DOUBLING DOWN Everyone in the OR benefits from donning 2 pairs of gloves.

Despite pages upon pages of clinical studies that have proven the effectiveness of double-gloving in protecting surgical team members from sharps injuries, needlesticks and infectious diseases such as HIV, and hepatitis B and C, the practice isn't yet routine. Time and again we hear that clinical proof is needed to drive change in the operating room. Well, here it is.

Indicators of safety
A survey published in the journal Infection Control and Hospital Epidemiology (tinyurl.com/pdjoesh) reveals 99% of polled surgeons suffered at least 1 needlestick in their careers. The problem, note the researchers, is that surgical glove punctures often go unnoticed during cases, meaning surgeons might be exposed to blood and associated infection risks without knowing it.

The researchers say glove puncture rates vary, although risks increase to as high as 70% during longer procedures as well as during surgeries requiring maximum effort in deep cavities and around bones. They further note that research shows the risk of blood contact is decreased from 70% with single gloves to as low as 2% with double gloves, likely because the inner glove was shown to remain intact in up to 82% of cases.

To determine how much blood is transferred through single and double layers of gloves at the point of percutaneous injuries, the researchers stuck pork skin with automatic lancets, which simulated suture needlesticks. According to the findings, a mean volume of 0.064??L of blood is transferred in punctures at a depth of 2.4mm through 1 glove layer, compared with only 0.011??L of blood through double-glove layers, which means the volume was reduced by a factor of 5.8.

Notably, the double gloves used in the study included an indicator system: a green inner glove worn with a straw-colored outer glove. According to the researchers, all punctures of the gloves' outer layers were clearly identifiable by the green coloring of the underglove showing at the puncture site. The color contrast reduces risk of blood exposure by alerting surgeons and staff to breaches that may have otherwise gone unnoticed.

"Double-gloving should be recommended for all surgical procedures and should be required for procedures performed on patients with known infections or patients who have not yet been tested for infections," say the researchers. They also point out that while the protective effect of double-gloving is evident, it is not yet routine because of an alleged reduction in dexterity and sense of touch (for evidence to the contrary, see sidebar below).

Surgery's riskiest specialty
A report in Acta Orthop??dica Belgica (tinyurl.com/qammhpz), official journal of the Belgian Society of Orthopedics and Traumatology, says glove perforation rates range from 10% in ophthalmology to 50% in general surgery. But the stress and strain of manipulating oscillating saws, metal instruments and implants during orthopedic procedures subject gloves to extreme shear force, putting orthopods at the greatest risk among surgical specialties, say the researchers.

In this study, the researchers assessed rates of glove perforations during major total hip and knee replacements and the more minor knee arthroscopies. They also examined how double-gloving impacted perforation rates and whether rates differed among surgeons, their assistants and OR nurses.

The overall glove perforation rate was 15.8%, with a 3.6% rate during arthroscopies and a 21.6% rate during joint replacements. More than 72% of the breaches went unnoticed until after the procedures had concluded. Only 3% of the inner gloves were jeopardized — none during arthroscopies — compared with 22.7% of the outer gloves. Notably, only 4% of perforations recorded during major procedures involved both glove layers. A quarter of the 668 surgeons involved in the study suffered perforated gloves, which was significantly higher than the 8% of the 348 assistants and 512 nurses who suffered the same fate.

The researchers note that double-gloving in orthopedic procedures significantly reduces the incidence of perforation of inner gloves. Although surgical personnel who scrub in properly lower their risks of contracting bloodborne diseases when gloves are perforated, they add, previous studies have shown bacteria cultures taken at perforation sites have been positive about 10% of the time.

SURGEON SENSATION
It Takes Only 2 Weeks to Get a Feel for Double-Gloving

TOUCH Surgeons say it takes only a few cases to get used to wearing 2 pairs of gloves.

Your surgeons probably think that double-gloving reduces hand sensitivity and dexterity. "Despite a large body of data supporting double-gloving, a major drawback of this intervention is the lack of surgeons' acceptance," write researchers Ramon Berguer, MD, and Paul Heller, MD, in the Journal of the American College of Surgeons (tinyurl.com/cd85fvl). The good news, the researchers say, is that it doesn't take long for surgeons to start feeling acclimated to the decreased hand sensitivity associated with double-gloving.

"Current underglove designs make double-gloving more comfortable and have led to improved 2-point discrimination — the ability of a surgeon to feel 2 points touching his skin," says Dr. Berguer, who feels surgeons can fully adapt to double-gloving within 2 weeks of trying it for the first time.

— Author Creds

What about the nurses?
Research published in the AORN Journal (tinyurl.com/8gwyy5a) involved the assessment of more than 8,500 gloves worn in double layers by a total of 702 surgical professionals, including surgical residents, RNs, attending surgeons, surgical fellows and surgical techs.

According to the findings, 1.3% of those who wore single gloves noticed visible defects during surgery while only 0.3% of those who double-gloved noticed breaches to the protective layer of the inner glove. Within 4 hours of surgery, investigators filled used gloves with 1,000ml of water, hung the gloves for 2 minutes and visually inspected them for leaks. The leak test revealed 6.3% of single gloves showed leaks, compared with 1.9% of inner gloves.

The researchers say the results show that double-gloving minimizes the risk of defect to the inner glove and exposure to blood during surgery, which backs claims that wearing 2 layers effectively minimizes risks of needlesticks and sharps injuries. They also note that surgical team members who wear an indicator glove when double-gloving are more likely to change the outer glove immediately when a breach occurs.

A report in the American Journal of Surgery (tinyurl.com/owvqdew) specifically addresses the effectiveness of double-gloving in protecting surgical nurses, a population glove-related studies don't often focus on. The study's authors detected perforations in 9% of single gloves, in 11% of outer gloves and in none of the inner gloves worn by double-gloved first assistants and scrub nurses. Specifically, perforations were noticed in 5.36% and 3.57% of single gloves worn by first assistants and scrub nurses, respectively, and 4.72% and 6.60% of outer gloves worn by double-gloved first assistants and scrub nurses, respectively.

The researchers conclude that research typically focuses on the protection double-gloving offers surgeons, but doubling up on glove layers does in fact help protect operating room nurses as well.

PROTECTIVE LAYERS Inner pairs of gloves are less likely to be compromised by needles, blades or bones.

Quantifiable dangers
According to a study in the journal BMC Infectious Diseases (tinyurl.com/pxavkyl) of 98 outer gloves and 96 inner gloves worn during open abdominal cases, small perforations occurred in 10% of outer gloves and 1% of inner gloves after an average of 100 minutes of use during surgery. The researchers noticed bacterial migration through 5% of outer gloves and 1% of inner gloves, with bacterial migration rates as high as 54.5% detected through the micro-perforations, which confirms previous results that bacterial migration through unnoticed micro-perforations in surgical gloves does occur under real practical surgical conditions.

"The intact surgical glove is the most important barrier to protect the patient from microorganisms from the hand of the surgical team, and the hands of the surgical team from the patient," write the researchers. They note 70% of the perforations to the outer gloves in this study could have been detected by an indicator-glove system. This, together with the fact that only 1 of all tested inner gloves was punctured, indicates that the double-gloving indicator system provides reliable prevention of microorganism transmission.