Serious risk of perforations in gloves – occurs in one in three operations

When Gerd Ødegård Hagen read an announcement offering a grant for surveys aimed at increasing knowledge about surgical gloves, latex allergy or disinfectants, she decided to submit an application. Her aim was to take a closer look during surgery at the barrier between the hands of a person working in an operating room and the patient’s body fluids. This was to be achieved by examining the level of safety and the risks involved in using surgical gloves during different surgical procedures.
  “I had discovered that we often had blood on our hands without noticing this during the operation and this was something I wanted to examine more closely,” says Gerd, an OR nurse and health and safety officer at Molde Hospital.


Gerd Ødegård Hagen 

She received the grant, which was provided by a firm of medical suppliers, Regent Medical now part of Mölnlycke
Health Care, and she involved all the surgical staff at Molde Hospital – surgeons, assistant surgeons and OR nurses. The survey took place over a period of approximately six months and covered a total of 655 operations. The procedures were divided into five main categories: orthopaedics, gastric surgery, gynaecology, vascular surgery and general surgery, as well as 16 sub-categories.
Double gloving with an indicator system was used during all the procedures.
  The principle behind double gloving with an indicator system is that the refraction of the light is changed when fluid comes between the inner glove, which is dark, and the outer glove, which is light and transparent. If there is a perforation in the glove a distinct dark patch appears where the inner glove comes into contact with body fluid. This increases the chance of discovering any perforations quickly.

For each operation during the survey period the operating room nurses at Molde Hospital completed a form with information about the operation, the duration of the procedure and details of the time at which a perforation in a glove was discovered and who in the team discovered it. As soon as a perforation was noticed in the outer glove it was replaced. “Perforations in gloves are a major problem. We previously thought that they occurred mainly during orthopaedic procedures and, consequently, many of the personnel used double gloving in that type of procedure but not in other procedures,” explains Gerd.

The survey at Molde Hospital confirmed that perforations in conjunction with orthopaedic operations are common. In 34.7% of the procedures perforations were discovered in the gloves. This was particularly the case in hiparthroplasty surgery, where perforations occurred in gloves in as many as 81% of the procedures. However, the results from the survey also show that perforations are relatively common in gastric surgery, where they occurred in 44.5% of the operations, and almost as common with gynaecological procedures, where perforations occur in 31.1 % of operations (1).
  “We were very surprised by the results. The fact that the risks are that high in all these three categories means that it is even more important than we previously thought to use double gloving during surgical procedures,” says Gerd.
  The survey shows that in total, 321 perforations were discovered in 203 of the 655 surgical procedures. The majority of perforations, 231, were in the surgeons’ gloves. In the case of OR nurses and assistant surgeons, 66 and 24 perforations respectively were discovered. It also emerged that the frequency of perforations increased considerably the longer the duration of the operation. For procedures shorter than one hour, perforations were discovered in 13.1%. However, if the operation lasted more than two hours the figure was 61.9%.

By using a double gloving indication system there is an extra barrier between the patient and the surgical staff. The risk of infection for both patient and staff is thus reduced. There are also studies that indicate that greater mechanical strength is required to make a
perforation in a double gloving system compared with a single glove (2).
  “A perforation in the glove paves the way for bacteria and infections in both directions. Staff often have injuries to their hands as a result of puncture wounds and abrasions. If a perforation in a glove is not discovered this could represent a major risk to both patients and staff,” says Gerd.
  She also refers to a survey in Norway which shows that 1 in 10 patients contract an infection as a direct result of their stay in hospital (3). This is equivalent to an annual cost of about 100 million Euro, so there are valuable savings to be made.
  “A surgeon operates on several patients each day and consequently an infection could affect many people before it is discovered,” she states.
  Several surveys also show that only between 5 and 40% of the perforations are discovered during the actual operation when using single gloves (4, 5).Consequently, on those occasions when a perforation is not discovered, exposure
to infections could continue over a prolonged period. With double gloving, the risk of perforation is reduced and at the same time it is easier to discover any perforations that may have occurred. The outer glove also protects the inner glove and can be replaced without breaking the vital barrier between a member of staff and the patient.

Currently, it is still common practice for staff in operating rooms to use single gloves.
In Norway, OR staff generally adopt double gloving during orthopaedic procedures and when operating on high-risk patients, such as those with hepatitis and HIV. Otherwise, it has hitherto been standard practice to use single gloves. However, it is not that easy to identify all high-risk patients through pre-operative routines, as HIV zero-conversion can take several months.
  The prevalence of infection from the transmission of blood-borne pathogens has also increased in recent years. This has meant that a number of patients undergoing surgery are infected and there is thus a greater risk, both to staff and other patients, of being exposed to HIV and hepatitis. A person who is infected by hepatitis C generally experiences no symptoms before the effects have become serious and developed into cirrhosis of the liver, or even cancer. It is therefore possible, in a worst case scenario, to be totally unaware of the infection for several years while at the same time infecting many other people. Such a case came to light recently in Norway, where a doctor had infected ten patients before the source of the infection was discovered.
  “As this type of infection is becoming increasingly common in society, it was vital to conduct the survey,” says Gerd.
  “It is extremely important to prevent such things from happening and one of the ways of doing this is to use double gloving during operations. All employers should therefore demand that every employee uses double gloving. It is, after all, the responsibility of the employers.”

Gerd Ødegård Hagen believes that the reason why it is still common to use single gloves is that some OR staff feel their manual dexterity is restricted when they use double gloving. She does not agree that sensitivity is restricted.
  “It feels strange at first, but we have noticed that our staff get used to double gloving very quickly. It was the same in the past, when people who did not wear gloves at all when operating were suddenly required to use single gloves.”
  Following the Molde Hospital survey, all OR staff there now use double gloving. The results have come as a surprise to them.
  “We have changed our routines based on the survey. All surgeons at the hospital have opted to continue with double gloving for all operations. The results of our survey highlight the importance of conducting this type of study so that quality and safety in the operating room are improved,” says Gerd.

The survey has attracted a great deal of attention from colleagues, both nationally and internationally. Several hospitals that Gerd has been in contact with have also changed their routines and now use a double gloving system for surgical procedures to a greater extent.
  “This means that the survey is worthwhile and relevant. I believe it has attracted such enormous attention because this is an issue that concerns us all. Everyone can be a patient and everyone knows someone who has been a patient,” she concludes.

References

1. Ødegaard Hagen G, Arntzen H. ”Risiko for perforasjon av operasjonshansker”. Tidsskrift for Den norske legeforening 2007; 7:856-858
2. Fisher MD, Reddy VR, Williams FM et al. Biomechanical performance of latex and non-latex double-glove systems. J Biomed Mater Res 1999; 48: 797 – 806
3. Regional smittevernplan 2003-2005 Helse Vest RHF. Stavanger: Helse Vest RHF, 2002
4. Thomas S, Agarwal M, Mehta G. Intraoperative glove perforation – single versus double gloving in protection against skin contamination.
   Postgrad Med J 200; 77: 458 – 60
5. Laine T, Aarnio P. Glove perforation in orthopaedic and trauma surgery.
   J Bone Joint Surg (Br) 2004; 86: 898 – 900