Anticipated Detection of Imminent Surgeon–Patient Barrier Breaches. A Prospective Randomized Controlled Trial Using an Indicator Underglove System

The double gloving indicator underglove system (IUS) is based on a colored detection of the outer glove perforation. Our objective was to determine the IUS efficiency to detect outer glove perforations and to reduce the risks of blood and body fluids exposure, warning the surgeon before the breach of the surgeon–patient barrier (SPB). A series of 100 visceral surgical procedures were randomly assigned to either double (IUS) or single gloving. The noticed glove perforations (using the water test method) and the IUS efficiency were analyzed in 99 procedures. In 49 single-gloving procedures, 19 perforations were noticed: one was immediately perceived (perceived accidental exposure, PAE); 3 were discovered as the gloves were being removed, and 15 were undetected before the water test (unperceived prolonged contact, UPC). In 50 double-gloving procedures (IUS), 16 perforations were noticed, all of them involving only the outer glove: the IUS allowed immediate detection of 3 perforations without any blood exposure; 13 other perforations went undetected but without any UPC. In conjunction with the protective quality of double gloving, the IUS allows detection of significant breaches of the outer glove before the breach of the SPB.     

Efficacy of double versus single gloving in protecting the operating team

Double-glove perforation rates and perforation rates in standard single-gloved operating teams were compared, in order to determine whether double gloving provides additional protection for the operating team. 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 individual digital distension; 115 single-gloved operations and 103 double-gloved operations were performed. There were 841 individual operating team members 'at risk'. In the single-glove group, 20.8% of individuals had perforations, but only 2.5% had perforations in both inner and outer gloves (dual perforation) in the double-glove group (P less than 0.0001). The surgeon was most at risk of glove perforation (34.7% of cases in the single-glove group, 3.8% dual perforation in the double-glove group). Longer operations were associated with increased risk of glove perforation. Double-gloving significantly reduces the risk of skin contamination by blood and body fluids and is recommended for all high risk cases.     

Surgical glove perforation

In a study to investigate the incidence and significance of surgical glove perforation, bacterial contamination of surgeons' hands and gloves before and after operation was measured and the gloves tested for damage. Perforations were found in 74 of 582 gloves (12.7 per cent) and occurred in 34.5 per cent of operations. Glove perforation did not influence bacterial counts on the surgeons' hands or on the outside of their gloves. A separate clinical study of 100 adult hernia repairs gave no evidence that perforation increased wound sepsis. After standard pre-operative hand preparation, glove perforations are of no clinical significance to the patient, but their high incidence should alert surgeons to the need for protection against pathogens transmissible during surgery, such as hepatitis B and the human immunodeficiency virus. Protection of the surgeon is the main indication for preoperative change of damaged gloves.     

Glove perforation rate in open lung surgery.

OBJECTIVE: In open lung surgery the surgical access is encircled by the ribs, which should result in a high glove perforation rate compared with other surgical specialities. METHODS: Prospectively the surgeon, first and second assistant and the scrub nurse wore double standard latex gloves during 100 thoracotomies. Parameters recorded were: procedure performed, number of perforations, localization of perforation, the seniority of the surgeon, manoeuvre performed at the moment of perforation, immediate cause of perforation, operation time, performance of rib resection during thoracotomy and time of occurrence of the first three perforations. RESULTS: One thousand, six hundred and seventy-three gloves (902 outer, 771 inner) were tested. In 78 operations perforations occurred. There were 150 outer glove perforations (8.9%, 0-8, mean 1.23), 19 inner glove perforations (1.13%, 0-2, mean 0.19). Cutaneous blood exposure was prevented in 78% of all operations and in 87% of all perforations. The perforation rate for the surgeon, the scrub nurse, the first and the second assistant were 61.2, 40.4, 9.7 and 3.1% of all operations, respectively. Rib resection and a duration of more than 2 h resulted in a significant rise of glove perforation rate (P<0.05). The personal experience of the surgeon and the type of operation did not correlate with glove perforation. The immediate cause leading to perforation was named in only 17 cases (13.7%) and comprised contact with bone (seven), a needle stitch (seven) and a production flaw (three). Leaks were localized mostly on the first finger (18%),second finger, (39%) palm and dorsum of the hand (16%). The average occurrence of all first perforations was 38.7 min (range 3-190) after the beginning of surgery, the second after 63.2 min (range 10-195). Fifty-four first perforations (50.5%) were found during the first 30 min of the operation. CONCLUSIONS: The reported perforation rate of 78% lies in the highest range of reported perforation rates in different surgical specialities. 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.     

Incidence of glove perforations in gastrointestinal surgery and the protective effect of double gloves: a prospective, randomised controlled study.

OBJECTIVE: To investigate the incidence of glove perforations during various types of gastrointestinal surgery, to record the incidence of blood contamination of the hands, and to evaluate the protective effect of double gloving. DESIGN: Randomised prospective trial. SETTING: University hospital, Denmark. MATERIAL: 566 pairs of gloves tested on surgeons, assistants, and scrub nurses. INTERVENTIONS: The participants were allocated to wear either single gloves or Indicator double gloves. MAIN OUTCOME MEASURES: The number of glove perforations and the incidence of blood contamination of the hands. RESULTS: The perforation rate in single gloves was 53/306 (17%), and that of both outer and inner Indicator gloves at corresponding sites was 6/260 (2%) (p < 0.0001). Double gloving reduced the rate of blood contamination of the hands among surgeons from 15/115 (13%) to 2/98 (2%) (p < 0.005). CONCLUSION: The use of Indicator double gloves is recommended in gastrointestinal surgery because of the appreciable protection against blood contamination that they offer.     

Glove Perforation in Outpatient Dermatologic Surgery

BACKGROUND: Intact surgical gloves ensure protection of health-care employees and health-care recipients. Nevertheless, glove perforation is very common and puncture rates above 50% have been published in the literature. OBJECTIVE: It was our aim to evaluate the perforation rate of surgical gloves in outpatient dermatologic surgery. METHODS: Six-hundred and sixty latex surgical gloves used in outpatient dermatologic surgery were evaluated for perforations using the approved water-leak method. Perforations were analyzed microscopically. RESULTS: Twenty of the 660 gloves were found to have perforations, which corresponds to a perforation rate of 3.0%. Only 5 of these perforations (25%) were noticed by the wearer. Perforations were more numerous in nondominant-handed gloves. Microscopically, all perforations could be identified as needle stick injuries. CONCLUSION: The risk of glove perforation in outpatient dermatologic surgery is lower than in many other medical specialties. The relatively high number of surgical procedures performed successively in outpatient dermatologic surgery, however, emphasizes the decisive relevance of an intact barrier between surgeon and patient. In view of the major fact that most perforations go unnoticed by the wearer, dermatologic surgeons must balance the improved safety of double gloving with costs and the loss of sensitivity and dexterity.     

Glove perforation during plastic surgery

Intraoperative perforation of surgical gloves is common. Nine hundred and forty surgical gloves were tested after 100 consecutive plastic surgical operations, each involving a surgeon, a variable number of assistants and a scrub nurse. In the first 52 operations, single gloves were used and 21.5% of the staff were found to have a perforated glove. In the second 48 operations, double gloves were used by all members of the surgical team and the number with perforations (of both inner and outer gloves) was reduced to 9%. Most perforations occurred on the dorsum of the hand and fingers and on the thumb tip, especially in the non-dominant hand. The risk of acquiring AIDS due to glove perforation is low but the consequences of such an event could be lethal.     

How often does glove perforation occur in surgery? Comparison between single gloves and a double-gloving system

BACKGROUND: In surgery, intact gloves protect the surgeon from bloodborne pathogens and the surgical wound from microorganisms on the skin of the surgeon. However, glove perforation is very common, and puncture rates as high as 61% are published in the literature. One objective of this study was to compare puncture rates between a unique double-gloving puncture indication system and single-use gloves, and another was to determine the extent to which glove perforations remain undetected during surgery. METHODS: The study material comprised all gloves used in surgical operations at our hospital for a period of 2 months. The analysis was made by the glove type in a prospective and randomized manner. Gloves were tested immediately after the surgical procedure using the approved standardized water-leak method for 2 minutes to detect any holes. The gloves used in this study were either a double-gloving puncture indication system or the standard glove used at our hospital. RESULTS: In 885 operations altogether, 2,462 gloves were tested; 1,020 single gloves, 1,148 double-glove systems, and 294 combination gloves were studied. The overall perforation rate was 192 out of 2,462 gloves (7.80%), and 162 out of 885 operations (18.3%). The detection of perforation during surgery was 28 out of 76 (36.84%) with single gloves, 77 out of 89 with the double-gloving system (86.52%), and 9 out of 27 with combination gloves (33.33%; P <0.001). The inner glove of the double-gloving system was punctured in 6 out of 88 outer glove perforations (6.82%). CONCLUSIONS: In view of the critical importance of safety at work by having a sterile barrier between surgeon and patient, it is very important to use a double-gloving puncture indication system, at least in operations where there is a high risk of glove perforation.     

Glove perforation in orthopaedic and trauma surgery. A comparison between single, double indicator gloving and double gloving with two regular gloves

The spread of viral diseases such as HIV has highlighted the importance of protecting medical personnel against contamination from blood. We have assessed the frequency of the perforation of surgical gloves during orthopaedic and trauma surgery and compared the efficiency of single and double gloving. We examined all the gloves used by surgeons for a period of two months. There were 1769 gloves from 349 operations. Perforations occurred in 18.5% of conventional and 5.8% of arthroscopic procedures. The risk of contamination from blood was 13 times higher when using single compared with double gloves. Surprisingly, the combination of two regular gloves was much less efficient than double indicator gloves when comparing the rate of perforation of the inner glove when the outer had been damaged (24% vs 4.9%; p = 0.02). We recommend double gloving in orthopaedic surgery in general and also in long arthroscopic procedures.     

Glove punctures in an orthopaedic trauma unit

A series of 421 operations in an orthopaedic trauma unit have been studied for glove punctures; 37.5 per cent of operations had a puncture demonstrated in the surgeon's gloves. The procedures at a high risk of glove punctures were hip operations (57 per cent) and internal fixation (54 per cent). The use of double gloving reduced the contamination of the surgeon's hand in these operation groups to 17 per cent (P less than 0.05). The potential risk of the surgeon being infected by his patients has become increasingly important with the increase in the number of people infected with HIV. The trauma surgeon is at a high risk due to frequent spillage of body fluids in trauma and the difficulty in identifying patients who may be at risk. Reducing the risk to the surgeon is difficult but awareness of the areas of potential contamination such as glove puncture may help.     

Glove punctures in major and minor orthopaedic surgery with double gloving

We assessed the frequency of glove perforation during major and minor orthopaedic surgeries, in order to determine the efficacy of double gloving. A total number of 1528 gloves (622 inner and 906 outer) used in 200 procedures (100 major-100 minor), and 100 pairs of unused gloves were examined. Glove perforation rate, incidence among surgical team, location of perforation and duration of surgery were compared. The overall perforation rate was 15.8% (242/1528). Perforation rates for major versus minor surgical procedures were 21.6% and 3.6%, respectively. The perforation rate for the unused control group was 1% (2/200). Inner-outer gloves perforation rates were 3.7% (23/622) and 22.7% (206/906), respectively. Surgeons had a higher perforation rate compared with the other staff. The right thumb and left index finger had more punctures than other fingers. Routine use of double gloving during orthopaedic procedures is recommended, because this significantly reduces the perforation of inner gloves.     

Double gloving and surgical technique.

A comparison of double gloving versus single gloving was made with regard to its effects on tactile discrimination and dexterity in 17 surgeons of all grades and specialties. Surgeons were assessed by their ability to tie surgical knots, and Dellon's moving two-point discrimination test. Tests were performed single gloved, double gloved with the larger glove on the outside, and double gloved with the larger glove on the inside. Double gloving did not alter two-point discrimination or the ability to tie surgical knots in this study. Wearing the smaller glove on the outside of the larger glove was considered more comfortable than the conventional technique.     

Needlestick injuries at operations for trauma. Are surgical gloves an effective barrier?

Surgeons are at risk from both hepatitis B and human immunodeficiency viruses. While vaccines have been developed against the former, barrier methods remain the mainstay of protection. Puncture wounds of the hand are a potential source of contamination; the protection afforded by surgical gloves has been investigated. Gloves from 280 orthopaedic operations for trauma were tested for perforations; one or more was found after 30% of the operations in gloves worn by the surgeon or scrub nurse. About 60% of the perforations were noticed at the time of penetration and most affected the dominant thumb and index finger. Puncture was more common during operations lasting more than one hour. The incidence of perforation was 19% for the outer of double gloves, 14% for a single glove and 6% for the inner of double gloves. These results indicate that surgical gloves function poorly as a protective barrier, especially in difficult, lengthy, fracture surgery. The practice of double-gloving confers increased but not absolute protection.     

Surgical glove use in France

Since the end of the 19th century, surgeons have used gloves to prevent infectious complications to the patient. The AIDS epidemic of the 1980's sparked the use of universal precautions to protect the surgeon from infection and vice-versa. The interface between surgeon and patient is in effect a two-way street. Surgical techniques must be modified and barrier protection optimized to minimize these risks. A single layer glove is a fragile barrier to blood exposure; unrecognized glove perforations may lead to unrecognized and prolonged exposure. Double gloving, though far from being a widespread practice in France, seems to be the best protection from pathogen exposure. Glove powder and latex allergies have their own inherent risks to both surgeon and patient in the form of latex allergies and adhesive peritonitis. New institutional protocols will be necesssary in order to make powder-free non-latex gloves available to French surgeons.     

Double gloving in reducing the interoperative risk of blood borne pathogens]

The potential for blood contact with skin puts operating room personnel at increased risk of exposure to hepatitis or HIV virus. One of the most common areas of contamination with infectious biological material is the hands and fingers due to failure of glove protection. There are varying opinions regarding the frequency of glove failure during orthopaedic procedures and the necessity of wearing two gloves for added protection. The authors performed a trial of 94 procedures involving 10 surgeons from Orthopaedic Department of Pomeranian Medical University from Szczecin, Poland to answer these questions. Outer-glove perforations occurred in 15% of the cases while inner-glove--in only 3.1% (p < 0.0001). In 5 cases there was an inner-glove defect without a corresponding outer-glove perforation. Both the duration of the operation longer than 2 hours and the type of the procedure (minor versus major) were associated with increased rates of perforation (p < 0.002 and p < 0.0007 respectively). From total amount of perforated outer-gloves, only 13 (28%) were changed by the surgeon during the operation. There was no statistically significant difference between latex and neoprene used as inner-gloves (p > 0.17) in failure rates. The authors conclude double gloving during orthopaedic procedures and changing the gloves every 2 hours may significantly reduce the operating room personnel's risk of exposure to blood borne pathogens.     

A prospective analysis of glove perforation in primary and revision total hip and total knee arthroplasty

Literature in regard to glove perforation rates in revision total joint arthroplasty (TJA) is scarce. Our purpose was to determine the incidence of perforation in revision TJA. Gloves from all scrubbed personnel were tested based on the American Society for Testing and Materials. A total of 3863 gloves were collected from 58 primary and 36 revision arthroplasty cases. Surgeons had a 3.7% outer-glove perforation rate in primary TJA compared with 8.9% in revision TJA. When both gloves were perforated, the outer-glove perforation was recognized intraoperatively 100% of the time, and the inner-glove perforation was noted only 19% of the time. The surgeon has the highest rate of glove perforation. Outer-glove perforations should prompt careful inspection of the inner glove.     

Subjective effects of double gloves on surgical performance.

This randomised trial compared single gloves with combinations of double gloves to determine the subjective effects on comfort, sensitivity and dexterity in 32 surgeons. Glove perforation rates were also compared. Single gloves of the surgeon's normal size (method A) were used as control. Double gloves were worn in three different ways, selected randomly: normal gloves inside and gloves one-half size larger outside (method B); the larger gloves inside and the normal gloves outside (method C); and lastly, two pairs of gloves of normal size (method D). Double gloves by all three methods significantly protected against needle perforation of the inner gloves when compared with single gloves, but also significantly impaired comfort, sensitivity and dexterity. When the three types of double gloving were compared, there appeared to be advantages for method C for all modalities, but the differences did not reach statistical significance; also, more surgeons expressed a preference for method C. Perforation of the inner gloves was significantly less for double gloves than for single gloves. We conclude that double gloves often protect the surgeon against needle perforations, but are felt to impair comfort, sensitivity and dexterity.     

Outer gloves in orthopaedic procedures. Cloth compared with latex

A randomized prospective study was undertaken to determine the rate of punctures of the inner glove when techniques of double-gloving were employed for orthopaedic operations. Group I consisted of twenty-five procedures in which double latex gloves were used, and Group II comprised another twenty-five in which latex inner gloves and cloth outer gloves were worn. As the outer glove was expected to act as a barrier against puncture of the inner glove, only inner gloves were tested. All glove exchanges done intraoperatively for presumed tears of the inner glove were noted, as were punctures of the skin. The type and length of the procedure were also documented. Group I (double latex gloves) had a significantly higher rate of total inner-glove perforations per procedure (p less than 0.0001) than Group II (cloth and latex gloves). Furthermore, unrecognized perforations were significantly higher in Group I than in Group II (p less than 0.01). In Group I, the number of punctures increased with the duration of the operation; a puncture was found in all procedures in which the operation lasted longer than three hours (p less than 0.01). In Group II, only two tears of the inner glove occurred. Both were unrecognized and were independent of the duration of the operation.     

Use of double gloves to protect the surgeon from blood contact during aesthetic procedures

The potential for blood contact with nonintact skin puts operating room personnel at an increased risk of exposure to hepatitis or HIV virus. Frank needle-stick injury to the surgeon has been shown to occur once every 20–40 operations. It has been shown that blood contact exposure during aesthetic surgery occurs in 32% of the operations in which a single pair of surgical gloves is used (surgeon 39.7%, assistant 23%). The reduction of blood contact exposure during aesthetic surgical procedures by using two pairs of gloves was tested and demonstrated. Contact rates decreased by 70%. Outer-glove perforations occurred in 25.6% of the cases, while inner-glove perforations occurred in only 10% of the cases (surgeon 8.7%, assistant 3.5%). All of the inner-glove perforations occurred during procedures that lasted longer than two hours, and in no case was there an inner-glove defect without a corresponding outer-glove perforation. The nondominant index forger (33%) was the most common location. Double gloving during aesthetic procedures reduced the operating room personnel's risk of blood contact exposure by 70% when compared with single-glove use.     

Cardiac surgical procedures and glove reinforcements

The purpose of this prospective study is to determine the frequency and site of glove perforation during cardiac surgical procedures. Over a period of six months, gloves from 206 surgical team members were collected at the conclusion of surgery. All cases of known perforations were eliminated from the study. The percentage of glove perforation was 14%. The distribution of perforation across locations of the hand was significantly unequal (P = 0.001). We found that 73% of the punctures occurred in one of four contiguous locations on the glove: the radial side of the index finger (28%), the radial side of the thumb (21%), the palmar side of the index (14%), and the palmar side of the thumb (10%). Therefore, we recommend glove reinforcement on these locations that would provide better protection against transmission of infectious agents. Discomfort from restricted dexterity and impaired sense of touch with double gloving renders glove reinforcement a suitable alternative for universal precautions, especially in cardiac surgery while high level of perfection and dexterity were needed in lengthy, critical operations.