INDICATOR GLOVE Most glove punctures are tiny and identified only after surgery, not at the time of the incident. Wearing a darker-colored indicator glove makes it easier to spot breaches.

The first time you ask them to wear 2 pairs of gloves, they might look at you like you have 3 heads. But if you want to make double-gloving mandatory for all surgical staff directly involved or assisting at the operating field, you must have zero tolerance for the well-worn excuses you'll hear: too tight, too thick, too bulky, too cumbersome, loss of sensation, cuts off my circulation.

Not long after we made double-gloving mandatory, I spotted a surgical tech who wasn't wearing 2 pairs of gloves. When I asked him why, he said he was worried that he'd stick himself while passing suture or picking up instruments because of the "bulky and tight" double gloves. This is the kind of pushback you can expect, even though wearing double gloves has been proven to significantly decrease sharps exposures, as in the study that found that the underglove reduced exposure to patient blood by as much as 87% when the outer glove is punctured.

Hearts and minds
Yes, gloves are a very sensitive subject for your surgeons and staff. And rightfully so. Those who make their living in the OR are very touchy about their sense of touch. Some will be adamant that they can't function wearing 2 pairs of gloves. No way, no how, they'll insist. But once you break down the barriers with education and a double-glove trial, you'll quickly convert the naysayers. Remember, not all clinicians were trained to double-glove, so adopting the practice may require a change in behavior for some healthcare workers. But you might find that they'll feel no difference after double-gloving for as little as 2 weeks. It'll be their new normal, a learned behavior, just like wearing your seatbelt.

TOUCHY ABOUT TOUCH While barrier protection should always be the primary consideration for glove selection, fit and comfort are important factors as well.

How did double-gloving become my mission? In 2013, right around the time I went back to school for my BSN, I started working as a quality and compliance nurse here at the Virginia Commonwealth University Health System. One of my first projects was to complete a tracer of the ORs to see how well we were following the surgical safety checklist and if our nurses, surgical techs and surgeons were wearing the proper personal protective equipment, including goggles and double-gloves. In the 4th quarter of 2013, 76% of our OR personnel were double-gloving. Three-fourths wasn't bad, but we were shooting for 100% compliance (98-99% actually — attending surgeons and ophthalmologists could opt out). Here's how we got there and stayed there.

MANDATORY DOUBLE-GLOVING
Should Double-Gloving Be Required?

More than half (54%) of the 300 online poll respondents feel both surgeons and staff should be required to double-glove.

Double-gloving should be mandatory for _____ .

• surgeons 13%
• staff 3%
• surgeons and staff 54%
• neither 30%

SOURCE: Outpatient Surgery Magazine InstaPoll, March 2017, n=300

1. Make it mandatory. One of the first things I did was stress that we weren't looking for volunteers to double-glove. Barrier protection is mandatory. Anyone working in the room who handles sharp instruments must wear a two-color indicator system for double-gloving. It never was a matter of if you would double-glove, only when must be your mindset.

2. Help your team visualize barrier protection. Explain in graphic terms how double-gloving helps reduce exposure to bloodborne pathogens. A couple examples:

• Intact glove=intact skin. If the innermost glove remains clean and intact when the outermost layer is punctured or perforated, so, too, will your skin. Most sticks, pricks and nicks happen on the outer layer.
• Windshield wiper effect. Say you're passing suture and you stick your finger. Double-gloving will wipe the tip of the needle, decreasing bloodborne pathogens before the needle punctures the skin: the outermost when the needle goes through, the innermost when the needle comes out. This windshield wiper effect decreases the inoculum.

We also extolled the benefits of double-gloving by posting information on a bulletin board, including common reasons why OR personnel are opposed, and an article about a pegboard experiment that found no decrease in dexterity when test subjects manipulated pegs, regardless of whether they were single-, double- or triple-gloving. The chairman of the division of infectious disease also conducted an in-service on double-gloving and exposure risk.

REMINDER We Velcroed this reminder to every OR computer workstation to remind staff to alert us when the outer glove was punctured or perforated.

3. Host a glove trial. We asked our glove manufacturer to station a vendor rep on-site to help us conduct a 2-week interactive glove fair for all surgical staff. This provided an opportunity for staff to choose a comfortable inner and an outermost glove to be worn during procedures. Our vendor brought in 4 different styles (textured, thin, thick) of latex-free indicator gloves as well as light-colored outermost gloves. After surgeons and staff chose the gloves they preferred, we asked them to double-glove for a few cases. We then recorded their sizes and their feedback in a preference log.

Proper sizing is critical. A frequent comment we heard: "The innermost glove was a little tight. Let me try the next size." Nothing's more miserable than wearing 2 tight, constricting gloves. You may think you're a size 7, but instead you're a 6 ? or 7 ?. Don't assume everybody will know what size double-gloving system will fit them best. A good rule-of-thumb: Go up a half size on the innermost glove and stick to your true size on the outermost glove.

4. Prove your point. We secured a laminated card (little bigger than a business card) to the top of the computer screens in each of our 36 ORs with a little piece of Velcro. The card asked circulators to page me or a colleague if the outer glove of a person scrubbed during a case was perforated, but the indicator glove remained intact. This happened 27 times over a 2-month period in early 2015. Here was tangible, powerful evidence that wearing double sets of gloves prevented exposure to bloodborne pathogens.

Try it, you'll like it
Along with identifying a neutral or hands-free zone when passing sharps and converting to blunt-tip sutures and safety scalpels, double-gloving is an easy and inexpensive intervention to reduce blood-borne pathogenic exposures. We've also streamlined our glove inventory and saved valuable storage space. We stock only the 4 inner and outer gloves we trialed, and we buy only from a single vendor. The hardest part of our double-glove conversion was convincing our team to try on a pair. OSM