Deal with latex allergy now — it’s not going away

Cost of priciest gloves doesn’t compare with workers’ comp costs

If you think you haven’t seen a latex-sensitive patient, you probably just haven’t noticed and have been lucky. It’s just a matter of time before a patient or staff worker with an allergic reaction to latex will surface, and this time the problem could escalate to proportions that won’t go unnoticed. (See the three related articles, in this issue, on the extent of this problem and where the Joint Commission and FDA stand.) The money this problem could cost your facility in terms of a workers’ compensation or a negligence case demands your attention. Quality of patient care is a priority issue here too. Sensitivity reactions can range from contact dermatitis to anaphylactic shock, resulting in death. The best therapy is prevention: avoidance of exposure.

The sooner your facility prepares to deal with this growing problem, the better. Latex- and powder-free gloves and other medical devices don’t come cheap, but they can pay for themselves in terms of risk reduction.

Kathleen Claussen, RN, used to see more than her share of work-related latex reactions — both dermatologic and systemic — in her job in the occupational health clinic at University Hospital in Albuquerque, NM. "Whatever extra expense is involved in buying special gloves and equipment has been more than offset by decreased employee downtime and workers’ comp claims. Providing a safe, latex-free environment has definitely saved staff time and improved occupational health."

"We’ve been developing our latex protocols for a couple of years," says Deborah McGuire, RN-C, a certified occupational health nurse specialist and manager of employee occupational health services at Clarian Health in Indianapolis, IN. "We have 100 latex-sensitive employees at the Methodist Hospital campus alone, so we had to start implementing latex safe measures for them and for our patients as well."

"In the beginning, cost issues surfaced," she explains. "But when we identified so many employees with the allergy, cost became secondary. It was still an issue, of course, but not the deciding issue in switching out gloves. We realized we had a significant problem."

The costs associated with losing employees and retraining new surgical nurses are sizeable. "We looked at long-term disability issues and their costs," says McGuire, "and came to the conclusion that in the long run, if we could create a safe environment, not only for identified employees but for those not yet sensitized, it would be cheaper to take the measures — to switch out gloves and clean the environment."

"If you haven’t begun to prepare for the patient with latex allergy," advises Janice Beene, MPH, senior consultant for infection control at Lovelace Health Systems in Albuquerque, NM, "it’s time to do so. The quality of latex-free equipment is out there, and it’s improving rapidly. When we first went out looking for information and products, in the early 1990s, we caught manufacturers unaware. They couldn’t respond to our need. One company rep told me he was stunned at the time by the question. Certain manufacturers recognized the latex issue early and came out strong. Others have quickly scrambled to develop comparable products. By now, manufacturers have been asked often enough if their products contain latex, so they can respond to the need in the marketplace."

Sterile latex gloves with powder cost about $16 for a box of 100; sterile powder-free, latex-free gloves cost about $82 for the same quantity. Would your institution undertake such a widespread protocol change? The switch to latex-safe gloves would probably have to be carefully evaluated and subjected to a cost-benefit analysis like that done at University Hospital.

"We’re not statisticians," says Claussen, "but we ran an informal cost-benefit study to induce our hospital to switch over to latex-free, powder-free equipment. Our group looked at the costs of lost work time due to latex-related illness and replacement temps, then added to that the costs of medication, occupational health visits, and special-order gloves. We concluded that the facility would actually save money by making the switch." Once University Hospital began using latex-free and powder-free gloves, the numbers of new and recurring cases of latex problems "dropped like a rock," she says.

Irene Foster Mount, RN, MSN, CPHQ, director of performance improvement at Columbia Hospital for Women in Washington, DC, deals with the cost containment issue this way: "We try to avoid ordering the special, more expensive gloves in every size, as we would regular gloves. We find out which staff are sensitive and what sizes they wear. That way we can order the gloves only in those sizes, not randomly. Also, we try to give the purchasing department some lead time on what gloves we’ll be needing for specific procedures, especially elective surgeries. We also keep a small supply of gloves in every size available for use on the occasional latex-sensitive patient. That way we’re not always ordering on an emergency basis."

"Our general workhorse glove at Clarian is a synthetic powdered vinyl glove," says McGuire. "Some employees have reactions to chemicals in the vinyl gloves, however, so we had to try out a couple of different brands. An additional problem arose in the lab and the NICU where the powder from the vinyl glove caused problems with tubing, so we went to powder-free vinyl gloves in those areas. In areas where workers are mixing chemotherapy drugs and working with chemicals, we switched to the petroleum-based Nitrile glove. They are heavy-duty and thick, and even though they fit well, they don’t have good tactile sensation. They are more expensive than other latex-free gloves."

"We can’t make our hospital totally latex-free," she continues, "but we can make it as safe as possible. Education is a big part of this, on the part not only of the employees but of patients and visitors as well. Visitors get upset when they come into the hospital with their big pretty latex balloons, and the information desk stops them in their tracks."

When someone says, "I’m not allergic to latex, I’m allergic to the powder," take the statement with a grain of salt. It’s not unheard of, but a person’s not likely to be allergic to any glove powder. What’s more plausible is that the person is reacting to the allergens bound to the powders. You can cut down a sensitive person’s exposure to latex by using powder-free gloves. They cost more than powdered but are less expensive than the latex-free.

The lubricating powder binds with the latex protein antigen and aerosolizes it. When gloves are snapped off, antigens can remain airborne for hours. Inhaling the powder can result in anaphalactic shock in a highly sensitive individual.

Each institution has to address its special needs, depending on its experience with sensitive workers and patients. "For a year now," says Claussen, "we’ve been purchasing both powder-free and latex-free gloves. That’s made a giant difference. The occupational health clinic here had been seeing 85 allergic workers out of the facility’s total 3,000 employees. Many of the affected workers don’t themselves wear gloves for direct patient care but are in the vicinity of nurses and other caregivers who do. By taking the powder out of gloves and powderborne allergens out of the environment, we’ve substantially reduced our numbers of latex allergies."

Lovelace Health Systems routinely buys powder-free gloves but reserves the purchase of completely latex-free gloves for those individuals who are highly sensitive. "Powder-free gloves are comparable in strength to regular latex," Beene says. "They’re just a little harder to put on and take off. You have to weigh the evidence about the quality of the glove against its allergic potential. "One reason we chose the surgical glove we did — one made by Regent Medical — was that the manufacturer gave our OR director some very convincing evidence about the glove’s failure rate." (See the boxed list of glove manufacturers, p. 96, for more information.) Vinyl gloves, however, are not as strong as latex. They tend to develop pinpoint holes.

"The costs are prohibitive," says Beene. "One powder-free glove costs three to five times a regular one, and one latex-free glove could cost twice as much as the powder-free."

"Patients and staff members are not routinely tested for latex sensitivity at most institutions," says Beene. (See "Latex allergy screening tool" and "Latex allergy decision tree," pp. 92 and 93.) "Levels of sensitivity and levels of reaction vary so much that no one is proposing that everyone be tested. Sometimes you don’t know until a person has an overwhelming anaphylactic reaction."

Virginia Printz, RN-C, MSN, education nurse specialist at Lovelace, helped develop her facility’s 10-page protocol for the management of patients and workers with latex sensitivity. She says the document is generic and meant to be used throughout the organization. Lovelace is an integrated delivery system that includes outpatient settings, mental health units, and home care.

The protocol stipulates that screening for latex allergy is best begun by taking a thorough history. Ask about itching, rash, or wheezing after wearing "rubber" gloves or inflating toy balloons, it says. It points out, however, that "Many times people will not correlate an incidence with latex exposure and a subsequent reaction to a latex sensitivity." Ask also about a sensitivity to banana, avocado, kiwi, chestnuts, pineapple, or passion fruit. Patients who’ve had multiple medical or surgical procedures or who have had non-medication-related anaphylactic reactions during anesthesia are at special risk.

The only screening tool recommended on most latex protocols is the radioallergosorbent (RAST) test, an in vitro serum test for the IgE antibody directed toward latex. RAST has variable sensitivity — 65% to 85%. Skin testing carries a risk of an anaphylactic reaction.

Lovelace put together an evaluation tool to see how useful nurses thought the generic protocol was. "We wanted to know if we’d have to modify the protocol and make it unit-specific for our patients in the OR," says Printz. "Surgery patients have an increased chance of being exposed to latex through mucous membranes." The nursing staff reported they were getting adequate guidance and management with the generic protocol, so the facility continued to use it in the OR with just the addition of some OR-specific products.