Aug 06

Despite Benefits, Many Surgeons Still Not Double Gloving
by Julie E. Williamson

It’s been vastly proven that glove failure in the operating room represents a significant risk of exposure to bloodborne pathogens for surgical staff.

While gloves can be compromised during any procedure, the risks are particularly magnified in certain types of surgeries involving bone manipulation, such as orthopedics, where gloved hands may come in contact with sharp edges that can shear or otherwise break the barrier of the glove material. The duration of the procedure may also play a role in barrier compromise. In fact, some studies have found a correlation between increased glove puncture rates and procedures lasting more than three hours.

To help reduce the risks, a number of medical associations have begun recommending double gloving, that is, donning one glove over another to serve as an added layer of protection. The American College of Surgeons (ACS), for example, clearly states that, “Double gloving does help cut down by a factor of ten the number of potential exposures.” The ACS also points out that double gloving will protect the patient better from surgical wound contamination by decreasing the likelihood of sweat leaking from inside the surgeon’s gloved hands. Even the Association of Perioperative Registered Nurses (AORN) states that double gloving may be indicated for some procedures, in accordance with policies and procedures in the practice setting. The AORN also states that perioperative nurses should seriously consider using double gloves when assisting surgeons at the surgical field during orthopedic and other procedures where glove material shearing is likely and contact with sharp-edged items is anticipated.

Studies show benefits
Many studies, some of which date back to the late 80s, clearly support the recommendation to don an extra pair of gloves in surgery. One 1992 study, for example, reported a 51% hand contamination rate with single gloves versus a 7% contamination rate for those who double gloved. It has also been documented that double gloves, tested every 15 minutes, leaked 25% of the time, while single gloves leaked 59% of the time.

More recent studies show similar results. A Cochrane review of double gloving, published in The Cochrane Database of Systematic Reviews 2006, issue 2, revealed that donning two pairs of latex gloves significantly reduced the number of perforations to the innermost glove. This evidence came from trials undertaken in low risk surgical specialties (those that did not include orthopedic joint surgery).

“Wearing two pairs of latex gloves does not cause the glove wearer to sustain more perforations to their outermost glove,” the authors concluded, adding that wearing double latex indicator gloves enables the glove wearer to detect perforations to the outermost glove more easily than when wearing double latex gloves alone. Still, they pointed out that donning a double latex indicator system will neither assist with the detection of perforations to the innermost glove, nor reduce the number of perforations to the outermost or innermost glove.

The authors of the Cochrane review also determined that wearing a glove liner between two pairs of latex gloves for joint replacement surgery “significantly reduces the number of perforations to the innermost glove compared with double latex gloves only.”

Barriers to surgeon acceptance
Despite the widespread studies that highlight the effectiveness of double gloving, many surgeons fail to incorporate the practice. One study published in the 2003 American Journal of Surgery revealed that more than half of surgeons do not double glove. Even more surprising is that after the researchers presented clear evidence of the risks – and the risk reduction that comes with double gloving – only 23% of general surgeons said they would change their practice and double glove.
So what is behind surgeons’ reluctance to don two gloves? Most often, it’s the fear of decreasing comfort, manual dexterity and sensitivity – several very real and valid concerns, for any surgeon, that have also been substantiated by research. One study that examined sensitivity and dexterity of 25 surgeons with a mean age of 45 found that significant differences in hand sensation were apparent when comparing single and double gloves.

It appears that some practices may alleviate those concerns, however. Glove size, for example, may impact wearer comfort and dexterity, according to a survey of 59 general surgeons and 47 orthopedic surgeons. The survey showed that 67% of respondents who double-gloved used their normal size glove inside and a half-size larger glove outside as a way to improve comfort. Studies have shown that wearing a smaller glove outside the slightly larger one can also have its benefits. Findings have shown that surgeons who wore their gloves this way were not only more comfortable, they were also able to improve dexterity (including their ability to effectively tie surgical knots), despite the use of two gloves.

Surgeons who, in the past, have avoided double gloving may want to reevaluate now that glove manufacturers are offering a much wider range of choices – many of which are geared toward improving comfort, sensitivity and dexterity. Aside from offering powder-free and latex-free varieties that reduce risks for allergies and uncomfortable irritation, many of the leading vendors are also offering thinner, yet stronger gloves – some of which feature tiny raised nodules at the fingertips for heightened dexterity. Electronic monitoring devices and gloves with color-puncture indicators can be useful in determining whether a glove has been compromised. This is considered important because monitoring gloves visually or by feel can be ineffective.

Facilities and surgeons who view cost as the deterrent to double gloving may benefit by thinking beyond the simple expense of the gloves themselves. Many infection control experts, healthcare associations and researchers have stressed that the reduction of bloodborne pathogen exposure and possible seroconversion of practitioners represents a significant savings that more than compensates for the added glove costs.

Julie Williamson has been covering key issues in the medical equipment industry for OR Today for over six years. She can be reached for questions and/or comments by e-mail at info@mdpublishing.com.