Discussion
infection, care-associated infection
INFECTION, EVENT
This cluster randomized clinical trial demonstrated that a policy endorsing a direct-gloving strategy compared with the current strategy requiring hand hygiene before glove use led to improved adherence with expected practices and increased overall glove use, was accepted by HCP, and did not increase bacterial contamination of gloves in most clinical areas, except where hand hygiene rates were low (ie, ED). Hands, including gloved hands, are the most important contributors to pathogen transfer in health care, resulting in pathogen spread and health care-associated infection.A rigorous approach to evidenced-based guidelines is needed to increase acceptance and adherence while improving efficiency and decreasing unnecessary demands on HCPs’ time. We found poor adherence with the expectation of hand hygiene before nonsterile glove use in the baseline period of this study at 35% overall, ranging from a low of 8% in EDs to a high of 63% in hemodialysis units, rates that are similar to prior reports.In the present study, the unit-based policy of the intervention allowing direct gloving when nonsterile gloves were worn led to 46% improved adherence to expectations. The intervention was also associated with a positive effect on glove use, leading to more appropriate use of gloves when expected for entry into contact precautions rooms or universal gloving areas. Additionally, there were no untoward effects on balancing measures, such as hand hygiene at room entry to non–contact precautions rooms or at room exit, despite potential concerns outlined in the semistructured interviews of HCP. These results indicate that an evidenced-based policy for direct gloving may have broad advantages with adherence to infection prevention practices.In a prior randomized trial, Rock et alBy contrast, we found high rates of contamination in the ED, particularly units that adopted the direct-gloving policy. The prevalence of pathogenic bacteria on gloved hands in EDs with direct gloving was 13% and associated with a bioburden greater than seen elsewhere in the study of 52.8 CFUs (Several other factors were associated with detection of pathogens and bioburden on gloved hands. Compared with nurses, physicians had less bacterial contamination on their gloves, whereas other HCP (eg, respiratory technicians, physical therapists) had more bacterial contamination. We also found that a longer time between the last hand hygiene event and sampling was associated with more frequent detection of contamination and higher total colony counts; also, rates of contamination increased with increasing time interval between the last hand hygiene event and sampling. These findings suggest that overall hand hygiene rates at opportunities other than those before glove donning are important for overall bacterial contamination of HCPs’ hands and their gloves.