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Challenges and Benefits of Double-Gloving in Surgery
By Deborah Davis, PhD
Ronald L. Nichols, MD, the William Henderson professor of surgery-emeritus and professor of microbiology and immunology at Tulane University School of Medicine in New Orleans has stated, Double-gloving should be routinely used in major surgery. His declaration is reinforced in the proposed Recommended Practices for Prevention of Transmissible Infections in the Perioperative Practice Setting, which includes a recommendation for healthcare practitioners to wear two pair of gloves, one over the other, during invasive procedures.1
At the April 2005 conference of the Association of PeriOperative Registered Nurses (AORN), 1,500 nurses were surveyed about double-gloving with surgical gloves. While 24 percent said they double glove in all cases, 26 percent said they double glove for only 10 percent of their surgical cases. Nearly half (47 percent) are very concerned about the need to double glove and 41 percent believe they should double glove for all of their cases.2
The first and best line of defense against infection is intact skin. According to the Occupational Health and Safety Administration (OSHA)s Bloodborne Pathogen Standard, gloves must be worn when there is reasonable likelihood of hand contact with blood or other potentially infectious material, mucous membranes, or nonintact skin when performing vascular access procedures and when handling contaminated items or surfaces.3 If used appropriately, medical-grade gloves and effective handwashing provide protection against bloodborne pathogens and infectious diseases, and reduce patient risk of nosocomial infection. Gloves alone do not guarantee two-way protection against infection. Additionally, the rigors of surgical procedures and potential contact with sharps can compromise protection.
Does double-gloving reduce the risk of exposure to bloodborne pathogens? There is much data supporting double-gloving, but there is a lack of acceptance from surgeons. The key issues are sensibility, comfort, and efficacy. A review of recent literature reveals 46 studies that evaluated the effectiveness of double-gloving in reducing the risk of skin contamination, especially in cases involving trauma or orthopedic procedures. Only five of these studies concluded that double-gloving had no impact on blood contact for surgeons. Twenty-one studies found that double- gloving helped prevent blood contact.
A prospective, randomized, controlled trial of single- and double-gloving methods in perineorrhaphy after vaginal delivery compared glove perforation between both methods. 4 In the double-gloving method, 1,316 individual gloves were examined and tested by immersing them in water. In the singlegloving method, 742 gloves were tested. The glove perforation rate was 5.2 percent. There was a significant reduction in the perforation rate of inner double gloves (2.7 percent) compared with single gloves (6.7 percent).
The perforation rate of the outer double gloves was 5.9 percent. The rate of matched outer and inner perforation was found in only 0.3 percent. The authors conclude that double-gloving significantly helps protect surgeons hands from blood exposure In another prospective study by Chiu, Fung, Lau, Ng, and Chow to determine the perforation rate of surgical gloves when double- gloving, techniques were employed in 120 hip fracture operations. One or more perforations occurred in 30 operations (25 percent).5 In 10 operations (8.3 percent), perforations of outer and inner gloves occurred at corresponding sites. Surgeons recognized the perforations on just five occasions. Of the 64 perforations, 41 (64 percent) occurred in the left (non-dominant) hands, and 42 (65.6 percent) occurred at the tips of thumbs and index fingers. Nearly half (46.9 percent) occurred at the thumb and index finger of left (non-dominant) hands. The authors recommend further protection of the thumb and index finger of the non-dominant hand of surgeons to reduce the perforation rate.
A randomized comparative trial was performed on 60 laparotomy procedures utilizing latex surgical gloves. Samples were divided into two groups. In the first group, surgeons were double-gloved and first assistants were single-gloved. In the second group, surgeons were single-gloved and first assistants were double-gloved. Operations of two hours or more were significantly associated with a higher incidence of glove perforation. Twelve (20.0 percent) outer gloves, three (5.0 percent) inner gloves and 15 (25.0 percent) single gloves were perforated. The double-glove contamination rate was significantly lower than the single-glove contamination rate. Perforation rates for double-gloved and single-gloved operating teams at Royal Newcastle Hospital in New South Wales, Australia, were compared to determine if double-gloving provides additional protection.6 Patients were randomized to undergo surgery with a double-gloved or single-gloved operating team. All gloves worn during the operation were tested for perforations by water-filling and digital distension. One hundred fifteen single-gloved operations and 103 double-gloved operations were performed. In the single-gloved group, 20.8 percent had perforations, but in the double-gloved group, only 2.5 percent had perforations in both inner and outer gloves (dual perforation). Of the surgical team, the surgeon was most at risk of glove perforation (34.7 percent of cases in the single-gloved group, 3.8 percent dual perforation in the double-gloved group). The authors concluded that double-gloving significantly reduces the risk of skin contamination by blood and body fluids and recommended it for all high-risk cases. Numerous studies have demonstrated that longer operations were associated with increased risk of glove perforation.7, 8, 9, 10, 11
Given that tactile sensitivity and dexterity are crucial in performing surgical procedures, several studies have assessed the impact of double-gloving on these factors. Novak, Patterson, and Mackinnon examined hand sensibility of surgeons wearing single and double gloves.12 Evaluation of hand sensibility was performed on 25 surgeons with a mean age of 45. The dominant-hand index finger was assessed with no glove, a single glove, and double gloves. The authors found significant differences in hand sensation when comparing single and double gloves.
The size of gloves worn when double-gloving may have an impact on comfort and dexterity. A survey of 59 general surgeons and 47 orthopedic surgeons indicated the majority of surgeons (67 percent) used their normal-size glove inside and a half-size-larger glove outside when double-gloving.13 These preferences appear to be region-specific.
A comparison of double-gloving vs. single-gloving was made with regard to the effects on tactile discrimination and dexterity in 17 surgeons of all grades and specialties. The ability to tie surgical knots and Dellons moving two-point discrimination test were assessed with single-gloves, double-gloves with larger gloves on the outside, and double- gloved with larger gloves on the inside. Double-gloving did not alter the ability to tie surgical knots or affect two-point discrimination. Wearing the smaller glove outside of the larger glove was considered more comfortable than the conventional technique.14
According to Berguer and Heller, surgeons who always or usually double glove report a period of up to 120 days (2 days in most cases) is required to adapt to double-gloving and surgeons who routinely double glove report decreased hand sensation much less frequently than those who do not.15
This limited review suggests benefits of double-gloving, especially where the patient is known or thought to be infected with a transmissible virus and for procedures longer than two hours. Things to consider when evaluating double-gloving include:
Skin Health and Surgical Hand Antisepsis
Frequent surgical scrubbing and skin occlusion from extensive glove use is hard on the hands. Repeated use of scrubs and handwashing products is a key contributor to contact dermatitis. Common irritants include iodophors, chlorhexidine, PCMX, triclosan, and alcohol-based products. The ramifications of chronic dry skin and dermatitis go beyond personal discomfort and into the issue of personal health and safety. Cracks and fissures in the skin of dry, dermatic hands increase occupational exposure of healthcare personnel to bloodborne viruses, such as hepatitis C and HIV.16
Dry, irritated skin is more difficult to disinfect than healthy skin,17 and is more likely to be colonized with non-resident pathogenic bacteria that are responsible for most healthcare- associated infections (HAIs).18, 19 Studies published in the American Journal of Infection Control demonstrated that with skin trauma there is increased shedding of damaged skin cells. Also, chronic dermatitis is associated with heavier colonization of bacteria, yeast, staphylococci, and other potential pathogens and outbreaks of HAIs.20 In addition, the flaking associated with dry, irritated skin increases the risk of transmitting an infection due to the larger numbers of microorganisms shed into the environment with the skin flakes.21 As a result, skin emollients and barrier creams are receiving new attention.22 The 2004 AORN Recommended Practices for Surgical Hand Antisepsis/Hand Scrubs include choosing appropriate skin moisturizing products to prevent dermatitis and reduce bacterial shedding from the skin.23 To protect their skin, some physicians coat their hands with petroleum jelly or sterile mineral oil, which can degrade natural rubber latex gloves. The Guidelines for Hand Hygiene in Healthcare Settings published by the Centers for Disease Control and Prevention (CDC) recommend that healthcare workers be provided with hand lotions or creams to reduce the occurrence of irritant contact dermatitis and the associated increased risk of HAI transmission.24
Cardinal Health sponsored a blind study utilizing self-administered questionnaires at the 90th annual Clinical Congress of the American College of Surgeons in 2004.25 Participants were screened to guarantee they were actively practicing surgeons or surgical assistants, working in the United States. The 138 participants were asked how they treat their hands and how often they experience dry skin, irritation, or contact dermatitis. They were also asked how their skin reacted to conditions such as open sores or cracked and peeling skin, their beliefs about the causes of these conditions and how they treat them. The majority of respondents indicated they have experienced dry skin (84 percent) and irritation/sensitivity (74 percent), and only 18 percent reported never having any skin problems.
The surgeons generally used over-the-counter creams or lotions to treat their skin problems. The CDC guideline emphasizes the use of products that replace or maintain skin hydration. Specifically, the guideline states that employers should provide personnel with efficacious hand-hygiene products that have low irritancy potential, particularly when the products are used multiple times per shift.26 Moisturizing with effective, clinically-appropriate products helps prevent dehydration, damage to barrier properties, excessive desquamation and loss of skin lipids, as well as restore the water-holding capacity of the skins keratin layer. Several controlled trials demonstrated that regular use of hand lotions or creams helps prevent and treat irritant contact dermatitis.27
A challenge in healthcare is to maximize the antimicrobial value of hand antisepsis practices while minimizing changes to skin health or microflora.28 Frequent and prolonged use of water, a scrub brush, or sponge and the surfactants in antiseptic soaps and detergents contribute to deterioration of the hands skin condition.29 Further, the occlusive quality that makes medical gloves such an effective barrier against pathogens potentially increases the risk of developing dermatitis. Because glove materials do not permit the evaporation of skin moisture, they can alter the stratum corneum, resulting in a reduction of protective barrier properties. Additionally, water under occlusion can disrupt the skins barrier lipids and damage the stratum corneum similar to the mechanism of surfactants.30, 31
A consistent, effective hand-care regimen maintains skin integrity as a first line of defense against the spread of bloodborne pathogens and other potentially infectious microorganisms. Gloves and skin-care products containing various additives provide vastly different skin benefits, depending on the amount and type of ingredient selected and the product formulation. It is key when assessing these products to examine test data that specifically demonstrates the products benefits. Gloves containing these additives should be considered for use as an under-glove when double-gloving.
Deborah Davis, PhD, is technical and clinical marketing director for Cardinal Healths Gloves business. Her primary responsibilities include driving clinical research initiatives, coordinating various aspects of product development among the marketing, regulatory, manufacturing, and research and development organizations. Davis is widely published and presents technical information for clinician customers and Cardinal Health sales personnel throughout the U.S. and internationally.
1. Hospital Materials Management. May 2005.
2. Occupational Safety and Health Administration. Occupational Exposure to Bloodborne Pathogens, Final Rule. Federal Register 29 CFR Part 1910; 1030; 56(235): 64004-64182. Dec 6, 1991.
3. Kovavisarach E; Jaravechson S. Comparison of perforation between single and double gloving in perineorrhaphy after vaginal delivery: a randomized controlled trial. Aust N Z J Obstet Gynacol, Feb 1998, 38(1), 58-60.
4. Chiu KY; Fung B; Lau SK; Ng KH; Chow SP. The use of double latex gloves during hip fracture operations. J Orthop Trauma, 1993, 7(4), 354-6.
5. Gani JS; Anseline PF; Bissett RL. Efficacy of double versus single gloving in protecting the operating team. Aust NZ J Surg, Mar 1990, 60(3), 171-5.
6. Gerberding, JL, Little, C, Tarkington, A, Risk of exposure of surgical personnel to patients' blood during surgery at San Francisco General Hospital. N Engl J Med, 1990; 322:1788-1793.
7. Quebbeman, EJ, Telford, GL, Hubbard, S, et al. Risk of blood contamination and injury to operating room personnel. Ann Surg 1991; 214:614-620.
8. Panlilio, AL, Foy, DR, Edwards, JR, et al. Blood contacts during surgical procedures. JAMA 1991; 265:1533-1537.
9. Popejoy, SL, Fry, DE, Blood contact and exposure in the operating room. Surg Gynecol Obstet 1991; 172:480-483.
10. White, MC, Lynch, P. Blood contact and exposures among operating room personnel: a multicenter study. Am J Infect Control 1993; 21: 243-248.
11. Novak CB; Patterson JM; Mackinnon SE. Evaluation of Hand Sensibility with Single and Double Latex Gloves. Plast Reconstr Surg, Jan 1999, 103(1), 128-31.
12. Keeling NJ; Ataullah CM; Wastell C. A survey of glove preferences of general and orthopaedic surgeons in North West Thames Regional Health Authority. J Hosp Infect Aug 1995, 30(4), 305 8.
13. Webb JM; Pentlow BD. Double gloving and surgical technique. Ann R Coll Surg Engl; Jul 1993, 75(4), 291 2.
14. Patterson, JM, Novak, CB, Mackinnon, SE, Patterson, GA, as cited in Berguer, R. and Heller, P., Preventing Sharps Injuries in the Operating Room, J Am Coll Surg,Vol 199, No. 3, September, 2004.
15. "NIOSH and Project NORA", Latex Allergy News, 1996, 11(5):1084-1121.
16. Ojajarvi J. Evaluation on hand washing and disinfection methods used in hospital wards. Academic Dissertation, Helsinki, 1981.
17. Larson,EL, Hughes CA, Pyrek JD, Sparks SM, Cagatay EU, Bartkus JM. Changes in bacterial flora associated with skin damage on hands of health care personnel. Am J Infection Control, 1998; 26: 513-521.
18. Falk, PS. Infection control and the employee health service. In: Mayhall CG, editor. Hospital epidemiology and infection control, 2nd edn. Philadelphia: Lippincott, Williams & Wilkins 1999;p.1381-86.
19. v Ibid.
20. Meers PD. The shedding of bacteria and skin squames after handwashing. In: Newsom SWB, Caldwell ADS, editors. Problems in the control of hospital infection. London: Royal Society of Medicine, 1980. p. 13-8.
21. Larson E. Skin hygiene and infection prevention: more of the same or different approaches? Clin Inf Dis 1999;29:1287-94.
22. Recommended Practices for Surgical Hand Antisepsis/Hand Scrubs. AORN Journal 79 (February 2004), 416-431.
23. Boyce, J.M., Pittet, D., Guideline for hand hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infection Control and Hospital Epidemiology, 2002; 23 (12) Suppl.
24. ACS 2004 Surgical Gloves Customer Satisfaction Study, Final Report. On file at Cardinal Health, McGaw Park, Illinois.
26. Grove, G.L., et al, "Methods for Evaluating Changes in Skin Condition Due to the Effects of Antimicrobial Hand Cleansers: Two Studies Comparing a New Waterless Chlorhexidine Gluconate/Ethanol Emollient Antiseptic Preparation with a Conventional Water-Applied Product", Am J Inf Con, 2001, Vol.29, No. 6, 361-369.
27. Larson, E., Silberger , M., Jakob, J., et al, Assessment of alternative hand hygiene regimens to improve skin health among neonatal intensive care unit nurses. Heart Lung. 2000; 29:136-142.
28. Larson, E., Aeillo, A., Heilman, J., et al. Comparison of Different Regimens for Surgical Hand Preparation. AORN Journal, 2001:Vol. 73, No. 2, 412-432.
29. Davis, D., Gloving and Skin Wellness: Resolving the Paradox. Managing Infection Control, 2003:Vol. 3, No. 11, 29-36.
30. Holness, D.L., Tarlo, S.M., Sussman, G., Nethercott, J.R., Exposure characteristics and cutaneous problems in operating room staff. Contact Dermatitis, 1995, 32:352-358.