The impact of glove misuse on patient safety during the Covid-19 pandemic

Introduction

During all healthcare interactions, whether a patient is known to be infectious or not, fundamental infection-prevention and control measures need to be in place to reduce the spread of infection. Standard infection control precautions (SICPs) (NHS England and NHS Improvement, 2022) require a risk assessment for all individuals who are admitted to a healthcare setting, which should assess the anticipated level of:

• Exposure to blood, body fluids (excluding sweat), non-intact skin and mucous membranes;
• Contaminated equipment in the care environment.

The SICPs have ten elements, two of which relate to the use of gloves: these are hand hygiene and personal protective equipment (PPE).

When a patient is suspected or known to be colonised or infected by specific infectious organisms, additional measures called transmission-based precautions (TBPs) need to be in place. TBPs are based on the route of transmission of the infection and include:

• Contact precautions;
• Droplet precautions;
• Airborne precautions (UKHSA, 2021a).

Hand hygiene and glove use are key elements of all the TBPs. However, the glove use they specify for contact precautions is different from that set out in the SICPs. NHS England and NHS Improve­ment’s (2022) guidelines for TBPs state health professionals must wear gloves for all interactions with patients requiring contact precautions, due to the environment potentially being heavily contaminated with organisms such as meticillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus; gloves are not only required if there is anticipated contact with blood or body fluids, mucous membranes or non-intact skin (World Health Organization, 2009a; Siegel, 2007). The appropriate application of hand hygiene and glove use as set out in the TBPs are key elements of infection prevention and control.

Infection transmission by hands

We commonly see photos and videos in the media of health professionals wearing gloves while delivering vaccines, pushing trolleys, administering oral medications and writing notes. Despite the culture of excessive glove use depicted on television and social media, health professionals must understand that inappropriate and unnecessary gloves use may have an impact on patient safety.

The misuse of gloves has been shown to be a contributing factor in the transmission of healthcare-associated infections and outbreaks in healthcare settings (Duong and McLaws, 2017; Wilson et al, 2017a; Wilson et al, 2017b; Wilson and Loveday, 2014). During the pandemic, healthcare systems have been overwhelmed with patients with Covid-19; this has created fear among health professionals, further exacerbating the misuse of PPE, specifically gloves (Cawcutt et al, 2020).

Numerous studies have concluded that health professionals’ hands are the most common mode of carrying micro-organisms between patients (Von Dolinger de Brito Röder et al, 2021; Presterl et al, 2019; Wolfensberger et al, 2018). Health professionals can pick up micro-organisms by touching surfaces and patients. During patient care, normal flora, as well as pathogenic organisms, can accumulate on their hands, which can then transfer to the next surface they touch, which could be another patient or a piece of equipment (Wolfensberger et al, 2018). These micro-organisms are easily destroyed by contact with alcohol-based hand sanitiser or removed from the skin surface by hand washing. Appropriate, timely hand decontamination is, therefore, essential in preventing transmission (Jain et al, 2018). The World Health Organization’s Guidelines on Hand Hygiene in Health Care (WHO, 2009b) recommends health professionals adopt the “five moments for hand hygiene” (Box 1) to protect patients from infection.

Inappropriate use of gloves

The gloves used most frequently in hospitals are examination gloves, which can be either sterile or non-sterile (WHO, 2009a). Sterile gloves are free from all micro-organisms and are used for procedures where aseptic technique is required; non-sterile gloves are used for most other procedures.

The two main reasons why health professionals use gloves are to reduce the risk of:

• Contaminating their hands with blood and other body fluids;
• Transmitting infection from themselves to patients and vice versa, as well as between patients (WHO, 2009a).

However, non-sterile gloves do not provide complete protection from contamination, because they have tiny defects in them that allow access for pathogens or contamination of hands during glove removal (WHO, 2009a). People who are unaware of this may believe the gloves are fully protective, rather than a measure to reduce the risk of cross-transmission (Baloh et al, 2019; Vikke et al, 2019). Box 2 outlines the risk assessment needed for the use of non-sterile gloves.

Gloves often acquire pathogens by touch in exactly the same way as bare hands, and misuse can lead to the transfer of pathogens. This occurs by donning (putting on) gloves too soon or doffing (removing) them too late, which can result in contaminating patients or surfaces when further tasks are done (Lindberg et al, 2020; Loveday et al, 2014).

Research has highlighted a shift in focus from hand hygiene to PPE to control the transmission of pathogens in the healthcare setting, which has created the impression among staff that standard precautions are not adequate; health professionals who falsely believe gloves are essential to protect themselves and prevent the spread of infection may then use them routinely for every contact (Wilson et al, 2017a; Wilson et al, 2017b). This can result in them no longer adhering to the five moments of hand hygiene, as well as forgetting the risk that inappropriate glove use may present to patients (Wilson et al, 2017b).

Inappropriate wearing of gloves has been found to increase the risk of cross-contamination due to missed moments of hand hygiene (Wolfensberger et al, 2018). A significant reduction in hand hygiene compliance has been observed when gloves are worn, caused by health professionals not performing hand hygiene before donning and after doffing gloves (Acquarulo et al, 2019; Mitchell et al, 2013; Fuller et al, 2011). Mitchell et al (2013) also recognised that compliance was probably worse when health professionals were not being audited. These findings could have major implications for patients who require contact precautions – set out by the TBPs – for antibiotic-resistant organisms, where glove use is indicated. If hand hygiene is not performed immediately before and after gloves are worn, this could also contribute to the transmission of infection.

Factors influencing glove use

The barriers that lead to the misuse of gloves and missed hand hygiene opportunities are complex and include:

• An inadequate supply of gloves, particularly in developing countries;
• Patients requiring immediate treatment, leaving staff with inadequate time for glove changing and hand hygiene;
• Senior leaders not taking accountability for poor compliance, leading to unimproved practice (Duong and McLaws, 2017).

Human factors also play a major role in the misuse of gloves. Emotion and personal preference are fundamental influences on hand hygiene compliance and glove use, and Wilson et al (2017b) found that some staff reported routinely wearing gloves for procedures where their use is not indicated for their own “personal hygiene”. Other research has found health professionals’ motivation for glove misuse to be protection either from a perceived threat of infection or from contact with something or someone not considered to be clean (Loveday et al, 2014; Fuller et al, 2011).

Socialisation also influences health professionals’ glove use: Loveday et al (2014) observed gloves being worn to reflect the expectations of patients, peers and organisations. This indicates the behaviour is learnt by watching colleagues or being encouraged to wear gloves by others, meaning the role of gloves to control infection and reduce cross-transmission could be overlooked.

Glove use during the Covid-19 pandemic

Health professionals receive both education and intense promotional messaging about hand hygiene being the pillar of infection prevention and control, because it removes potentially pathogenic organisms from the hands (Jain et al, 2018). However, despite this, the use of non-sterile gloves dominates routine clinical practice, with potential cross-contamination occurring in almost 50% of the episodes in which they are used (Wilson et al, 2017a).

This issue may have been exacerbated during the Covid-19 pandemic, due to frequent media coverage about staff shortages and limited PPE leading to health professionals’ fear about contracting Covid-19 dominating their decision-making process around glove use and its appropriateness (Cawcutt et al, 2020; Wilson et al, 2017a). For example, wearing two layers of gloves was observed in critical care units: before seeing each patient, health professionals would don one pair of gloves, rub their gloved hands with alcohol, then don a second pair (Patel et al, 2021). However, this was contrary to the SICPs’ PPE guidance, which specifically states that “double gloving is not recommended for routine clinical care” for Covid-19 cases (UKHSA, 2021a).

The pandemic also disrupted routine clinical practice. The influx of patients with Covid-19 meant that many clinical spaces were reconfigured and makeshift wards were used, which were not always fit for purpose (Patel et al, 2021; Farfour et al, 2020). Staff members were redeployed to increase critical care bed capacity (Farfour et al, 2020), many of whom felt anxious and afraid about being redeployed to an unfamiliar environment; this created a feeling of needing to protect themselves from Covid-19 (Panda et al, 2021).

“A shift in focus from hand hygiene to PPE has created the impression that standard precautions are not adequate”

Hospital-acquired infections

Sun Jin and Fisher (2021) observed that a number of outbreak reports from around the world cited glove misuse as a potential source of multidrug-resistant organism transmissions in acute hospitals during the Covid-19 pandemic. In particular, practices involving prolonged glove use and double gloving compromised hand hygiene, causing transmissions.

A lack of adequate hand hygiene caused by inappropriate use of gloves can result in the accumulation of pathogenic organisms on gloved hands. This can contaminate both environmental surfaces touched – such as door handles and equipment – and patients (Wolfensberger et al, 2018; Moore et al, 2013). Poor hand hygiene compliance and overuse of gloves is highly likely to have contributed to the increased number of hospital-acquired bloodstream infections and antibiotic-resistant organisms that has occurred during the Covid-19 pandemic (Baskaran et al, 2021; Miltgen et al, 2021; Patel et al, 2021). In England, annual rates of hospital-acquired E coli, Klebsiella spp and Pseudomonas bloodstream infections increased considerably in 2020-2021, becoming the highest rates in the past four years (UKHSA, 2021b). Of this period, England recorded the highest monthly count of hospital-acquired Klebsiella spp and Pseudomonas bacteraemias in January 2021, during the peak of the second wave of the pandemic (UKHSA, 2021b).

Farfour et al’s (2020) clinical case study details an outbreak of carbapenemase-producing Enterobacterales in a 12-bedded intensive care unit (ICU) for patients with Covid-19 in a French hospital. The unit was originally a post-anaesthesia care unit, which was converted to an ICU to create additional critical care bed capacity for patients with Covid-19. The outbreak affected six patients: five were colonised and one was infected. Several factors were believed to contribute to the transmission of the multidrug-resistant micro-organism, including:

• The lack of staff training in caring for ICU patients;
• Undercompliance with standard and contact precautions;
• Physical reconfiguration of the ICU;
• Staff being overworked due to patients’ acuity;
• Glove misuse.

Farfour et al (2020) noted that gloves and aprons were worn all the time without appropriate risk assessment, which could have resulted in missed opportunities for hand hygiene.

Recommendations

The effectiveness of non-sterile gloves in preventing contamination of health professionals’ hands and reducing the transmission of pathogens depends on two critical factors:

• Appropriate indication;
• Timely hand hygiene using alcohol-based hand rub or hand washing.

Gloves must be removed and hands decontaminated after each task to ensure pathogens are not transferred to a site on a patient where they may cause infection, and the same pair of gloves should never be used to deliver care to more than one patient.

Health professionals must be able to distinguish between clinical situations in which gloves must be worn and those in which their use is not indicated. They must also be able to risk assess situations and identify the key points during care when gloves must be removed and hands decontaminated – the WHO’s (2009b) five moments of hand hygiene (Box 1). Pathogens acquired on the surface of gloves by touch are easily transferred onto the skin as gloves are removed. Hands should, therefore, always be decontaminated with alcohol-based hand rub, or soap and water, after gloves are removed. This requires health professionals to be accurately informed of when gloves must be donned and doffed (Box 3) (WHO, 2009a).

In addition to education and training, the availability and placement of gloves may also have an influence on how non-sterile gloves are used in healthcare settings. Wilson et al (2017a) found that, when gloves were widely available but not located by the patient’s bedside, this increased the tendency for health professionals to don them early in an episode of care, increasing the risk of cross-contamination. To optimise compliance, they recommended that sinks, alcohol-based hand rub and gloves should be made available at the point of care.

Conclusion

Glove misuse and inadequate hand hygiene are commonplace in healthcare settings. It is a complex issue and has been linked to multiple factors, including:

• A lack of time between procedures;
• A lack of knowledge, leading to a false sense of security;
• Internal drivers such as emotion and socialisation.

This may put patients at increased risk of acquiring infections, and the fear caused by the Covid-19 pandemic is increasing the use of gloves, exacerbating the issue.

For this reason, we need to improve health professionals’ understanding of when and why to use PPE such as non-sterile gloves. A desire to protect themselves from exposure to Covid-19, and the focus on standard and transmission-based precautions, have led many health professionals to use gloves for almost everything, without appropriate risk assessment of potential exposure to blood, body fluids, mucous membrane and non-intact skin.

Non-sterile gloves must be used to not only safeguard health professionals but – equally importantly – to protect patients. To reduce the risk of cross-contamination and infection transmission in healthcare settings, it is essential to:

• Risk assess the appropriateness of glove use;
• Understand the indications for changing gloves;
• Perform hand hygiene immediately before and after glove use.