Donning gloves before surgery is as automatic as blinking. But don't take this most basic barrier protection for granted. Gloves protect your hands from exposure to blood, mucous membranes and non-intact skin. They decrease the likelihood that staff will transmit their own endogenous body flora to patients, reducing the possibility of transmitting microorganisms from one patient to another. If you haven't reviewed your hand hygiene basics in a while, it's time for another look at why gloves matter.

Imperfect protection
A look at how and why gloves fail reinforces the importance of the protection they offer. Gloves undergo standardized testing before being put on the market; the properties of latex, vinyl and synthetic gloves are scientifically evaluated for their barrier effectiveness.

The recommendations for manufacturing standards from the American Society for Testing Materials, which are supported by the FDA, include a glove failure rate of 1.5 percent for sterile latex gloves and a 2.5 percent failure rate for non-sterile or non-latex gloves.1

Many recorded cases of surgical gloves failing exist.2,3 Failure happens as a result of exposure to substantial physical and chemical stresses during surgical procedures. Gloves can either fail outright (by getting punctured with a sharp, for example) or as a consequence of gradual chemical changes in their barrier properties, developing while the gloves are worn. In general, glove failures fall into three categories:

• cuts, tears, punctures and holes;
• microperforations; and
• permeation and hydration.

Researchers have documented that individual surgical specialties have different frequencies of glove perforations during procedures.3,4,5 Failure rates may be as low as 0.3 percent for gloves worn by ophthalmic surgeons and as high as 61 percent for gloves worn by during cardiothoracic surgical procedures. Glove failure is more likely during longer procedures. For three-hour procedures, the failure rate can be as high as 60 percent.1,5 Several researchers found that, during routine operative procedures, gloves worn on surgeons' or clinical team members' non-dominant hands were more likely to sustain punctures.5,7

Cuts and tears are normally easy to spot, although even major glove damage can sometimes remain undetected.6,7,8 Damage from suture needle punctures often goes unrecognized; surgeons are sometimes unaware of glove perforations caused by blunt needles during procedures such as mass abdominal closure.9,10

• Microperforations. These undetectable breaks in a glove's barrier protection are too small to be seen, but they're large enough for microorganisms to pass through.11,12 Microperforations can result from manufacturing defects, material fatigue or extensive wear. The flexible nature of latex lets microperforations open and close, depending on whether the gloves are stretched.13
• Permeation and hydration. Permeation may occur through diffusion, capillary action or forced movement across the microporous latex membrane. Many OR personnel already know that toxic antineoplastic medications can permeate rapidly through intact surgical gloves.5,14 The term "glove hydration" describes the penetration of aqueous fluids into and through the microporous structure of latex. The state of maximal fluid uptake is termed "fluid saturation."15,16 This occurs while the gloves are worn and can be detected by a change in the gloves' appearance (such as a glassy sheen) or in their feel (boggy with less tactility, for example). All latex gloves will hydrate while in use.

Researchers have used a variety of methods to test the effectiveness of gloves in stopping viruses. Some studies suggest that, under simulated use conditions, viruses may pass through the intact glove membrane.17,18

So regardless of the brand of surgical glove you use, the barrier may still lack integrity with continued use.

Twice as safe?
Double-gloving is one possible way to reduce surgical site infections during a procedure. This technique can reduce the potential risk of exposure from a needlestick, sharps injury or cross-contamination. One study noted that the risk of breach increases 1.115 percent for every 10 minutes of surgery.11 Other research discovered a 51 percent hand-contamination rate for staff who single-gloved versus a seven percent contamination rate for staff who double-gloved; the research also noted that about 60 percent of perforations in single gloves go unnoticed.19,20,21 Further, another study found that hand contact with body fluids was 72 percent lower for surgeons who double-gloved.22

Although several studies demonstrate a benefit to double-gloving, we still lack data associated with the identification of a barrier breach at the time of an incident.14,22,23 Studies have examined gloves' barrier integrity when gloves were removed compared to the hand's degree of contamination at that time, but researchers haven't explored gloves' integrity during surgery and potential surgical contamination related to the degree of intraoperative integrity.20,24,25 Most studies centering on surgeons showed a lower frequency of inner glove perforation and less visible blood on the surgeons' hands when double gloves are worn, but factors associated with contamination of the surgical field, rate of needlestick or sharps injury and perception of risk associated with bloodborne pathogens still haven't been clearly investigated by researchers.10,26

Using two gloves may have benefits that go beyond protecting your staff's hands. A recent study found that double-gloving reduced the breach of barrier integrity to 0.3 percent, while using only one glove produced a rate of 8.7 percent.27 It's also interesting to note that, during this study, four patients developed surgical site infections. In three of those cases the gloves used by the healthcare workers were perforated. The authors concluded that there is a relationship between the perforation of gloves and surgical site infections.

Pointing to the future
While clinical teams face many challenges related to gloves today, tomorrow's gloves may solve some of these problems. The latest technologies associated with surgical gloves include:9,28,29

• non-latex, coated gloves to improve skin condition;
• indicator gloves that help clinical staff recognize barrier breaches;
• antimicrobial hand hygiene surgical rubs that decrease cross-contamination when the glove barrier is compromised; and
• glove liners that protect hands when outer gloves tear or perforate.

The next generation of surgical gloves might be based on the type of surgical procedure they are intended for or the duration that the glove can be effectively and safely used (perhaps designed with an "end of use" indicator system). Manufacturers might indicate a glove's level of barrier protection through standardized color-coding. Some gloves may even feature computer chips that work in conjunction with "smart" operating rooms to record hand-to-glove breaches and hand-to-hand or cross-contamination.30,31

So for all we think we know about surgical gloves, we haven't yet embraced technologies that may enhance how well we monitor their use in the OR. Now is the time to be proactive in our thinking to develop newer surgical gloves with superior barrier characteristics, enhanced infection control qualities and wireless monitoring systems that provide feedback during each phase of surgery. The gloves of the future can only be developed if healthcare workers continue to emphasize the importance of barrier protection and provide input in developing innovative ways to improve the gloves that we've come to hardly notice.