Natural rubber latex gloves have long been standard protective equipment in surgery. Over the past two decades, however, after universal precautions spread their use throughout healthcare environments, it's become increasingly clear that they're a hazard to patients and staff who are allergic to latex proteins and may cause sensitivities among others who work with latex.

This spring, the Johns Hopkins Hospital in Baltimore, Md., discarded its last latex surgical glove. It was the final step in 10 years of efforts toward creating a latex-safe facility. Here's how the hospital reached that goal.

Origin of an issue
"In the late 1980s and early 1990s, we'd begun seeing rashes, wheezing and other anaphylactic reactions among some of our pediatric patients," says Robert H. Brown, MD, MPH, professor of anesthesiology and critical care medicine at Johns Hopkins. "These symptoms, which were traced to the use of medical products containing natural rubber latex, later began appearing among adults as well. Fortunately, we saw no fatalities, but the morbidities were evident and were soon supported by literature describing the appearance of such allergies at other institutions."

In 1997, the hospital convened a latex task force to reduce or eliminate the risks that latex posed throughout Johns Hopkins' medical facilities. Since building latex-safe environments would demand changes in routines on multiple fronts, the task force included representatives from risk management, safety, infection control, occupational health, surgery, anesthesiology, nursing, materials management and purchasing. Including administrators as well as those on the front lines ensured that all levels could have input but that recommendations and changes would be enacted from the top down, says Dr. Brown, the task force's chairman.

Find and replace
One of the task force's earliest efforts was identifying where the latex risks were by compiling a list of every product used that contained latex and determining which required action.

What presented a viable risk? "Any product that had direct mucosal contact with a patient or created airborne latex proteins," says Dr. Brown. "Not everything that's flexible contains latex, or is a latex risk, though." For instance: a rubber band or a pencil eraser present little risk. They're vulcanized rubber, not dipped rubber like gloves, so their protein content is lower. Also, they don't tend to have prolonged contact with patients' mucous membranes. (Similarly, latex paint doesn't actually contain natural rubber.) "But snapping on a latex glove has been shown to disperse enough powder to incite a reaction," says Dr. Brown.

The federal Food & Drug Administration Act of 1998 mandated the labeling of all medical products containing latex, but the task force started its search before that requirement took effect. If an item was flexible but wasn't labeled for latex, they called its manufacturer to confirm its content.

Room-by-room and specialty-by-specialty, the group parsed out latex content: blood pressure cuffs, IV ports and tubing, tourniquets, syringe plungers, anesthesia masks and anesthesia machine valves, Foley catheters and surgical drains. It prohibited latex balloons from the facilities, which required educating patients' families, security officers and even the Baltimore area's floral distributors. It asked the Red Cross to refrain from using latex gloves during its periodic blood drive visits. It even became concerned that syringes puncturing vial stoppers to draw out medication may be a risk for some patients.

"For every item that presented mucosal or respiratory contact with a patient, we asked the manufacturer whether a non-latex alternative existed," says Dr. Brown. "When safe, suitable alternatives were available, we removed the latex products from use and substituted the non-latex products."

While some facilities have chosen to remove latex products on a limited basis, screening patients for sensitivities and employing such in situ measures as latex-safe carts and rooms, the task force opted to sidestep the risks entirely. "What if the latex-safe cart is in use or can't be found?" Dr. Brown reasons. "What if the latex-safe room is occupied?" Also, you don't always know which patients and staff are allergic to latex, and it's entirely possible they don't either, he says. "As is often the case in medicine, it's not the problems you know, it's the ones you don't know."

Since an overwhelming number of medical and non-medical products containing latex are used in an average healthcare facility, it would be difficult, impractical and expensive to make a facility truly latex-free. Better to aim for latex-safe, says Dr. Brown, whose group identified and replaced a set of major factors in order to decrease the risk while still allowing the end user to do her job. "If we knocked out, say, 95 percent of our latex issues, we'd create a far safer environment for patients and staff," he says. "Eliminating another three or four percent would be wonderful, but may not have been practical."

Hand in glove
Once the task force had identified the major latex risks, the next job was replacing them with latex-free alternatives. The criteria for replacements were whether they'd be as safe and effective as the items they replaced and whether they could be purchased at a reasonable cost. "We were willing to pay more for latex safety, but not extravagantly more," says Dr. Brown.

The primary source of latex at Johns Hopkins, and the replacement which proved the biggest challenge, was medical gloves. Since powdered latex examination gloves were used in all patient areas by a wide range of staff members, the conversion took some doing.

After user trials and evaluations of alternatives and pamphlets to educate staff on why the change was necessary, they chose to switch to vinyl exam gloves. "At that time, vinyl gloves were the only cost-effective choice," says Dr. Brown. But it didn't take long before the staff began expressing their concerns over vinyl gloves' efficiency as barrier protection - some strikethrough incidents had occurred - and their loose fit at the wrist.

The search continued. By the following year, 1998, competition in the non-latex glove market had increased and prices had decreased. Nitrile exam gloves became a viable option and were trialed among staff. Finding their barrier protection and fit concerns answered, the task force conducted a successful re-replacement.

Convincing the surgeons
The conversion to sterile, non-latex surgical gloves was even more challenging, says Dr. Brown. Cost was the main hurdle, as alternatives to natural rubber latex gloves were pricier (the switch would cost $500,000 more per year). Physician preference was also a considerable obstacle.

For physicians, he says, giving up latex meant a change of routine and a sacrifice of the feel to which they'd become accustomed. "Some physicians argued that, since they'd never observed a latex sensitivity issue among their patients, they didn't need to switch." To change the surgeons' minds, the task force needed evidence and institutional support.

Some members had published studies on latex allergens and had in fact discovered that 12 percent of the Johns Hopkins anesthesiology staff were sensitized to latex. "That was the kind of data that helped to convince the surgeons," says Dr. Brown.

The group was also fortunate in that the surgery department chair changed hands and that the new chairwoman - one of whose colleagues left surgery on account of a latex allergy - was on board for their efforts.

Surgeons were invited to try various types of non-latex gloves. "Everyone who participated found at least one type of glove that was an acceptable replacement," says Dr. Brown. The hospital purchased a selection of gloves from two different companies to satisfy a range of preferences.

By 2002, two of Johns Hopkins' ORs were latex-safe. Once non-latex gloves were made available, surgeons began using them on a regular basis. The purchasing department continued to review the evolving options and negotiate for lower prices as costs fell and demand for non-latex products grew.

Johns Hopkins finally converted its surgeons, and its facilities, to non-latex gloves this past spring. "It was rather anti-climactic," remarks Dr. Brown. "The last package of latex gloves was switched out over the weekend. When we came in on Monday, we were latex-safe and entirely latex glove-free." Even without fanfare or ceremony, he adds, there has been growing number of healthcare facilities and manufacturers that have contacted the hospital for more information on the issue.

A continual process
Dr. Brown describes latex safety as "a revolution" similar in nature to the universal precautions adopted in the 1980s, before which healthcare providers didn't wear exam gloves to start an IV - something that would be unthinkable today.

"It's not hard to make your facility latex-safe, even if you're a small facility," he says. "The good news is, the cost of doing so has really come down."

First, he says, discuss the competing expenses of safety versus risk with those who can affect change at your facility. Then identify your latex liabilities and purchase non-latex substitutes whenever possible. Continue to evaluate the available alternatives and, if your supplies don't all arrive through a central purchaser, monitor what products come into your facility for latex content. Finally, make latex safety a regular part of your personnel education process, as your surgeons and nurses are frontline educators to your patients and their families.

Reference:
Brown RH, Hamilton RG, McAllister MA. "How Health Care Organizations Can Establish and Conduct a Program for a Latex-Safe Environment." Jt Comm J Qual Saf 2003 Mar; 29(3):113-123.