The Use of Single-Use Medical Gloves in Doctors’ Practices and Hospitals

Background: Single-use medical gloves achieve their purpose only when properly used. Proper use also helps avoid undesired consequences such as excessive waste and CO₂< emissions, as well as inadequate hand hygiene.

Methods: In this selective review of the primary scientific literature, we summarize the current state of knowledge on the use of single-use medical gloves in the health-care sector. We also provide further information from national recommendations, guidelines, and regulatory provisions.

Results: Single-use medical gloves mainly serve to protect the health-care professional and are only rarely meant to promote patient safety. For reasons of occupational safety and self-protection, hand hygiene should be performed after single-use medical gloves are removed. In a study of opened glove boxes, human pathogenic bacteria were detected on around 13% of single-use medical gloves. A meta-analysis found that wearing single-use medical gloves can lower the risk of nosocomial infection (incidence rate ratio, IRR: 0.77 [0.67; 0.89]. In a randomized controlled trial, adherence for putting on single-use medical gloves without prior hand disinfection was 87%. On the other hand, where hand disinfection was expected to be performed before putting on gloves, adherence was 41%. Proper use can lower the rate of occupational skin diseases and improve adherence to hand hygiene for the five moments in which it is recommended (before and after patient contact, before aseptic procedures, after contact with potentially infectious material, and after contact with the immediate patient environment).

Conclusion: Limiting the use of single-use medical gloves to its proper indications promotes the safety of health-care professionals and patients and has beneficial ecological and economic effects as well.

Disposable gloves are in ubiquitous, routine use wherever health care is provided. The SARS-CoV-2 pandemic brought about a marked rise in their sales and consumption (1). A German university hospital reported that 1,558,780 single-use medical gloves were used there in April 2020 alone (2).

Gloves are also being worn for longer times than before the SARS-CoV-2 pandemic. Koyuncu et al. found an increase in average wearing times from 7.69 (± 3.13) to 14.73 (± 3.68) hours per patient-day (3). Gloves should always be worn when contact with potentially infectious materials (blood, urine, feces, other bodily fluids) is expected; they then serve to protect health-care personnel and interrupt chains of infection. It has often been observed, however, that health-care workers wear SSM even without needing them for self-protection or patient safety during the tasks at hand (4). In the observational study of Baloh et al., hygienic hand disinfection was carried out in 43% of cases before gloves were put on (4).

According to a Dutch study, gloves and hygienic hand disinfection were correctly implemented in only 19% of cases. For multiple consecutive care tasks, this figure dropped to 2%. Examples include patient transport and mobilization and the manipulation of vascular access devices without any contact with blood.

There are many possible reasons for the improper use of gloves. The socialization and emotional reactions (fear, disgust) of the health-care personnel play a major role (5). Their level of knowledge is important as well. The stated indications for the use of gloves may be incompletely known or misunderstood (6). There are also conflicting regulatory recommendations for the use of gloves.

As an illustrative example, during the SARS-CoV-2 pandemic, the Biological Agents Commission in Germany (ABAS) recommended that personnel carrying out vaccinations should wear gloves for purposes of occupational safety (7). Meanwhile, the Commission for Hospital Hygiene and Infection Prevention at the Robert Koch Institute (KRINKO) recommended that gloves should not be worn as a precaution to prevent infection by persons providing subcutaneous injections (8, 9), and this recommendation was in line with the practice of occupational physicians (10).

Moreover, the overuse of gloves generates unnecessary expense, waste, and greenhouse-gas emissions. Proper use can reduce all of these.

This review is intended to give health-care personnel a practically implementable summary of current developments and recommendations for the proper, indication-specific use of gloves.

The article describes the routine use of gloves in health care as a medical product and as a component of personal protective equipment (PPE) to protect oneself and others.

The scope of this article does not extend to the wearing of gloves to protect against dangerous chemicals and microorganisms, during the handling of dangerous material, or during non-medical activities, such as cleaning.

Learning objectives

This article is intended to acquaint the reader with

• the indications for using and changing gloves,
• the basic quality requirements for gloves in health care, and
• the importance and risks of using gloves for the safety of patients and health-care workers.

Methods

For this narrative review, we identified pertinent research articles and reviews as well as the currently applicable standards, rules, and recommendations by means of a selective literature search in the main Internet databases and evaluated them relation to the topic.

We were able to find only a small number of relevant studies, including a few randomized, controlled trials, systematic reviews, and meta-analyses. A selection can be found in the Table.

Table

The wearing of single-use medical gloves to prevent infectious transmission, and adherence to indications for hand disinfection*

The definition of single-use medical gloves

Unsterile single-use medical gloves are designated in various ways in the German-language literature, e.g., as “protective gloves” (Schutzhandschuhe) (11), “pathogen-free medical single-use gloves” (pathogenfreie medizinische Einmalhandschuhe) (12), or “low-germ-content gloves” (keimarme Handschuhe) (9). These terms are ”meant to indicate the important function of gloves of this this type both to insure a safe working environment for the wearer (occupational protection) and to prevent infection among the persons being treated (patient safety). The KRINKO has decided to use the expression medizinische Einmalhandschuhe, which will be translated in this article as “single-use medical gloves” (8).

It is important to note that such terms as “pathogen-free,” “low-germ-content,” and “unsterile” do not enable any inferences to be drawn about the safety (or otherwise) of these gloves with respect to contagious diseases, as these qualities have no uniform definition, and microbial contamination varies depending on the length of time the glove-box has been open and the manipulations to which it has been subjected (13).

Hughes et al. found environmental pathogens (mainly Bacillus species) on 81.6% of samples aseptically taken from single-use gloves when the glove box was opened and on days 3, 6, and 9 afterward. Human pathogenic bacteria were cultured from 13.2% of the samples studied. The rate of contamination was higher if the box had already been open for several days (13).

Requirements for single-use medical gloves

Gloves are intended by their manufacturers for use in direct patient care and are thus classified as medical devices (MD) (Directive 93/42/EEC). Gloves used in patient care are also considered to be a component of personal protective equipment (PPE, Directive 89/656/EEC), as they also serve to protect the wearer against chemical or physical hazards and dangerous biological substances. Gloves for use in patient care should be doubly declared as both a medical device and PPE (EU Directive 2007/47/EC) with the corresponding double CE marking.

Disposable gloves that are neither medical devices nor personal protective equipment and that do not meet the quality criteria of the EN 455 (disposable medical gloves) and EN 374 (protective gloves against chemicals and microorganisms) series of standards may not be used in patient care.

The gloves usually used in routine patient care are made of either latex-free synthetic rubber (e.g. nitrile rubber) or latex-free plastics (e.g. polyethylene or polyvinyl chloride).

Powdered latex gloves are highly allergenic because they contain high concentrations of latex proteins. These proteins can attach themselves to the powder and escape into the air when the gloves are put on and taken off. They can then provoke an allergic response through contact with the skin or respiratory tract, as has been documented in the past primarily in healthcare workers (14). Powdered latex gloves are, therefore, no longer allowed in medical facilities such as doctors‘ offices and hospitals. Instead, powder-free latex gloves or alternatives such as nitrile or vinyl gloves are recommended to lessen the risk of allergy.

Suitable protective gloves for potential contact with bodily fluids and secretions must also meet an Acceptable Quality Level (AQL) of ≤ 1.5. The AQL is a statistical quality determination procedure that uses defined samples to assess glove quality and estimate the percentage of defective (leaky) gloves in a batch. For example, for an AQL of ≤ 1.5 and a batch size of 10,000 gloves, a maximum of seven defective gloves are permitted in a sample of 200.

Single-use medical gloves as an occupational safety tool

The use of gloves in the health care sector as a component of occupational safety is addressed in Technical Rule for Biological Agents (TRBA) 250 and elsewhere. Single use medical gloves are there designated as “protective gloves” and are classified as protective clothing. Protective clothing is to be worn depending on the hazard classification of a workplace or specific activities (16).

Employees are assigned to one of four protection levels depending on the risks associated with the activities in which they engage. In routine clinical practice, protection level 1 (no contact or occasional, minimal contact with potentially infectious material and no other obvious risk of infection) is most common, and the use of gloves is not required. Protection level 2 (regular contact with potentially infectious material and obvious risk of infection by other means, e.g., by cuts and penetrating injuries) is also common. From protection level 2 onward, the wearing of protective gloves is recommended whenever a hazard is present.

Single-use medical gloves and potentially infectious material

TRBA 250 requires the wearing of protective gloves if the hands are expected to be in contact with potentially infectious material. This is generally a bodily fluid such as blood or saliva, an excretion such as stool, or body tissue. Such exposures can occur, e.g., during blood drawing or the washing of patients with urinary and/or fecal incontinence.

Furthermore, for reasons of occupational safety and self-protection, hygienic hand disinfection is required immediately after gloves are taken off to ensure the prompt removal of potential contaminants, as single-use medical gloves often have perforations. In an observational study in a German intensive care unit, Hübner et al. found that 10.3% of the gloves examined had perforations while being used (17). The wearers only noticed the perforations in 5.2% of cases. It should also be noted that taking off gloves can contaminate the surroundings (18). In a quasi-experimental study conducted in four different hospitals, Tomas et al. found contamination after the removal of used gloves was detected in 52.9% of the situations examined (19). In 58% of cases, contamination was detected on the skin of the hands immediately after medical examining gloves were removed. A meta-analysis of the pertinent literature did not clearly demonstrate whether, or how well, the use of a specific procedure or training concept for taking off gloves might sustainably lessen contamination (20).

Single-use medical gloves and hazardous substances

Whenever there is potential contact with medications, particularly during the preparation and administration of parenteral infusions, healthcare workers often use gloves (21). The technical rules for hazardous substances in medical care facilities (TRGS 525) specifically address this topic. Drugs are classified as being either without or with carcinogenic, mutagenic, or reprotoxic properties. For drugs in the former class, the exposure of health-care workers, room contamination, and the formation of aerosols containing the drug must be avoided. The use of protective gloves may be additionally required in individual health-care facilities for protection against skin contact, but it must be noted that data are generally lacking on the necessary glove thickness or the breakthrough time for pure drugs (22). In particular, international projects and campaigns highlight the effect that a dedicated review of the current assessment can have on the use of medical gloves in healthcare.

The recommended use of single-use medical gloves to prevent infection

The German Commission for Hospital Hygiene (KRINKO) addresses the use of gloves in multiple recommendations, which, in accordance with the KRINKO‘s mandate, focus on patient safety and infection prevention. These include, among others, the “Recommendations for hand hygiene in healthcare facilities” (12) and the recently added commentary on the indication-based use of disposable medical gloves in health care (1).

Analogously with TRBA 250, KRINKO also recommends that, in the event of foreseeable or probable contact with bodily secretions and excretions, including pathogens, low-germ-content gloves should be applied immediately after hygienic hand disinfection and complete drying of the hands (Box 1).

Box 1

Indications for the use of single-use medical gloves in health care*1

Wearing gloves is particularly recommended if the expected pathogens are resistant to alcohol-based hand disinfectants or have a particularly high potential for infection. This applies, for example, to Clostridioides difficile and the viruses that cause hemorrhagic fevers. In contrast, situations in health care where gloves are not necessary are listed in Box 2. In a new risk assessment from an occupational safety perspective, other activities may yet be identified among the medical procedures listed in Box 1 for which the need to gloves should be reevaluated.

Box 2

Health-care situations in which single-use medical gloves need not be worn

Gloves should be changed in accordance with the need for hygienic hand disinfection as per the WHO concept of the “five moments of hygienic hand disinfection” (Figure). Moreover, gloves must always be changed if they are visibly perforated, contaminated with blood, secretions, excretions, or non-enveloped viruses (e.g. norovirus), or after use for patient washing. The need for glove changing between patients already follows from the stated indication for hygienic hand disinfection before and after patient contact. An overview of the indications for an obligatory glove change is provided in Box 3.

Box 3

Indications for changing single-use medical gloves*

Figure

Five moments of hand hygiene*

Hygienic hand disinfection is indicated after gloves are removed. In a pertinent study, bacteria from patients were detected on the hands of almost 30% of health-care personnel after prolonged glove-wearing for patient contact (23).

This is especially relevant in view of the reportedly low adherence (65%) to hand disinfection after glove removal, which poses a risk to health-care workers and patients alike e (24).

There is recurring debate about the universal use of gloves to prevent nosocomial infections. In a meta-analysis, universal glove wearing as an isolated measure was found to lower nosocomial infection rates significantly (IRR 0.77, 95% confidence interval [0.67; 0.89]) (25). Yet, when gloves were universally worn as a component of a bundle of measures, no significant independent effect of universal glove wearing was seen (IRR 0.95; [0.86; 1.05]). These limited data permit the conclusion that the universal wearing of gloves may be appropriate in high-risk areas, such as pediatric intensive care units.

Double gloving was widely discussed during the SARS-CoV-2 pandemic in particular. A meta-analysis did not show any relevant improvement of efficacy against viral contamination and dissemination (20).

Undesired effects of single-use medical gloves

The wearing of gloves in health care also carries a number of risks.

Dampness of the skin

Skin dampness is generally recognized as a major cause of dermatologic disease in health-care workers. Reports of skin reactions in health-care workers were more frequent during the SARS-CoV-2 pandemic (26). 46% of surveyed health-care workers in the UK described the health status of their hands as poor (27). 53% of those affected said they had reduced or completely stopped hand hygiene measures (disinfection and/or washing with soap and water; only 18% said they had reduced the use of gloves. In a German study, the prevalence of symptoms of acute dermatitis in participating health-care workers was 90.4%; a 14.9% prevalence of eczema was found but was thought to be markedly underreported (28). The participants significantly increased their frequency of hand washing and hygienic hand disinfection during the pandemic. In further studies, using personal protective equipment (disposable medical gloves) for longer times was found to be an independent risk factor for skin reactions (29).

In the past, wearing watertight protective gloves for a major part of the working day (2 hours per day cumulatively) was classified as “wet work.” This definition has been updated in the most recent version of TRKS 401(2022): it is no longer the prolonged wearing of gloves in itself, but rather the frequent changing of gloves combined with skin contact with water or aqueous solutions is considered a risk factor for skin diseases (30). Hazardous wet work in health care usually consists of the wearing of watertight protective gloves in combination with skin contact with aqueous liquids in the form of water and soap or (alcohol-containing) hand disinfectant more than 10 times per working day. In particular, repeated hand washing combined with regular or permanent glove use is the main risk factor for irritative skin damage (10).

The effect of single-use medical gloves on hygienic hand disinfection

Glove-wearing does not obviate the need for hygienic hand disinfection, yet adherence to the “five moments” concept of the WHO has been found to be lower when gloves are worn (31, 32). This promotes nosocomial infection and the transmission of infectious pathogens (5, 11, 12, 13).

During the SARS-CoV-2 pandemic in particular, there were increased reports of nosocomial infections, transmission events, and outbreaks of multidrug-resistant pathogens on wards for patients with SARS-CoV-2 (33, 34, e10). The universal use of surgical masks by health-care workers treating patients with SARS-CoV-2 is thought to be partly responsible for these developments, as this may have led to a failure to disinfect the hands when indicated (e11).

Support for this hypothesis is derived, for example, from the finding of Cusini et al. that hand hygiene adherence improved when universal glove use was no longer required in the care of patients under contact isolation (32).

In a German study, direct adherence monitoring in inpatient care revealed that gloves alone were used in an average of 12% of situations with an indication for hygienic hand disinfection as a necessary measure (21). This was especially so for indication 2 (“before aseptic activities”), where hygienic hand disinfection was carried out in 65% of cases, and gloves alone were used in 24%.

The appropriate use of gloves involves hygienic hand disinfection immediately before they are put on and immediately after they are taken off, as well as when they are changed.

Imhof et al. found that the staff at a university hospital in Germany hygienically disinfected their hands when changing gloves on 47.2% of occasions (24); moreover, they only changed gloves on 27.5% of the occasions where this was necessary. Hygienic hand disinfection was carried out in 18.6% of cases before putting gloves on, and in 65.1 of cases before taking them off.

Interestingly, a cluster-randomized intervention study from the USA revealed that the introduction of direct gloves without prior hygienic hand disinfection on entering “isolation rooms” had no negative effect on observed hand hygiene on inpatient wards (72% vs. 66%; relative risk: 1.00 [0.91; 1.10]) (37). In the USA, however, hand disinfection is counted when the health-care worker enters or leaves the patient’s room, so the methods of this study are at variance with the WHO concept..

As the “five moments” of the WHO concept also apply when gloves are worn, a change of gloves and hygienic hand disinfection are required, for example, when changing from non-aseptic to aseptic activities. In this situation, however, hand disinfection is often omitted, especially when actions follow each other in rapid succession. The disinfection of gloved hands is an option for improving hand hygiene compliance in this situation, but there are number of additional relevant considerations here, such as the resistance of the glove material to chemicals and the glove manufacturers’ product information (12). More information on this topic and the pertinent legal requirements can be found online. Further aspects of the disinfection of gloved hands are discussed in the eBox (e5).

eBox

The disinfection of gloved hands

Measures for promoting the proper use of single-use medical gloves according to their indications

Surveys and qualitative studies have shown that the improper use of single-use medical gloves (against their indications) can result, for example, from ignorance of the indications, divergent recommendations, a perceived need for self-protection, and/or the established or exemplified practices in a particular health-care facility (5, 24). Thus, measures for promoting their proper use must address complex social, professional, and emotional aspects (38).

In the UK, the National Health Service recently launched a national campaign entitled “The Gloves are Off,” based on measures that were originally taken in 2019 at the Great Ormond Street Hospital (a major academic children’s hospital in London) (39). Information and intervention materials on the topics of sustainability, skin health, and employee and patient safety are provided and implemented in the participating health-care facilities.

Knowledge transfer on the proper use of gloves must be tailored to the target group and should also include information on the rationale for the recommendation, including the aspect of sustainability and the risks for staff and patients. Not only the doctors and nurses with specific responsibility for hospital hygiene, but also all other members of the treatment team can serve as role models and multipliers for measure implementation.

The regular, direct monitoring of adherence to hand disinfection and glove use as indicated (35), as well as the monitoring of glove consumption at the hospital and/or ward level, can help sensitize health-care workers to the topic while enabling an assessment of the current situation, so that suitable further measures can be determined and implemented as necessary.

The aspect of sustainability could help motivate medical professionals to optimize their own use of gloves in their daily work.

Conclusions and future perspectives

The proper use of single-use medical gloves is very important for the health and safety of patients and health-care workers. At present, however, their excessive and inappropriate use in patient care is still commonly observed. Targeted research projects for updating and re-evaluating the risk assessment of specific activities could help to optimize the indications for the use of gloves.

Until now, only a few studies have examined the effects of glove use on hand hygiene adherence as a patient-safety measure. In the future, such effects should be examined more closely, and potential strategies should be studied for improving the proper use of gloves in accordance with their indications.

Conflict of interest statement

TSK states that he has received a lecture honorarium and reimbursement for travel and meals from the Hartmann Science Center, as well as a consultant’s fee from Infectopharm. He owns stock in ISG Intermed Service & Co KG.

SS has received study support from Essity Professional Hygiene Germany GmbH and lecture honoraria from Bode Chemie GmbH.

AB has received reimbursement for travel and meals from Schülke & Mayr GmbH and from Essity Professional Hygiene Germany GmbH.

The other authors state that they have no conflict of interest.

Manuscript received on 31 March 2024 and accepted after revision on 22 August 2024

Translated from the original German by Ethan Taub, M.D.

Corresponding author
PD Dr. med. Tobias Siegfried Kramer

Charité Universitätsmedizin Berlin

Hindenburgdamm 27, D-12203 Berlin, Germany

Cite this as:
Kramer TS, Brodzinski A, Paul M, Drexler H, Scheithauer S, Geffers C: The use of single-use medical gloves in doctors’ practices and hospitals. Dtsch Arztebl Int 2024; 121: 715–24. DOI: 10.3238/arztebl.m2024.0159

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