Should double gloving be standard practice in OR?

Research points to reduced exposure

With evidence mounting that routine double gloving may reduce bloodborne infection risks to both surgeons and patients, the time has come for public health officials and surgical groups to recommend the practice as a new standard of care in the operating room, a leading epidemiologist advocates.

"I am very frustrated by the lack of a stance on double gloving," said Julie Gerberding, MD, MPH, director of HIV testing and counseling services at San Francisco General Hospital and associate professor of medicine at the University of California San Francisco. "There is more data supporting the value of double gloving in preventing blood exposures than any single other infection-control intervention that we have access to in the operating room."

Gerberding's research on double gloving is among an emerging body of studies that indicate the practice can reduce lacerations and tears of the "inner" glove by as much as 80%.1-3 That minimizes blood exposures to the hands of health care workers and theoretically improves protection of patients from infection by members of the surgical team. And, while gloves will not prevent needlesticks, donning a second glove can "clean" the outside of penetrating solid sharps like suture needles and reduce the amount of blood on the surface before they puncture the skin, infection control researchers report.4

Yet despite such research and recent reports of transmission of hepatitis B and hepatitis C to surgical patients, both the Centers for Disease Control and Prevention in Atlanta and the American College of Surgeons in Chicago have essentially left the issue to individual surgeons.5,6 (See Hospital Infection Control, June 1995, pp. 74-76; and June 1993, pp. 73-77.)

"I think the complacency about not accepting this as an appropriate standard in the operating room is long past," Gerberding said recently in Washington, DC, at the annual conference of the Society for Healthcare Epidemiology of America (SHEA), which is based in Woodbury, NJ. Double gloving should be more broadly considered as a general infection control approach to minimize blood exposures, particularly in light of recent discussions of screening surgeons for HBV in the United Kingdom, she noted at SHEA. (See Hospital Infection Control, August 1995, pp. 97-101.)

"We need to think generically," she said. "Screening for a high-risk infection might be appropriate, but there are also things that can be done to offer protection across the board."

Yet in the absence of formal guidelines, infection control professionals may face resistance in recommending a practice that may not be popular with all surgeons and entails the higher costs of using more gloves. Still, Gerberding said double gloving is now routinely practiced at San Francisco General and other West Coast hospitals. The key is bringing in the support and leadership from the surgical service, she noted. Acceptance of double gloving at San Francisco General has been attributed to excessive concern about blood borne pathogens in patients, but it is really more reflective of surgical personnel accepting the practice as a standard of care that is simply required by the chief of surgery, Gerberding said.

"While it is true that we do have an inner city population with a larger number of AIDS and hepatitis-infected patients, I don't think we are much different than hospitals in New York City or Baltimore," she said.

Presenting an analysis of 6,396 gloves used by surgical personnel during 200 procedures at her hospital, Gerberding noted that those donning a second outer glove can "expect anywhere from a two- to five-fold reduction in the frequency of perforation of the glove closest to your skin." Gloves tended to degrade over the course of long procedures, with almost 50% of the outer gloves perforated after three-hour cases. The inner glove perforation rates were significantly lower, but they also increased over time.

"For the inner gloves for up to six hours, less than 10% had visible blood on the site closest to the hand -- although there was a trend of increasing [exposure] over time," she said.

While the findings suggest there may be merit in checking and changing gloves during procedures longer than two or three hours, the data also support routine double gloving for many surgical procedures, she said.

"Dr. Gerberding has shown, I think conclusively, that wearing double gloves in the operating room decreases the risk for blood on the hands of the health care worker," David Henderson, MD, deputy director of the clinical center at the National Institutes of Health in Bethesda, MD, said at SHEA. "One could argue it also decreases the risk for transmission in the other direction."

CDC, ASC cite individual preference

Despite such contentions, the CDC and ACS have left double gloving decisions up to individual surgeons, some of whom feel adding the extra glove layer sacrifices comfort and tactile sensation needed for procedures. In discussions at SHEA, David Bell, MD, chief of the HIV infections branch in the CDC hospital infections program, said the agency may have been "remiss" but has left the issue to the discretion of surgeons.

"We have had a certain reluctance about prescribing a lot of technique issues and even personal protective equipment issues in the operating room," he said. "[We] have tended to prefer that these come from surgeons. We have perhaps been remiss in that belief but that's something that we have basically held."

A liaison member of the ACS bloodborne pathogens committee, Bell said the double gloving issue has been discussed by the panel, but surgeons -- particularly those who do delicate procedures like cardiac valve surgery -- fear the impairment of tactile sensation and loss of dexterity.

Regarding that issue, Gerberding said surgeons at San Francisco General hospital have found wearing a slightly larger glove under a normal size glove seems to alleviate tightness and numbness.

"This is a feasible approach to infection control," she said. "I don't think our surgeons are particularly more facile."

Beyond the comfort issue, some surgeons may not feel the infection risks warrant double gloving, says Robert Rhodes, MD, chairman of the ACS bloodborne pathogen committee and chief of the department of surgery at the University of Mississippi School of Medicine in Jackson.

"Each individual surgeon that does not double glove may have specific reasons, but some may feel as far as HIV is concerned that the risk is so small with solid [suture] needlesticks," he tells Hospital Infection Control. "That may be a little cavalier, but that is the way they feel. With hepatitis B, of course, if you are successfully immunized that is the greatest protection you can have, and the data on HCV are not clear enough yet to show that there is any particular advantage."

The ACS basically has no position on the issue, he noted, adding that there is some concern that setting such a standard could create a precedent that could be used legally against surgeons who routinely single glove. At any rate, simply issuing a recommendation from the CDC or ACS would not necessarily translate to glove practice changes across the board for the nation's surgeons.

"It is unlikely that would bring surgeons in line," Rhodes says. "It would create a lot of turmoil and there would be a lot of questions about whether it would really achieve what was intended. Someone would also raise the issue, of course, at what price? You'd be paying for all the extra pairs of gloves they would use, and they are not cheap."

At any rate, both Rhodes and Bell reminded that routine double gloving would not resolve the issue of transmission to patients, as there have been cases of HBV-infected surgeons who double gloved as a condition of continuing practice and still transmitted the virus to patients.

Nonetheless, double gloving could reduce the risk to both surgeons and patients by minimizing the surgical phenomenon of suture "shearing" injuries, says Donald Fry, MD, chairman of the department of surgery at the University of New Mexico Hospital in Albuquerque. A frequent national spokesman on issues of infection control in the surgical setting, Frye routinely double gloves for the 500 to 700 surgeries he performs annually.

"I can tell you that surgeons doing long and complex procedures inevitably have shearing injuries of their digits," he tells Hospital Infection Control. "These are not cuts or punctures, but tangential shear injuries that are the consequence of tying large monofilament suture material under tension. I believe that double gloving reduces shearing injuries of the digits, but I am still being cut."

When surgeons draw a suture knot together, a "banjo string" effect occurs as the suture material is arched over the finger, creating a shearing or cutting effect on the surgeon's finger without lacerating the glove, he explains.

"Those wounds potentially become the source for small amounts of the surgeon's serum and extracellular fluid being released into the space around the digits within the glove," he says. "If one then has a procedure that goes several hours, I can guarantee you that glove fatigue occurs and you have a potential route for viral transmission from the glove space to the soft tissues of the patient."

Indeed, in the recently published case of HBV transmission to 19 patients, the investigators reported that the surgeon reported pain in his index fingers during prolonged suturing. In a one-hour simulation of suture knot-tying, the surgeon developed "paper cut" lesions on his fingers, and HBV was recovered from his hands. The surgeon did not routinely double glove and reported glove failure as evidenced by patient blood on his hands at the conclusion of procedures.

"Such lesions combined with the failure of his gloves, may have allowed contamination of patients with HBV," the authors concluded. ". . . Although there is increasing evidence that double gloves can prevent exposure of surgeons to blood during surgery, there is no evidence regarding the effectiveness of double gloves in protecting patients from bloodborne infections. Further, advisory groups and professional organizations have not generally recommended the use of double gloves by surgeons."

References

1. Gerberding JL, Littell, C, Tarkington A, et al. Risk of exposure of surgical personnel to patients blood during surgery at San Francisco General Hospital. N Engl J Med 1990; 332:1,788-1,793.

2. Quebbeman EJ, Telford GL, Wadsworth K, et al. Double gloving: protecting surgeons from blood contamination in the operating room Arch Surg 1992; 127:213-217.

3. Matta H, Thompson AM, Rainey JB. Does wearing two pair of gloves protect operating theater staff from skin contamination? BMJ 1988; 297:597-598.

4. Lynch P, White MC. Surgical blood exposures after the OSHA bloodborne pathogens standard: frequency and prevention. Today's O.R. Nurse 1993; 15:34-39.

5. Harpaz R, Von Seidlein L, Averhoff FM, et al. Transmission of hepatitis B virus to multiple patients from a surgeon without evidence of inadequate infection control. N Engl J Med 1996; 334:549-554.

6. Estaban, JI, Gomez J, Martell M, et al. Transmission of hepatitis C virus by a cardiac surgeon. N Engl J Med 1996; 334:555-560. *