Selected Topics: Wound Care
A global inventory of hospitals using powder-free gloves: a search for principled medical leadership1,

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Abstract

Scientific experimental and clinical studies have demonstrated that cornstarch on surgical and examination gloves promotes disease by acting as a reactive foreign body in tissue and serving as a vector for latex allergy. Consequently, hospitals have selected an innovative glove selection program utilizing only powder-free gloves. Healthcare workers in emergency medical systems are now wearing powder-free, latex-free gloves to care for the growing number of patients sensitized to latex. A global Internet search has now identified 70 hospitals in the United States and three hospitals in Europe that use only powder-free gloves.

Introduction

Most physicians have an unfounded confidence in cornstarch and mistakenly believe that it is safe. It is a substance recognized on the surface of examination and surgical gloves by all emergency physicians, surgeons, nurses, and hospital administrators. Nevertheless, this familiar powder can cause a wide variety of sometimes deadly complications. While first used as a donning agent for gloves, recent technologic advances in glove manufacture have resulted in the development of inexpensive powder-free gloves with equal or superior performance characteristics to that of powdered gloves. Today, cornstarch is a substance that has outlived its benefits. Consequently, there are a growing number of hospitals that are using exclusively powder-free glove products.

The purpose of this report is to first describe the mechanisms by which cornstarch elicits human disease. Second, we describe a powder-free glove selection program for the hospital. Finally, we enumerate the results of our global Internet search for hospitals using only powder-free gloves.

Scientific experimental and clinical studies have confirmed that cornstarch promotes disease by two different mechanisms. First, it acts as a foreign body that causes a severe inflammatory response and interferes with the host’s defenses against infection. When cornstarch is deposited in soft tissues, it potentiates the development of wound infection 1, 2. Small amounts of cornstarch encourages wound induration, bacterial growth, and infection. Calcium carbonate has been recently introduced as a glove mold release agent to replace cornstarch. A study has demonstrated that this new glove powder, calcium carbonate, is significantly more damaging to host wound defenses than cornstarch (3).

When cornstarch enters the peritoneal cavity, it can elicit granuloma formation, adhesion formation, and peritonitis 4, 5, 6, 7. Cornstarch induced adhesions can cause intestinal obstruction, infertility, and pelvic pain. It is interesting that the new surgical glove powder, calcium carbonate, promotes significantly more abdominal adhesions in experimental animals than does cornstarch (8). Scientists have reported numerous other adverse reactions to cornstarch that include endophthalmalitis, post-thoracotomy syndrome, meningismus after craniotomy, retroperitoneal fibrosis, and synovial inflammation 9, 10, 11, 12, 13.

It is important to understand that simply washing the cornstarch off gloves prior to use does not prevent the deleterious effects of cornstarch. Jagelman and Ellis show that washing with water decreases the number of starch particles, but leaves considerable cornstarch on the glove that aggregates as clumps (14). They suggest that cornstarch clumps would provoke a delay in absorption and an increase of the foreign-body reaction. In 1980, the investigation by Tolbert and Brown provided further evidence that glove washing with a saline solution leaves residual cornstarch on the glove’s surface (15).

Fraser found the most efficient method of washing the cornstarch from the gloves to be a one-minute cleansing with 10 mL of povidone-iodine followed by a 30-s rinse under sterile water (16). This technique decreases the median number of starch granules per mm2 of glove, as seen on microscopic examination, from 2,720 (when no attempt to remove the powder is performed) to 0 (with the povidone-iodine method). However, this technique was time-consuming, costly, and burdensome to the clinical staff and did not ensure removal of all powder particles.

Despite the effectiveness of these procedures, it would still be advisable that health care workers adhere to the washing guidelines if the cornstarch powder is to be removed completely. In a later clinical trial, Fay and Dooher examined the surgical staff’s compliance with glove washing to remove cornstarch lubricants. They note that only 17% of the surgeons and 21% of the surgical nursing staff washed their gloves after donning (17).

It is also valuable to appreciate that healthcare workers in some hospital settings use powdered surgical gloves because they do not have easy access to sterile wash basins. Emergency physicians in Emergency Departments (EDs) treat more than 10 million patients annually using sterile surgical gloves. During wound care, they usually do not have the benefit of a nursing assistant who aseptically sets up a sterile wash basin filled with saline in which they can remove the cornstarch from their gloves. Therefore, many emergency physicians resort to using gloves lubricated with cornstarch during wound treatments.

The second mechanism by which cornstarch on gloves elicits disease is based on its role as a carrier for latex allergens. Documented reactions to latex include contact urticaria, rhinitis, asthma, and anaphylactic shock 18, 19, 20, 21, 22, 23, 24, 25. The development of reactions to latex exposure has been linked to the individual’s production of IgE antibodies to natural latex when exposed to this substance 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27. IgE mediated latex allergy has several presentations with symptoms varying from mild itching to severe anaphylaxis (28). Three clinical presentations are frequently seen. Glove induced local contact or irritant dermatitis may occur that may progress to contact urticaria, pruritis, erythema, and angioedema in the first group. Some of these individuals may develop mucosal involvement with varying degrees of systemic allergic reactions ranging from hives, wheezing, to laryngeal edema to anaphylaxis. The second group displays occupational disease of the lower or upper respiratory tract, or both, which includes rhinoconjunctivitis and bronchial asthma with or without skin reactions. The third group develops anaphylaxis during a medical or surgical procedure.

In 1992, the Food and Drug Administration reported more than 1,000 combined Medical Device Reporting Program and Product Problem Reporting Program reports of allergic or anaphylactic reactions in conjunction with the use of plant-derived rubber or latex containing medical products (29). It is important to realize that there is some overlap between these two reporting programs. Recently, Dillard, an official in the Center for Devices and Radiological Health in the FDA, noted that there were 305 reports to the FDA of allergic or anaphylactic reactions associated with the use of latex gloves in the last year alone for which data are available (August 15, 1996–August 15, 1997) (29).

Health care workers are at high risk for this allergy due to occupational exposure to latex. In 1992, Zoltan, Luciano, and James reported that 8.8% of dentists in the U.S. Army Dental Corp have self-reported histories consistent with latex allergy (30). Kaczmarek and colleagues in 1996 demonstrated that 5.5% of hospital personnel are positive for latex specific IgE antibody by employing a radioallergosorbent test (31). Two other studies in 1997 indicated that 12.1% of health care workers and 21% of hospital nursing staff are sensitized to latex, as determined by skin prick tests 32, 33.

This high incidence of latex sensitization has enormous human costs, as trained healthcare workers who have symptoms may require reassignment, or potentially can even need to discontinue their career in healthcare. Not only is this devastating to the healthcare worker, society also loses the benefit of the training of these professionals. A role of cornstarch in the development of latex allergy by health care workers is suggested by Beezhold and Beck, who found a significant interaction between latex proteins and cornstarch powders (34). In addition, Tomazic et al. demonstrated that cornstarch binds latex proteins (35). This binding between cornstarch and latex has been implicated as the major cause of airborne latex. Tarlo and associates found low or undetectable latex aeroallergens in work areas where only powder-free gloves were used (36).

There is considerable evidence that these airborne cornstarch-latex particles act as an agent for exposure and sensitization of healthcare workers to latex protein through the release of latex-cornstarch particles into the air. First, latex-protein or starch particles are allergenic proteins (35). Sensitized people display allergic symptoms such as rhinitis, cough, conjunctivitis, or breathing problems when only exposed to airborne latex through the handling of cornstarch powdered latex gloves (37). Of 11 sensitized people, four developed shortness of breath, wheezing, and had evidence of enhanced airway resistance. Four sensitized nurses experienced immediate bronchoconstriction when handling powdered latex surgical gloves and bronchial challenges with powdered latex surgical glove extracts resulted in more severe reactions than challenges with non-powdered latex surgical glove extracts (38). Consequently, it can be concluded that the interaction between cornstarch and latex provides a route of exposure to the latex proteins that the absence of cornstarch would minimize.

Case reports in the literature provide further evidence for the role of cornstarch in latex allergy of healthcare workers. Tarlo and colleagues describe one hematology laboratory technician who had developed contact dermatitis, contact urticaria, and anaphylaxis following contact with latex. She continued to experience symptoms, such as facial urticaria and rhinitis, after she switched to vinyl gloves, and eventually stayed home from work. She was able to return to work after her laboratory changed to powder-free gloves (36). Lagier and associates examined an intensive care nurse who immediately had asthmatic symptoms when powdered latex gloves were manipulated in front of her, but had no reaction to vinyl gloves (39).

Jackson Memorial Hospital (Miami, FL), Methodist Hospital (Indianapolis, IN) and Brigham and Women’s Hospital (Boston, MA) also found an important role of powdered gloves in the development of latex allergy. Their latex sensitized healthcare workers were able to continue work in a powder-free hospital environment (40). All three hospitals banned the use of powdered gloves, converting to powder-free gloves after discovering that latex allergies were a substantial problem among their staff. The favorable experiences of these hospitals with the elimination of powder-free gloves demonstrate that a commitment to eliminating cornstarch powder is a valuable tool against the growing problem of latex allergy among healthcare workers.

This linkage between increased exposure of healthcare workers to latex proteins due to the use of cornstarch powder on gloves is now well documented by the literature. The National Institute for Occupational Safety and Health (NIOSH) released a safety alert report in June 1997 entitled: “Preventing Allergic Reactions to Natural Rubber Latex in the Workplace” (41). It alerted the public, employers, and safety and health officials to the increase in allergic reactions to latex, particularly among healthcare workers, but also recommended that “If latex gloves are chosen, provide reduced protein, powder-free gloves to protect workers from infectious materials.”

In the 1980’s, manufacturers devised two different techniques to produce powder-free gloves. They used either a hydrogel polymer or surfactant as mold-release agents for latex gloves that allowed for the production of powder-free gloves in the absence of cornstarch. The other approach involved chlorination of the powdered glove to remove surface glove powders resulting in a glove product with only small levels of residual cornstarch (42).

Biomechanical studies have demonstrated that the performance of powder-free latex gloves is remarkably similar to that of powdered latex gloves. Cote and associates report that the forces required to don many manufactured powder-free latex examination gloves do not differ significantly from that encountered with powdered latex examination gloves (43). Similarly, Fisher and colleagues document that the glove donning forces for powder-free and powdered sterile latex surgical gloves do not differ significantly (44). Furthermore, the puncture resistance of powder-free and that of powdered latex surgical gloves are remarkably similar. Pavlovich and colleagues note that powder-free latex gloves are especially suited for tape wound closure (45). They found that cornstarch powder bound to the microporous tapes and interfered with tape adhesion to skin. In contrast, microporous tapes handled with powder-free surgical latex gloves adhered aggressively to skin, facilitating wound approximation.

There have been major technologic advances in the design and manufacture of powder-free gloves. The surface of the fingertips of powder-free gloves has been textured to improve the physician’s grasp of surgical instruments (46). In addition, a unique double glove puncture indication system has been designed for powder-free gloves (47). This puncture indication system consists of a double glove system with an inner glove uniformly colored green under a transparent outer glove. When the outer glove is punctured, the green inner glove develops a dark patch under the puncture site, a warning to the physician to change the glove immediately. The color change is an optical effect; it does not involve release of dye or any other material, but it works on the principle of capillary action. This double glove system has twice the resistance to puncture as a single glove.

For healthcare environments managing latex sensitized patients, like ambulances and EDs, nitrile examination and surgical gloves are commonly used (48). Nitrile powder-free examination gloves that comply with the National Fire Protection Association Standards 1999 are especially suited for EMTS (48). The thickness of nitrile gloves are half that of latex, enhancing the tactile discrimination of the healthcare worker. These thin nitrile gloves exhibit twice the puncture resistance of latex gloves. The handling characteristics of the nitrile gloves are judged to be excellent with donning forces that are comparable to those encountered with latex gloves. Another unique advantage of the nitrile gloves is that tape adhesive has limited adherence to the glove surface. In contrast, tape adhesive aggressively adheres to latex gloves.

These unique performance characteristics of nitrile examination gloves have been found useful in surgical gloves used in the ED (49). First, their thickness is significantly less than that of surgical latex gloves. The puncture resistance of nitrile gloves is twice that of latex gloves. Donning surgical nitrile gloves can be easily accomplished with either single or double gloves.

Since the advent of the latex allergy epidemic in healthcare workers and patients, many hospitals have implemented a comprehensive glove management program that involves the use of powder-free gloves. To search for this principled medical leadership, we have devised an inventory of hospitals using only powder-free examination and surgical gloves throughout the world utilizing an Internet website (www.deadlydust.com). This site welcomes all hospitals using only powder-free examination and surgical gloves to be registered. To date, 70 hospitals have registered on this website. Twenty-one states have hospitals using only powder-free gloves (Table 1). Virginia [17] and Minnesota [11] have the highest number of registered hospitals. In June 2000, Kaiser Permanente managed care organizations will be listed on this website, including its 12 participating hospitals. Three hospitals in Europe have taken a leadership role in banning the use of powdered gloves (Table 2).

Section snippets

Discussion

Despite overwhelming evidence of the dangers of powdered glove lubricants, many hospitals across the world continue to use powdered examination and surgical gloves. During the last century, scientists repeatedly demonstrated that the powder on gloves causes serious disease requiring hospitalizations (50). Investigations also identified a latex allergy epidemic that threatens millions of healthcare workers and patients and pointed to the significant role of powdered glove lubricants in latex

Conclusions

Cornstarch powder promotes disease by two different mechanisms. It acts as a reactive foreign body in tissue, which results in a wide range of diseases, and serves as a vector for the latex allergy epidemic. A glove selection program for hospitals has been identified that utilizes only examination and surgical gloves without the cornstarch powder. Powder-free, latex-free gloves are recommended for treatment areas caring for latex sensitized patients, especially the emergency medical system. An

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    Supported by a Grant from the Texaco Foundation, White Plains, NY.

    1

    Selected Topics: Wound Care is coordinated by Richard F. Edlich, MD, PhD, of the University of Virginia Medical Center, Charlottesville, Virginia

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