Does Double Gloving Double the Protection?
A Look at the Issues
By Carolyn Twomey, RN, BSN
This article addresses:
* Perceived risks for healthcare workers.
* Recent research conducted on double gloving.
The issues surrounding personal protective equipment have never been more hotly contested than they are today. It is no surprise given the abundance of thorny clinical issues such as antimicrobial resistance, surgical site infection rates, and pathogen spread in the critical care environment. When you factor in issues such as the quality and cost of the multitude of barriers today with financial ramifications such as the Balanced Budget Act, the pot really starts to boil. In fact, as regulators and lawmakers have entered the fray over "safe-needle" devices, other hazardous devices are being addressed. These include scalpels with a blade-shielding feature, sharp suture needles versus blunt suture needles, and sharp versus blunt towel clips among others.
The Occupational Safety and Health Administration's (OSHA) revised compliance directive (CPL2-2.44L) for bloodborne pathogen standards was released on November 5, 1999. The term used to group these "safe" devices is "engineering controls." In this directive, employers are "required to institute engineering and work practice controls as the primary means of eliminating or minimizing employee exposure to bloodborne pathogens."1 As it so often happens when issues such as these surface, regulations requiring healthcare employers to provide safe devices are being considered by Congress and 20 states.2
Perceived risk is an issue that begs to be addressed when talking about personal protective equipment. A recent study, focused on emergency services personnel, surveyed a mix of physicians, physician assistants, nurses, and technicians and had 64% responding. Despite the unique circumstances of emergency care where a patient's serology status is known rarely at the time care is delivered, 38% of those responding believed their lifetime occupational risk of HIV infection to be "insignificant," 23% had not employed new safety measures in their practice, and of the recalled hollow-bore needlesticks, only 17% were reported to employee health. Only half (55%) said they would seek post-exposure prophylaxis.3 In a study reported in the Annals of Surgery of 768 surgeons surveyed from two universities and surgical societies, 88% admitted to slight or moderate concern over the possibility of seroconversion after exposure to bloodborne pathogens. Surgeons who had been in practice less than seven years were more likely to have been vaccinated against hepatitis B. When the same surgeons were surveyed about seroconversion rates, the following data listed in Table 1 was obtained.
Is this a true reflection of a cross-section of today's healthcare professional? Many believe that it is. Healthcare professionals need to see and understand their risks clearly, whether it is the emergent nature of patient care, prolonged contact with a patient's blood, antimicrobial resistance, trauma care, or others too numerous to mention. In reality, a healthcare worker's risk of bloodborne pathogen transmission can be significant.
As familiar as we are with the risk of needlestick injuries, it is important to note that OSHA, in their revised compliance directive, defines occupational exposure as "reasonably anticipated skin, eye, mucous membrane, or parenteral contact (to include human bites that break the skin) with blood or other potentially infectious materials that may result from the performance of an employee's duties."
The most common personal protective equipment, or barrier, used today in healthcare is gloves. Historically, gloves were introduced to protect the healthcare worker. Dr. William Halstead first introduced the surgical use of gloves to protect his nurse's hands from the caustic chemicals encountered in the surgical environment. There was no consideration, at that time, as to glove performance or infection rates. Instead, gloves simply became incorporated as a "standard surgical practice" in the operating room and became a common surgical barrier.5 Before long, surgeons recognized that gloves decreased the rate of postoperative infections by protecting patients from the transmission of pathogens from the surgical team.
With the institution of Universal Precautions in the late 1980s, examination glove use escalated and became the most common barrier outside the surgical arena. The evolution of pathogens, including HIV, HBV, and HCV as well as the emerging issues of antimicrobial resistance, have led healthcare professionals to demand that their barriers perform effectively, for both their patients as well as themselves. This risk has helped contribute to the efforts of manufacturers to provide quality barrier products with good performance characteristics.
Glove Barrier Compromise
Much of the research on surgical gloves has focused on holes created during surgery. One report cites a puncture rate of 11.5% after use during surgery.6 Other studies point to increased puncture rates in gloves worn longer than three hours.7 It is no surprise to perioperative professionals that the risk for puncture increases with the duration of the procedure as well as its complexity. One study found the relative risk of perforation for surgeons to be (0.31), for assistants (0.21), and for scrub nurses (0.17).8 An Association of peri-Operative Registered Nurses (AORN) study, using trained circulating nurses to record exposures, resulted in the following findings: 55.1% of exposures, both percutaneous and mucotaneous, occurred with surgeons; scrub persons ranked 19.1%. The highest proportion of injuries, 33.4%, occurred in the surgical field, and 93% of the injuries occurred to the hands with the left hand predominating.9
Of significance is the lack of identification of barrier breach at the time of the incident. Often impaired barrier integrity is not known until the close of the case when gloves are removed and direct contamination of the hand with blood is noted. One study states unnoticed punctures are reported as occurring as much as 12% to 17% of the time.10-11 In both of the aforementioned studies, the recommendation was made for the surgeon to change gloves every hour to avoid contamination with patient fluids. A study reported in Plastic Reconstructive Surgery documented 67 unnoticed perforations in which the surgical team had an exposure. The study concluded that one "must balance the improved security of double gloving with possible discomfort or reduced sensitivity."12
Other factors that can affect the quality of the glove barrier include chemicals encountered in the clinical environment, stress applied to the glove, and specialized surgical equipment that may cause holes. Of particular note is the effect of uncured methyl methacrylate (MMA), bone cement, on gloves. In one study, uncured MMA was found to penetrate the glove within 1-2.5 minutes. Some reports describe actual dissolving of or damage to the glove.13
To Double Glove or Not to Double Glove
That is the question. The American College of Surgeons states, "Double gloving does help to cut down by a factor of 10 the number of potential exposures." In addition, they acknowledge that double gloving will protect the patient better from surgical wound contamination by decreasing the likelihood of sweat spilling from inside the surgeon's gloved hands. In fact, they state that a "distant second option" is changing surgical gloves at least every two hours.14 AORN recommends, "Wearing two pairs of gloves (double gloving) may be indicated for some procedures in accordance with policies and procedures in the practice setting."15
What Does Research Show?
A number of studies were designed to look at the efficacy of double gloving and other possible alternatives. Quebbeman has published a number of studies on exposure in the surgical environment and all recommend the practice of double gloving. His 1992 study reported a 51% hand contamination rate of those who single gloved versus a 7% contamination rate for those who double gloved.16 Korniewicz and Rabussay in their studies have stressed the high in-use failure rates of gloves.5 Albin reports that surgical gloves worn in double-glove fashion, tested every 15 minutes, had leaks 25% of the time while those worn singly had leaks 59% of the time.17 Chapman and Duff reported data on double gloving in obstetric surgical procedures. Of 67 sets of double gloves studied, 66 holes were found in the outer gloves and seven holes in the inner glove. Their summary found that the difference in the frequency of injury of inner and outer gloves to be highly significant. Their recommendations included routine double gloving to decrease the potential for patient fluid contact.18 In Infection Control and Hospital Epidemiology, Tokars found that hand contact with patient fluids were 72% lower for those surgeons who double gloved.19 A study by Greco and Garza supports the data stating that perioperative personnel's risk decreased by 70% in comparison with single glove use.20 In the European Journal of Cardiothoracic Surgery, Hollaus, et. al. concluded, "The perforation rate of 78% lies in the highest range of reported perforation rates in different surgical specialties. Double gloving effectively prevented cutaneous blood exposure and thus should become a routine for the thoracic surgeon to prevent transmission of infectious diseases from the patient to the surgeon."21 In summary, the research data supports the practice of double gloving.
The use of methyl methacrylate and its effect on latex gloves was discussed earlier. One surgical glove manufacturer has measured breakthrough times with their latex glove and uncured methyl methacrylate. The study was performed on both their single and double standard surgical gloves. A breakthrough time for their single glove was 1.5 minutes and for their double glove was 9.0 minutes. They also performed the same test on their orthopaedic gloves resulting in a breakthrough time on their single glove of 3.0 minutes and their double glove of 13.0 minutes. In both cases, double gloving exponentially increased breakthrough times and hence, an exponential increase in protection for the perioperative practitioner.22
Change Is Always Challenging
It is well acknowledged throughout the perioperative professions that one of the devices that is most challenging to change is a surgical glove. It is difficult for so many reasons, not the least of which include the wearer's perceptions about his or her gloves. From the studies mentioned previously, it is also essential for wearers to understand their true risk of exposure and the probability of post-exposure seroconversion. When first using double gloves, it is crucial that the practitioner be prepared to persist through an evaluation period, trying different glove combinations to find the best fit for dexterity and tactile sensitivity. One survey found that surgeons took from 1 to 120 days to adapt to double gloving.23
Perhaps the most challenging issue when a practitioner begins double gloving is the anticipated or perceived change in tactile sensitivity. Quebbeman's study found an 88% acceptance rate in the group that wore double gloves. Of those, 88% did not perceive any decrease in tactile sensitivity.16 In the Annals of the Royal College of Surgeons, Webb and Pentlow compared double gloving and single gloving and the effects on tactile discrimination and dexterity. The double-glove testing was performed when the larger glove was worn on the inside as well as when the larger glove was worn on the outside. Surgeons were assessed for their ability to tie surgical knots and with Dellon's moving two-point discrimination test. Findings showed no alteration in two-point discrimination or the ability to tie surgical knots. In addition, the consensus found that wearing the larger glove on the outside, rather than the tradition of the larger glove inside, was more comfortable.24 Another study, mentioned previously, found almost an equal distribution: larger glove inside 31%, smaller glove inside 35%, and both gloves the same size 31%.21 The study reads: Given a comfortable size combination, it is likely that during the accommodation period, cortical retraining will occur. The somato-sensory cortex will undergo cortical remapping when challenged with new sensory stimuli. Therefore, the perception of decreased sensation, experienced by the surgeon when first using double gloves, will likely be minimized and overcome with sensory cortical remapping...The surgeon who is just beginning to use double gloves should try various combinations; when a comfortable fit is found, perceived hand sensibility will likely improve with increased experience using double gloves.21
Clearly, it will take patience and time to accept a new glove format.
Why not wear one thicker glove? Certainly the question should be considered. One study from the University of Virginia compared the biomechanical performance of orthopaedic surgical gloves to double gloving. By virtue of the greater thickness of orthopaedic gloves, they had a greater resistance to glove puncture than the standard surgical gloves. The double-glove systems had similar characteristics to many of the orthopaedic gloves. However, "their [double-glove] performance in the glove hydration tests and the force required to don the double-glove systems were much more desirable than any of the orthopaedic gloves. The results of this study indicate that the double-glove systems may provide a desirable alternative to the use of single orthopaedic gloves."25 In addition, one glove cannot offer the same protection as a double glove once the single barrier is breached. Many of the studies mentioned above found that many of the outer glove holes did not correlate with a hole on the inner glove.
While double gloving offers significantly more protection to the wearer, one issue remains. The failure of a surgical glove often goes unrecognized. The cost and consequences of undetected barrier breach are significant. For that reason, some form of barrier breach detection was recommended.26 Today the integrity of a surgical glove in use is monitored most effectively by wearing glove pairs with color-puncture indicators or by using electronic monitoring devices.27 Glove integrity can be monitored visually or by feel; however, these are the least effective because of human error.
Color-puncture indicators significantly increase the awareness of perforation.28-29 One study found that there were "fewer unnoticed perforations in the glove perforation indication group than the standard surgical glove (19% compared with 79%, P < 0.0001).30
Carolyn Twomey, RN, BSN, is a Clinical Nurse Consultant for Regent Medical (Norcross, Ga).
For a list of references, click here.
When Double-Gloving Is Not Enough
By Leni Reiss
To double-glove or not to double-glove? Or, in fact, is double-gloving sufficient? In this present climate of legitimate concerns for the well being of healthcare providers, the issue of personal protective equipment is a critical one. And, the surgical use of protective gloves is important to both patient and physician. Neil Gimbel, an orthopedic surgeon in Phoenix, Ariz, comments, "Double-gloving typically provides protection from tears and, as such, serves a definite purpose." But he says, "The next level of concern is protection from punctures, and double-gloving does not perform that need nor does it guarantee protection from blood against the skin." While offering protection from cuts, open-weave glove liners do not provide puncture protection. Puncture-resistant gloves can help address this concern. The puncture resistant gloves available from Gimbel Glove feature a special multi-layered polymer pad attached to the thumbs and fingertips during its manufacture, allowing physicians the dexterity and sensitivity to perform surgery. Additionally, when another glove is worn over the puncture resistant glove and the outer one is contaminated, it can be replaced with minimal expense while still having the benefit and security of puncture protection and double-gloving.
The operating room is not the only environment where healthcare providers are at risk. Hospital waste collectors face similar threats to their well being under significantly less controlled circumstances. When this environment requires sterile gloves, Gimbel Glove offers a heavy-duty semi-reusable puncture resistant glove.
The healthcare community is under constant pressure to provide quality
healthcare at reasonable costs. At the same time, it is dedicated to the use of
those tools necessary to protect both healthcare worker and patient by the use
of the most modern technology. The glove industry shares these goals, and recent
strides will go a long way to attaining them. Whether it be through the use of
single or double gloving with standard surgical gloves, premium gloves designed
for comfort and performance, or super premium gloves designed for performance,
comfort, and extra protection, provider and patient alike can be assured of
additional safety and security in the surgical arena.
For a complete list of references click here