OR workers have to mentally multitask when sharps are in use, focusing simultaneously on patient and worker safety. The human tendency is to devise a pecking order, and most often, patient safety comes first. Even if there is unexpected bleeding during a procedure, and speed becomes a factor, patient safety is still at the fore, right? This is by no means wrong - it's just that you must give worker safety nearly as much attention.
Wearing two rather than one pair of gloves won't prevent needlesticks or scalpel cuts. But studies clearly and repeatedly show that double-gloving significantly reduces occupational exposure to blood during surgical procedures. Many studies also suggest the traditional use of a single pair of latex gloves can't provide an effective barrier during most surgical procedures. A rundown of some of the proof:
- Leaks may be demonstrated in as much as 2 percent to 4 percent of gloves before use.
- One study found defects in 1.4 percent of 210 unused surgical gloves and in 35 percent of surgical gloves tested post-operatively.
- Many studies have found defects in 30 percent to 50 percent of gloves tested post-operatively.
- In one study of 3,018 gloves from 800 surgical procedures, duration of the procedure had a profound effect on the incidence of glove failure; a comparison of single and double-gloving found that double gloves had significantly fewer defects, especially the inner glove layer (see "Clock Ticks and Glove Rips" at right).
- One study showed visible blood on operator's hands in 38 percent of single-gloved procedures and in only 4 percent of double-gloved procedures.
Where, when and how
Several factors should influence gloving practices: Type and length of procedure, the stresses gloves will be exposed to, and the individual needs and preferences of surgical team members. Most surgical procedures easily lend themselves to double-gloving, including gynecologic, general and cosmetic/plastic surgical procedures, where the expectation for exposure to blood is always high.
Sometimes, switching might be the best route. Based on my observation of a series of coronary artery bypass graft and other cardiothoracic procedures, I believe these procedures lend themselves to a combination of single and double-gloving - and that was one of my recommendations as a consultant for that facility. Opening and closing the chest, where stresses on gloves are considerable, clearly call for double-gloving. On the other hand, where cardiothoracic surgeons may feel that double gloving would unduly compromise tactile sensation during delicate vessel anastomosis, they might want to perform this portion of the procedure wearing a single pair of gloves.
Clock Ticks and Glove Rips
Here's a look at the likelihood of glove failure in correlation to length of procedure, based on a study of 3,018 gloves from 800 surgical procedures.
Length of procedure
Less than one hour
One to three hours
Three to five hours
Over five hours
And here's the failure rate of single versus double gloves, based on the same study.
Double gloves, outer layer
Double gloves, inner layer
Adapted from Cohn GM, Seifer DB. Blood exposure in single versus double gloving during pelvic surgery. Am J Obstet Gynecol 1990;162;715-717.
Some materials lend themselves to double-gloving better than others. Latex gloves, which have traditionally provided maximum sensitivity, may have an advantage in this regard. Because of concerns about latex allergy, however, there is an increasing shift to non-latex gloves. We need to further explore opportunities to double-glove with synthetic materials.
Glove size may vary slightly from manufacturer to manufacturer. Although it takes a little time and effort, every member of the OR team can benefit from experimenting with different brands, materials and sizes to facilitate effective double-gloving.
Other glove-safety tips
Some other things to consider.
- Armored gloves and glove liners. Despite varying degrees of diminished tactile sensitivity, gloves and glove liners made of more or less impervious materials such as steel mesh, Kevlar, leather and other materials may be useful in some orthopedic and trauma procedures where you might encounter bone fragments and sharp, tearing foreign bodies. Some of these types of gloves may be better than others in protecting against needle punctures, but one should always bear in mind that blunt-tipped sutures, where applicable, provide the best protection against suture needlesticks.
- The glove-gown interface. Because surgical gowns are designed to prevent blood strikethrough, they have a slippery surface, which promotes fluid runoff. This, combined with the smooth inner surface of gloves, allows cuff slide-down that can let blood and other potentially infectious fluids contaminate the operator's hands. Conversely, sweat can leak back to contaminate the sterile field or wound. Given the ingenuity and resources of medical equipment manufacturers, it's somewhat surprising that gown and glove manufacturers have yet to devise a solution to the vulnerable glove-gown interface. Until technology catches up with the needs of clinicians, one solution others and I have found useful is to use gloves with extended cuffs.
Safe donning and removal
Remember, healthcare worker and patient safety don't begin and end in the OR. Here are three final tips to keep in mind:
- Replace both layers of gloves if a defect is detected in the outer layer.
- Remove gloves carefully to avoid splatter.
- Wash the hands after completing the procedure, even if double-gloving - it's an OSHA requirement.
Personal protective equipment (PPE) is essential in preventing transmission of bloodborne pathogens - in either direction - between patients and operating room professionals. One key component of PPE is the surgical glove.
Bloodborne pathogens can be transmitted to ORPs due to needlestick injury, mucous membrane exposure and even exposure of unprotected chapped or abraded skin. For many reasons, the skin of ORPs' hands may often be chapped or abraded, making selection of an effective glove barrier extremely important.
Here are some frequently asked questions from my surgical audiences.
Is double-gloving necessary during a minor procedure with low expectation of exposure to blood, such as a diagnostic dilatation and curettage?
Not necessarily, but bear in mind you might occasionally encounter emergencies during minor procedures. If you have to convert to a major procedure, double-gloving should then become routine protocol.
Should scrub personnel double-glove?
If they're assisting the surgeon, they certainly should. But I see no disadvantage to the scrub person's routinely double-gloving during any major procedure or where exposure to blood is anticipated.
What size gloves should I use when double-gloving?
In my personal experience - after some experimentation - I found that using my regular size for both layers of gloves worked reasonably well. Others have recommended a smaller or larger size for the outer layer of gloves. Base your preferences on experimentation with various brands and sizes of gloves.
- Mark S. Davis, MD