Skipping Hand Hygiene Before Donning Gloves May Be Just as Safe, Trial Suggests

Among healthcare providers, a direct-gloving strategy led to improved adherence and was found to be as safe as the current practice of hand hygiene prior to donning nonsterile gloves, a cluster randomized clinical trial showed.

Among 13 hospital units including nearly 3,800 healthcare providers, adherence to expected practice was greater among the units asked to directly glove without hand hygiene compared with the units asked to clean hands prior to donning gloves (87% vs 41%, P<0.001), reported Kerri Thom, MD, MS, of the University of Maryland School of Medicine in Baltimore, 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 noted 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 in Iowa City, told MedPage Today in an email. “Particularly burdensome is the recommendation to clean your hands with soap and water or alcohol hand rub prior to putting on gloves since you have to wait a minute or more for your hands to dry before putting on gloves.”

“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,” he added.

A previous randomized trial also showed no difference in glove contamination when nonsterile 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 sanitizer 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, Suraj Kumar Saggar, DO, of Holy Name Medical Center in Teaneck, New Jersey, told MedPage Today that the findings of this study are probably less relevant now since the data were collected prior to the COVID-19 pandemic.

“COVID-19 reiterated and brought to the forefront infection prevention,” he said. “This [study] was done before that, [so] the potential advantages of direct gloving and saying that more or less that it’s equivalent and increases adherence, the advantage may not be as strong as this paper is trying to say.”

However, Saggar noted the study does address a worthwhile topic related to infection prevention in hospitals.

“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.

“I wouldn’t say there’s any lack of guidance at the federal level, state level, local level, as well as internally from hospitals. I think every major medical system in the United States now recognizes that, and they have infection prevention teams,” he added. “There’s plenty of awareness of potential benefits, as well as detriments if those [practices] aren’t followed.”

Perencevich acknowledged that since the study was conducted prior to the COVID-19 pandemic, the data may not apply to practices during and after the pandemic, especially if infection control practices at hospitals have changed.

This cluster randomized clinical trial was conducted at four academic centers — two in Baltimore and two in Iowa City — from January 2016 through November 2017. In total, the trial involved 3,790 healthcare providers from 13 hospital units.

Thom and colleagues used assigned each participating unit to either continue usual glove practices or use a direct-gloving approach. They observed baseline rates for 6 months before initiating the intervention in six randomly selected units, which included one emergency department, one hemodialysis unit, one pediatrics unit, and three intensive care units.

The researchers used a standardized 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 pediatrics 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 hemodialysis 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 hemodialysis unit) in the other units.

The authors concluded that a rigorous approach to evidenced-based guidelines will 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.

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