Double Protecting Surgeons From Edward J. Quebbeman, MD,
Blood Contamination in the
L. Telford, MD; Karen Wadsworth, RN; Susan Hubbard, RN, BSN, CNOR; Hannah Goodman, MS; Mark S. Gottlieb, PhD
workers, particularly surgeons, understand importance of preventing contamination from blood of patients infected with deadly viruses. One of the most common areas of contamination is the hands and fingers due to the failure of glove protection. There are varying opinions regarding the frequency of glove failure, the necessity of wearing two gloves for added protection, and the ability to operate when wearing two gloves. We performed a prospective, randomized, trial of 143 procedures involving 284 persons to answer these questions for the
surgeons and first assistants. Overall, the glove failure rate (blood contamination of the fingers) was 51% when one glove was worn and 7% when two gloves were worn. Acceptability was 88% in the group who agreed to wear two gloves, and 88% of these did not perceive that tactile sense was significantly impaired. We believe that double gloving should be, and can be, used routinely during major surgical procedures to protect surgeons from blood contamination.
(Arch Surg. 1992;127:213-217)
who work in the operating of flu¬ blood other the Persons and bodily exposure realization that There ids of room are aware
patients.
to
is
increasing
poten¬
as human immunodeficiency tially deadly virus and hepatitis and C viruses, may be transmitted to operating room staff by this contaminated blood. In a previous study, we found that the fingers were contam¬ inated with blood most frequently during operative pro¬
viruses, such
cedures' and that this was most often due to undetected holes in the gloves. The purposes of this study were to determine whether the practice of double gloving would be effective in reducing the frequency of finger contami¬ nation by blood and to determine whether there were reasons surgeons either would not or could not follow this
practice routinely. Accepted
publication September 8, 1991. Department of Surgery (Drs Quebbeman for
and Telford, From the and Mss Wadsworth, Hubbard, and Goodman) and Division of Biostatistics (Dr Gottlieb), Medical College of Wisconsin, Milwau-
kee. Presented at the 11th Annual Meeting of the Surgical Infection Society, Fort Lauderdale, Fla, April 10, 1991. Reprint requests to Department of Surgery, Medical College of Wisconsin, 8700 W Wisconsin Ave, Milwaukee, Wl 53226 (Dr
Quebbeman).
Operating Room
PhD; Gordon
\s=b\ Health care
constant
Gloving
SUBJECTS, MATERIALS, AND METHODS Two experienced operating room nurses were employed solely to observe and record data for this study and had no other patient care or administrative responsibilities. The study was performed at three hospitals that are major teaching affiliates of The Medical College of Wisconsin, Milwaukee. Most operations were performed with the participation of the surgical residents and medical students. The nurses observed only the surgeon and first assistant since these two partici¬ pants are the most frequently contaminated.1 The study nurse began recording data on the procedure and the participants as the room was being prepared. The nurse then consulted a
randomization chart to determine if the surgeon should wear one or two gloves on each hand. The first assistant automat¬ ically used the alternate gloving practice. If for some reason the participants refused this randomization, the reason was recorded and the participants wore the number of gloves they desired. At the end of the surgical procedure or when indi¬ viduals changed gloves, the nurses inspected the participants' fingers and hands closely. Any visible holes or tears in the glove were noted and recorded. The nurse then assisted each person in removing their gloves and, in the process, noted and recorded the presence of blood on the fingers and the inner glove if two gloves were worn. The nurses' presence and the study itself were well accepted by the surgeons and other operating room personnel since the topic of protection from blood contamination was of interest and concern to all. Questions from the nurses regarding the cause of blood contamination were readily answered. Operations were observed in several surgical specialties to achieve as wide a cross section of procedures and participants as possible. The procedures chosen for observation were predicted to last more than 2 hours and to include blood loss of more than 100 mL; this identified the surgical procedures and surgeons with the greatest risk of contamination. As a result, only in tra thoracic, intra-abdominal, and major extremity procedures were included in the study. At the completion of the operation, participants were asked several questions to evaluate the subjective problems of wearing two
gloves.
significance of differences between performed using the 2 test. For comparison of one
A statistical analysis of the
groups
was
proportion with another, the rate ratio or relative risk (RR) of the occurrence of events (ie, contamination) was generated. This RR
calculation indicates the magnitude of the difference of the two proportions. An RR of 1.0 indicates an equivalent risk of the event to occur. In addition, a logistic regression analysis was performed to evaluate the influence of several simultaneous fac¬ tors on the outcome.
Downloaded From: http://archsurg.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/22/2015
Table 1. —Participants and Glove No. of
Operations
No. of
Performed
Service
Participants
Assignments*
Assigned
Assigned
2,
Wore 1, No.
1,
Wore 2, No.
Compliance, %
Cardiothoracic
13
26
5
81
General surgery
52
104
17
80
Gynecology Orthopedics Transplant surgery
18
36
5
86
29
57
1
1
2
28
49
100
Trauma
4
7
1
1
71
Urology
7
14
1
1
86
19
38
16
143
284
46
Vascular surgery Total or mean •Variations from the
technique.
58 34
"Glove failure related to randomization assignment and actual number of gloves used. See text for statistical analysis.
—————————————— *
100-
/
80-
60-
RESULTS One hundred forty-three operations were observed, involving 284 gloved participants. Two staff surgeons were assigned and randomized but did not scrub for the procedure and only observed. Compliance with the ran¬ domization (72%) was less complete than originally ex¬ pected, but both single-glove and double-glove assign¬ ments were affected as listed in Table 1. There were several comments explaining the reasons that the randomization assignments were not accepted. Most common was the belief that double gloving de¬ creased tactile sense (24 cases) followed by the perception that two gloves would be too tight and cause numbness (10 cases). Other comments were that surgeons did not like double gloving or did not want to participate (six cases), two gloves were too cumbersome (three cases), there is no need to double glove (one case), and the surgeon needed dexterity (one case). Personnel choosing double gloves when assigned to wear a single glove indicated that it was their routine and they needed the extra protection. Due to the divergence from the original randomization, there was no difference in finger contamination rates be¬ tween single and double gloving when compared accord¬ ing to original group assignments (Table 2). There was, however, a large and significant difference when the groups were compared according to the number of gloves actually used; 51% contamination for participants wear¬ ing single gloves and 7% contamination for those wearing double gloves ( 2 52, P
Blood Contamination in the
L. Telford, MD; Karen Wadsworth, RN; Susan Hubbard, RN, BSN, CNOR; Hannah Goodman, MS; Mark S. Gottlieb, PhD
workers, particularly surgeons, understand importance of preventing contamination from blood of patients infected with deadly viruses. One of the most common areas of contamination is the hands and fingers due to the failure of glove protection. There are varying opinions regarding the frequency of glove failure, the necessity of wearing two gloves for added protection, and the ability to operate when wearing two gloves. We performed a prospective, randomized, trial of 143 procedures involving 284 persons to answer these questions for the
surgeons and first assistants. Overall, the glove failure rate (blood contamination of the fingers) was 51% when one glove was worn and 7% when two gloves were worn. Acceptability was 88% in the group who agreed to wear two gloves, and 88% of these did not perceive that tactile sense was significantly impaired. We believe that double gloving should be, and can be, used routinely during major surgical procedures to protect surgeons from blood contamination.
(Arch Surg. 1992;127:213-217)
who work in the operating of flu¬ blood other the Persons and bodily exposure realization that There ids of room are aware
patients.
to
is
increasing
poten¬
as human immunodeficiency tially deadly virus and hepatitis and C viruses, may be transmitted to operating room staff by this contaminated blood. In a previous study, we found that the fingers were contam¬ inated with blood most frequently during operative pro¬
viruses, such
cedures' and that this was most often due to undetected holes in the gloves. The purposes of this study were to determine whether the practice of double gloving would be effective in reducing the frequency of finger contami¬ nation by blood and to determine whether there were reasons surgeons either would not or could not follow this
practice routinely. Accepted
publication September 8, 1991. Department of Surgery (Drs Quebbeman for
and Telford, From the and Mss Wadsworth, Hubbard, and Goodman) and Division of Biostatistics (Dr Gottlieb), Medical College of Wisconsin, Milwau-
kee. Presented at the 11th Annual Meeting of the Surgical Infection Society, Fort Lauderdale, Fla, April 10, 1991. Reprint requests to Department of Surgery, Medical College of Wisconsin, 8700 W Wisconsin Ave, Milwaukee, Wl 53226 (Dr
Quebbeman).
Operating Room
PhD; Gordon
\s=b\ Health care
constant
Gloving
SUBJECTS, MATERIALS, AND METHODS Two experienced operating room nurses were employed solely to observe and record data for this study and had no other patient care or administrative responsibilities. The study was performed at three hospitals that are major teaching affiliates of The Medical College of Wisconsin, Milwaukee. Most operations were performed with the participation of the surgical residents and medical students. The nurses observed only the surgeon and first assistant since these two partici¬ pants are the most frequently contaminated.1 The study nurse began recording data on the procedure and the participants as the room was being prepared. The nurse then consulted a
randomization chart to determine if the surgeon should wear one or two gloves on each hand. The first assistant automat¬ ically used the alternate gloving practice. If for some reason the participants refused this randomization, the reason was recorded and the participants wore the number of gloves they desired. At the end of the surgical procedure or when indi¬ viduals changed gloves, the nurses inspected the participants' fingers and hands closely. Any visible holes or tears in the glove were noted and recorded. The nurse then assisted each person in removing their gloves and, in the process, noted and recorded the presence of blood on the fingers and the inner glove if two gloves were worn. The nurses' presence and the study itself were well accepted by the surgeons and other operating room personnel since the topic of protection from blood contamination was of interest and concern to all. Questions from the nurses regarding the cause of blood contamination were readily answered. Operations were observed in several surgical specialties to achieve as wide a cross section of procedures and participants as possible. The procedures chosen for observation were predicted to last more than 2 hours and to include blood loss of more than 100 mL; this identified the surgical procedures and surgeons with the greatest risk of contamination. As a result, only in tra thoracic, intra-abdominal, and major extremity procedures were included in the study. At the completion of the operation, participants were asked several questions to evaluate the subjective problems of wearing two
gloves.
significance of differences between performed using the 2 test. For comparison of one
A statistical analysis of the
groups
was
proportion with another, the rate ratio or relative risk (RR) of the occurrence of events (ie, contamination) was generated. This RR
calculation indicates the magnitude of the difference of the two proportions. An RR of 1.0 indicates an equivalent risk of the event to occur. In addition, a logistic regression analysis was performed to evaluate the influence of several simultaneous fac¬ tors on the outcome.
Downloaded From: http://archsurg.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/22/2015
Table 1. —Participants and Glove No. of
Operations
No. of
Performed
Service
Participants
Assignments*
Assigned
Assigned
2,
Wore 1, No.
1,
Wore 2, No.
Compliance, %
Cardiothoracic
13
26
5
81
General surgery
52
104
17
80
Gynecology Orthopedics Transplant surgery
18
36
5
86
29
57
1
1
2
28
49
100
Trauma
4
7
1
1
71
Urology
7
14
1
1
86
19
38
16
143
284
46
Vascular surgery Total or mean •Variations from the
technique.
58 34
"Glove failure related to randomization assignment and actual number of gloves used. See text for statistical analysis.
—————————————— *
100-
/
80-
60-
RESULTS One hundred forty-three operations were observed, involving 284 gloved participants. Two staff surgeons were assigned and randomized but did not scrub for the procedure and only observed. Compliance with the ran¬ domization (72%) was less complete than originally ex¬ pected, but both single-glove and double-glove assign¬ ments were affected as listed in Table 1. There were several comments explaining the reasons that the randomization assignments were not accepted. Most common was the belief that double gloving de¬ creased tactile sense (24 cases) followed by the perception that two gloves would be too tight and cause numbness (10 cases). Other comments were that surgeons did not like double gloving or did not want to participate (six cases), two gloves were too cumbersome (three cases), there is no need to double glove (one case), and the surgeon needed dexterity (one case). Personnel choosing double gloves when assigned to wear a single glove indicated that it was their routine and they needed the extra protection. Due to the divergence from the original randomization, there was no difference in finger contamination rates be¬ tween single and double gloving when compared accord¬ ing to original group assignments (Table 2). There was, however, a large and significant difference when the groups were compared according to the number of gloves actually used; 51% contamination for participants wear¬ ing single gloves and 7% contamination for those wearing double gloves ( 2 52, P
