bowen et al, 2012), staff education and training, and how to evaluate compliance as well as carry out effectiveness monitoring (Hatchett and Coady, 2013; NHS England, 2018).
It may be helpful to visit services that have implemented the change you are looking to make, and to use tools such as SWOT (strengths, weaknesses, opportunities, threats) to identify and demonstrate to stakeholders the viability of the switch (Hatchett and Coady, 2013). The Change Model, advocated by NHS England (2018), provides a five-step approach to help effectively manage the intended change from conception to completion (Box 1), as well as a model for improvement to provide a framework for developing, evaluating and implementing changes. There are also many other change management models that may be explored, such as Kotter's eight-step change model (Barrow et al, 2020).
| Preparation | This first step includes everything you need to do before officially starting your particular project |
| Launch | This marks the official start of your project |
| Diagnosis | This step is about understanding your current process, dispelling assumptions, using data to define the problem and to building upon the baseline data |
| Implementation | This step evaluates potential solutions using a Plan-Do-Study-Act cycle; the best solution is implemented and standard work and mistake-proofing are introduced to establish a quality sustainable process |
| Evaluation | In the final step, achievements are celebrated, learning is captured and the new improvement becomes the norm |
Creating a business case
To switch to a latex-free glove policy, considerable planning and information gathering must support the case for change (Hatchett and Coady, 2013). To create a clinical and business case, the extent of latex allergy will need to be assessed and quantified. Many nurses and health professionals collect existing data routinely and it is important to work collaboratively with colleagues who can assist in providing these data, which may be used in a SWOT analysis and presented in your business case.
Trusts may carry out new starter screenings and reporting systems such as Datix can help you to record instances of allergies to latex as well as near-misses, storing the corresponding data to monitor this over time (for both staff and patients). Regular skin checks can also be undertaken with any redness or irritation documented.
At-risk patients can be identified through a thorough history-taking and risk assessment, and allergy bracelets should be provided to alert staff. Data can be collated such as how many patients in the system have specified a latex sensitivity/how many latex-free gloves are being used for these cases, and information can also be collected to document the patient experience.
Once those at risk are identified, estimates can be made of what percentage may develop allergic reactions, or in the case of staff, partial or full disability. Some risk factors for latex allergy include the presence of asthma, food allergies and children with spina bifida (Anaphylaxis Campaign, 2019).
A cost analysis should determine the financial burden of latex allergy on the institution, by quantifying resources when someone is treated for latex allergy, the cost of diagnostic tests (eg skin prick test), time and money lost through staff sick leave, increased employee turnover, funding for locum staff, decreased productivity, decontamination costs and even litigation costs. This can then be communicated to the head of procurement for their consideration.
Monitoring effectiveness
Generally when implementing change, there are three stages involved: the planning stage prior to the change, implementing the change itself, and the phase after the change is in place which will include monitoring its effectiveness. Audits are an important part of ensuring that the change is achieving what it set out to accomplish. Some performance management indicators may include an improvement in staff health; an increase in patient satisfaction; current versus planned cost savings, etc (NHS England, 2018).
Latex-free theatre
A switch to latex-free gloves would be beneficial, particularly within the surgical setting, where patients are vulnerable to surgical site infections, and where at-risk patients need to be operated in a completely latex-free environment. For patients who are at-risk of a latex allergy, the operating schedule must be planned accordingly, either scheduling at-risk patients first, or ensuring the theatre has been latex-free for at least one hour to reduce airborne latex particles. A latex-free glove policy would avoid resulting lost productivity, while ensuring patients and staff are safe from allergy. Anecdotal evidence suggests that good clinical outcomes can be assured with the use of latex-free gloves, to an extent that is equal to those achieved with standard NRL gloves, or superior when risks of sensitisation are considered.
Conclusion
Various teams across different hospitals recently evaluated the latex-free gloves from Cardinal Health, noting that they were a smoother texture than latex, but with equal comfort, ease of donning and doffing, and grip on the equipment, even when wet (Henry, et al, 2020). Importantly, the gloves were found not to restrict dexterity and were concluded to be equal to latex gloves in terms of establishing asepsis (Henry et al, 2020). Their tactile feedback enabled the tying of suture knots with relative ease and they did not restrict dexterity intraoperatively, allowing for supple manipulation of tissues, sutures and instruments. Importantly, no detectable macroperforations of the gloves were noted when used for skin cases (Henry et al, 2020).
However, further trials to determine their suitability for more invasive surgery such as major pelvic or trauma surgery are recommended. A larger evaluation of both macroperforations and, in particular, microperforations via the American Society for Testing and Materials (ASTM) one-litre load test is recommended.
Anecdotal evidence suggests that a latex-free glove policy may be beneficial across various healthcare environments, particularly within the theatre. An inspection by the HSE to determine whether the routine use of latex is even justified could support the case of making the switch to a latex-free glove policy across hospital departments and trusts.