Theatre safety: latex-free theatres, protocols
Romaine Mitchell, Nurse/Midwife, Sussex and Hampshire
The widespread use of gloves started in the 1980s, to help protect staff from blood-borne viruses, such as hepatitis C and B and HIV (Blizzard et al, 2017). These gloves are made of natural rubber latex, which is produced from the milk white fluid drawn from the bark of the Hevea brasiliensis tree. While the main content is natural, the manufacturing process introduces chemical additives, which has led to many occupational risks for healthcare staff.
Irritant contact dermatitis arises because of handwashing, scrubbing, inadequate rinsing, prolonged glove use, sweating and restrictive impact of gloves. However, this condition is avoidable and can be prevented with the use of latex free gloves (synthetic alternatives), such as Protexis® gloves (Cardinal Health), which 79% of the company's customers said led to significant cost savings and improved safety.
Latex gloves can lead to different allergic reactions (NHS Plus et al, 2008). Type 1 allergy is known as immediate hypersensitivity that could lead to potential anaphylaxis. Symptoms include local or generalised rash (urticaria), conjunctivitis and rhinitis. It could also lead to asthma or difficulty breathing (Health and Safety Executive, 2024). Another type of allergy is the Type IV allergy, which is referred to as delayed type hypersensitivity. This is the most common latex allergy and can result in redness and an itchy and scaly rash localised to the hands and arms.
Case studies, containing latex free gloves manufactured by Cardinal Health, were discussed to provide some light in the benefits of synthetic alternatives. The gloves were made of synthetic polyisoprene and neoprene. The studies were conducted in different NHS Trusts across departments including plastic surgery, anaesthesia and hand and wrist surgery wards (Henry et al, 2020; Jeffery, 2020). Health professionals in all the trusts found that donning and doffing the gloves was easy, surgeon safety was not a concern, there were no issues with redness or irritation and it was comfortable to wear and did not interfere with medical procedures. Thus, the case studies found that there is significant benefit in adopting latex free theatre environments. However, further trials and extensive research is needed, including an assessment of macro and micro perforation and the cost effectiveness of a complete transition to latex free theatres.
Importance of hand health and glove use in the theatre setting
Danel Meno, MSc (IPC), BSc (Hons), RGN, IPS Nurse Educational Lead; Whittington Health NHS Trust
The evolution of gloves started in 1889, when Dr William Halsted, a well-known doctor for his surgical procedures, made a cast for a nurse to protect her from rashes and blisters from the use of anaesthetics. This led to the creation of the first custom made rubber glove (Kean, 2020). Since then, gloves have become a routine part of healthcare protocols. This gained momentum with the emergence of HIV and the development of universal precautions in the mid-1980s that included the use of gloves in its infection control guidelines (NHS England, 2024).
However, in recent years gloves have provided a false sense of security against diseases, leading to falling standards of hand hygiene (Wilson et al, 2017). Thus, staff should be trained in good hand hygiene practices (Wilson et al, 2017). It is important to wet hands before applying soap and ensure that temperature when performing hand hygiene is about 32°C (lukewarm temperatures). Theatre nurses should also ensure that they dry their hands thoroughly before donning gloves to prevent them from becoming soggy and affecting the skin barrier (Hawkey et al, 2016). After a shift, it is advisable for staff to use emollients and hands creams to protect against allergic reactions.
In October 2022, the team at Whittington Health hospital North London conducted a study to find out the reason behind an increase in central venous catheter-related bloodstream infections in the intensive care unit. To understand the potential cause, they looked at data relating to healthcare associated infections across NHS hospitals in England. They found that hands were not decontaminated before touching the central line.
Interventions to address this involved encouraging all staff to risk assess the need for non-sterile gloves during routine IV drug preparation and perform aseptic non touch technique practices. The team created posters, visual aids and interactive educational videos to inform nurses about safe and effect hand hygiene techniques while drawing up intravenous medication for administration. Since April 2023, the hospital has seen significant improvements, and in September 2024 they recorded sustainable non glove wearing, and found that myth busting exercises about gloves and hand hygiene were effective to achieve the goals.
Reducing the risk of DVT: is NG89 sufficient to protect patients?
Emma Gee, Nurse consultant. Thrombosis & Coagulation, King's College Hospital and Dr Sanjay Deshpande, Consultant in Anaesthesia and Intensive Care, South Tyneside and Sunderland, NHS Foundation Trust Venous thromboembolism (VTE) is an umbrella term used to describe deep vein thrombosis and pulmonary embolism. These conditions refer to blood clots that form deep inside any vein and travel up in the body, partially or completely obstructing blood flow. More than 50% of blood clots are associated with hospital admissions. This is because patients are immobilised in a bed and invasive methods can affect inflammatory and clotting processes, making them more susceptible to thrombosis. However, about 73% of the people in hospitals are not diagnosed with the condition until after being discharged, further increasing the risk of obstructing circulation (Jha et al, 2013).
The National Institute for Health and Care Excellence (NICE) provides guidance (NG89) to reduce the risk of VTE in people aged over 16 years (NICE, 2019). In summary, NICE requires healthcare professionals to risk assess for thrombosis and bleeding on admission to hospital, start pharmacological thromboprophylaxis within 14 hours of admission, provide patients with information about VTE and consider mechanical thromboprophylaxis for surgical patients (NICE, 2019). NICE also uses the terms ‘balance’ and ‘consider’ to enable mindful decision making. For example, the guideline states that healthcare professionals must balance the individual's risk of VTE against their risk of bleeding when deciding whether to offer thromboprophylaxis (NICE, 2019).
Emma Gee, Nurse consultant. Thrombosis & Coagulation, King's College Hospital
Evidence suggests that pharmacological thromboprophylaxis has an efficacy rate of about 50–60% and is also equally safe to use in medical patients (Geerts et al, 2001). However, a meta analysis in about 5000 surgical patients studying the effect of low molecular weight heparin (LMWH) with a placebo, found that while the pharmacological interventions significantly reduced risks, it increased the risk of bleeding (Mismetti et al, 2001). The authors concluded that sometimes it could be better to not give anything to the patient when considering the risk of bleeding, highlighting the importance of conducting risk assessments and evaluating clinical judgements.
In some cases, mechanical thromboprophylaxis using intermittent pneumatic compression (IPC) is beneficial. IPC improves hypercoagulability, which is the ability of the blood to clot (Arabi et al, 2019). It does this by stimulating fibrinolysis, a biological process that helps the body to break down clots. Using IPC and pharmacological prophylaxis together for surgical patients has significant benefits in reducing the risk of thrombosis. However, while IPC is effective in reducing the risk of bleeding, sometimes adding LMWHs with the use of IPC can increase the risk (Shalhoub et al, 2020).
Thrombosis UK conducted the National Thrombosis Survey (2021) as part of the Getting in Right the First Time (GIRFT) programme to assess the real-world application of NICE guidelines in treating VTE. In about 90% of cases there was an appropriate prescription of mechanical and pharmacological thromboprophylaxis. However, the survey found that only about 67% of patients were provided with the treatment within 14 hours, suggesting that there is scope for improvement in terms of the timing at which the risk is identified and treatment provided. A crucial finding in the survey was that around 8.1% of patients missed their doses, mostly because of patient refusal. Only about 30% of patients were documented as having been provided with written or verbal information.
Some initiatives to improve healthcare delivery for VTE include (Clapham et al, 2020):
Dr Sanjay Deshpande, Consultant in Anaesthesia and Intensive Care, South Tyneside and Sunderland, NHS Foundation Trust
Patient empowerment is critical in practice. On admission, patients should be informed about the risks and possible consequences of VTE, importance of VTE prophylaxis and measures that they can take to reduce the risk of developing the condition (Popoola et al. 2016). On discharge, patients should be given an information leaflet about care plans, using prophylaxis correctly, signs and symptoms of adverse events and means of help and support (Popoola et al. 2016).
Clinical trials have tested the best management options to treat the condition. In some cases, mechanical thromboprophylaxis using intermittent pneumatic compression (IPC) is beneficial. IPC improves hypercoagulability, which is the ability of the blood to clot (Arabi et al, 2019). It does this by stimulating fibrinolysis, a biological process that helps the body to break down clots. Using IPC and pharmacological prophylaxis together for surgical patients has significant benefits in reducing the risk of thrombosis. However, while IPC is effective in reducing the risk of bleeding, sometimes adding low molecular weight heparins with the use of IPC can increase the risk (Shalhoub et al, 2020).
South Tyneside and Sunderland NHS trust conducted an audit in 2023, which compared practice standards in the hospital against NG89. Data were compared in four areas of initial assessment, prescriptions within 14 hours, reassessment and providing prophylaxis according to guidance. Results found that 100% the patients completed VTE assessment on admission, 51% of patients received their VTE prophylaxis dose within 14 hours or had a valid reason for omission, 64% medical and 56% surgical patients were reassessed within 24 hours of admission and 84% of patients received pharmacological VTE prophylaxis according to trust guidelines.
NICE (2019) classifies mechanical prophylaxis into two categories; active and passive. Active mechanical prophylaxis includes intermittent pneumatic compression and neuromuscular electrostimulation devices, while passive mechanical prophylaxis includes anti-embolic stockings. NICE guidance emphasises that in surgery and critical care, IPC should be continued until the person has achieved good mobility. However, antiembolism stockings should not be worn in certain circumstances, including peripheral arterial disease, dermatitis, gangrene, severe leg oedema in congestive heart failure and venous leg ulcers (NICE, 2019).
Multimodal management for VTE that integrates surgical, interventional and medical treatments is important to consider including good pain control, physiotherapy, mobilisation and patient empowerment (Delcroix et al, 2023).
Panel discussions
The panel discussion brought together key considerations from the sessions, providing an opportunity for the delegates to seek clarification on any issue, ask questions or share their experiences. The key takeaways from the discussion focused on practical tips and considerations in clinical practice including:
Risk assessment: conducting risk assessments using tools such as the Department of Health's VTE tool, Caprini score, Pauda VTE and Rogers risk assessment score model, which are important to evaluate the most appropriate treatment and management plan and provide patient-centred care. Moreover, shared decision-making between health professionals and patients while implementing risk assessment tools facilitates patient empowerment by providing patients and their families with information about the condition, treatment and care plans to make informed decisions. It also helps health professionals share knowledge and make decisions to ensure the most effective outcome.
Patient safety: Patient safety is a nonnegotiable requirement that serves as the foundation for good quality care and trust between patients and healthcare providers. A safe healthcare environment is one where risks are minimised and adverse events prevented to ensure effective and reliable care. In theatre environments, surgical care must be of high quality, built on evidence-based reports and involve products that are reputable and compliant with industry standards. Safeguarding patients from harm also involves being compassionate and attending to them with empathy and respect.
Data collection: evidence-based practice is key to making impactful change in care delivery as it can help to improve the quality of care, reduce medical errors, promote cost effectiveness. Data should be gathered consistently and shared with the wider team and senior management to make changes to practice. Making reports public and collaborating between different trusts and hospitals can aid in more effective outcomes for patient-centred care.
Considering costs: it is crucial to go beyond the shortsightedness of considering only the initial costs and see the long-term benefits of implementing something that will have a significant impact on patient care. Health professionals should aim to make challenges with latex use part of the dialogue with colleagues and the senior management. Research has shown that implementing robust quality improvement projects reduces costs, for example, lowering the rates of infection can have an indirect positive impact on the costs involved in areas such as treatment, staff and equipment. This is particularly important given the high costs of healthcare associated infections, which, based on pre-pandemic reports, were around £2000–5000 per infection and more than £1 billion per annum for the NHS. Organisations must prioritise root cause analyses and record themes or commonalities across infections to find out the most optimum solution for patient care and financial longevity.
The engagement from the audience enabled critical discussions about patient-centred care and the importance of continuous learning and professional development to improve practice and healthcare outcomes. The delegates showed a keen interest in the discussions and highlighted the importance of holding regular conferences and panel discussions to facilitate sharing of knowledge.
Interview with Professor Ian Peate, OBE, Editor-in-Chief British Journal of Nursing
How did you find the Theatre Safety Club programme?
Thank you to Cardinal Health for sponsoring this event. The location and the duration of the activity suited most people perfectly. The timings of the event allowed practitioners to attend for the half day and return to clinical practice after the event. The half day format also allowed participants to take time to reflect on the activities and to think of ways in which they might use the information gained to advance practice and promote patient safety. The eclectic mix of practitioners was very welcome. I very much enjoyed hearing multidisciplinary perspectives on key issues.
Why are such events important for health professionals to engage with?
These events offer delegates protected time away from clinical practice to attend CPDcertified opportunities, access current practice and knowledge and focus on learning and self-improvement. Delegates can learn new information, acquire advanced skills, understand guidelines and techniques and to stay updated with the latest developments in their field.
The ability to meet with likeminded people in a convivial atmosphere can pave the way for developments in practice and enhance care provision. Participants can connect with peers who share similar interests and may be experiencing similar challenges, fostering collaboration, sharing of best practices along with a sense of professional support. The space to collaborate with peers has the potential to spark initiatives that can be a catalyst to drive better outcomes for patients.
What are some of the key takeaways from the conversations?
The first was the need to generate and use data to promote safe practice. The second key takeaway was the importance of focusing on risk assessments. The third important point was that care provision should be based on sound evidence. It was my impression that delegates were unanimous in their belief that safety is not just a component of healthcare, but the foundation on which trust and quality are built. Without a commitment to safety, the effectiveness of healthcare will diminish and the trust that patients place in their caregivers will erode.
Moving forward, what additional themes or topics would you like to be discussed with regards to theatre safety?
In future events like these, it would be good to include and discuss patient perspectives and lived experiences of people whom health professionals care, to get a holistic perspective.
Delegate feedback
The conference drew an audience from diverse roles and specialisations in healthcare including senior healthcare assistants, theatre nurses, lead pharmacists and surgical care practitioners. All of the 62 delegates surveyed said that the content of the sessions was relevant to their practice, they would recommend the Theatre Safety Club to their colleagues and would like to attend similar educational activities in the future, highlighting the significance of such CPDcertified events for health professionals. A key recommendation for future events was to organise full day conferences, for speakers to have the opportunity to discuss topics in depth and for delegates to attend presentations on a wider range of topics.
Some of the main topics mentioned for future conferences included sustainability in the operating theatre that focuses on the environmental impact of latex gloves, alternative options and effective recycling methods. Delegates also suggested more sessions on theatre safety and safeguarding of patients, considering issues such as preventing pressure sores and hypothermia during long procedures, sharps safety, diathermy risks and occupational hazards of surgical smoke plume.
‘Everyone did really well in the sessions, which were all so informative. I hope these events can be held annually.’
‘Excellent day that exceeded my expectations in the organisation and running of the day. Superb and skilful chairing. This is an important and much needed platform that can truly drive change by engaging the right people, being inclusive of all levels of the theatre workforce and other stake holders. Would definitely be keen to participate in future events.’
‘Thank you. The sessions were informative and I will apply many important points in my practice. Particularly the importance of risk assessments and speaking with patients about their history and informing them about risks and care plans.’
‘All the sessions were relevant to my professional practice. The speakers were passionate and knowledgeable.’
‘The event was useful for me to learn about specific topics and I would have been happy to take all day off to attend more sessions. It was a good opportunity to network and interact with colleagues from different healthcare professions.’
‘The format was brilliant! The sessions were engaging, there was time to ask questions and share thoughts and we could interact with people at the stalls and learn about new products.’
Conclusions
The Theatre Safety Club 2024 marked a great success, exceeding expectations and leaving a lasting impact on all who attended. Delegates unanimously agreed that the sessions were informative and relevant to their practice, emphasising the importance of holding similar sessions in the future to provide an opportunity to enhance their learning and skills.
Following the success of the event, the Theatre Safety Club will be back in 2025. Readers can register their interest for next autumn (https://www.theatresafetyclub.com/theatresafetyclub2025/en/page/home).