Blood exposure in single versus double gloving during pelvic surgery Gabriel M. Cohn, MD, and David B. Seifer, MD Syracuse, New York In light of continued reports suggesting the inadequacy of surgical gloves as sterile barriers, as well as an increasing number of reports describing intraoperative cross infections, a prospective study was performed comparing the presence of visible blood on the hands of surgeons wearing single or double gloves during 45 consecutive major obstetric and gynecologic operations. Single-gloved hands revealed the presence of visible blood in 38% of cases (n = 42) whereas visible blood was noted in only 2% of double-gloved hands (n = 48) (p < 0.001). These results demonstrate that the sterile barrier between surgeon and patient was compromised intraoperatively and that particles the size of red blood cells were able to cross this barrier. In addition, these data suggest single gloving may be less than optimal in maintaining a sterile barrier, as well as strongly suggesting that double gloving can improve the integrity of the patient-surgeon sterile barrier during pelvic surgery. (AM J OBSTET GVNECOL 1990;162:715-7.)
Key words: Blood exposure, double gloving, pelvic surgery Intraoperative surgical glove use was introduced in 1889 by William S. Halsted to protect his scrub nurse from exacerbation of a previously acquired mercuric chloride dermatitis. 1. 2 The first published report of the routine operative use of surgical gloves was by H. H. Robb, who recommended in 1894 that gloves be used for the prevention of operative infections." Subsequently, the effectiveness of surgical gloves has been addressed in the nursing, I dental,3 '. and surgical literature. 5 -8 The incidence of intraoperative glove perforations has been reported to range from 16% to 43%,\,5-8 with only 2.5% of these recognized intraoperatively.8 Bacteriologic studies have shown that the presence of a pinhole in an otherwise impermeable surgical glove results in significant recolonization of the surgeon's hands. 7 The presence of pinholes in approximately 2% of unused surgical and latex gloves has been reported.' Qualitative differences between generic and brand name nonsterile latex gloves also has been suggested, as have lot-to-Iot and interiot variations in water tightness of unused surgical gloves. g , Although numerous reports have examined the effectiveness of surgical gloves, none has directly linked glove perforations to higher infection rates in patients. However, numerous reports have unequivocally traced intraoperative transmission of hepatitis Band j(I
From the Department of Obstetrics and Gynecology. State Univemtv of New York Health SCIence Center at Syracuse. ReceIVed for publicatton August 23. 1989; rev LIed October 23. 1989; accepted October 27, 1989. Reprint requests: Gabriel M. Cohn, MD. Department of Obstetric; and Gynecology. SUNY Health Science Center at S.vracuse. 750 East Adams St,. Room 5142. Svracuse. NY 13210.
6/1/17788
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Staphylococcus epidermidis infections from surgeon to patient. 11-13 In light of these reports, as well as growing concerns of human immunodeficiency virus exposure, many surgeons have begun the routine practice of double gloving. Reports have demonstrated a threefold to sixfold higher incidence of outer glove perforations compared with inner glove perforations. 14, 15 However, we are not aware of any study to date that has examined the efficacy of single versus double gloves in maintaining the integrity of the sterile barrier between surgeon and patient. This study was performed to determine if a significant difference in blood contamination could be demonstrated between surgeons wearing single gloves and those wearing double gloves during pelvic surgery.
Material and methods The presence of visible blood on the surgeon's gloved hands was determined in 45 consecutive major obstetric and gynecologic operations. Surgery was performed between February 1989 and April 1989 in two hospitals, Crouse-Irving Memorial Hospital and St. Joseph's Hospital Health Center. Both hospitals are State University of New York Health Science Center affiliates located in Syracuse, N.Y. A pelvic operation was included in the study if the duration of the procedure was 2:30 minutes or at least 100 ml of blood loss was estimated by an attending anesthesiologist who was blinded to the study design. These arbitrary criteria were chosen to assure adequate surgical exposure. Any case not meeting these criteria was excluded. Furthermore, because the end point was visible blood, any case in which overt needle or instrument puncture of a finger was noted intraoperatively or any case in which a glove defect was 715
716
Cohn and Seifer
March 1990 Am J Obstet Gynecol
Table II. Summary table of operations performed with and without blood present on surgeon's hands*
Table I. Summary table of single- versus double-gloved surgeons with and without blood present*
Blood
Present Not present TOTAL
Singlegloved surgeons
Doublegloved surgeons
Total
OperatIOn
16 26 42
1 47 48
17 73 90
Adnexal surgery§ Birch procedure H ysterectomyll Primary low transverse cesarean section Repeat low transverse cesarean section
*p < 0.001, Fisher's exact test.
noted was excluded. In addition, surgeons with finger or hand cuts or abrasions before or after operation were excluded from the study. The surgical team consisted of one of 18 full-time or clinical faculty obstetrician-gynecologists plus a senior resident (G. M. C.). Each attending surgeon was informed preoperatively of the study design, intent, and end point. During the first part of the study, the attending surgeon was asked to wear single gloves while the resident used double gloves. In the remainder of the cases the attending surgeons were asked to use double gloves while the resident wore single gloves. On completion of the procedure, the attending surgeon and resident discussed whether any overt glove punctures had been noted. Postoperatively the surgical gloves were carefully removed and the fingers and hands inspected for the presence of visible blood. The gloves used were brand name surgical gloves randomly selected by a circulating nurse who was unaware of the study. Statistical analysis by Fisher's exact test was performed on the data collected. Comparisons included the presence of visible blood in single- versus doublegloved surgeons, differences between the attending surgeons and resident, and a comparison of the type of surgery performed and the presence of visible blood. Results
In the 45 cases evaluated, a total of 42 surgeons wore single gloves and 48 surgeons wore double gloves (i.e., in three of the 45 cases both surgeons used double gloves.) At the conclusion of each operation, each surgeon's hands were inspected for the presence of visible blood. Operative time ranged from 17 to 300 minutes with a mean time of 65 minutes per case. Surgical operative time was approximately equal for attending surgeons and residents. Estimated blood loss ranged from 25 to 1200 ml with a mean of 500 ml per case. Table I summarizes the results of inspection for the presence of visible blood for single- and double-gloved surgeons. Of 42 instances in which surgeons wore single gloves, visible blood was demonstrated in 16 (38%) after removal of the gloves. Visible blood was demonstrated
TOTAL
No. of operations performed
Single gloves / double glovest
10
1 12 14
7 1 12 14
2 1 7 5
8 45
8 42
1 16
Blood present:f:
*No significant difference, Fisher's exact test. tCases in which one surgeon used single gloves and the other used double gloves. *Cases in which blood was detected on the single-gloved hands. §Oophorectomy, salpingectomy, salpingotomy, salpingostomy, ovarian cystectomy. IIVaginal or abdominal hysterectomy, with or without adnexal removal.
in only one (2%) of the 48 instances of double-gloved surgeons. Fisher's exact test demonstrated a statistically significant difference between the single- and doublegloved groups (p < 0.001) for the presence of visible blood. The data were further analyzed to exclude surgeon's experience as a factor involved in these observations. A significant difference in the presence of visible blood between single- and double-gloved attending surgeons was noted among 18 individuals (11 of 27 single-gloved surgeons vs. 1 of 19 double-gloved surgeons; p = 0.006 with Fisher's exact test). The difference also was true when the results for the single senior resident were examined (5 of 15 single-gloved vs. 0 of 30 doublegloved; p = 0.002 with Fisher's exact test), which suggests that expertise was not a factor in the observed differences. Too few cases were performed by any single attending surgeons (range 1 to 6) to test statistical differences among various individuals. Fisher's exact test revealed that the presence of visible blood is not related to the type of pelvic operation performed (Table II). Examination of the 21 sites of visible blood revealed equal frequency between right and left hands (10 and 11, respectively) despite the "hand dominance" of the surgeons. All of the 21 sites but one involved the index finger, thumb, and middle finger (in decreasing order of frequency). Comment
These data illustrate that whereas visible blood was detected on the surgeon's gloved hand in 38% of 45 cases after pelvic surgery, the presence of visible blood
Volume 162
Single versus double gloving
Number 3
could be significantly reduced through the use of a double-gloving technique. The overall incidence of single glove blood exposure is comparable to that of glove perforations during abdominal surgery." The distribution of visible blood primarily on the index finger, thumb, and middle finger, as well as the equal distribution of blood on the right and left hands, is consistent with prior observations. I 3 7 ".14-16 However, two previous studies did find as much as a threefold higher incidence of perforations in the nondominant hand. 15 The finding that both surgeon and surgical assistant were at significant risk of blood exposure while wearing single gloves, is supported by previous reports demonstrating that surgeon, first and second assistants, and scrub nurse incur a significant percentage of glove perforations.l. 14-16 Unlike other studies that have used dyes: watertightness;' 7-10 airtightness, 1. , or electrical currents 6 to detect the presence of glove perforations, this study was unique in evaluating the presence or absence of blood on the operating surgeon's hands. The presence of visible blood on the surgeon's gloved hand was direct evidence (1) that the sterile barrier between patient and surgeon was compromised intraoperatively, (2) that particles (i.e., red blood cells) larger than bacteria and viruses crossed this barrier, and (3) that, at the very least, one-way transmission across this barrier occurred. These findings may explain how previously reported intraoperative infections I 1-13 could have occurred. It is noted that there are several limitations of this study. Randomization for single or double gloves did not occur among surgeons. Since neither microscopic, bacteriologic, nor virologic evaluations were performed, the presence of occult blood and microscopic perforations in both groups may have been significantly underestimated. In addition, because of the small sample size, the clinical consequences of single versus double gloves relating to postoperative wound infections was not assessed. However, the unequivocal findings of the benefits of double gloves provided the impetus for reporting these data. The marked significant reduction in visible blood when double- versus single-gloved surgeons (2% vs. 38%) were compared could not be attributed to surgical expertise nor type of procedure performed. These findings strongly suggest that the practice of single gloving during pelvic surgery may be less than optimal in maintaining a sterile barrier between surgeon and patient. They further suggest that double gloving significantly reduces the risk of intraoperative blood transmission, when compared with single gloving.
717
Finally, several surgeons who had reservations and insisted on single gloving expressed concerns regarding their previous experience of discomfort, loss of dexterity, and decreased sensation when using double gloves. These concerns have not as yet been substantiated and perhaps should be reconsidered in light of the intraoperative blood contamination that may take place when surgeons use single gloves during pelvic surgery. We wish to thank William D. Grant, EdD, for his statistical expertise and assistance in the analysis of the data. We further thank Ms. Pamela Schroeder for her assistance in the preparation of this manuscript. REFERENCES 1. O'Connor AG. Glove puncture during operation. Nurs Times J984;80(suppl):5-6. 2. Geelhoed GW. The pre-Halstedian and post-Halstedian history of the surgical rubber glove. Surg Gynecol Obstet J 988; 167:350-6. 3. Otis LL, Cotton JA. Prevalance of perforations in disposable latex gloves during routine dental treatment. J Am Dent Assoc 1989;118:321-4. 4. Katz IN, Gobetti JP, Shipman C Jr. Fluorescein dye evaluation of glove integrity. J Am Dent Assoc 1989; 118:32732. 5. Should ice EE, Martin CJ. Wound infections, surgical gloves and hands of operating personnel. Can Med Assoc J 1959;81 :636-49. 6. Russell TR. Roque FE, Miller FA. A new method for detection of the leaky glove. Arch Surg 1966;93:245-8. 7. Skaug N. Micropunctures of rubber gloves used in oral surgery. Int J Oral Surg 1976;5:220-5. 8. Berg GA, Kirk AJB, Bain WHo Punctured surgical gloves and bacterial re-colonisation of hands during open heart surgery: implications for prosthetic valve replacement. Br J Clin Pract 1987;41:903-6. 9. Paulssen J, Eidem T, Kristiansen R. Perforations in surgeons' gloves. J Hosp Infect 1988; 11 :82-5_ 10. Polit SA. A warning about nonsterile rubber gloves. N Engl J Med. 1988;319: 1485. 11. WelchJ, Webster M, Tilzey AJ, Noah ND, BanatvalaJE. Hepatitis B infections after gynecological surgery. Lancet 1989;1:205-7. 12. Lettau LA. Smith D, Williams D, et al. Transmission of hepatitis B with resultant restriction of surgical practice. JAMA 1986;255:934-7. 13. Van Den Broek PJ, Lampe AS, Berbee GAM, Thompson J, Mouton RP. Epidemic of prosthetic valve endocarditis caused by Staphylococcus epldermidis. Br Med J 1985;291: 949-50. 14. McCue SF, Berg EW, Saunders EA. Efficacy of doublegloving as barrier to microbial contamination during total joint arthroscopy. J Bone Joint Surg 1981 ;63-A:811-3. 15. Matta H, Thompson AM, Rainey JB. Does wearing two pairs of gloves protect operating theatre staff from skin contamination? Br Med J 1988;297:597-8. 16. Brough SJ. Hunt TM, Barrie WW. Surgical glove perforations. Br J Surg 1988;75:317_
Key words: Blood exposure, double gloving, pelvic surgery Intraoperative surgical glove use was introduced in 1889 by William S. Halsted to protect his scrub nurse from exacerbation of a previously acquired mercuric chloride dermatitis. 1. 2 The first published report of the routine operative use of surgical gloves was by H. H. Robb, who recommended in 1894 that gloves be used for the prevention of operative infections." Subsequently, the effectiveness of surgical gloves has been addressed in the nursing, I dental,3 '. and surgical literature. 5 -8 The incidence of intraoperative glove perforations has been reported to range from 16% to 43%,\,5-8 with only 2.5% of these recognized intraoperatively.8 Bacteriologic studies have shown that the presence of a pinhole in an otherwise impermeable surgical glove results in significant recolonization of the surgeon's hands. 7 The presence of pinholes in approximately 2% of unused surgical and latex gloves has been reported.' Qualitative differences between generic and brand name nonsterile latex gloves also has been suggested, as have lot-to-Iot and interiot variations in water tightness of unused surgical gloves. g , Although numerous reports have examined the effectiveness of surgical gloves, none has directly linked glove perforations to higher infection rates in patients. However, numerous reports have unequivocally traced intraoperative transmission of hepatitis Band j(I
From the Department of Obstetrics and Gynecology. State Univemtv of New York Health SCIence Center at Syracuse. ReceIVed for publicatton August 23. 1989; rev LIed October 23. 1989; accepted October 27, 1989. Reprint requests: Gabriel M. Cohn, MD. Department of Obstetric; and Gynecology. SUNY Health Science Center at S.vracuse. 750 East Adams St,. Room 5142. Svracuse. NY 13210.
6/1/17788
-
Staphylococcus epidermidis infections from surgeon to patient. 11-13 In light of these reports, as well as growing concerns of human immunodeficiency virus exposure, many surgeons have begun the routine practice of double gloving. Reports have demonstrated a threefold to sixfold higher incidence of outer glove perforations compared with inner glove perforations. 14, 15 However, we are not aware of any study to date that has examined the efficacy of single versus double gloves in maintaining the integrity of the sterile barrier between surgeon and patient. This study was performed to determine if a significant difference in blood contamination could be demonstrated between surgeons wearing single gloves and those wearing double gloves during pelvic surgery.
Material and methods The presence of visible blood on the surgeon's gloved hands was determined in 45 consecutive major obstetric and gynecologic operations. Surgery was performed between February 1989 and April 1989 in two hospitals, Crouse-Irving Memorial Hospital and St. Joseph's Hospital Health Center. Both hospitals are State University of New York Health Science Center affiliates located in Syracuse, N.Y. A pelvic operation was included in the study if the duration of the procedure was 2:30 minutes or at least 100 ml of blood loss was estimated by an attending anesthesiologist who was blinded to the study design. These arbitrary criteria were chosen to assure adequate surgical exposure. Any case not meeting these criteria was excluded. Furthermore, because the end point was visible blood, any case in which overt needle or instrument puncture of a finger was noted intraoperatively or any case in which a glove defect was 715
716
Cohn and Seifer
March 1990 Am J Obstet Gynecol
Table II. Summary table of operations performed with and without blood present on surgeon's hands*
Table I. Summary table of single- versus double-gloved surgeons with and without blood present*
Blood
Present Not present TOTAL
Singlegloved surgeons
Doublegloved surgeons
Total
OperatIOn
16 26 42
1 47 48
17 73 90
Adnexal surgery§ Birch procedure H ysterectomyll Primary low transverse cesarean section Repeat low transverse cesarean section
*p < 0.001, Fisher's exact test.
noted was excluded. In addition, surgeons with finger or hand cuts or abrasions before or after operation were excluded from the study. The surgical team consisted of one of 18 full-time or clinical faculty obstetrician-gynecologists plus a senior resident (G. M. C.). Each attending surgeon was informed preoperatively of the study design, intent, and end point. During the first part of the study, the attending surgeon was asked to wear single gloves while the resident used double gloves. In the remainder of the cases the attending surgeons were asked to use double gloves while the resident wore single gloves. On completion of the procedure, the attending surgeon and resident discussed whether any overt glove punctures had been noted. Postoperatively the surgical gloves were carefully removed and the fingers and hands inspected for the presence of visible blood. The gloves used were brand name surgical gloves randomly selected by a circulating nurse who was unaware of the study. Statistical analysis by Fisher's exact test was performed on the data collected. Comparisons included the presence of visible blood in single- versus doublegloved surgeons, differences between the attending surgeons and resident, and a comparison of the type of surgery performed and the presence of visible blood. Results
In the 45 cases evaluated, a total of 42 surgeons wore single gloves and 48 surgeons wore double gloves (i.e., in three of the 45 cases both surgeons used double gloves.) At the conclusion of each operation, each surgeon's hands were inspected for the presence of visible blood. Operative time ranged from 17 to 300 minutes with a mean time of 65 minutes per case. Surgical operative time was approximately equal for attending surgeons and residents. Estimated blood loss ranged from 25 to 1200 ml with a mean of 500 ml per case. Table I summarizes the results of inspection for the presence of visible blood for single- and double-gloved surgeons. Of 42 instances in which surgeons wore single gloves, visible blood was demonstrated in 16 (38%) after removal of the gloves. Visible blood was demonstrated
TOTAL
No. of operations performed
Single gloves / double glovest
10
1 12 14
7 1 12 14
2 1 7 5
8 45
8 42
1 16
Blood present:f:
*No significant difference, Fisher's exact test. tCases in which one surgeon used single gloves and the other used double gloves. *Cases in which blood was detected on the single-gloved hands. §Oophorectomy, salpingectomy, salpingotomy, salpingostomy, ovarian cystectomy. IIVaginal or abdominal hysterectomy, with or without adnexal removal.
in only one (2%) of the 48 instances of double-gloved surgeons. Fisher's exact test demonstrated a statistically significant difference between the single- and doublegloved groups (p < 0.001) for the presence of visible blood. The data were further analyzed to exclude surgeon's experience as a factor involved in these observations. A significant difference in the presence of visible blood between single- and double-gloved attending surgeons was noted among 18 individuals (11 of 27 single-gloved surgeons vs. 1 of 19 double-gloved surgeons; p = 0.006 with Fisher's exact test). The difference also was true when the results for the single senior resident were examined (5 of 15 single-gloved vs. 0 of 30 doublegloved; p = 0.002 with Fisher's exact test), which suggests that expertise was not a factor in the observed differences. Too few cases were performed by any single attending surgeons (range 1 to 6) to test statistical differences among various individuals. Fisher's exact test revealed that the presence of visible blood is not related to the type of pelvic operation performed (Table II). Examination of the 21 sites of visible blood revealed equal frequency between right and left hands (10 and 11, respectively) despite the "hand dominance" of the surgeons. All of the 21 sites but one involved the index finger, thumb, and middle finger (in decreasing order of frequency). Comment
These data illustrate that whereas visible blood was detected on the surgeon's gloved hand in 38% of 45 cases after pelvic surgery, the presence of visible blood
Volume 162
Single versus double gloving
Number 3
could be significantly reduced through the use of a double-gloving technique. The overall incidence of single glove blood exposure is comparable to that of glove perforations during abdominal surgery." The distribution of visible blood primarily on the index finger, thumb, and middle finger, as well as the equal distribution of blood on the right and left hands, is consistent with prior observations. I 3 7 ".14-16 However, two previous studies did find as much as a threefold higher incidence of perforations in the nondominant hand. 15 The finding that both surgeon and surgical assistant were at significant risk of blood exposure while wearing single gloves, is supported by previous reports demonstrating that surgeon, first and second assistants, and scrub nurse incur a significant percentage of glove perforations.l. 14-16 Unlike other studies that have used dyes: watertightness;' 7-10 airtightness, 1. , or electrical currents 6 to detect the presence of glove perforations, this study was unique in evaluating the presence or absence of blood on the operating surgeon's hands. The presence of visible blood on the surgeon's gloved hand was direct evidence (1) that the sterile barrier between patient and surgeon was compromised intraoperatively, (2) that particles (i.e., red blood cells) larger than bacteria and viruses crossed this barrier, and (3) that, at the very least, one-way transmission across this barrier occurred. These findings may explain how previously reported intraoperative infections I 1-13 could have occurred. It is noted that there are several limitations of this study. Randomization for single or double gloves did not occur among surgeons. Since neither microscopic, bacteriologic, nor virologic evaluations were performed, the presence of occult blood and microscopic perforations in both groups may have been significantly underestimated. In addition, because of the small sample size, the clinical consequences of single versus double gloves relating to postoperative wound infections was not assessed. However, the unequivocal findings of the benefits of double gloves provided the impetus for reporting these data. The marked significant reduction in visible blood when double- versus single-gloved surgeons (2% vs. 38%) were compared could not be attributed to surgical expertise nor type of procedure performed. These findings strongly suggest that the practice of single gloving during pelvic surgery may be less than optimal in maintaining a sterile barrier between surgeon and patient. They further suggest that double gloving significantly reduces the risk of intraoperative blood transmission, when compared with single gloving.
717
Finally, several surgeons who had reservations and insisted on single gloving expressed concerns regarding their previous experience of discomfort, loss of dexterity, and decreased sensation when using double gloves. These concerns have not as yet been substantiated and perhaps should be reconsidered in light of the intraoperative blood contamination that may take place when surgeons use single gloves during pelvic surgery. We wish to thank William D. Grant, EdD, for his statistical expertise and assistance in the analysis of the data. We further thank Ms. Pamela Schroeder for her assistance in the preparation of this manuscript. REFERENCES 1. O'Connor AG. Glove puncture during operation. Nurs Times J984;80(suppl):5-6. 2. Geelhoed GW. The pre-Halstedian and post-Halstedian history of the surgical rubber glove. Surg Gynecol Obstet J 988; 167:350-6. 3. Otis LL, Cotton JA. Prevalance of perforations in disposable latex gloves during routine dental treatment. J Am Dent Assoc 1989;118:321-4. 4. Katz IN, Gobetti JP, Shipman C Jr. Fluorescein dye evaluation of glove integrity. J Am Dent Assoc 1989; 118:32732. 5. Should ice EE, Martin CJ. Wound infections, surgical gloves and hands of operating personnel. Can Med Assoc J 1959;81 :636-49. 6. Russell TR. Roque FE, Miller FA. A new method for detection of the leaky glove. Arch Surg 1966;93:245-8. 7. Skaug N. Micropunctures of rubber gloves used in oral surgery. Int J Oral Surg 1976;5:220-5. 8. Berg GA, Kirk AJB, Bain WHo Punctured surgical gloves and bacterial re-colonisation of hands during open heart surgery: implications for prosthetic valve replacement. Br J Clin Pract 1987;41:903-6. 9. Paulssen J, Eidem T, Kristiansen R. Perforations in surgeons' gloves. J Hosp Infect 1988; 11 :82-5_ 10. Polit SA. A warning about nonsterile rubber gloves. N Engl J Med. 1988;319: 1485. 11. WelchJ, Webster M, Tilzey AJ, Noah ND, BanatvalaJE. Hepatitis B infections after gynecological surgery. Lancet 1989;1:205-7. 12. Lettau LA. Smith D, Williams D, et al. Transmission of hepatitis B with resultant restriction of surgical practice. JAMA 1986;255:934-7. 13. Van Den Broek PJ, Lampe AS, Berbee GAM, Thompson J, Mouton RP. Epidemic of prosthetic valve endocarditis caused by Staphylococcus epldermidis. Br Med J 1985;291: 949-50. 14. McCue SF, Berg EW, Saunders EA. Efficacy of doublegloving as barrier to microbial contamination during total joint arthroscopy. J Bone Joint Surg 1981 ;63-A:811-3. 15. Matta H, Thompson AM, Rainey JB. Does wearing two pairs of gloves protect operating theatre staff from skin contamination? Br Med J 1988;297:597-8. 16. Brough SJ. Hunt TM, Barrie WW. Surgical glove perforations. Br J Surg 1988;75:317_
