TRIAL AND ERROR You might need to test several options before settling on the right gloves for your surgeons.

We haven't heard much about natural rubber latex allergies in healthcare workers lately, but that doesn't mean it's a problem you can ignore. We began the process of going latex-safe at the Johns Hopkins Hospital several years ago, and now there's not a latex glove to be found in our ORs. If our large health system can transition to non-latex surgical gloves, so can you.

Non-latex alternatives
Non-latex gloves are not all the same; they vary in their barrier properties and the degree of protection they offer against exposure to infectious agents. The alternative glove materials to natural rubber (Hevea brasiliensis) latex are vinyl (polyvinyl chloride), nitrile rubber, neoprene and artificial polysioprene from oil (not the rubber tree). Their names define their material compositions. Review independent studies of their barrier properties against viral transfer, and the content of chemical residue in the gloves that can cause delayed-type hypersensitivity (more on that later).

We've used each type of non-latex glove here at Hopkins. Some of the gloves will age and rip more easily. The chlorination process used to sterilize the gloves can diminish a glove's lifespan. Surgical gloves have the most rigorous manufacturing requirements because surgeons are extremely demanding when it comes to the feel and performance of the gloves they use. As we discovered at Johns Hopkins, some surgeons don't want to give up their natural rubber latex gloves, because of the tactile feel (see "Why Latex-Safe Matters"). We solved the issue, but it's best to avoid the situation.

Powder-free latex gloves generally have reduced levels of latex allergen, when compared with powdered latex gloves. A non-powdered glove still might contain very low levels of latex particulate, however. When latex gloves are manufactured, they're placed on a ceramic or glass mold of a size 7 right hand, which gets dipped into a vat of latex and passes through a dryer. The surface of the mold typically contains calcium carbonate or a similar material that serves as a donning lubricant and lets the gloves be stripped off the form for packaging. Powered latex gloves were historically dipped into a vat of cornstarch, which served as the donning lubricant.

That process has been replaced by a chemical treatment that makes the insides of the gloves smooth for easy donning. The gloves might contain traces of latex particulate, but it's not as dangerous as powdered cornstarch, which was notorious for absorbing latex-allergenic proteins that had leached out of the gloves and built up in the vats.

While switching from powdered to powder-free latex gloves is a positive step, moving to a totally synthetic option is the best solution for members of the surgical team who have a natural latex allergy. Leading glove manufacturers that have a line of non-latex options have monitoring built into the manufacturing process that ensures latex contamination does not occur. They have a vested interest in ensuring their products remain well-established and pure.

Delayed-type hypersensitivity reactions to accelerator chemicals used during the manufacturing of some non-latex gloves are important concerns for latex-allergic individuals who adopt the use of non-latex, non-sterile examination or sterile surgical gloves. These chemicals — thiurams, thioureas, carbamates and mercaptobenzothiazole — penetrate the skin and can induce the sensitization of lymphocytes to the specific antigens. Repetitive exposure in sensitized individuals can lead to chronic dermatitis on the wrist and hands.

Your staff members might not develop latex sensitivity, but if they have abraded skin — a common trait of surgical team members who scrub in every day — or a genetic predisposition to contact dermatitis, they might react adversely to the chemicals. Whether or not these chemicals are used to manufacture the synthetic gloves you're considering or already stock is another piece of information your supply purchaser will want to obtain. Ideally, your facility should opt for non-latex gloves that do not contain the accelerants.

SKIN SENSITIVITY
Why Latex-Safe Matters

A spectrum of reactions can occur when allergic individuals are exposed to natural rubber latex allergens, depending on the route and the level of exposure. Irritant contact dermatitis is a non-allergic reaction. Localized contact urticaria can occur with itchy patches of hives that result from contact exposure to the skin. The inhalation of allergens can lead to upper and lower respiratory allergy symptoms — such as allergic rhinitis and conjunctivitis, angioedema and asthma — and in rare cases, systemic anaphylaxis.

At Johns Hopkins Hospital in Baltimore, Md., we began the process of becoming latex-safe by switching out latex examination gloves for non-latex alternatives. Sterile procedure gloves supplied in custom procedure packs were next. The last bullet we bit were the gloves used by the medical staff. The proposed transition caused infighting among the surgeons, many of whom threatened to quit because they could no longer use latex gloves.

COMFORT MATTERS Some gloves can cause serious harm to surgical team members with sensitivities to rubber latex allergens.

The surgery department's chairman finally said, Listen, we're doing this. If you want to quit, quit. That's your choice. The hard line stance worked. Johns Hopkins now spends more each year to stock the ORs with synthetic glove alternatives that our surgeons say come closest to matching the tactile feel of natural rubber latex gloves. Latex gloves are no longer used in the OR and we feel staff and patient safety are worth the added expense.

— Robert G. Hamilton, PhD, D(ABMLI)

Assess the options
Finding the right glove for your surgeons demands some trial and error to determine which they like best. In years past, many facilities formed latex committees comprised of representatives from the medical staff and the individual in charge of supply purchasing. That's less common today, because latex allergy isn't as significant a problem as it was in the past, but the committee review process can still prove useful when you're previewing non-latex glove options.

Check with the department or person in charge of your supply purchasing to ensure they have specifications on the gloves you're considering. The purchasing department at Johns Hopkins did most of the groundwork to identify alternative sources of gloves and negotiate the best price with manufacturers. Refer to the material data safety sheets, which describe the chemical contents of gloves. That's the best way to present the options to the medical staff, who don't necessarily have the time to assess glove options beyond comfort and performance in the OR.

Once you identify a few synthetic glove options, ask the companies to provide samples so that you can conduct a trial that gives surgeons and OR staff a sense of how the gloves feel during actual cases. Have manufacturer reps present a 5-minute overview of the glove options and provide a box of gloves to each individual on the purchasing committee. The purchasing department head can then collect critiques from the committee members before trialing the gloves that garner the most positive feedback.

There is no magic length of time for how long an effective glove trial should last. At Hopkins, we surveyed physicians for several weeks. Manufacturer reps were present and provided gloves to the surgeons. It ultimately came down to the heads of supply purchasing and the medical staff to decide on which glove to stock once they got feedback from the surgeons and rest of the OR team about the real-life performance of the gloves.