When the nurse entered the OR at Lancaster General Hospital as a patient, her hysterectomy went off without a hitch. But during recovery, her blood pressure suddenly dropped, she had trouble breathing and she lost consciousness. Chest scans revealed nothing. Abdominal scans revealed nothing. The patient was slipping away, and the team was perplexed. Then, a miracle happened: Some-one removed her Foley catheter and, within hours, the patient was walking and talking.

Despite her years in the OR, this nurse-turned-patient didn't know she was allergic to natural rubber latex. In fact, studies show that as many as 50 percent of latex-sensitive people have no history of atopic illness. The allergy can build up with repeat exposure - of which there is no shortage in your facility. At any point, just one more exposure can cause symptoms to erupt, and not always mildly.

"You may not know it until disaster strikes," says Linda M. Coulombe, RN, BS, CNOR, CRCST, a department head with Lancaster General in Lancaster, Pa.

When you consider the number of supplies that may contain latex and that roughly 10 percent of healthcare workers are latex-sensitive, it's important to take measures to prevent disaster. Here are five ways to fend off the latex threat in your facility.

1. Believe it
The biggest obstacle to protecting OR personnel and patients is, ironically, the OR personnel.

"Many people still don't believe this is real even though there has been a lot of publicity," says Ms. Coulombe, who admits she wasn't gung-ho on reducing latex exposure in her OR until her employee and friend almost died. Now, she says, it's essential to educate everyone until they understand the realities of latex allergy: "They don't need to be advocates, but you need to bring them to the point where they will at least support you in your efforts to reduce latex exposure in the OR."

Your efforts should focus on reducing the two primary routes of exposure for OR personnel: skin contact, from supplies such as gloves, face masks and bandages; and airborne latex proteins that latch onto powder, of which gloves are the main cause. And on the primary route for patients: direct mucosal contact from gloves as well as catheters, tubing and even medications dispensed from containers with rubber stoppers.

Before you can get the latex out, you need to change the mindset from latex as an everyday supply and "as a life-saving product, to latex as a potential life-taking product," says Gail Lenehan, RN, EdD, FAAN, FAEN, latex allergy educator and member of the Massachusetts Nurses' Association Congress on Occupational Health and Safety. Here are three key elements of any good latex education program.

• Prove it. Ms. Coulombe recommends sharing the FDA's latex allergy reporting data to demonstrate the reality of the problem. In the five years after universal glove-wearing precautions took hold in 1987, the FDA received more than 1,100 reports of serious allergic reactions in patients and healthcare workers - including 15 reports of patient deaths linked to latex barium enema catheters. Between 1992 and 2002, the FDA received another 1,200 reports, including some deaths.
• Define it. When OR personnel understand how latex allergy develops, they begin to understand that it can happen to them and their patients. Many believe latex glove-wearers who are prone to contact dermatitis - especially those with allergic contact dermatitis - are more likely to develop latex allergy, because breaks in the skin allow latex proteins to enter the body. This can cause sensitization, the development of immunological memory to the proteins. With continued exposures, about one-third of sensitized people will develop reactions ranging in severity from rhinoconjunctivitis and urticaria to asthmatic reactions, airway obstruction, anaphylactic shock and even death (see "Differing Allergy From Irritation" on page 22). It's even possible for sensitized people, like the aforementioned patient, to have no outward manifestation of sensitivity until one "final drop," or exposure, causes the barrel to overflow, as it were.

"I try to teach the fact that latex allergy is cumulative and results from repeated exposure," says Ms. Coulombe. "It may not hurt you today, but six years down the road, after you change gloves 12 times a day, five days a week, where will you be?"

• Evaluate it. Ask your employees to evaluate their own situations. Even small amounts of itching, watering of the eyes or other minor symptoms can signal the beginning of a potentially serious cascade of events if exposure continues. "The biggest thing in the OR setting is to make people aware that this is a big deal," says Mary Elizabeth Bollinger, DO, associate professor of pediatrics with the Division of Pediatric Pulmonology and Allergy at the University of Maryland School of Medicine in Baltimore. "It can start with a minor rash and develop into asthma and symptoms that can put a stop to your career," she says. Research shows that more than 2 percent of all healthcare workers have asthma caused by occupational exposure to latex.

Once you enforce awareness, adds Ms. Coulombe, you can begin to garner support. "I recently did a presentation and three surgeons spoke up and said they had latex allergy. Then, I was in a better position to do something about it."

2. Screen patients and personnel
The routine, generalized allergy assessment may not uncover latex allergy, since many symptomatic people don't associate their reactions with glove use. To help identify at-risk patients, Dr. Lenehan advocates a quick, two-question screen:

• Do you wear latex gloves for your job?
• Have you experienced any allergic symptoms while using gloves, while receiving treatment at the dentist or gynecologist, or after invasive medical or surgical procedures?

If the patient says yes to either question, says Dr. Lenehan, use latex-free gloves; prevent their ingestion of or injection with latex; and avoid mucous membrane and skin contact with latex.

For healthcare personnel, who are much more likely to be affected due to occupational exposure, many recommend more stringent screening protocols. Dr. Bollinger, who co-developed personnel screening guidelines after finding that 8.6 percent of employees at her institution were latex-sensitive, recommends screening all employees in high-usage areas like the OR and all new employees, including those who transfer within clinical services. She also advises screening anyone who presents with risk factors and allergic tendencies. Dr. Bollinger recommends using a questionnaire and a serologic test but warns against relying too much on serology, because the current test misses at least one-fourth of sensitized people.

"The fact that there is no skin test yet available in the U.S. greatly limits the screening process, because skin tests can be more sensitive," she adds. "This is very much needed in this country."

The questionnaire, then, represents an important line of defense against latex allergy, so it must be well thought-out. Simply asking if a staffer has latex allergies isn't effective, because she likely doesn't know she's sensitized.

"Ask questions that will help the employee who doesn't know she has allergy uncover symptoms and risk factors," says Denise M. Korniewicz, DNSc, RN, FAAN, professor and senior associate dean for research with the University of Miami School of Nursing & Health Studies in Miami, Fla. "Did you ever react to a latex balloon or cleaning gloves at home? Do you react to bananas, avocadoes or other fruits and foods?"

People tend to dismiss itchy eyes or mild dermatitis, or they attribute these symptoms to other causes and, she says, a targeted questionnaire will help them connect the dots.

There are three lines of questioning to any good employee screening questionnaire, says Ms. Bollinger:

• Atopic history. For example, is there a history of rhinitis, asthma, eczema, or food allergy? Does the individual react to bananas, avocadoes or other fruits?
• Latex allergy history. For example, is there a history of any localized or systemic symptoms suggestive of latex allergy?
• Prior natural rubber latex exposure. This includes occupational exposures (gloves), wearing condoms, prior surgeries and number of years in the healthcare field.

Dr. Bollinger says the screens produce the added benefit of helping symptomatic employees who are unaware that latex is the cause of their problems. She cites the case of one employee who had chronic conjunctivitis for years and was able to address it only after discovering, via the employee screen, that she had latex allergy. "These screenings should be done yearly," adds Dr. Korniewicz. "This merely costs some time, and it's a good preventive measure."

3. Switch out your gloves
Avoidance is the cornerstone of preventing latex allergy and avoiding symptoms in sensitized people. To minimize exposure to personnel and patients alike, according to Dr. Lenehan, managers should prioritize latex-laden items and address the most common and potentially dangerous offenders first. "Begin with gloves. They are 95 percent of the problem," she says. Gloves are not only in constant contact with skin, but the powder carries latex proteins into the air during glove changes, which employees and patients breathe in.

The challenge for facility managers is determining how far to go. That is, should you switch to low-protein, powder-free latex gloves or should you go latex-free altogether? Should you still stock more conventional, powdered latex gloves for physicians and practitioners who prefer them? At the least, advises Dr. Korniewicz, replace conventional powdered gloves with powder-free, low-protein gloves. This reduces the allergic content of the glove and reduces the chance for the allergenic proteins to become airborne.

"OSHA has been very clear about this," says Dr. Korniewicz. She recently completed a two-year study of a conversion to powder-free, low-protein gloves, and her research shows that about 40 percent of the OR staff who experienced latex-associated symptoms before the conversion were symptom-free post-conversion. Dr. Bollinger says her own soon-to-be published data from the University of Maryland show a similar result.

Still, low-protein, low-powder gloves don't solve the problem entirely. More than one-quarter of all OR personnel in Dr. Korniewicz's study still had symptoms, and Dr. Bollinger says some highly allergic personnel in her study continued to have increasingly severe symptoms even after conversion. Even worse, worries Ms. Coulombe, patients remain vulnerable even after such a conversion. "My concern is that patient who doesn't know she is allergic. If we keep latex gloves in the facility, they are still touching my patients. That's the part that scares me," she says.

For these reasons, experts recommend having latex-free gloves on hand and readily available. At Ms. Coulombe's prior facility, where her nurse-employee experienced the anaphylactic reaction, about 35 percent of the 170 OR staffers and practitioners now wear nothing but latex-free gloves. The good news, she says, is that the latest generation of latex-free alternatives perform very well. "You have to be extremely persistent to affect this kind of change, because no one likes change. But once you get used to these gloves, they are great," she says, noting that her latex-free glove of choice has the necessary grip and tactility and is also true to size.

Despite concerns that alternative gloves are expensive, conversions can save money. When she switched to low-protein, low-powder and latex-free gloves, Ms. Coulombe standardized her inventory, took advantage of volume discounts and saved $30,000 a year in the process. "We went from 23 glove vendors down to five for all of our exam and surgical gloves," she says. At the University of Maryland Medical Center, a similar thing happened. Dr. Bollinger realized $80,000 in annual savings just by centralizing glove purchases. "You need to look beyond straight costs," she says, noting that alternative gloves can reduce workman's comp costs. In mid-1997, when she first began work on her glove conversion program, six employees had lost an average of 50 workdays each due to latex allergy. "When you look at the big picture, glove changes can save money and improve employee and patient satisfaction," she adds. "The days of everyone picking their own gloves are over."

4. Create safe zones
When you do identify allergic employees, say our managers, you must work to protect them. Foremost, they say, latex-sensitive personnel should wear synthetic gloves. "I have seen terrific nurses and doctors with years of experience leave the OR. We should not be throwing away allergic employees," says Dr. Lenehan. "Instead, we should be throwing away the products and making the surgical facility a safe place for everyone." At the University of Maryland Medical Center, Dr. Bollinger and her team have established several latex-restricted units, including the NICU and ER, where no latex gloves are permitted at all.

Once you identify an allergic patient, says Dr. Lenehan, a simple glove change is not enough. Be sure that everything that enters the patient or touches a mucous membrane, she says, is latex-free. "Once you get rid of the glove threat to the patient, you must then look at anything you intend to insert or inject and be sure you have latex-free replacements," she says. Have latex-free catheters and wound drainage tubes available, she advises, as well as latex-free injection ports. Dr. Lenehan recommends against coated latex tubing and catheters because, she says, the coating can crack. She also recommends notifying the pharmacy when patients are latex-sensitive so rubber-containing syringes and syringe stoppers can be eliminated, since latex may find its way into the medication.

Additionally, always have a latex-free crash cart available. As a third priority, consider replacing latex-containing items that touch the patient's skin, like blood pressure cuffs, Ace bandages and electrode pads. Experts also recommend scheduling allergic patients as the first cases of the day, when latex is least likely to be present in the air.

Don't let your guard down
Once you've made the effort to raise consciousness and protect personnel and patients, keep it there. "I have seen situations where a manager did an excellent job and was very diligent," says Dr. Lenehan, "but then the manager left, someone new came in and latex crept back in."

To keep this from happening at your facility, create latex awareness committees. As part of her efforts, Dr. Bollinger formed a multidisciplinary task force that included representatives from every area of the hospital. The members worked together to establish and enact policies and procedures to reduce the risk of employee exposure. At her prior facility, Ms. Coulombe did something similar and charged the members of her committee with the additional tasks of evaluating and recommending latex-free products and conducting an annual latex allergy in-service. By creating this kind of institutional knowledge and commitment, she says, you'll be doing what you can to leave a lasting legacy of safety in your facility for patients and staff alike.