The RAMER Reviews: Non-Sterile Gloves in the Emergency Department
Written by: Dylan Ngyuen MD; Edited by: Timothy Khowong MD MSEd
Background
Laceration repair is a common occurrence in the emergency department. Sterile gloves, drapes, and dressings are not always immediately available, their usage may necessitate an assistant, and utilization can prolong the time taken to perform suture repair. Most available literature regarding wound infection rates using sterile materials for minor bedside procedures suggested that there is no difference in infection rates, but was not specific for the ED.
The Study
This study was a randomized controlled trial performed in three emergency departments in the Netherlands. The objective was to determine if there was a difference in wound infection rates when using sterile gloves, drapes, and gloves versus non-sterile gloves and dressings. The measured outcome was wound infection 5-14 days after suture repair; the physician reevaluating the wound was blinded to the sterility of the repair materials.
Noninferiority was defined as less than a 2% increase in wound infection when using non-sterile materials. Wound infection was defined as an abscess originating from the wound, cellulitis >10mm, purulent fluid, wound dehiscence, and/or the physician found wound treatment to be necessary at the time of follow-up.
Of the 2468 eligible adult patients, 1480 consented to be included in the study and were randomized 1:1 to the sterile or non-sterile groups. Patients were excluded if: there was bone, vascular, tendon, nerve, or cartilage involvement; the wound was the result of a human or animal bite; the injury occurred over 24 hours prior to presentation; the wound already appeared infected; it was determined that the laceration should be repaired in the operating room.
There was a 6.8% wound infection rate in the sterile group compared to a 5.7% rate in the non-sterile group. The confidence interval for the difference was -3.7% (i.e. 3.7% fewer infections in the non-sterile group) to 1.5%.
The study design necessitated a sample size of 2140 to have adequate power to detect a statistically significant difference which was not achieved. There were also subjective components to determining if the patient could be included in the study (i.e. if the laceration required OR repair) and if the patient should be prescribed antibiotics during their wound check, which could introduce bias.
It was also noted that the rate of infection in both groups was higher than cited literature, but those studies were not performed in the emergency department. This study did not measure the cost-effectiveness of using non-sterile materials for suture repair.
Discussion
Overall, while not being adequately powered, this study suggests that there is no difference in wound infection rates when using sterile and non-sterile materials. All patients in the study had their wounds irrigated with tap water prior to repair; irrigation of wounds is widely recognized as an important step to prevent wound infection. Use of sterile materials can pose logistical difficulties without measurable benefit, but may be more reassuring to a patient.
Of note, patients in the Netherlands have easier access to primary care and general practitioners are comfortable with performing minor laceration repair. Their integrated triage system can allow a nurse to refer patients to a GP instead of the ED, so the severity of injuries seen in an ED in the Netherlands can vary from those seen in the States.
Further study could be done with an appropriate sample size and measure secondary outcomes such as cost-effectiveness of using non-sterile materials and ED length-of-stay.
References
Lewis K, Pay JL. Wound Irrigation. In: StatPearls. Treasure Island (FL): StatPearls Publishing; March 27, 2023.
Zwaans JJM, Raven W, Rosendaal AV, et al. Non-sterile gloves and dressing versus sterile gloves, dressings and drapes for suturing of traumatic wounds in the emergency department: a non-inferiority multicentre randomised controlled trial. Emerg Med J. 2022;39(9):650-654. doi:10.1136/emermed-2021-211540