Double gloving for complete protection
In discussion with surgeons and other O.R. staff, such as surgical nurses, safety for their patients and for themselves is a key concern.
`I always double-glove, and have from the very beginning. It's never been a challenge to work this way.´
David Revez, Neurosurgeon
When asked about double gloving as a safety practice, no matter the type of surgery, there are mixed reactions. While all surgeons will exclaim, 'My hands are my everything!', 'My hands are an extension of all my years of training' or 'After my brain, my hands are the most important part of my body. Without my hands, I cannot do anything', the resistance to double gloving still exists among some surgeons, while others refuse to operate without using double gloves.
Any contact with blood introduces risk in the form of blood borne illnesses, such as hepatitis and HIV, which is why the use of surgical gloves was universally adopted in the first place. But knowing that glove punctures happen frequently (up to 45 percent in some types of surgery) 1 and can easily go undetected (up to 92 percent of the time) 2, double gloving has been recommended as an extra layer of protection in all surgical procedures – not only high-risk cases 3. Double gloving is proven to reduce the risk of spreading blood borne illnesses 4 , lessening the risk of exposure for both patient and surgeon to dangerous and costly cross-contamination and infection. The Cochrane Review 2014 states that using double gloves reduces the risk of blood contamination by 65 percent and reduces the risk of an inner-glove perforation by 71 percent, compared to single gloves 4.
Protecting human investment
Why is this extra layer of safety important, and where does the resistance come from? Apart from the peace of mind and proven protection to staff and patient health that double gloving provides, double gloving is also a protective measure in other ways. For example, for a hospital, double-gloving practice and policy is a form of protecting its investment. How?
First and foremost, a surgeon's hands and training are his/her livelihood, and by extension, the "life blood" of the hospital. The training and work s/he has done at a hospital has a value. The same applies for the entire surgical staff. From a health economics perspective, double gloving protects hospital staff and the hospital by reducing risk.
Healthcare professionals who have sustained a sharps or needlestick injuries have explained the anxiety, sleeplessness and worry of waiting for days after exposure to blood to learn their status. They work with their hands and depend on having the most protection they can get. This kind of injury can lead to lost work time, potential emotional trauma for patient and staff and even legal action and financial consequences.
Post-exposure testing and preventive treatment can be expensive. According to four US healthcare facilities, the mean cost of managing an exposure to a patient with hepatitis C is USD 650, and exposure to an HIV-infected patient is 2,456 5. Costs in Europe are also high; in Spain the costs ranged from EUR 172, if the patient tested negative for hepatitis B and C and HIV, to EUR 1,502 if the patient were positive for hepatitis C and HIV 6.
Another concern, of course, is the risk for and treatment of a surgical site infection, which can double the length of a patient’s hospital stay (average of 16.8 additional days) and require an extra week (7.4 days) of antibiotic therapy 7 . Essentially this is a 61 percent increase in the overall cost of care 7.
Double gloving is a simple and effective way to reduce the cost of Occupational Exposure to percutaneous injuries.
Retrain the brain for protection: The last tactile mile
Quote by Julie Karlsson, Trauma Nurse: To clinicians who don´t double-glove, I say, 'Do it!'. It´s such a simple way to protect yourself and everyone else.The evidence shows the risks and costs, and the last piece of the puzzle is fighting against resistance to double gloving and providing more incentive to double glove. More surgeons and their staff need to protect themselves against the dangers and risks, starting with rethinking and retraining with an even more vigilant, evidence-based, safety-first approach.
Healthcare professionals indicate a need and want for extra protection, and this demand appears as a priority in legislation and recommendations. The Sharps Agenda in the US and the EU Sharps Directive (external link, opens in a new window) in Europe, for example, both recommend double gloving as a protective measure against sharps injuries and their real consequences. In conjunction, authorities such as the Centers for Disease Control and Prevention (CDC) 8, Occupational Safety and Health Administration (OSHA) 9, the Association of Perioperative Registered Nurses (AORN) 10 and American College of Surgeons (ACS) 11, to name a few, all recommend double gloving for invasive surgeries. Evidence supports making double gloving standard for all surgical procedures 12, and most recommendations, legislation and evidence name double gloving as best practice.
The last argument against – and often the last mile to go – in adopting double gloving is usually tactile sensitivity. Compared against the gains in safety, the loss of tactile sensitivity resulting from double gloving is insignificant. Performance is not compromised with double gloving; studies have shown that after an initial period of getting used to double gloving (most surgeons adapt fully within two days 13 ), manual dexterity and tactile sensitivity is not reduced when compared with no gloves or single gloving 12 13. Innovations in creating thinner-than-ever, more responsive surgical gloves are one way to counter arguments against double gloving.
The next step in complete protection is adopting a double gloving puncture indication system. Double gloving with a coloured puncture indication system (with a clear, fast and large indicator for early detection and enabling quick action to reduce risk) 14 means even greater safety in the O.R. and is the best protected a surgeon, her staff and patient can be.
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'References'
- Laine T, et al. How often does glove perforation occur in surgery? Comparison between single gloves and a double-gloving system. Am J Surg. 2001;181(6):564-566.
- Maffulli N, et al. Glove perforation in hand surgery. J Hand Surg. 1991;16(6):1034-1037.
- Thomas-Copeland J. Do surgical personnel really need to double-glove? AORN J. 2009;89(2):322-328.
- Mischke C, et al. Gloves, extra gloves or special types of gloves for preventing percutaneous exposure injuries in healthcare personnel. Cochrane Database Syst Rev. 2014 [cited 14 Sep 2017];(3):CD009573. URL: doi:10.1002/14651858.CD009573.pub2.
- O'Malley EM, et al. Costs of management of occupational exposures to blood and body fluids. Infect Control Hosp Epidemiol 2007;28(7):774-782.
- Solano VM, et al. Actualización del coste de las inoculaciones accidentals en el personal sanitario hospitalario. Gac Sanit. 2005 [cited 14 Sep 2017];19(1):29-35. URL: http://scielo.isciii.es/pdf/gs/v19n1/original4.pdf.
- Junker T, et al. Prevention and control of surgical site infections: review of the Basel Cohort Study. Swiss Med Wkly. 2012 [cited 14 Sep 2017];142:w13616. URL: doi: 10.4414/smw.2012.13616.
- Mangram AJ, et al. Guideline for prevention of surgical site infection. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20(4):250-278.
- Ocupational Safety and Health Administration. Occupational safety and health standards. Toxic and hazardous substances. 1910.1030 Bloodborne pathogens. Washington, DC, USA: United States Department of Labor. 1999.
- Association of periOperative Registered Nurses (AORN). Recommended practices for sterile technique. Perioperative Standards and Recommended Practices. Denver, Colorado, USA: AORN; 2013: 91-119.
- American College of Surgeons. Statement on Sharps Safety. October 2007.
- McNeilly L. Double gloving: myth versus fact. Infection Control Today. 2011;1-4.
- Walczak DA, et al. Surgical gloves—do they really protect us? Pol Przegl Chir. 2014;86(5):238-243.
- Wigmore SJ & Rainey JB. Use of coloured undergloves to detect puncture. BJS 1994: 81:1480. https://doi.org/10.1002/bjs.1800811026
