Comparison of perforation between single and double-gloving in perineorrhaphy after vaginal delivery: a randomized controlled trial

Preventing Infection in Implant-based Breast Reconstruction: Evaluating the Evidence for Common Practices and Standardized Protocols

Infection following implant-based breast reconstruction (IBBR) results in increased rates of hospital readmission, reoperation, patient and hospital expenses, and reconstructive failure. IBBR is a complex, multistep procedure, and there is a relative lack of high-quality plastic surgery evidence regarding "best practices" in the prevention of implant infections. In the absence of strong data, standardizing procedures based on available evidence can reduce error and improve efficacy and outcomes.

Methods

We performed a focused literature review of the available evidence supporting specific interventions for infection prevention in the preoperative, intraoperative, and postoperative phases of care that are applicable to IBBR. In addition, we examined previously published standardized perioperative protocols for implant reconstruction.

Results

Preoperative, intraoperative, and postoperative planning and organization is crucial in IBBR. Preoperative planning involves skin decolonization in advance of surgery with either chlorhexidine gluconate or mupirocin. Intraoperative methods that have shown potential benefit include double-gloving, breast pocket irrigation, separate closing instruments, and the utilization of "no-touch" techniques. In the postoperative period, the duration of drain removal and postoperative antibiotic administration play an important role in the prevention of surgical site infection.

Conclusions

There is a crucial need to establish an evidence-based set of "best practices" for IBBR, and there exists a paucity of evidence in the breast literature. These data can be utilized to develop a standardized protocol as part of a rigorous quality improvement methodology.

Effectiveness of double-gloving method on prevention of surgical glove perforations and blood contamination: A systematic review and meta-analysis

AIMS

To determine the effectiveness of the double-gloving method on preventing surgical glove perforation and blood contamination compared with single gloving.

DESIGN

Systematic review.

DATA SOURCES

Seven electronic databases were searched including: Embase, CINAHL, OVID, Medline, Pubmed, Web of Science, and Foreign Medical Literature Retrieval Service in March 2020.

REVIEW METHOD

Our systematic review and meta-analysis was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting guideline. Risk of bias of Cochrane Handbook (Version 5.1.0) was applied to evaluate the study quality. Revman 5.3 was used to calculate the effect size of odds ratio (OR) with 95% confidence interval (CI). Meta-analysis with forest plot and funnel plot was performed to compare the rate of surgical glove perforation and to determine the published bias, respectively. This review has been registered with ID: CRD42020189694 on the web site of PROSPERO.

RESULTS

Seven randomized controlled trials regarding the efficacy of double gloving on reducing surgical glove perforation were identified and a total of 7090 gloves were tested. After analyzing the pooled data, we identified that the rate of surgical glove perforation in the double-gloving group was lower than that of single gloving with statistical significance (OR = 0.75, 95% CI: 0.64-0.89, p < .05). It was statistically significant that surgical glove perforation was lower in the double-inner gloves as well as matched outer-inner perforated gloves compared with that of single glove (OR = 0.05, 95% CI: 0.03-0.07, p < .05).

CONCLUSION

Findings of this systematic review demonstrate that double gloving could reduce the rate of surgical-glove perforation. Meanwhile, the risk of being contaminated by a blood-borne pathogen during surgery could be reduced by wearing double gloves. We strongly suggest that surgical team members when operating should wear double gloves to protect themselves and reduce the risk of occupational blood exposure.

IMPACT

The necessity of double gloving for preventing blood contamination was demonstrated. The rate of surgical glove perforation is statistically significant in double-gloving group compared to single gloving. Double gloving could reduce the risk of being contaminated during surgery by blood-borne pathogen. Evidence is provided for surgical team and decision makers that double gloving could reduce occupational exposure.

Gloves, extra gloves or special types of gloves for preventing percutaneous exposure injuries in healthcare personnel

BACKGROUND

Healthcare workers are at risk of acquiring viral diseases such as hepatitis B, hepatitis C and HIV through exposure to contaminated blood and body fluids at work. Most often infection occurs when a healthcare worker inadvertently punctures the skin of their hand with a sharp implement that has been used in the treatment of an infected patient, thus bringing the patient's blood into contact with their own. Such occurrences are commonly known as percutaneous exposure incidents.

OBJECTIVES

To determine the benefits and harms of extra gloves for preventing percutaneous exposure incidents among healthcare workers versus no intervention or alternative interventions.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, NHSEED, Science Citation Index Expanded, CINAHL, NIOSHTIC, CISDOC, PsycINFO and LILACS until 26 June 2013.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with healthcare workers as the majority of participants, extra gloves or special types of gloves as the intervention, and exposure to blood or bodily fluids as the outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility and risk of bias, and extracted data. We performed meta-analyses for seven different comparisons.

MAIN RESULTS

We found 34 RCTs that included 6890 person-operations as participating units and reported on 46 intervention-control group comparisons. We grouped interventions as follows: increased layers of standard gloves, gloves manufactured with special protective materials or thicker gloves, and gloves with puncture indicator systems. Indicator gloves show a coloured spot when they are perforated. Participants were surgeons in all studies and they used at least one pair of standard gloves as the control intervention. Twenty-seven studies also included other surgical staff (e.g. nurses). All but one study used perforations in gloves as an indication of exposure. The median control group rate was 18.5 perforations per 100 person-operations. Seven studies reported blood stains on the skin and two studies reported self reported needlestick injuries. Six studies reported dexterity as visual analogue scale scores for the comparison double versus single gloves, 13 studies reported outer glove perforations. We judged the included studies to have a moderate to high risk of bias.We found moderate-quality evidence that double gloves compared to single gloves reduce the risk of glove perforation (rate ratio (RR) 0.29, 95% confidence interval (CI) 0.23 to 0.37) and the risk of blood stains on the skin (RR 0.35, 95% CI 0.17 to 0.70). Two studies with a high risk of bias also reported the effect of double compared to single gloves on needlestick injuries (RR 0.58, 95% CI 0.21 to 1.62).We found low-quality evidence in one small study that the use of three gloves compared to two gloves reduces the risk of perforation further (RR 0.03, 95% CI 0.00 to 0.52). There was similar low-quality evidence that the use of one fabric glove over one normal glove reduces perforations compared to two normal gloves (RR 0.24, 95% CI 0.06 to 0.93). There was moderate-quality evidence that this effect was similar for the use of one special material glove between two normal material gloves. Thicker gloves did not perform better than thinner gloves.There was moderate to low-quality evidence in two studies that an indicator system does not reduce the total number of perforations during an operation even though it reduces the number of perforations per glove used.There was moderate-quality evidence that double gloves have a similar number of outer glove perforations as single gloves, indicating that there is no loss of dexterity with double gloves (RR 1.10, 95% CI 0.93 to 1.31).

AUTHORS' CONCLUSIONS

There is moderate-quality evidence that double gloving compared to single gloving during surgery reduces perforations and blood stains on the skin, indicating a decrease in percutaneous exposure incidents. There is low-quality evidence that triple gloving and the use of special gloves can further reduce the risk of glove perforations compared to double gloving with normal material gloves. The preventive effect of double gloves on percutaneous exposure incidents in surgery does not need further research. Further studies are needed to evaluate the effectiveness and cost-effectiveness of special material gloves and triple gloves, and of gloves in other occupational groups.

Infection control guidelines for prevention of health care-associated transmission of hepatitis B and C viruses

Viral hepatitis was first identified as an occupational hazard for health care workers more than 60 years ago. For the past few decades, hepatitis B has been one of the most significant occupational infectious risks for health care providers. With the increasing prevalence of hepatitis C infections around the world, occupational transmission of this flavivirus from infected patients to their providers has also become a significant concern. Several factors influence the risk for occupational blood-borne hepatitis infection among health care providers, among them: the prevalence of infection among the population served, the infection status of the patients to whom workers are exposed (ie, the source patient's circulating viral burden), the types and frequencies of parenteral and mucosal exposures to blood and blood-containing body fluids, and whether the patient or provider has been immunized with the hepatitis B vaccine. This article reviews patient-to-provider, patient-to-patient, and provider-to-patient transmission of hepatitis B and C in the health care setting. Current prevention strategies, precautions, and guidelines are discussed.

Surgical glove practice: the evidence

Surgical gloves are worn to protect both the patient and the surgical team from transferred infections. Wearing two pairs of gloves, perforation indicator systems, glove liners, knitted gloves and triple gloving are said to offer additional protection. This paper presents the main findings from a Cochrane systematic review of 30 trials examining surgical gloving practice.

Double gloving to reduce surgical cross-infection

BACKGROUND

The invasive nature of surgery, with its increased exposure to blood, means that during surgery there is a high risk of transfer of pathogens. Pathogens can be transferred through contact between surgical patients and the surgical team, resulting in post-operative or blood borne infections in patients or blood borne infections in the surgical team. Both patients and the surgical team need to be protected from this risk. This risk can be reduced by implementing protective barriers such as wearing surgical gloves. Wearing two pairs of surgical gloves, triple gloves, glove liners or cloth outer gloves, as opposed to one pair, is considered to provide an additional barrier and further reduce the risk of contamination.

OBJECTIVES

The primary objective of this review was to determine if additional glove protection reduces the number of surgical site or blood borne infections in patients or the surgical team. The secondary objective was to determine if additional glove protection reduces the number of perforations to the innermost pair of surgical gloves. The innermost gloves (next to skin) compared with the outermost gloves are considered to be the last barrier between the patient and the surgical team.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register (January 2006), and the Cochrane Central Register of Controlled Trials (CENTRAL)(The Cochrane Library Issue 4, 2005). We also contacted glove manufacturing companies and professional organisations.

SELECTION CRITERIA

Randomised controlled trials involving: single gloving, double gloving, triple gloving, glove liners, knitted outer gloves, steel weave outer gloves and perforation indicator systems.

DATA COLLECTION AND ANALYSIS

Both authors independently assessed the relevance and quality of each trial. Data was extracted by one author and cross checked for accuracy by the second author.

MAIN RESULTS

Two trials were found which addressed the primary outcome, namely, surgical site infections in patients. Both trials reported no infections. Thirty one randomised controlled trials measuring glove perforations were identified and included in the review. Fourteen trials of double gloving (wearing two pairs of surgical latex gloves) were pooled and showed that there were significantly more perforations to the single glove than the innermost of the double gloves (OR 4.10, 95% CI 3.30 to 5.09). Eight trials of indicator gloves (coloured latex gloves worn underneath latex gloves to more rapidly alert the team to perforations) showed that significantly fewer perforations were detected with single gloves compared with indicator gloves (OR 0.10, 95% CI 0.06 to 0.16) or with standard double glove compared with indicator gloves (OR 0.08, 95% CI 0.04 to 0.17). Two trials of glove liners (a glove knitted with cloth or polymers worn between two pairs of latex gloves)(OR 26.36, 95% CI 7.91 to 87.82), three trials of knitted gloves (knitted glove worn on top of latex surgical gloves)(OR 5.76, 95% CI 3.25 to 10.20) and one trial of triple gloving (three pairs of latex surgical gloves)(OR 69.41, 95% CI 3.89 to 1239.18) all compared with standard double gloves, showed there were significantly more perforations to the innermost glove of a standard double glove in all comparisons.

AUTHORS' CONCLUSIONS

There is no direct evidence that additional glove protection worn by the surgical team reduces surgical site infections in patients, however the review has insufficient power for this outcome. The addition of a second pair of surgical gloves significantly reduces perforations to innermost gloves. Triple gloving, knitted outer gloves and glove liners also significantly reduce perforations to the innermost glove. Perforation indicator systems results in significantly more innermost glove perforations being detected during surgery.

Surgical gloves: perforation and protection

The risk of surgical glove perforation is affected by a number of factors including the type of surgery, length of operative procedure, hand dominance and role of the glove wearer. This article provides an overview of each of these factors and discusses protective gloving measures taken to reduce perforations based on the findings of the Cochrane review.

Prospective study of glove perforation in obstetrical and gynecological operations: are we safe enough?

OBJECTIVES

To assess the glove perforation rate, efficacy of double gloving, effect of duration of surgery, expertise of surgeon and operative urgency on the glove perforation rate in obstetrical and gynecologic operations.

METHODS

From February to September 2002, double glove protocol was made necessary for all major obstetrical and gynecologic procedures. The operating surgeon, first and second assistant were included in the study. Gloves damage was noted (overt by inspection, occult by hydroinsufflation technique).

RESULTS

Of the 156 procedures included in study, 32 procedures were performed (all emergency operations) single-gloved because surgeons found double gloving clumsy (56%), made it difficult to tie knots due to lack of dexterity (24%), or were too tight (20%). One thousand one hundred and twenty single gloves were examined after each procedure by hydroinsufflation. The overall perforation rate was 13.6% (single versus double outer gloves, 13.8% versus l3.2%, P > 0.05). Matching perforations were found in six cases (4.6%). Thus, the protection offered by double gloves was 95.4% even if the outer gloves were perforated. Four inner gloves had preexisting perforations. Sixty unused gloves checked similarly revealed a perforation rate of 1.6%. Emergency cases had higher perforation rate compared to elective surgeries (16.6% versus 10.8%, P < 0.00 1). Surgeries lasting for more than 40 min had a higher perforation rate compared to those finished in less than or equal to 40 min (18.6% versus 7.6%, P < 0.001). The middle finger of the left hand was the most commonly involved. The surgeon, first assistant and second assistant were involved in 73.6, 23.3 and 3.2% cases, respectively.

CONCLUSION

Double gloving offers considerable protection against exposure to contaminants in the blood and body fluids of the patient and should be made routine, especially in developing countries where HIV, hepatitis B and C are widely prevalent. Double gloving should be made mandatory in emergency procedures, which have a higher perforation rate due to operative urgency, and gloves should be changed in operations lasting for more than 40 min to ensure integrity of barrier.

Randomized controlled trial of glove perforation in single- and double-gloving in episiotomy repair after vaginal delivery

OBJECTIVE

The aims of the study presented here were to compare the rate of glove perforation between single-gloving and double-gloving methods, and the time of operation and level of surgeon in episiotomy repair after vaginal delivery.

METHOD

A prospective randomized controlled trial was performed from the beginning of May to the end of December, 2002 at Ramathibodi Hospital. A comparison of glove perforation between single-gloving and double-gloving methods was performed. Glove perforations were tested by filling each glove with water. Glove perforation rate, position of perforation, time of operation and surgeon level of experience were analyzed.

RESULTS

One hundred and fifty sets of double-gloving method and 150 sets of single-gloving method were evaluated. The glove perforation rates were 4.6 and 18% in double-inner gloves and single-gloves, respectively, with statistical difference (P < 0.05). There was no significant difference between glove perforation rates in double-outer gloves (22.6%) and single-gloves (18%). There was matched perforation of the same finger of both outer and inner gloves in 2% of all double-inner gloves. The frequency of glove perforation was classified by the surgeon's level of experience and time of operation was no difference in each level.

CONCLUSION

The double-gloving method significantly reduced the risk of exposure of the surgeon's hand to the patient's blood, when compared with the single-gloving method in episiotomy repair. There were no differences in the rate of glove perforations compared to the time of operation and level of surgeon.

Randomised controlled trial of glove perforation in single and double-gloving methods in gynaecologic surgery

OBJECTIVE

To assess the value of double-gloving in gynaecological surgery.

DESIGN

A prospective randomised controlled trial of glove perforation in single- and double-gloving methods.

SETTING

Rajavithi Hospital between 1 September 1999 to 31 August 2000.

SAMPLE

Eighty-eight (88) and 82 primary surgeons were selected at random to make up single- and double-gloving groups, respectively, while performing total abdominal hysterectomy (TAH) with or without bilateral salpingo-oophorectomy (BSO).

METHODS

The gloves were tested by immersion in water.

RESULTS

The glove perforation rate was 6.09% and 22.73% in double-inner and single gloves, respectively, with this difference being statistically different (p < 0.05). There was no significant difference between the glove perforation rates in single gloves (22.73%) and in double-outer gloves (19.51%). There was matched perforation of the same finger of both outer and inner gloves in 1.22% of total double-inner gloves.

CONCLUSIONS

The double-gloving methods significantly reduced the risk of surgeons' hands contacting blood, when compared with the single-gloving method, in TAH with/or without BSO.

Double gloving to reduce surgical cross-infection

BACKGROUND

The invasive nature of surgery, with its increased exposure to blood, means that during surgery there is a high risk of transfer of pathogens. Pathogens can be transferred through contact between surgical patients and the surgical team, resulting in post-operative or blood borne infections in patients or blood borne infections in the surgical team. Both patients and the surgical team need to be protected from this risk. This risk can be reduced by implementing protective barriers such as wearing surgical gloves. Wearing two pairs of surgical gloves, as opposed to one pair, is considered to provide an additional barrier and further reduce the risk of contamination.

OBJECTIVES

The primary objective of this review was to determine if double gloving (wearing two pairs of gloves), rather than single gloving, reduces the number of post-operative or blood borne infections in surgical patients or blood borne infections in the surgical team. The secondary objective of this review was to determine if double gloving, rather than single gloving, reduces the number of perforations to the innermost pair of surgical gloves. The innermost gloves (next to skin) compared with the outermost gloves are considered to be the last barrier between the patient and the surgical team.

SEARCH STRATEGY

The reviewers searched the Cochrane Wounds Group Specialised Trials Register, MEDLINE, CINAHL, EMBASE and the Cochrane Controlled Trials Register. Glove manufacturing companies and professional organisations were also contacted.

SELECTION CRITERIA

Randomised controlled trials involving: single gloving, double gloving, glove liners or coloured puncture indicator systems.

DATA COLLECTION AND ANALYSIS

Both reviewers independently assessed the relevance and quality of each trial. Trials to be included were cross checked and authenticated by both reviewers. Data was extracted by one reviewer and cross checked for accuracy by the second reviewer.

MAIN RESULTS

Two trials were found which addressed the primary outcome. A total of 18 randomised controlled trials which measured glove perforations were identified and included in the review. DOUBLE GLOVING (wearing two pairs of latex gloves). Nine trials compared single latex gloves versus double latex gloves. These found no difference in the number of perforations between the single latex gloves and the outermost pair of the double latex gloves, but the number of perforations to the double latex-innermost glove was significantly reduced when two pairs of latex gloves were worn. ORTHOPAEDIC GLOVES (thicker than standard latex gloves). One trial compared single latex orthopaedic gloves with double latex gloves. This showed there was no difference in the number of perforations to the innermost gloves when wearing double latex gloves compared with a single pair of latex orthopaedic gloves. INDICATOR GLOVES (coloured latex gloves worn underneath latex gloves). Three trials compared double latex gloves versus double latex indicator gloves. These trials showed similar numbers of perforations to both the innermost and the outermost gloves for both gloving groups. Perforations to the outermost gloves were detected more easily when double latex indicator gloves were worn. Wearing double latex indicator gloves did not increase the detection of perforations to the innermost gloves. GLOVE LINERS (an insert worn between two pairs of latex gloves). Two trials compared double latex gloves versus double latex gloves with liners. These trials showed a significant reduction in the number of perforations to the innermost glove when a glove liner was worn between two pairs of latex gloves. CLOTH GLOVES (cloth gloves worn on top of latex gloves). Two trials compared double latex gloves versus latex inner with cloth outer gloves. These trials showed that wearing a cloth outer glove significantly reduced the number of perforations to the innermost latex glove. STEEL WEAVE GLOVES (steel weave gloves worn on top of latex gloves). One trial compared double latex gloves versus latex inner with steel weave outer gloves. This trial showed no reduction in the number of perforations to the innermost glove when wearing a steel weave outer glove.

REVIEWER'S CONCLUSIONS

Wearing two pairs of latex gloves significantly reduces the number of perforations to the innermost glove. This evidence comes from trials undertaken in 'low risk' surgical specialties, that is specialties which did not include orthopaedic joint surgery. Wearing two pairs of latex gloves does not cause the glove wearer to sustain more perforations to their outermost glove. Wearing double latex indicator gloves enables the glove wearer to detect perforations to the outermost glove more easily than when wearing double latex gloves. However wearing a double latex indicator system will not assist with the detection of perforations to the innermost glove, nor reduce the number of perforations to either the outermost or the innermost glove. Wearing a glove liner between two pairs of latex gloves to undertake joint replacement surgery significantly reduces the number of perforations to the innermost glove compared with double latex gloves only. Wearing cloth outer gloves to undertake joint replacement surgery significantly reduces the number of perforations to the innermost glove compared with wearing double latex gloves. Wearing steel weave outer gloves to undertake joint replacement surgery does not reduce the number of perforations to innermost gloves compared with double latex gloves.

Glove reinforcement: an alternative to double gloving

Gloves, worn by the surgical team to prevent transmission of infections from and to patients, are prone to tears and perforations. This study was done to determine the frequency and sites of unrecognized glove perforation during surgical procedures. The percentage of glove perforation was 14%. Of the punctures, 73% occurred in one of four contiguous locations on the glove. We recommend glove reinforcement at these locations to provide better protection, as well as to reduce the burden of double gloving.

Perforation in single- and double-gloving methods for cesarean section

OBJECTIVE

To compare glove perforation between the single- and double-gloving method in cesarean section.

METHOD

Three hundred primary surgeons selected at random to be two equal groups--single and double gloving in cesarean section--at Rajavithi Hospital from 1 November 1997 to 31 March 1998. The gloves were tested by immersing in water. The level of statistical significance was noted at P < 0.05.

RESULT

The prevalence of glove perforation was 10.67% and 2% in single- and double-inner glove, respectively, with significant difference.

CONCLUSION

The double-gloving method had a significant benefit in protecting the primary surgeons' hands from exposure to blood compared with the single-gloving method in cesarean section.

The integrity of surgical gloves during gynaecological operations

The study was designed to evaluate the integrity of all surgical gloves, worn as single-gloving, used in 100 consecutive gynaecological operations. Glove perforations were tested by a standardized hydrosufflation technique. Of the 326 pairs of gloves used, 46 were found to have perforations (an overall rate of 7.1%) and about 30% had more than 1 perforation. The rate of glove perforation was 19% among charge nursing sisters, 16% among surgeons and 13% among first assistants--these differences were not statistically significant. The duration of the operation and degree of operative difficulty strongly influenced the rate of perforation. We recommend that surgeons, charge sisters and first assistants should change their gloves after every hour of the operation and use double-gloving in anticipation of a difficult operation.

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.