Surgeons voluntarily give up latex gloves for synthetic alternatives
Surgeons voluntarily give up latex gloves for synthetic alternatives
Clinic works with suppliers to meet special needs for surgical gloves
The notion that surgeons would willingly don synthetic gloves rather than natural latex gloves in the operating room might once have been considered ludicrous. But as evidence mounts about the growing incidence and dangers of latex allergies, a small group of surgeons, often at the urging of the institutions where they work, have voluntarily made a transition to synthetic surgical gloves.
At the multicenter Marshfield (WI) Clinic, the shift away from latex has become a matter of policy. For nearly two years, the clinic, which conducts ambulatory surgical procedures, virtually eliminated latex gloves and other latex-containing products from its surgical suites, according to Bruce Cunha, RN, MS, COHN-S, manager of employee health and safety. Marshfield Clinic consists of 38 facilities throughout central and northern Wisconsin, with its largest site located in Marshfield. It employs about 550 physicians.
Discovery of allergy lends impetus to effort
In 1995, responding to a growing concern nationwide about latex allergies among health care workers and patients, Marshfield considered its options for reducing latex usage. Examination and surgical gloves were clearly the greatest source of latex exposure for both patients and health care workers. Cunha explains that the main clinic facility had been working gradually on the development of joint allergy protocols with the hospital to which it is physically attached and to which it supplies all surgeons. But a year later, a sense of urgency interjected itself when a Marshfield surgeon developed severe latex allergy. A leading allergist told him he would have to give up practice unless he forswore the use of latex gloves.
Marshfield administrators, led by the clinic’s medical director, weighed their options: change to low-protein, non-powdered latex gloves; change entirely to synthetic gloves; or use some of each. They opted for synthetics because at the time of the decision, the facility "didn’t have any scientific evidence that there were any acceptable levels of [latex] proteins that would not cause someone to become sensitized," explains Cunha. "Therefore, we were putting everyone at risk every time someone put on a latex glove."
The transition to synthetic non-sterile examination gloves drew few objections from the staff, who could choose from vinyl or nitrile gloves. Vinyl proved to be suitable for simple procedures in which little stress is placed on the glove, such as bandaging and vaginal or rectal exams. The material, however, does not conform to the hand as well as latex and tears easily. Nitrile gloves, which many health care professionals say approximate the characteristics of latex more than any other synthetic material on the market, are used at Marshfield for more extensive examinations or in the presence of sharp instruments. Nitrile, notes Cunha and others, is significantly more expensive than vinyl. "By mixing the two types of gloves, we were able to keep costs close to what we’d been paying for latex exam gloves," he says.
A successful transformation in the OR
In response to the latex threat, many medical facilities have greatly decreased the use of latex exam gloves. However, Marshfield went a major step further, pushing its latex-free campaign into its surgical suites — a rarity except for cases in which patients or surgical staff are known to be latex-sensitive. Administrators at Marshfield plunged into untested waters, and, after some concentrated persuasion and cajoling, succeeded in virtually eliminating the use of latex gloves by surgeons. Since the change, not a single documented case of latex-allergic reaction has been reported among clinic employees, says Cunha.
Marshfield made the change-over at a time when concern about latex allergies was waxing. The selection of synthetic surgical gloves was quite limited and quality was sometimes suspect, according to Cunha; for the most part, the sterile synthetic gloves on the market could not meet all the needs of surgeons, he adds.
Vinyl gloves, for instance, fit too loosely and tore too easily. Stretch vinyl was better, but still lacked consistent integrity. Nitrile gloves, which closely approximate the characteristics of latex, were not yet available in sterile packaging and were very costly. Especially challenging was finding gloves for orthopedic surgeons, who often require thicker gloves and gloves that can withstand surgical glues. Some surgeons circumvented the problem by double-gloving with synthetics.
One surgeon who performs operations on AIDS patients, recalls Cunha, was very concerned about protection from bloodborne pathogens. When they found a glove of adequate strength, it was too slick to wear as an outer layer. Finally, the surgeon was able to find a combination of two different synthetic gloves that provided both adequate protection and tactile feel. Ophthalmologists require very thin gloves, so many opted for Tactylon. Gloves made of neoprene became popular with other surgeons. (See list of non-latex glove manufacturers, inserted in this issue.)
As a group, the surgeons understood the clinic’s reasons for doing away with latex gloves. The fact that the medical director, Frederick Wesbrook, MD, firmly supported the transition to synthetics in the OR, smoothed the process considerably. "Without [his support], it would have been very difficult to accomplish," says Cunha.
There were some missteps. "We made mistakes at first by just handing out various gloves to surgeons to try on without educating them about the materials," recalls Cunha. "They’d come back and say, I didn’t like these because they ripped.’" Cunha enlisted the aid of glove manufacturers’ representatives, who came in to explain the strengths and weaknesses of their synthetic gloves. Acceptance levels rose quickly after that.
A few surgeons objected strenuously to the change. Wesbrook and Cunha met individually with reluctant surgeons and persuaded the holdouts to give synthetics a chance by stressing the seriousness of latex allergies and the fact that Marshfield was seeing more patients with latex sensitivities. Eventually, they succeeded in marshaling the support of the entire medical staff. No surgeons left the Marshfield system because of the move to synthetic gloves, says Cunha.
Initially, surgical glove costs at Marshfield nearly doubled, though the increase was almost certainly offset by the looming threat of workers’ compensation cases that might have occurred as the result of latex allergy, says Cunha. Since Marshfield began the program, synthetic glove costs have greatly declined as competition for the burgeoning synthetic market has grown, he adds.
During the transition, Marshfield worked closely with the companies that became its major suppliers of synthetic gloves to iron out difficulties. For instance, pull tabs on packages of sterile gloves were too small to open without contaminating the contents. The manufacturers responded by making the tabs larger. Some stretch vinyl gloves didn’t fit tightly enough and got pinched in the wheels used to guide endoscopes. The manufacturer responded by improving the glove fit.
After two years of keeping Marshfield surgical procedures free from latex gloves, complaints from surgeons about glove quality began to climb. Demand for synthetic gloves was on the rise, straining manufacturing capacities and compromising quality control, says Cunha. "There had always been some surgeons who had problems with the synthetics. When they became too great, we had to back up a bit." Marshfield retreated to limited use of nonpowdered latex in its OR suites, but has managed to remain largely latex-free.
"Since reintroducing to the OR, we have not been able to switch totally back to synthetic gloves," explains Cunha. "We know that’s a compromise, but [latex] has been helpful in filling in gaps that we had before and it’s making the surgeons feel more comfortable. As new synthetic and other gloves become available, we will re-evaluate the use of latex gloves in the OR."
Increasing the challenge
If convincing several hundred surgeons at a mostly rural clinic system to adopt synthetic gloves was a tour de force, accomplishing the same feat at a major medical center would seem monumental to some. But Johns Hopkins University is making the attempt — and so far is succeeding.
The facility, which now uses only vinyl or nitrile examination gloves, is in the process of systematically evaluating the use of latex gloves in each of its units and working with surgeons to identify suitable sterile, non-latex alternatives, according to Robert G. Hamilton, PhD, associate professor of medicine and pathology at the Johns Hopkins University School of Medicine in Baltimore.
About a quarter of the surgeons and all of the anesthesiologists and surgical nurses have converted to synthetic gloves, says Hamilton, who predicts that most surgical procedures at Johns Hopkins will be latex-free in about six months. (See related story, p. 101.) Other sources of latex in the OR are also being eliminated or greatly decreased with the help of a computerized database of latex-free alternative products. Select OR suites are already latex-safe, particularly in the pediatric areas.
"First we explain the problem [to surgeons], then we provide alternative gloves that they try on to determine which is best for them," Hamilton explains. "Generally, they can find one synthetic glove that works fine," says Hamilton, who adds that totally eliminating all latex sources from the surgical environment is a challenging goal at this point. "We at least want to eliminate use of latex in gloves and other sources that, based on the literature, are primary sources of allergen exposure."
Objections from surgeons were predictable and met with reasoning and one-on-one meetings to discuss the pressing need to reduce the risk of latex sensitivity among patients and staff, says Hamilton.
Hamilton offers several suggestions for facilities that wish to reduce the use of latex in their ORs:
• Establish a latex task force with defined goals. "For us, it was to create a latex-safe working environment for all employees and patients," says Hamilton.
• Place benefit over cost. Spending a little more money on synthetic gloves is worth the investment and is a decision that should be made institutionwide. Often, hospitals will make crucial medical decisions based on cost, not benefit, notes Hamilton.
• Systematically eliminate powdered latex examination gloves. "Not everyone needs to go to the great extent that we are to eliminate all latex gloves," explains Hamilton. "Powdered latex gloves represent the group of products that historically have contained the highest levels of allergens, and the cornstarch powder carries the latex protein into the air. Eliminating powdered gloves reduces skin contact with the allergen."
• Create a list of alternatives to products that contain latex and develop a nursing protocol for latex-allergic patients and staff.
• Develop an education program so that all staff members realize the gravity of this issue and what their options are.
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