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

Juliette J M Zwaans ,Wouter Raven , Arthur V Rosendaal, Esther M M Van Lieshout, Geesje Van Woerden ,Peter Patka ,Juanita A Haagsma , Pleunie P M Rood

Aim

To assess if the use of non-sterile gloves gives equally as few wound infections for traumatic wounds as sterile gloves.

Rationale

Previous systematic reviews and one observational study in the emergency department have shown no difference in infection rates. The use of non-sterile gloves would save time and resources.

Design

Single label multi-centre randomised non-inferiority controlled trial

Setting

Three Dutch Emergency departments

Population

Inclusion criteria; Adult, traumatic wound requiring suturing

Exclusion criteria; Complex wound (bone, vascular, nerve, cartilage involvement), >24 hours old, needing theatre closure or bite wounds.

1480 patients enrolled.

Intervention

All patient’s had wound washed out, chlorhexidine, 1 % lidocaine used and sterile instruments

Standard group; sterile gloves, gauze and drapes.

Intervention group; Non-sterile gloves, gauze and drapes.

Primary outcome

Wound infection (composite of various markers). Patient returned to ED for suture removal and blinded physician review.

Secondary outcomes

Nil

Results

The wound infection rate was non statistically significant (6.8 % in sterile vs 5.7 % in non sterile).

Author’s Discussion

It is likely than non-sterile gloves are non-inferior to sterile gloves in causing wound infections.

Strengths

Useful clinical question

Simple intervention, easily applied in most low resource settings.

Sensible patient-orientated outcome

Good use of non-inferiority trial design.

Sensible inclusion criteria.

Weakness

Did not reach pre-targeted sample size for statistical power

Practitioner undertaking procedure not blinded.

Generalisability to immunosuppressed patients (e.g. those with diabetes) questionable

External validity in low-resource settings who have a very different cohort of wounds

My humble opinion

This well run trial demonstrates there is likely little benefit to certain aspects of the sterility process. This is useful in situations when you need to save resources or time. However it should be remembered in this settings you tend to have a much expanded practice (undertaking wound closure or complex wounds or heavily contaminated wound more often). This is a reminder that the more important aspect of prevent infection is good anaesthetic to allow thorough wound washout rather than the gloves you are wearing.