Infection Control Today - Does Double Gloving Double the Protection?

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.

Theissues surrounding personal protective equipment have never been more hotlycontested than they are today. It is no surprise given the abundance of thornyclinical issues such as antimicrobial resistance, surgical site infection rates,and pathogen spread in the critical care environment. When you factor in issuessuch as the quality and cost of the multitude of barriers today with financialramifications such as the Balanced Budget Act, the pot really starts to boil. Infact, 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 needlesversus blunt suture needles, and sharp versus blunt towel clips among others.

The Occupational Safety and Health Administration's (OSHA) revised compliancedirective (CPL2-2.44L) for bloodborne pathogen standards was released onNovember 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 theprimary means of eliminating or minimizing employee exposure to bloodbornepathogens."¹ As it so often happens when issues such as thesesurface, regulations requiring healthcare employers to provide safe devices arebeing considered by Congress and 20 states.²

Perceived Risk

Perceived risk is an issue that begs to be addressed when talking aboutpersonal protective equipment. A recent study, focused on emergency servicespersonnel, surveyed a mix of physicians, physician assistants, nurses, andtechnicians and had 64% responding. Despite the unique circumstances ofemergency care where a patient's serology status is known rarely at the timecare is delivered, 38% of those responding believed their lifetime occupationalrisk of HIV infection to be "insignificant," 23% had not employed newsafety measures in their practice, and of the recalled hollow-bore needlesticks,only 17% were reported to employee health. Only half (55%) said they would seekpost-exposure prophylaxis.³ In a study reported in the Annals ofSurgery of 768 surgeons surveyed from two universities and surgicalsocieties, 88% admitted to slight or moderate concern over the possibility ofseroconversion after exposure to bloodborne pathogens. Surgeons who had been inpractice less than seven years were more likely to have been vaccinated againsthepatitis 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 healthcareprofessional? Many believe that it is. Healthcare professionals need to see andunderstand their risks clearly, whether it is the emergent nature of patientcare, prolonged contact with a patient's blood, antimicrobial resistance, traumacare, or others too numerous to mention. In reality, a healthcare worker's riskof bloodborne pathogen transmission can be significant.

As familiar as we are with the risk of needlestick injuries, it is importantto note that OSHA, in their revised compliance directive, defines occupationalexposure as "reasonably anticipated skin, eye, mucous membrane, orparenteral contact (to include human bites that break the skin) with blood orother potentially infectious materials that may result from the performance ofan employee's duties."

The most common personal protective equipment, or barrier, used today inhealthcare is gloves. Historically, gloves were introduced to protect thehealthcare worker. Dr. William Halstead first introduced the surgical use ofgloves to protect his nurse's hands from the caustic chemicals encountered inthe surgical environment. There was no consideration, at that time, as to gloveperformance or infection rates. Instead, gloves simply became incorporated as a"standard surgical practice" in the operating room and became a commonsurgical barrier.⁵ Before long, surgeons recognized that glovesdecreased the rate of postoperative infections by protecting patients from thetransmission of pathogens from the surgical team.

With the institution of Universal Precautions in the late 1980s, examinationglove use escalated and became the most common barrier outside the surgicalarena. The evolution of pathogens, including HIV, HBV, and HCV as well as theemerging issues of antimicrobial resistance, have led healthcare professionalsto demand that their barriers perform effectively, for both their patients aswell as themselves. This risk has helped contribute to the efforts ofmanufacturers to provide quality barrier products with good performancecharacteristics.

Glove Barrier Compromise

Much of the research on surgical gloves has focused on holes created duringsurgery. One report cites a puncture rate of 11.5% after use during surgery.⁶Other studies point to increased puncture rates in gloves worn longer than threehours.⁷ It is no surprise to perioperative professionals that therisk for puncture increases with the duration of the procedure as well as itscomplexity. 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 AnAssociation of peri-Operative Registered Nurses (AORN) study, using trainedcirculating 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%, occurredin the surgical field, and 93% of the injuries occurred to the hands with theleft hand predominating.⁹

Of significance is the lack of identification of barrier breach at the timeof the incident. Often impaired barrier integrity is not known until the closeof the case when gloves are removed and direct contamination of the hand withblood is noted. One study states unnoticed punctures are reported as occurringas much as 12% to 17% of the time.^10-11 In both of the aforementionedstudies, the recommendation was made for the surgeon to change gloves every hourto avoid contamination with patient fluids. A study reported in PlasticReconstructive Surgery documented 67 unnoticed perforations in which thesurgical team had an exposure. The study concluded that one "must balancethe improved security of double gloving with possible discomfort or reducedsensitivity."¹²

Other factors that can affect the quality of the glove barrier includechemicals encountered in the clinical environment, stress applied to the glove,and specialized surgical equipment that may cause holes. Of particular note isthe effect of uncured methyl methacrylate (MMA), bone cement, on gloves. In onestudy, uncured MMA was found to penetrate the glove within 1-2.5 minutes. Somereports 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 ofpotential exposures." In addition, they acknowledge that double glovingwill protect the patient better from surgical wound contamination by decreasingthe likelihood of sweat spilling from inside the surgeon's gloved hands. Infact, they state that a "distant second option" is changing surgicalgloves at least every two hours.¹⁴ AORN recommends, "Wearing twopairs of gloves (double gloving) may be indicated for some procedures inaccordance 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 glovingand other possible alternatives. Quebbeman has published a number of studies onexposure in the surgical environment and all recommend the practice of doublegloving. His 1992 study reported a 51% hand contamination rate of those whosingle gloved versus a 7% contamination rate for those who double gloved.¹⁶Korniewicz and Rabussay in their studies have stressed the high in-use failurerates of gloves.⁵ Albin reports that surgical gloves worn indouble-glove fashion, tested every 15 minutes, had leaks 25% of the time whilethose worn singly had leaks 59% of the time.¹⁷ Chapman and Duffreported data on double gloving in obstetric surgical procedures. Of 67 sets ofdouble gloves studied, 66 holes were found in the outer gloves and seven holesin the inner glove. Their summary found that the difference in the frequency ofinjury of inner and outer gloves to be highly significant. Their recommendationsincluded routine double gloving to decrease the potential for patient fluidcontact.¹⁸ In Infection Control and Hospital Epidemiology,Tokars found that hand contact with patient fluids were 72% lower for thosesurgeons who double gloved.¹⁹ A study by Greco and Garza supports thedata stating that perioperative personnel's risk decreased by 70% in comparisonwith single glove use.²⁰ In the European Journal of CardiothoracicSurgery, Hollaus, et. al. concluded, "The perforation rate of78% lies in the highest range of reported perforation rates in differentsurgical specialties. Double gloving effectively prevented cutaneous bloodexposure and thus should become a routine for the thoracic surgeon to preventtransmission of infectious diseases from the patient to the surgeon."²¹In summary, the research data supports the practice of double gloving.

The use of methyl methacrylate and its effect on latex gloves was discussedearlier. One surgical glove manufacturer has measured breakthrough times withtheir latex glove and uncured methyl methacrylate. The study was performed onboth their single and double standard surgical gloves. A breakthrough time fortheir 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 abreakthrough time on their single glove of 3.0 minutes and their double glove of13.0 minutes. In both cases, double gloving exponentially increased breakthroughtimes and hence, an exponential increase in protection for the perioperativepractitioner.²²

Change Is Always Challenging

It is well acknowledged throughout the perioperative professions that one ofthe devices that is most challenging to change is a surgical glove. It isdifficult for so many reasons, not the least of which include the wearer'sperceptions about his or her gloves. From the studies mentioned previously, itis also essential for wearers to understand their true risk of exposure and theprobability of post-exposure seroconversion. When first using double gloves, itis crucial that the practitioner be prepared to persist through an evaluationperiod, trying different glove combinations to find the best fit for dexterityand tactile sensitivity. One survey found that surgeons took from 1 to 120 daysto adapt to double gloving.²³

Perhaps the most challenging issue when a practitioner begins double glovingis the anticipated or perceived change in tactile sensitivity. Quebbeman's studyfound 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 Annalsof the Royal College of Surgeons, Webb and Pentlow compared double glovingand single gloving and the effects on tactile discrimination and dexterity. Thedouble-glove testing was performed when the larger glove was worn on the insideas well as when the larger glove was worn on the outside. Surgeons were assessedfor their ability to tie surgical knots and with Dellon's moving two-pointdiscrimination test. Findings showed no alteration in two-point discriminationor the ability to tie surgical knots. In addition, the consensus found thatwearing the larger glove on the outside, rather than the tradition of the largerglove inside, was more comfortable.²⁴ Another study, mentionedpreviously, found almost an equal distribution: larger glove inside 31%, smallerglove inside 35%, and both gloves the same size 31%.²¹ The studyreads: Given a comfortable size combination, it is likely that during theaccommodation period, cortical retraining will occur. The somato-sensory cortexwill undergo cortical remapping when challenged with new sensory stimuli.Therefore, the perception of decreased sensation, experienced by the surgeonwhen first using double gloves, will likely be minimized and overcome withsensory cortical remapping...The surgeon who is just beginning to use doublegloves should try various combinations; when a comfortable fit is found,perceived hand sensibility will likely improve with increased experience usingdouble 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 performanceof orthopaedic surgical gloves to double gloving. By virtue of the greaterthickness of orthopaedic gloves, they had a greater resistance to glove puncturethan the standard surgical gloves. The double-glove systems had similarcharacteristics to many of the orthopaedic gloves. However, "their[double-glove] performance in the glove hydration tests and the force requiredto don the double-glove systems were much more desirable than any of theorthopaedic gloves. The results of this study indicate that the double-glovesystems may provide a desirable alternative to the use of single orthopaedicgloves."²⁵ In addition, one glove cannot offer the sameprotection as a double glove once the single barrier is breached. Many of thestudies mentioned above found that many of the outer glove holes did notcorrelate with a hole on the inner glove.

Detection Devices

While double gloving offers significantly more protection to the wearer, oneissue remains. The failure of a surgical glove often goes unrecognized. The costand consequences of undetected barrier breach are significant. For that reason,some form of barrier breach detection was recommended.²⁶ Today theintegrity of a surgical glove in use is monitored most effectively by wearingglove pairs with color-puncture indicators or by using electronic monitoringdevices.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 ofperforation.^28-29 One study found that there were "fewerunnoticed perforations in the glove perforation indication group than thestandard surgical glove (19% compared with 79%, P < 0.0001).³⁰

Carolyn Twomey, RN, BSN, is a Clinical Nurse Consultant for Regent Medical(Norcross, Ga).

When Double-Gloving Is Not Enough
By Leni Reiss

To double-glove or not to double-glove? Or, in fact, is double-glovingsufficient? In this present climate of legitimate concerns for the well being ofhealthcare providers, the issue of personal protective equipment is a criticalone. And, the surgical use of protective gloves is important to both patient andphysician. 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 isprotection from punctures, and double-gloving does not perform that need nordoes it guarantee protection from blood against the skin." While offeringprotection from cuts, open-weave glove liners do not provide punctureprotection. Puncture-resistant gloves can help address this concern. Thepuncture resistant gloves available from Gimbel Glove feature a specialmulti-layered polymer pad attached to the thumbs and fingertips during itsmanufacture, allowing physicians the dexterity and sensitivity to performsurgery. Additionally, when another glove is worn over the puncture resistantglove and the outer one is contaminated, it can be replaced with minimal expensewhile still having the benefit and security of puncture protection anddouble-gloving.

The operating room is not the only environment where healthcare providers areat risk. Hospital waste collectors face similar threats to their well beingunder significantly less controlled circumstances. When this environmentrequires sterile gloves, Gimbel Glove offers a heavy-duty semi-reusable punctureresistant glove.

The healthcare community is under constant pressure to provide qualityhealthcare at reasonable costs. At the same time, it is dedicated to the use ofthose tools necessary to protect both healthcare worker and patient by the useof the most modern technology. The glove industry shares these goals, and recentstrides will go a long way to attaining them. Whether it be through the use ofsingle or double gloving with standard surgical gloves, premium gloves designedfor comfort and performance, or super premium gloves designed for performance,comfort, and extra protection, provider and patient alike can be assured ofadditional safety and security in the surgical arena.