The excuses drivers give for not wearing seatbelts sound a lot like those surgeons and surgical team members give for not double gloving during surgery. It makes me feel restrained. It's uncomfortable. Sound familiar?
You're likely to hear these excuses, and more, from OR team members opposed to double gloving. Why the resistance? For one, double gloving is far from a universal practice. Even though AORN is firm on the matter of double gloving with an inner indicator glove a colored pair of gloves worn underneath a standard pair of gloves only about half (49%) of the 192 perioperative personnel Outpatient Surgery Magazine polled last month routinely double glove. Could AORN's recommendation be any more direct? "Scrubbed team members should wear 2 pairs of surgical gloves, one over the other, during surgical and other invasive procedures that have the potential for exposure to blood, body fluids or other potentially infectious materials." For another, surgeons and nurses subscribe to several myths about double gloving. Here's evidence-based advice for overcoming those objections.
1. Glove barrier failure is rare. Glove tears and perforations are anything but rare. Whatever the reason, glove barrier failure occurs more frequently than you might think. It's scary when you consider the many different ways gloves can fail. Glove failures can be caused by punctures, tears from sharp devices or spontaneous failures. And oftentimes, glove failures go unnoticed.
For a study that assessed glove perforation rates in 130 consecutive orthopedic procedures, researchers tested nearly 1,500 gloves from all surgical team members. The overall perforation rate was 3.58%. What's really significant is that perforations went unnoticed nearly two-thirds (61.5%) of the time. When you have an unnoticed glove perforation, you're at an increased risk for bloodborne pathogen transmission. You also increase the patient's risk of wound infection via transfer of organisms from surgical team members. Not surprisingly, researchers found that healthcare providers observed blood on their hands after surgery more frequently when they wore a single pair of gloves than when they wore 2 pairs of gloves.
It's no secret that double gloving helps prevent surgical site infections. It's also no secret that your surgeons and staff would rather not wear 2 pairs of gloves. Only about half (49%) of the 192 respondents to a recent online poll say their surgical teams routinely double glove. The results:
- all of the time 25%
- most of the time24%
- some of the time38%
- none of the time13%
SOURCE: Outpatient Surgery Magazine, January 2015, n=192
Study after study shows that double gloving protects against perforations. One study of glove perforations when team members double gloved during hip and knee arthroplasty showed a perforation rate of 18.4% to the outer glove and 8.4% to the inner glove. Interestingly, the most frequent site of perforation was the second finger of the nondominant hand. Another found that single-glove perforations occurred at a rate of 10.87%, compared to 3.34% when 2 pairs of gloves were used. When double gloves were used, the inner glove was perforated at a rate of 0.36%. It's hard to argue against numbers like those.
2. You don't have to change your gloves during a case. Once you don your gloves for a case, you're good to go, right? Not so fast. We tend to feel safe once we put our gloves on, but it's not necessarily always the case. AORN recommends you inspect gloves immediately after donning them, before making contact with the sterile field and throughout use for punctures and tears. AORN also recommends scrub members change their gloves every 90 to 150 minutes, regardless of whether you spot a perforation. Studies demonstrate a correlation between the rate of perforation and length of time gloves are worn. A comparison study of single and double gloving analyzed the frequency of glove perforations during surgery. The rate of perforations during surgical procedures that lasted less than 2 hours was 4.21%; the rate of perforations during procedures that were longer than 2 hours was 11.69%. Researchers calculated the increased perforation risk per additional 10 minutes of operating time to be 1.115 times. When single gloves were worn, the detection rate of a perforation was 36.84%. When a double glove perforation indication system was worn, the detection rate for a perforation was 86.52%. Which brings us to our next myth
3. It's just as easy to detect perforations in single gloves as within double gloves. A perforation indicator system uses a colored pair of gloves worn beneath a standard pair of gloves. Wearing dark-colored gloves under light-colored gloves helps surgeons and surgical team members more readily notice glove perforations and change gloves more easily than if they're wearing 2 pairs of the same-colored gloves, studies have found. When glove perforation occurs, moisture from the surgical field seeps through the perforation between the layers of gloves, revealing the underlying color and signaling a perforation. Wearing a colored pair of gloves underneath a standard pair of gloves makes it much easier to spot a perforation. A study found that only 21% of perforations were visible when wearers wore 2 pairs of standard gloves. When they wore a perforation-indicator system, the detection rate soared to 77%.
Another study found that regular glove changes during a procedure can reduce the incidence of perforation and contamination. Researchers evaluated the incidence of glove perforation and contamination when personnel scrubbed for primary cemented total hip replacement surgeries changed their outer gloves at specific intervals. In the study group, outer gloves were changed every 20 minutes prior to cementation, and when a visible puncture was detected. In the control group, outer gloves were changed prior to cementation and when a visible puncture was detected. There was a statistically significant lower rate of perforations for surgeons and scrub persons in the study group compared with surgeons and scrub persons in the control group. There also was a statistically significant lower rate of glove contamination in the study group compared to the control group.
Gloves should be changed when a suspected or actual perforation occurs or a visible defect is noted. Surgical gloves develop microperforations depending on the length of time the gloves are worn. Perforations let bacteria pass from the surgical site through the glove. Sterile gloves should be changed:
- after each patient procedure;
- when a visible defect or perforation is noted;
- when suspected or actual contamination occurs; and
- when a suspected or actual perforation occurs.
4. Needle sticks and sharps injuries are uncommon events. Nearly 400,000 hospital healthcare workers annually sustain a percutaneous injury. Most of these injuries occur in the perioperative setting, a particularly high-risk environment for needle stick and sharps injuries because we work for prolonged periods in the presence of large quantities of blood and potentially infectious body fluids, we frequently handle sharp devices and we coordinate the passing of those devices between the team. All of these factors put surgical teams at a much higher risk. And did you know that most sticks and sharps injuries are suffered by nurses and techs while passing, disassembling or disposing of sharps devices, rather than by the surgeons who are using them?
The good news: Double gloving by itself may protect the wearer's skin from needle sticks because breaches are more likely to occur to the outer gloves than the inner gloves. That was the finding of a 24-month study, "Exploring the Benefits of Double Gloving During Surgery," which was published in the March 2012 AORN Journal and examined the effect of double gloving with inner indicator gloves on the durability of inner gloves and the detection of glove tears or perforations during surgery.
5. Wearing 2 pairs of gloves will cause a dangerous decrease in tactile sensitivity. Yes, there might be some loss of tactile sensitivity when double gloves are worn. You can exercise some clinical discretion here. The AORN recommendation states that when indicated by a clinical need for high tactile sensitivity (cataract surgery, for example), you may wear a single pair of gloves. On these occasions, use an abundance of caution and weigh the risk of sensitivity versus the risk of percutaneous injury associated with wearing only a single pair of gloves. I started out my career in the days before gloves were used as personal protective equipment. I remember picking up bloody sponges with my bare hands, and the first time I had to start an IV with a pair of gloves on. There was a learning curve, for sure, but the body can learn to accommodate for the loss of tactile sensitivity. Nurses are intuitive and creative. For our safety and our patients' safety, we made up our minds to wear gloves.
Science is on your side
There's overwhelming evidence that double gloving offers layers of protection against transmission of infection, sharps injuries and breaches of sterility. So there's really no valid excuse for not wearing 2 pairs of gloves during most every case to improve OR safety and sterility. Like a seatbelt, it seems like a good idea to double glove. Maybe "Double or Trouble" could do for OR safety what "Click It or Ticket" did for traffic safety.