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Hand Hygiene and the Wearing of Gloves

Hand hygiene is the single most effective way for preventing transmission of infections. Hospital-based studies indicate that noncompliance with hand hygiene practices can be correlated with healthcare–associated infections and the spread of multi-resistant organisms. Noncompliance has been a major contributor to outbreaks. The prevalence of healthcare–associated infections decreases as adherence to proper hand hygiene measures improves.

Hand hygiene is the cleaning of the hands by either application of alcohol-based hand rubs (ABHR) or traditional soap-and-water hand washing. Recent evidence has demonstrated superiority of ABHR for decontaminating hands in all healthcare settings and it is now the preferred method of hand hygiene unless the hands are visibly soiled, when washing with soap and water is required.

Hand hygiene compliance by healthcare workers has been notoriously low, averaging 40% to 50%. However, recent campaigns have modestly increased compliance rates. Even when hand hygiene occurs, however, it sometimes fails to follow proper procedures (e.g., times less than 15 seconds for soap and water washing or incomplete coverage of all skin surfaces when using ABHR). 

Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients and themselves. One such time involves the use of gloves. Wearing gloves alone is not enough to prevent the transmission of pathogens in healthcare settings. When properly used, gloves reduce hand contamination by 70% to 80%. Hand hygiene must deal with the remaining 20% to 30%.

When asked, many respondents with lower levels of compliance stated “that wearing gloves was a suitable substitute for hand hygiene.” Most infection prevention organizations and experts, governmental agencies and professional associations recommend that hand hygiene be performed before donning examination and sterile surgical gloves and immediately after removing the gloves. Some studies report lower rates of hand hygiene compliance if gloves are worn, while others indicate the opposite. Most of these studies were small (one facility) with limited indications for glove use.

However, a larger study (Fuller VC, Savage J, Besser S, et al. “The dirty hand in the latex glove”: a study of hand hygiene compliance when gloves are worn. Infect Control Hosp Epdidemiol 2011;32(12):194-199) was recently published. The authors performed an observational study of glove use and associated hand hygiene behaviors on 56 wards in 15 hospitals during 249 one-hour sessions. Observed were glove wearing and performance of hand hygiene. The quality of the hand hygiene was not evaluated. The rate of hand hygiene after patient contact by ungloved workers was 50.0%, while compliance when wearing gloves was 41.4%. After adjusting for ward, healthcare worker type, contact risk level and whether the hand hygiene opportunity occurred before and/or after patient contact, glove use was strongly associated (p<0.001) with lower levels of hand hygiene.

The authors were unclear as to why glove use should be associated with poorer hand hygiene compliance and suggested that glove use and performance of hand hygiene may be two distinct behaviors with different behavioral determinants. Wearing gloves protects both the wearer and the patient, thus obviating the need for hand hygiene. The reality is when gloves are worn without hand hygiene, the contamination present on hands multiples rapidly under gloves (warmth and moisture) and may not be cleaned after glove removal. This result can be called ”the dirty hand in the glove.” This poses a hazard for the worker and for the patient if contacted by an ungloved hand or if glove integrity is compromised during treatment. 

*Courtesy of the Organization for Safety, Asepsis, and Prevention

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