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Noye N, Steadman W, Whittaker B, Cacioli P, Wall C. Does exposure to polymethyl methacrylate bone cement increase the risk of surgical glove failure? ANZ J Surg 2024; 94:724-732. [PMID: 38572937 DOI: 10.1111/ans.18927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 04/05/2024]
Abstract
INTRODUCTION Surgical glove perforation has been linked to a double-fold increased risk of surgical site infection. Infection in the context of arthroplasty can have devastating consequences. In orthopaedics, use of polymethyl methacrylate (PMMA) bone cement is commonplace, and the impact on glove strength and perforation risk is not fully understood. This study aimed to examine the resistance to perforation and thickness of gloves following PMMA exposure, in accordance with the International Organization for Standardization (ISO) standard for glove integrity. METHODS Pairs of gloves were separated and randomly sorted into exposure and control groups. Twenty pairs of latex and 40 pairs of polyisoprene gloves were used. Exposure group glove cuffs were in contact with cement from a single surface of the glove for 13 min as cement cured. Force to perforation and glove thickness were tested in accordance with ISO guidelines. RESULTS Latex gloves were found to have a significantly increased force to perforation following PMMA exposure (10.26 Newtons (N) vs. 9.81 N, P = 0.048). Both polyisoprene under- and over-gloves were shown to have no significant change in strength to perforation post exposure (9.69 N vs. 9.83 N, P = 0.561, and 10.26 N vs. 10.65 N, P = 0.168, respectively). All groups were over the ISO standard minimum strength of 5 N. CONCLUSIONS Exposure of latex and polyisoprene surgical gloves to PMMA bone cement does not appear to increase glove perforation risk and rather may improve natural rubber latex glove strength. This study supports the use of latex and polyisoprene surgical gloves in procedures that involve the handling of PMMA bone cement.
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Affiliation(s)
- Nicholas Noye
- Department of Orthopaedics, Toowoomba Hospital, Darling Downs Health, Toowoomba, Queensland, Australia
- School of Medicine, Rural Clinical School, University of Queensland, Toowoomba, Queensland, Australia
| | - William Steadman
- Department of Orthopaedics, Toowoomba Hospital, Darling Downs Health, Toowoomba, Queensland, Australia
- School of Medicine, Rural Clinical School, University of Queensland, Toowoomba, Queensland, Australia
| | - Brent Whittaker
- Department of Orthopaedics, Toowoomba Hospital, Darling Downs Health, Toowoomba, Queensland, Australia
- School of Medicine, Rural Clinical School, University of Queensland, Toowoomba, Queensland, Australia
| | - Paul Cacioli
- Department of Orthopaedics, Toowoomba Hospital, Darling Downs Health, Toowoomba, Queensland, Australia
- School of Medicine, Rural Clinical School, University of Queensland, Toowoomba, Queensland, Australia
| | - Christopher Wall
- Department of Orthopaedics, Toowoomba Hospital, Darling Downs Health, Toowoomba, Queensland, Australia
- School of Medicine, Rural Clinical School, University of Queensland, Toowoomba, Queensland, Australia
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Biehl K, Rogovskyy AS, Jeffery N, Douglas P, Thieman Mankin KM. Influence of closed glove exchange on bacterial contamination of the hands of the surgical team. Vet Surg 2023; 52:747-755. [PMID: 37080898 DOI: 10.1111/vsu.13962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 02/09/2023] [Accepted: 04/02/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVE To determine if closed glove exchange (CGE) increases hand contamination. STUDY DESIGN Prospective experimental study. SAMPLE POPULATION Surgical teams participating in 65 individual surgical procedures were included, resulting in 200 individual enrollments. METHODS At the completion of surgery, gloves were removed and hands were swabbed. The inside of the gown cuff was swabbed. Each participant regloved, using a closed gloving technique. The new gloves were removed, and hands were swabbed for culture a second time. Swabs underwent standard bacterial culture. RESULTS Before glove exchange, or baseline, contamination was found on 17/200 dominant hands and 13/200 nondominant hands. After performing CGE, contamination was found on 14/200 and 15/200 dominant and nondominant hands, respectively. No difference was detected between the number of CFUs cultured from a surgeon's hands before CGE and the number of CFUs cultured from a surgeon's hands post-CGE (one sided sign test, p = .61). Twelve (12) different bacterial species were identified, the most common were Staphylococcus spp. (97/154; 63%). CONCLUSION Closed glove exchange did not increase bacterial hand contamination over baseline levels. CLINICAL SIGNIFICANCE We found no evidence to support discontinuing CGE.
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Affiliation(s)
- Kathryn Biehl
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Artem S Rogovskyy
- Department of Veterinary Pathobiology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Nicholas Jeffery
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Pamela Douglas
- Veterinary Medical Teaching Hospital, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Kelley M Thieman Mankin
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
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Reducing ventriculoperitoneal shunt infection with intraoperative glove removal. Infect Control Hosp Epidemiol 2023; 44:234-237. [PMID: 35438070 PMCID: PMC9929712 DOI: 10.1017/ice.2022.70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Contamination of ventriculoperitoneal shunts (VPS) by cutaneous flora, particularly coagulase-negative staphylococci, is a common cause of shunt infection and failure, leading to prolonged hospital stay, higher costs of care, and poor outcomes. Glove contamination may occur during VPS insertion, increasing risk of such infections. METHODS We performed a systematic search of the PubMed database for studies published January 1, 1970, through August 31, 2021 that documented VPS infection rates before and after implementing a practice of double gloving with change or removal of the outer glove immediately prior to shunt insertion. RESULTS Among 272 reports screened, 4 were eligible for review based on our inclusion criteria. The incidence of VPS infection was reduced in all 4 quasi-experimental studies with an aggregate incidence of VPS infection of 11.8% before the change in intraoperative protocol and 4.9% after protocol change. One study documented reduced hospital stay with this change in protocol. CONCLUSION The risk of VPS infection is reduced by removal or replacement of the outer surgical gloves immediately prior to intraoperative insertion of a VPS as part of an infection control bundle.
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Enz A, Klinder A, Bisping L, Lutter C, Warnke P, Tischer T, Mittelmeier W, Lenz R. Knot tying in arthroplasty and arthroscopy causes lesions to surgical gloves: a potential risk of infection. Knee Surg Sports Traumatol Arthrosc 2022; 31:1824-1832. [PMID: 36048202 PMCID: PMC10089991 DOI: 10.1007/s00167-022-07136-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 08/19/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Recent studies have shown that the incidence of glove lesions during arthroscopy is much lower than that during primary and revision arthroplasty. However, the rate of glove damage after knot tying has not yet been systematically recorded. Therefore, the aim of the study was to determine the impact of surgical knot tying on glove integrity. It was hypothesized that knot tying increases the rate of glove damage, especially in arthroscopic surgery, which could be of special relevance in the treatment of rotator cuff tears. METHODS Gloves that were changed immediately before suturing and only worn during knot tying were investigated for their integrity by means of water tightening test according to EN455. A total of 234 gloves from 40 total hip arthroplasties (THAs), 42 total knee arthroplasties (TKAs) and 36 rotator cuff repairs (RCRs) were collected. A bacterial pass-through test (BPTT) on glove lesions was performed under simulated sterile surgical conditions for 3 surgeons after a wear duration of 45 min. RESULTS Glove damage by knot tying occurred in 25% of THA, 36.6% of TKA and 25% of RCR surgeries. In THA, the pulling hand (PH) was affected in 46.2%, and the main area of damage (15.4%) was detected on the tip of the middle finger; in TKAs the PH was damaged in 75%, and in RCRs the PH was affected in 66.7%, with most of the lesions (20% each) occurring on the tip of the index finger and the ring finger. The BPTT showed Staphylococcus hominis and Bacillus cereus. CONCLUSION Intraoperative knot tying causes damage to gloves, which is of special relevance for arthroscopic surgery. Whereas knot tying is only partly responsible for glove damage in arthroplasty, the general rate of glove damage in arthroscopic surgery is low without knot tying. The surgical knot tying process must be understood as a possible damaging impact on the glove. Therefore, single gloving is not recommended, which is especially important in arthroscopic surgery, where double gloving is not yet standard. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Andreas Enz
- Orthopaedic Clinic and Policlinic, University Medicine Rostock, Doberanerstraße 142, 18057, Rostock, Germany.
| | - Annett Klinder
- Orthopaedic Clinic and Policlinic, University Medicine Rostock, Doberanerstraße 142, 18057, Rostock, Germany
| | - Lucas Bisping
- Orthopaedic Clinic and Policlinic, University Medicine Rostock, Doberanerstraße 142, 18057, Rostock, Germany
| | - Christoph Lutter
- Orthopaedic Clinic and Policlinic, University Medicine Rostock, Doberanerstraße 142, 18057, Rostock, Germany
| | - Philipp Warnke
- Institute of Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| | - Thomas Tischer
- Orthopaedic Clinic and Policlinic, University Medicine Rostock, Doberanerstraße 142, 18057, Rostock, Germany
| | - Wolfram Mittelmeier
- Orthopaedic Clinic and Policlinic, University Medicine Rostock, Doberanerstraße 142, 18057, Rostock, Germany
| | - Robert Lenz
- Orthopaedic Clinic and Policlinic, University Medicine Rostock, Doberanerstraße 142, 18057, Rostock, Germany
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Jahangiri M, Choobineh A, Malakoutikhah M, Hassanipour S, Zare A. The global incidence and associated factors of surgical gloves perforation: A systematic review and meta-analysis. Work 2022; 71:859-869. [PMID: 35253703 DOI: 10.3233/wor-210286] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Surgeon's hands are exposed to a range of chemical and physical stressors that influence the integrity of gloves. Thus, glove perforation facilitates pathogen transmission through the holes. Numerous studies have shown that glove perforation is of great importance, but there is still no complete consensus. OBJECTIVE This study aimed to investigate the safety conditions of surgical gloves based on the incidence of glove perforation among surgical teams. METHODS A literature review was conducted by searching PubMed, Embase, Scopus, ISI, and ProQuest databases. The incidence of glove perforation was reviewed in eight categories. A total of 580 articles were found in the initial search. RESULTS 109 articles containing 130 datasets were analyzed. The overall incidence of glove perforation was 14.44 %. Surgeons had the highest incidence of glove perforation (23.09 %). An increase in the duration of surgery increased the odds of perforation. It was found that 68.58% of the glove perforations were not identified by practitioners. CONCLUSION Despite major advances in the design of surgical gloves, the issue of safety and integrity of gloves has not improved. Due to the high incidence of surgical glove perforations, most of which had not been identified, it is imperative to consider strategies to minimize the incidence of perforation. The results of the present study can be used to integrate information related to the rate of perforation of surgical gloves in different surgeries.
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Affiliation(s)
- Mehdi Jahangiri
- Research Center for Health Sciences, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Choobineh
- Research Center for Health Sciences, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahdi Malakoutikhah
- Department of Occupational Health Engineering, School of Health, Kashan University of Medical Sciences, Kashan, Iran
| | - Soheil Hassanipour
- Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Asma Zare
- Department of Occupational Health Engineering, Sirjan School of Medical Sciences, Sirjan, Iran
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Thomson I, Krysa N, McGuire A, Mann S. Recognition of intraoperative surgical glove perforation: a comparison by surgical role and level of training. Can J Surg 2022; 65:E82-E88. [PMID: 35135784 PMCID: PMC8834241 DOI: 10.1503/cjs.016720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 11/19/2022] Open
Abstract
Background: The aim of this study was to characterize the risk of glove perforation among surgical team members performing a typical set of trauma procedures, as well as to identify the rate at which these people recognize potential perforations. Methods: Gloves used in orthopedic trauma room procedures were collected from all participating team members over 2 weeks and were subsequently examined for perforations. Perforation rates based on glove position, type, wearer and procedure were assessed. Results: Perforations were found in 5.9% of gloves; 4.3% of the perforations were found in outer gloves and 1.6% in inner gloves. Among the outer gloves, 30.7% of the perforations were recognized by the wearer at the time of perforation; none of the inner glove perforations were recognized, even when they were associated with an accompanying outer glove perforation. Significantly more perforations were identified in the gloves of attending staff than in those of other team members. Attending staff experienced more perforations than other wearers, regardless of whether they were acting as the primary surgeon or as an assistant. Perforations were more common in open reduction internal fixation and amputation procedures. For open reduction internal fixation procedures, longer operative times were associated with more frequent glove perforations. Conclusion: The rates of glove perforation are high in orthopedic trauma surgeries, and often these perforations are not recognized by the wearer. Attending staff are at an elevated risk of glove perforation. It is recommended that all members of the surgical team change both pairs of gloves whenever an outer glove perforation is observed.
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Affiliation(s)
- Ian Thomson
- From the Division of Orthopaedic Surgery, Queen's University, Kingston, Ont. (Thomson, McGuire, Mann); and the Queen's School of Medicine, Kingston, Ont. (Krysa)
| | - Nicole Krysa
- From the Division of Orthopaedic Surgery, Queen's University, Kingston, Ont. (Thomson, McGuire, Mann); and the Queen's School of Medicine, Kingston, Ont. (Krysa)
| | - Andrew McGuire
- From the Division of Orthopaedic Surgery, Queen's University, Kingston, Ont. (Thomson, McGuire, Mann); and the Queen's School of Medicine, Kingston, Ont. (Krysa)
| | - Steve Mann
- From the Division of Orthopaedic Surgery, Queen's University, Kingston, Ont. (Thomson, McGuire, Mann); and the Queen's School of Medicine, Kingston, Ont. (Krysa)
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Comparison of Unnoticed Glove Perforations during Minimally Invasive versus Open Surgeries: A Systematic Review and Meta-Analysis. CHILDREN 2022; 9:children9020179. [PMID: 35204901 PMCID: PMC8870279 DOI: 10.3390/children9020179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/19/2022] [Accepted: 01/29/2022] [Indexed: 11/17/2022]
Abstract
Objective: Various studies have depicted the incidence of glove perforations during open (OS) and minimally invasive surgeries (MIS). The aim of this meta-analysis was to compare the incidence of macroscopic and microscopic glove perforations during MIS and OS. Methods: The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Scientific databases (PubMed, Web of Science, Scopus, and EMBASE) were systematically searched for comparative studies depicting the glove perforation rates during MIS and OS. Risk ratios (RR) were calculated for both the outcomes (dichotomous) and the Mantel–Haenszel method was utilized for the estimation of pooled RR. The methodological quality assessment was performed by two independent investigators using the Downs and Black scale. The main outcomes of the study were the proportion of gloves with gross (macroscopic) perforations and the proportion of gloves with microscopic perforations. Results: Four comparative studies including a total of 1428 gloves (435 from the MIS group) were included. Pooling the data demonstrated no difference in the incidence of macroscopic glove perforations among the MIS and OS groups (RR 0.57, 95% CI 0.21 to 1.54, p = 0.27). On the other hand, the incidence of microscopic perforations was significantly higher in the OS group versus the MIS group (RR 0.72, 95% CI 0.55 to 0.95, p = 0.02). However, all the studies had a moderate risk of bias. Conclusions: When compared to OS, the macroscopic glove perforation rate during MIS showed no significant difference. The incidence of microscopic glove perforations was significantly higher during OS as compared to MIS. However, due to the moderate risk of bias of the available comparative studies, the level of evidence of these studies is limited.
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Ruiz-Tovar J, Boermeester MA, Bordeianou L, Chang GJ, Gorgun E, Justinger C, Lawson EH, Leaper DJ, Mahmoud NN, Mantyh C, McGee MF, Nfonsam V, Rubio-Perez I, Wick EC, Hedrick TL. Delphi Consensus on Intraoperative Technical/Surgical Aspects to Prevent Surgical Site Infection after Colorectal Surgery. J Am Coll Surg 2022; 234:1-11. [PMID: 35213454 PMCID: PMC8719508 DOI: 10.1097/xcs.0000000000000022] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/19/2021] [Accepted: 09/22/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Previous studies have focused on the development and evaluation of care bundles to reduce the risk of surgical site infection (SSI) throughout the perioperative period. A focused examination of the technical/surgical aspects of SSI reduction during CRS has not been conducted. This study aimed to develop an expert consensus on intraoperative technical/surgical aspects of SSI prevention by the surgical team during colorectal surgery (CRS). STUDY DESIGN In a modified Delphi process, a panel of 15 colorectal surgeons developed a consensus on intraoperative technical/surgical aspects of SSI prevention undertaken by surgical personnel during CRS using information from a targeted literature review and expert opinion. Consensus was developed with up to three rounds per topic, with a prespecified threshold of ≥70% agreement. RESULTS In 3 Delphi rounds, the 15 panelists achieved consensus on 16 evidence-based statements. The consensus panel supported the use of wound protectors/retractors, sterile incision closure tray, preclosure glove change, and antimicrobial sutures in reducing SSI along with wound irrigation with aqueous iodine and closed-incision negative pressure wound therapy in high-risk, contaminated wounds. CONCLUSIONS Using a modified Delphi method, consensus has been achieved on a tailored set of recommendations on technical/surgical aspects that should be considered by surgical personnel during CRS to reduce the risk of SSI, particularly in areas where the evidence base is controversial or lacking. This document forms the basis for ongoing evidence for the topics discussed in this article or new topics based on newly emerging technologies in CRS.
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Affiliation(s)
- Jaime Ruiz-Tovar
- From the Department of Surgery, Universidad Rey Juan Carlos, Madrid, Spain (Ruiz-Tovar)
| | - Marja A Boermeester
- the Department of Surgery, Free University Hospital, Amsterdam, The Netherlands (Boermeester)
| | - Liliana Bordeianou
- the Department of Surgery, Massachusetts General Hospital, Boston, MA (Bordeianou)
| | - George J Chang
- the Department of Colon and Rectal Surgery, The University of Texas, MD Anderson Cancer Center, Houston, TX (Chang)
| | - Emre Gorgun
- the Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH (Gorgun)
| | - Christoph Justinger
- the Department of General and Visceral Surgery, Klinikum Karlsruhe, Karlsruhe, Germany and Albert-Ludwigs-University Freiburg, Freiburg, Germany (Justinger)
| | - Elise H Lawson
- the Division of Colorectal Surgery, Department of Surgery, University of Wisconsin, Madison, WI (Lawson)
| | - David J Leaper
- Emeritus Professor of Surgery, University of Newcastle, Newcastle upon Tyne, UK (Leaper)
| | - Najjia N Mahmoud
- the Division of Colon and Rectal Surgery, University of Pennsylvania, Philadelphia, PA (Mahmoud)
| | - Christopher Mantyh
- the Department of Surgery, Duke University Medical Center, Durham, NC (Mantyh)
| | - Michael F McGee
- the Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL (McGee)
| | - Valentine Nfonsam
- the Department of Surgery, University of Arizona, Tucson, AZ (Nfonsam)
| | - Ines Rubio-Perez
- the General Surgery Department, Colorectal Surgery Unit, La Paz University Hospital, Madrid, Spain (Rubio-Perez)
| | - Elizabeth C. Wick
- the Department of Surgery, University of California, San Francisco, San Francisco, CA (Wick)
| | - Traci L Hedrick
- the Department of Surgery, University of Virginia Health System, Charlottesville, VA (Hedrick)
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Enz A, Kostuj T, Warnke P, Osmanski-Zenk K, Mittelmeier W, Klinder A. Intraoperative damage to surgical gloves during various operations on the musculoskeletal system: a multicenter study. Arch Orthop Trauma Surg 2022; 142:57-65. [PMID: 32862266 PMCID: PMC8732942 DOI: 10.1007/s00402-020-03594-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/16/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Various orthopedic surgical procedures cause mechanical stress for gloves. In some cases, sharp-edged objects impact on the glove surfaces. The systematic description of lesions is still missing. METHODS 2289 gloves from 409 surgeries [primary hip and knee arthroplasties (PA), revisions arthroplasties (RA) and arthroscopic shoulder, hip and knee surgery (AY)] from 3 clinics were examined for lesions using water tightening test according to the European norm EN 455-1. RESULTS Arthroscopies showed the lowest rate of operations with damaged gloves (6.9%). Depending on clinic, 32.7% and 59.2% of PA surgeries generated damaged gloves, while in RA, these numbers rose to 76.0% and 72.8%, respectively. In PA and RA, the most affected finger was the index finger, whereas in arthroscopies, more damage occurred on the middle finger and the thumb. The size of the lesions was rather small with the vast majority being 1 mm or 2 mm in size. CONCLUSION All investigated interventions led to glove lesions. With increasing mechanical stress, the number of glove defects increased. EN 455 does not account for the intraoperative tear risk. Stricter requirements for gloves should be introduced. Glove change intervals should be defined and implemented, and new materials should be developed.
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Affiliation(s)
- Andreas Enz
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, Rostock, Germany.
| | - Tanja Kostuj
- Orthopädisch-Traumatologisches Zentrum, St. Marien-Hospital Hamm, Hamm, Germany
| | - Philipp Warnke
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsmedizin Rostock, Rostock, Germany
| | - Katrin Osmanski-Zenk
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, Rostock, Germany
| | - Wolfram Mittelmeier
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, Rostock, Germany
| | - Annett Klinder
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, Rostock, Germany
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Wistrand C, Falk-Brynhildsen K, Sundqvist AS. Important interventions in the operating room to prevent bacterial contamination and surgical site infections. Am J Infect Control 2021; 50:1049-1054. [PMID: 34971709 DOI: 10.1016/j.ajic.2021.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/22/2021] [Accepted: 12/22/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND The aim of this study was to explore interventions that Swedish operating room (OR) nurses considered important for the prevention of bacterial contamination and surgical site infections (SSIs). METHODS A web-based cross-sectional survey with an open-ended question was answered by OR nurses and analyzed using summative content analysis and descriptive statistics. RESULTS The OR nurses (n = 890) worked within 11 surgical specialties and most of them worked at university hospitals (37%) or county hospitals (53%). The nurses described twelve important interventions to prevent bacterial contamination and SSI: skin disinfection (25.9%), the OR environment (18.2%), aseptic technique (16.4%), OR clothes (13.4%), draping (9.8%), preparation (6.1%), dressing (3.6%), basic hygiene (3.4%), normothermia (2.1%), communication (0.7%), knowledge (0.3%), and work strategies (0.2%). DISCUSSION Skin disinfection was considered the most important intervention in order to prevent bacterial contamination and SSI. The responses indicated that many OR nurses believed the patients' skin to be sterile after the skin disinfection process. This is not a certainty, but skin disinfection does significantly decrease the amount of bacterial growth. CONCLUSIONS This study shows that many OR nurses' interventions are in line with recommendations. Although, knowledge regarding the effect of skin disinfection needs further research, and continued education.
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Matsuoka S, Kondo T, Seishima R, Okabayashi K, Tsuruta M, Shigeta K, Ishida T, Hasegawa H, Kitagawa Y. Surgical glove perforation during laparoscopic colorectal procedures. Surg Endosc 2021; 36:3489-3494. [PMID: 34382122 PMCID: PMC8356683 DOI: 10.1007/s00464-021-08670-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 07/29/2021] [Indexed: 11/18/2022]
Abstract
Background It has been reported that in conventional open surgery, approximately 10% of surgical gloves are perforated during surgery without being noticed. To protect both the patient and medical staff from harm, double gloving or changing gloves routinely at certain intervals during surgery is recommended. However, whether these protective measures are also necessary for laparoscopic colorectal surgery is unknown because the actual perforation rate during laparoscopic procedures is unclear. Methods Seventy-seven laparoscopic colorectal surgeries were evaluated, and a total of 616 surgical gloves used in the surgeries were collected for analysis. The presence of glove perforation was tested by the standard water-leak test method (EN455-1). Results Seven perforations were detected (1.1%). The duration of the laparoscopic procedure was not a statistically significant risk factor for glove perforation (p = 0.41). Postoperative surgical site infections (SSIs) were observed in 12 cases (15.6%), but there was no significant correlation between the presence of glove perforation and SSI (p = 0.92). According to the bacterial cultivation results, the majority of causative agents of SSI were enterobacteria, which belong to the major gut flora. Conclusion Although the perforation rate was considerably lower than that in open surgery, surgical glove perforation occurred during laparoscopic procedures. Double gloving in laparoscopic colorectal surgery is recommended not to prevent SSI but to protect medical workers from harmful infections after direct contact with the patient.
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Affiliation(s)
- Shinsei Matsuoka
- Department of Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Takayuki Kondo
- Department of Surgery, Kawasaki Municipal Hospital, Kawasaki, Japan
| | - Ryo Seishima
- Department of Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Koji Okabayashi
- Department of Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Masashi Tsuruta
- Department of Surgery, Faculty of Medicine, International University of Health and Welfare, Narita, Japan
| | - Kohei Shigeta
- Department of Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Takashi Ishida
- Department of Surgery, Faculty of Medicine, International University of Health and Welfare, Narita, Japan
| | - Hirotoshi Hasegawa
- Department of Surgery, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
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Scheer VM, Jungeström MB, Serrander L, Kalén A, Scheer JH. Benzoyl peroxide treatment decreases Cutibacterium acnes in shoulder surgery, from skin incision until wound closure. J Shoulder Elbow Surg 2021; 30:1316-1323. [PMID: 33545336 DOI: 10.1016/j.jse.2020.12.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 12/11/2020] [Accepted: 12/17/2020] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Most surgical site infections after shoulder surgery are caused by Cutibacterium acnes. Topically applied benzoyl peroxide (BPO) has for years been used to decrease the skin load of C acnes in treatment of acne vulgaris. The purpose of this study was to examine this effect on bacterial colonization in patients subjected to elective shoulder surgery at different stages of the procedure. METHODS A total of 100 patients scheduled for primary elective open shoulder surgery were randomized to prepare either with BPO or according to local guidelines-with soap (control group). Four skin swabs were taken in a standardized manner at different times, before and after surgical skin preparation, 1 in dermis, and finally after the skin was sutured. Before skin incision, 5 punch biopsies (3 mm in diameter and maximum 4 mm deep) were retrieved spaced 2 cm apart in the planned skin incision. On culturing, quantification of C acnes was made by serial dilutions. RESULTS Men had a 5-fold higher amount of C acnes on untreated skin. Treatment with BPO considerably lowered this count (P = .0001) both before and after skin disinfection compared to the control group. This positive effect of BPO persisted until skin closure, the point at which some recolonization of C acnes had occurred, but to a higher degree in the control group (P = .040). CONCLUSION Preoperative BPO treatment of the shoulder may be an effective method to decrease bacterial skin load of C acnes from skin incision until wound closure.
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Affiliation(s)
- Vendela M Scheer
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | | | - Lena Serrander
- Division of Clinical Microbiology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Anders Kalén
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Orthopedics, Linköping University, Linköping, Sweden
| | - Johan H Scheer
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Orthopedics, Linköping University, Linköping, Sweden
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13
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DE SOUZA ARAÚJO IJ, CARLETTI TM, MEDEIROS FDCDD, LIMA IPC. Rubbing ethanol and time of use: critical factors compromising latex gloves structure. REVISTA DE ODONTOLOGIA DA UNESP 2021. [DOI: 10.1590/1807-2577.02321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Introduction Personal protective equipment is mandatory to protect patients and professionals from diseases, especially in the dental environment. The risk of gloves micro-perforations is imminent when using sharp instruments or cleaning them up during lengthy clinical procedures. Objective This study evaluated the integrity of sterile and non-sterile gloves before clinical use and clarified whether friction with disinfectant solution modifies surface morphology and integrity. Material and method Samples of gloves from four different brands were divided into two groups: (1) Sterile surgical gloves (n=260) and (2) Non-sterile gloves (n=260). They were scissored and placed in Ostby’s arch so that three solutions - distilled water, ethanol 70°, ethanol 96° - were rubbed with a cotton swab. After 30s, 5, 10, and 15 minutes of solution rubbing, samples were verified by a Scanning Electron Microscope. The pore sizes were measured by Image J software. Result Regardless of the brands, all gloves have been significantly affected by solutions and assessment periods. In general, remarkable changes were evident with ethanol 70° and 96°, and higher pore diameters were observed compared to distilled water. Conclusion Rubbing disinfectant solutions increases gloves’ pores sizes, and time negatively influenced its quality.
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Larsson H, Hälleberg-Nyman M, Friberg Ö, Falk-Brynhildsen K. Perioperative routines and surgical techniques for saphenous vein harvesting in CABG surgery: a national cross-sectional study in Sweden. J Cardiothorac Surg 2020; 15:5. [PMID: 31915020 PMCID: PMC6950860 DOI: 10.1186/s13019-020-1056-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 01/03/2020] [Indexed: 11/17/2022] Open
Abstract
Background The saphenous vein is the most commonly used conduit for coronary artery bypass grafting (CABG). Wound healing complications related to saphenous vein harvesting are common, with reported surgical site infection rates ranging from 2 to 20%. Patients’ risk factors, perioperative hygiene routines, and surgical technique play important roles in wound complications. Here we describe the perioperative routines and surgical methods of Swedish operating theatre (OT) nurses and cardiac surgeons. Methods A national cross-sectional survey with descriptive design was conducted to evaluate perioperative hygiene routines and surgical methods associated with saphenous vein harvesting in CABG. A web-based questionnaire was sent to OT nurses and cardiac surgeons at all eight hospitals performing CABG surgery in Sweden. Results Responses were received from all hospitals. The total response rate was 62/119 (52%) among OT nurses and 56/111 (50%) among surgeons. Chlorhexidine 5 mg/mL in 70% ethanol was used at all eight hospitals. The OT nurses almost always (96.8%) performed the preoperative skin disinfection, usually for three to 5 minutes. Chlorhexidine was also commonly used before dressing the wound. Conventional technique was used by 78.6% of the surgeons, “no-touch” by 30.4%, and both techniques by 9%. None of the surgeons used endoscopic vein harvesting. Type of suture and technique used for closing the wound differed markedly between the centres. Conclusions In this article we present insights into the hygiene routines and surgical methods currently used by OT nurses and cardiac surgeons in Sweden. The results indicate both similarities and differences between the centres. Local traditions might be the most important factors in determining which procedures are employed in the OT. There is a lack of evidence-based hygiene routines and surgical methods.
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Diedrich S, Scholz S, Below H, Baguhl R, Heidecke CD, Papke R, Seifert U, Assadian O, Kramer A. Influence of Bio-sorb ® Cream on Sweat Production and Efficacy of Surgical Hand Antisepsis Under Surgical Gloves. Surg Infect (Larchmt) 2019; 21:293-298. [PMID: 31770084 DOI: 10.1089/sur.2019.098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Aim: Since the introduction of surgical gloves, one of the main challenges has been to improve donning and wearability. For the wearer, the formation of "glove juice" is problematic. To improve gliding properties for donning the gloves and absorbing sweat, in 1963 Bio-sorb® cream: sterile powder cream (Johnson & Johnson Medical, Gargrave, Skipton, United Kingdom) was introduced. Individuals subjectively reported a reduction of sweat production inside the glove, however, the actual effect on sweat accumulation and surgical hand antisepsis has not been examined. Methods: Twenty-six volunteers were used in a study designed to examine the effect of a sterile hand cream applied after surgical hand antisepsis on sweat accumulation inside surgical gloves. A woven cotton glove was worn underneath the surgical glove. Weight differences were used to determine the amount of sweat produced. The influence of Bio-sorb on the efficacy of surgical hand antisepsis was tested immediately and after 90 minutes of wear time by the sampling technique as per EN 12791 and by bacterial analysis of glove juice according to tentative final monograph 1994. Results and Discussion: The amount of sweat produced inside the glove was not reduced by the cream (1.07 ± 0.5 g versus control 1.03 ± 0.5 g; p = 0.75). Considering different skin conditions, it may be possible that some wearers might subjectively observe decreased sweat production after using Bio-sorb cream before donning surgical gloves, because sweat production did decrease in 10 of 26 test subjects. Bio-sorb cream did not affect the efficacy of surgical hand antisepsis either immediately or after 90 minutes. Conclusion: Because of possible risks of contamination of the surgical site with cornstarch from Bio-sorb cream in the case of a glove breach and the failed statistical proof of reduced sweat production, the use of Bio-sorb cream should not to be recommended.
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Affiliation(s)
- Stephan Diedrich
- Department of Surgery, Clinic of General, Visceral, Vascular and Thoracic Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Sonja Scholz
- Institute for Hygiene and Environmental Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Harald Below
- Institute for Hygiene and Environmental Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Romy Baguhl
- Institute for Hygiene and Environmental Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Claus-Dieter Heidecke
- Department of Surgery, Clinic of General, Visceral, Vascular and Thoracic Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Roald Papke
- Institute for Hygiene and Environmental Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Ulrike Seifert
- Institute for Hygiene and Environmental Medicine, University Medicine Greifswald, Greifswald, Germany.,Friedrich Loeffler Institute of Medical Microbiology, University Medicine Greifswald, Greifswald, Germany
| | - Ojan Assadian
- Department for Infection Control and Hospital Epidemiology, Medical University of Vienna, Vienna, Austria.,Hospital Landesklinikum Neunkirchen, Neunkirchen, Austria
| | - Axel Kramer
- Institute for Hygiene and Environmental Medicine, University Medicine Greifswald, Greifswald, Germany
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Idota N, Nakamura M, Akasaka Y, Tsuboi H, Bando R, Ikegaya H. Perforation rates in double latex gloves and protective effects of outer work gloves in a postmortem examination room: A STROBE-compliant study. Medicine (Baltimore) 2019; 98:e16348. [PMID: 31277191 PMCID: PMC6635159 DOI: 10.1097/md.0000000000016348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Medical staff face the risk of exposure to blood-borne infectious agents during postmortem examinations. This study investigated the effectiveness of non-slip work gloves worn over 2 layers of surgical latex gloves (outer and inner gloves) as a means of reducing hand and finger injuries. Complete sets of outer and inner gloves worn during postmortem examinations were collected from participating forensic staff. Latex gloves were categorized into 2 groups based on the users' actions during the examination: the wearing group if the wearer wore their work gloves continuously without interruption, and the taking-off group if the wearer removed them at least once. Perforation rates, locations, and shapes were compared between these groups. Outer-glove perforation occurred significantly more often in the taking-off group (n = 102 pairs) than in the wearing group (n = 91 pairs) (30.4% vs 3.8%, P < .001). Inner-glove perforation occurred at rates of 2.0% and 0.5% (P = .38), respectively. The wearers did not incur hand or finger injuries. Perforation rates were similar between the dominant and non-dominant hands (P = .18). Regarding location, gloves were punctured most frequently at the thumb, followed by the index finger. Most examiners (85.6%) did not notice the perforation when the damage occurred. Therefore, we could not confirm that a specific operation within a set of plural operations affected the rate of perforation. Additionally, we could not prove a relationship between glove perforation and each operation performed with/without work gloves. The perforation appearances varied greatly in shape and size, suggesting multiple causes of perforation. The continuous (i.e., uninterrupted) wear of work gloves during postmortem examinations reduced the incidence of perforations in both latex glove layers and thus reduced the risk of hand and finger injury.
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Abstract
BACKGROUND The alcohol rub has been proposed as an alternative to the traditional surgical scrub in preparing the hands for surgical procedures. Few reviews have examined critically the evidence that favors or discredits the use of the alcohol rub instead of the traditional scrub. METHODS A review of available published literature was undertaken to define the evidence for the best methods for hand preparation before surgical procedures. The focus of this literature review was to compare the bacteriologic and clinical outcomes of conventional surgical scrubbing of the hands compared with alcohol rubs. RESULTS The bacteriologic studies of the hands after the conventional scrub versus the alcohol rub demonstrated consistently comparable or superior reductions in bacterial presence on the hand with the alcohol rub. Only four clinical studies were identified that compared the scrub versus the rub in the frequency of surgical site infections. No difference in surgical site infections were identified. CONCLUSIONS The alcohol rub appears to have comparable results to the surgical scrub and is a reasonable alternative in preparation of the hands for surgical procedures.
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Affiliation(s)
- Donald E Fry
- 1 Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,2 Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
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Scholz R, Hönning A, Seifert J, Spranger N, Stengel D. Effectiveness of architectural separation of septic and aseptic operating theatres for improving process quality and patient outcomes: a systematic review. Syst Rev 2019; 8:16. [PMID: 30626433 PMCID: PMC6325836 DOI: 10.1186/s13643-018-0937-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 12/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Architectural division of aseptic and septic operating theatres is a distinct structural feature of surgical departments in Germany. Internationally, hygienists and microbiologists mainly recommend functional separation (i.e. aseptic procedures first) without calling for separate operating floors and rooms. However, patients with severe musculoskeletal infections (e.g. joint empyema, spondylodiscitis, deep implant-associated infections) may benefit from the permanent availability of septic operating capacities without delay caused by an ongoing aseptic surgical program. A systematic literature review on the influence of a structural separation of septic and aseptic operating theatres on process and/or outcome quality has not yet been conducted. METHODS Systematic literature search in PubMed MEDLINE, Ovid Embase, CINAHL and the Cochrane Library, screening of referenced citations, and assessment of grey literature. RESULTS A total of 572 articles were found through the systematic literature search. No head-to-head studies (neither randomised, quasi-randomised nor observational) were identified which examined the impact of structural separation of septic and aseptic operating theatres on process and/or outcome quality. CONCLUSIONS This review did not identify evidence in favour nor against architectural separation of septic or aseptic operating theatre. Specifically, there is no evidence of a harmful effect of architectural separation. Unless prospective studies, ideally randomised trials, will be available, it is unjustified to call for abolishing established hospital structures. Future investigations must address patient-centered endpoints, surgical site infections, process quality and hospital economy. SYSTEMATIC REVIEW REGISTRATION PROSPERO (International prospective register of systematic reviews): CRD42018086568.
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Affiliation(s)
- Romy Scholz
- Centre for Clinical Research, BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
| | - Alexander Hönning
- Centre for Clinical Research, BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
| | - Julia Seifert
- Department of Trauma and Orthopaedic Surgery, BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
| | - Nikolai Spranger
- Department of Trauma and Orthopaedic Surgery, BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
| | - Dirk Stengel
- Centre for Clinical Research, BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
- Department of Trauma and Orthopaedic Surgery, BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
- Hospital Group of the Statutory Accident Insurance, Berlin, Germany
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Enz A, Klinder A, Mittelmeier H, Kundt G, Mittelmeier W, Zaatreh S. Damages with High Consequences: Analysis of Perforations in Surgical Latex Operation Gloves from Orthopedic Surgeries. Eur J Microbiol Immunol (Bp) 2018; 8:159-162. [PMID: 30719334 PMCID: PMC6348699 DOI: 10.1556/1886.2018.00028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 10/14/2018] [Indexed: 11/19/2022] Open
Abstract
Introduction To prevent surgical site infections (SSIs) during operation, the use of sterile surgical latex gloves is common. The aim of this study was to examine the damage of the gloves in surgeries with different mechanical stress and the influence on the kind of damages. Gloves were collected during primary arthroplasty, revision arthroplasty (hip and knee), and arthroscopy (shoulder, hip, and knee). Materials and methods Surgical latex operation gloves were collected from surgeons after the operation and were tested with watertightness test (ISO EN 455-1:2000). Results A total of 1460 surgical gloves were retrieved from 305 elective operations. On average, 15.9% of the gloves showed postoperative lesions, with the highest incidence occurring in revision arthroplasty with 25%. In primary and revision arthroplasty, the index finger of the dominant hand was most frequently affected (62.7% and 58.6%); in contrast, gloves from arthroscopies had most lesions on thumb and middle finger (42.9% each). Tear and perforation size differed from ≤1 mm to >5 mm, and primary and revision arthroplasty showed bigger damages. Conclusions Surgical gloves have a high malfunction, which increases with growing mechanical stress. A high rate of perforation occurred mostly in revision arthroplasty. Breaching the integrity of the gloves, especially by high mechanical loads, could lead to an increased rate of infection.
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Affiliation(s)
- Andreas Enz
- Department of Orthopedics, University Medicine Rostock, Rostock, Germany
| | - Annett Klinder
- Department of Orthopedics, University Medicine Rostock, Rostock, Germany
| | - Hannah Mittelmeier
- Department of Orthopedics, University Medicine Rostock, Rostock, Germany
| | - Günther Kundt
- Institutes for Biostatistics and Informatics in Medicine and Ageing Research, University of Rostock, Rostock, Germany
| | | | - Sarah Zaatreh
- Department of Orthopedics, University Medicine Rostock, Rostock, Germany
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20
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Vallejo RBDB, Fernandez DS, Cervera LA, Aragón LM, Iglesias MEL, Yurrita LRC, Lopez DL. Effectiveness of surgical hand antisepsis using chlorhexidine digluconate and parachlorometaxylenol hand scrub: Cross-over trial. Medicine (Baltimore) 2018; 97:e12831. [PMID: 30334981 PMCID: PMC6211836 DOI: 10.1097/md.0000000000012831] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Chlorhexidine and parachlorometaxylenol (PCMX) are antiseptics recommended for surgical hand antisepsis. To our knowledge, PCMX has not been evaluated for bactericidal efficacy "in vivo. METHODS We conducted a randomized, double-blind, controlled crossover trial to compare the bacterial loads on fingertips and fingernails under laboratory conditions after use of antiseptic test products, including chlorhexidine digluconate 4%, PCMX 3%, and a reference solution of propan-1-ol 60% (P-1). We assessed bacterial load after a prewash with soft soap, immediately after application of an antiseptic, and 3 hours after application and wearing of sterile, powder-free gloves. Our procedures followed those specified by European Norm (EN) 12791 for evaluating surgical hand antiseptics and using cotton swab for fingertips and fingernails. RESULTS Chlorhexidine digluconate 4% and PCMX 3% did not decrease bacterial load on the hands. The bactericidal performances of chlorhexidine digluconate 4% and PCMX 3% did not differ significantly. Chlorhexidine digluconate 4% and PCMX 3% increased bacterial load on the fingertips after participants had worn gloves for 3 hours. Fingernails had greater bacterial loads than skin on the fingertips. CONCLUSIONS Chlorhexidine digluconate 4% and PCMX 3% had similar bactericidal efficacy, but they failed to meet the EN 12791 efficacy standard. Fingernails should be a particular focus of antisepsis in preparation for surgery.The trial was registered at ClinicalTrials.gov (ID: NCT02500758).
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21
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Glove Perforation in Orthopaedics: Probability of Tearing Gloves During High-Risk Events in Trauma Surgery. J Orthop Trauma 2018; 32:474-479. [PMID: 29889823 DOI: 10.1097/bot.0000000000001233] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the risk of glove perforation during common maneuvers or events in trauma-related orthopaedic surgical procedures. METHODS Four investigators executed 6 high-risk maneuvers in a simulated laboratory setting. Alternative techniques were also performed for most maneuvers. Glove integrity was examined by 2 standard methods of fluid leak testing. The rates of perforation were compared between techniques using χ and Fisher exact tests. RESULTS Investigators were only able to identify 14.3% of perforations. Cleaning drill bit flutes by hand had the highest overall tear rate (85%). Catching a glove along the guide wire when passing a cannulated drill bit resulted in a 50% perforation rate. Catching a glove around a rotating drill shaft had a tear rate of 40%. Palpating the end of a flexible nail cut with a wire cutter had a significantly higher perforation rate than a nail cut with a proprietary, nail-specific tool (35% vs. 5%, P = 0.022). Blind digital fracture reduction had a tear rate that was not statistically different than directly visualizing the reduction (20% vs. 15%, P = 0.5). Inserting screws while stabilizing the threads with one's fingers resulted in a perforation rate of 15%. CONCLUSIONS Orthopaedic surgeons should be aware that microperforation of surgical gloves often goes undetected and should consider modifying or using alternative techniques when performing certain surgical maneuvers. The results of this study can be used by orthopaedic and surgical first assist training programs to promote safe surgical practice.
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Edmiston CE, Leaper DJ, Barnes S, Jarvis W, Barnden M, Spencer M, Graham D, Johnson HB. An Incision Closure Bundle for Colorectal Surgery: 2.0 www.aornjournal.org/content/cme. AORN J 2018; 107:552-568. [PMID: 29708612 DOI: 10.1002/aorn.12120] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Wistrand C, Falk-Brynhildsen K, Nilsson U. National Survey of Operating Room Nurses' Aseptic Techniques and Interventions for Patient Preparation to Reduce Surgical Site Infections. Surg Infect (Larchmt) 2018; 19:438-445. [PMID: 29672240 DOI: 10.1089/sur.2017.286] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Surgical site infection (SSI), the third most common type of nosocomial infection in Sweden, is a patient injury that should be prevented. Methods of reducing SSIs include, for instance, disinfecting the skin, maintaining body temperature, and ensuring an aseptic environment. Guidelines for most of these interventions exist, but there is a lack of studies describing to what extent the preventive interventions have been implemented in clinical practice. We describe the daily clinical interventions Swedish operating room (OR) nurses performed to prevent SSIs following national guidelines. METHODS A descriptive cross-sectional study using a Web-based questionnaire was conducted among Swedish OR nurses. The study-specific questionnaire included 32 items addressing aspects of the interventions performed to prevent SSI, such as preparation of the patient skin (n = 12), maintenance of patient temperature (n = 10), and choice of materials (n = 10). The response format included both closed and open-ended answers. RESULTS In total, 967 nurses (43% of the total) answered the questionnaire; of these, 77 were excluded for various reasons. The proportions of the OR nurses who complied with the preventive interventions recommended in the national guidelines were high: skin disinfection solution (93.5%), sterile drapes (97.4%) and gowns (83.8%) for single use, and the use of double gloves (73.0%). However, when guidelines were lacking, some interventions differed, such as the frequency of glove changes and the use of adhesive plastic drapes. CONCLUSION To standardize OR nurses' preventive interventions, implementing guidelines seems to be the key priority. Overall, OR nurses have high compliance with the national guidelines regarding interventions to prevent bacterial growth and SSIs in the surgical patient. However, when guidelines are lacking, the preventive interventions lose conformity.
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Affiliation(s)
- Camilla Wistrand
- 1 Department of Cardiothoracic and Vascular Surgery, University Hospital, Örebro University , Örebro, Sweden
| | - Karin Falk-Brynhildsen
- 2 School of Health Sciences, Faculty of Medicine and Health, Örebro University , Örebro, Sweden
| | - Ulrica Nilsson
- 1 Department of Cardiothoracic and Vascular Surgery, University Hospital, Örebro University , Örebro, Sweden .,3 Centre for Perioperative Nursing , Örebro University
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Harnoss JC, Assadian O, Kramer A, Probst P, Müller-Lantzsch C, Scheerer L, Bruckner T, Diener MK, Büchler MW, Ulrich AB. Comparison of chlorhexidine–isopropanol with isopropanol skin antisepsis for prevention of surgical-site infection after abdominal surgery. Br J Surg 2018; 105:893-899. [DOI: 10.1002/bjs.10793] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 09/11/2017] [Accepted: 11/17/2017] [Indexed: 11/06/2022]
Abstract
Abstract
Background
Prevention of surgical-site infection (SSI) has received increasing attention. Clinical trials have focused on the role of skin antisepsis in preventing SSI. The benefit of combining antiseptic chlorhexidine with alcohol has not been compared with alcohol-based skin preparation alone in a prospective controlled clinical trial.
Methods
Between August and October 2014, patients undergoing abdominal surgery received preoperative skin antisepsis with 70 per cent isopropanol (PA). Those treated between November 2014 and January 2015 received 2 per cent chlorhexidine with 70 per cent isopropanol (CA). The primary endpoint was SSI on postoperative day (POD) 10, which was evaluated using univariable analysis, and a multivariable logistic regression model correcting for known independent risk factors for SSI. The study protocol was published in the German Registry of Clinical Studies (DRKS00011174).
Results
In total, 500 patients undergoing elective midline laparotomy were included (CA 221, PA 279). The incidence of superficial and deep SSIs was significantly different on POD 10: 14 of 212 (6·6 per cent) among those treated with CA and 32 of 260 (12·3 per cent) in those who received PA (P = 0·038). In the multivariable analysis, skin antisepsis with CA was an independent factor for reduced incidence of SSI on POD 10 (P = 0·034).
Conclusion
This study showed a benefit of adding chlorhexidine to alcohol for skin antisepsis in reducing early SSI compared with alcohol alone.
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Affiliation(s)
- J C Harnoss
- Department of General, Visceral and Transplantation Surgery and Study Centre of the German Surgical Society, University Hospital Heidelberg, Heidelberg, Germany
| | - O Assadian
- Department for Hospital Epidemiology and Infection Control, Medical University of Vienna, Vienna, Austria
| | - A Kramer
- Institute of Hygiene and Environmental Medicine, University Medicine Greifswald, Greifswald, Germany
| | - P Probst
- Department of General, Visceral and Transplantation Surgery and Study Centre of the German Surgical Society, University Hospital Heidelberg, Heidelberg, Germany
| | - C Müller-Lantzsch
- Department of General, Visceral and Transplantation Surgery and Study Centre of the German Surgical Society, University Hospital Heidelberg, Heidelberg, Germany
| | - L Scheerer
- Department of General, Visceral and Transplantation Surgery and Study Centre of the German Surgical Society, University Hospital Heidelberg, Heidelberg, Germany
| | - T Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - M K Diener
- Department of General, Visceral and Transplantation Surgery and Study Centre of the German Surgical Society, University Hospital Heidelberg, Heidelberg, Germany
| | - M W Büchler
- Department of General, Visceral and Transplantation Surgery and Study Centre of the German Surgical Society, University Hospital Heidelberg, Heidelberg, Germany
| | - A B Ulrich
- Department of General, Visceral and Transplantation Surgery and Study Centre of the German Surgical Society, University Hospital Heidelberg, Heidelberg, Germany
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Prävention postoperativer Wundinfektionen. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018; 61:448-473. [PMID: 29589090 DOI: 10.1007/s00103-018-2706-2] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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26
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Tlili MA, Belgacem A, Sridi H, Akouri M, Aouicha W, Soussi S, Dabbebi F, Ben Dhiab M. Evaluation of surgical glove integrity and factors associated with glove defect. Am J Infect Control 2018; 46:30-33. [PMID: 28893444 DOI: 10.1016/j.ajic.2017.07.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 07/20/2017] [Accepted: 07/20/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Surgical glove perforation may expose both patients and staff members to severe complications. This study aimed to determine surgical glove perforation rate and the factors associated with glove defect. MATERIAL AND METHODS This descriptive cross-sectional study was conducted between January and March 2017 at a Tunisian university hospital center in 3 different surgical departments: urology, maxillofacial, and general and digestive. The gloves were collected and tested to detect perforations using the water-leak test as described in European Norm NF EN 455-1. For percentage comparisons, the χ2 test was used with a significance threshold of 5%. RESULTS A total of 284 gloves were collected. Of these, 47 were found to be perforated, a rate of 16.5%. All perforations were unnoticed by the surgical team members. The majority of perforated gloves (61.7%) were collected after urology procedures (P = .00005), 77% of perforated gloves were detected when the duration of the procedure exceeded 90 minutes (P = .001), and 96% were from brand A, which were the thicker gloves (P = .015). CONCLUSIONS This study highlighted an important problem neglected by surgical teams. The findings reaffirm the importance of double-gloving and changing gloves in surgeries of more than 90 minutes' duration.
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Affiliation(s)
- Mohamed Ayoub Tlili
- Health Sciences Research, Higher School of Health Sciences and Techniques of Sousse, University of Sousse, Tunisia.
| | - Amina Belgacem
- Health Sciences Research, Higher School of Health Sciences and Techniques of Sousse, University of Sousse, Tunisia
| | - Haifa Sridi
- Higher School of Health Sciences and Techniques of Sousse, University of Sousse, Tunisia
| | - Maha Akouri
- Higher School of Health Sciences and Techniques of Sousse, University of Sousse, Tunisia
| | - Wiem Aouicha
- Health Sciences Research, Higher School of Health Sciences and Techniques of Sousse, University of Sousse, Tunisia
| | - Sonia Soussi
- Health Sciences Research, Higher School of Health Sciences and Techniques of Tunis, University of Tunis El Manar, Tunisia
| | - Faten Dabbebi
- Department of Occupational Medicine, University Hospital Center of Sahloul, Tunisia
| | - Mohamed Ben Dhiab
- Health Sciences Research, Higher School of Health Sciences and Techniques of Sousse, University of Sousse, Tunisia
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Biermann NM, McClure JT, Sanchez J, Doyle AJ. Observational study on the occurrence of surgical glove perforation and associated risk factors in large animal surgery. Vet Surg 2017; 47:212-218. [DOI: 10.1111/vsu.12757] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 06/11/2017] [Accepted: 06/22/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Nora M. Biermann
- Department of Health Management; Atlantic Veterinary College, University of Prince Edward Island; Charlottetown Prince Edward Island Canada
| | - JT. McClure
- Department of Health Management; Atlantic Veterinary College, University of Prince Edward Island; Charlottetown Prince Edward Island Canada
| | - Javier Sanchez
- Department of Health Management; Atlantic Veterinary College, University of Prince Edward Island; Charlottetown Prince Edward Island Canada
| | - Aimie J. Doyle
- Department of Health Management; Atlantic Veterinary College, University of Prince Edward Island; Charlottetown Prince Edward Island Canada
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Burn MB, Holtorf HL, Smith KM, Bernstein DT, Delgado DA, Prudhomme N, Deavers MT, McCulloch PC, Harris JD. Do Skin Lacerations Imply Tissue Transfer From Surgeon to Patient During Arthroscopic Knot Tying? Arthroscopy 2017; 33:2248-2254. [PMID: 29066268 DOI: 10.1016/j.arthro.2017.07.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 07/27/2017] [Accepted: 07/27/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To use simulated arthroscopic knot tying to assess (1) whether epithelial cells from the surgeon's hands were transmitted to the suture and (2) whether the number of knots tied or the presence of glove tears would correlate with the number of cells transmitted. METHODS Knots were tied in a simulated arthroscopic environment using a nonabsorbable No. 2 suture over a metal hook. The surgeon was double gloved for each knot tied. For each "anchor," a surgeon's knot was tied, followed by 3 reversed half-hitches on alternating posts. Multiple skin lacerations were sustained by the surgeon during each knot-tying session. Gloves were collected after tying 2, 4, or 6 anchors. Gloves were tested for perforation by (1) electroconductivity and (2) saline solution load testing. Cytopathologic ThinPrep analysis was applied and allowed for the number of epithelial cells found on each suture (within 10 high-powered fields) to be counted. Statistical analysis included analysis of variance and logistic regression. RESULTS There was no significant difference in the number of epithelial cells identified in any of the groups compared with the negative control groups (P > .05) or with each other (P > .05). Glove tears were present in 3.3% of gloves (50% in inner and 50% in outer gloves) and 1.7% of gloves (50% in inner and 50% in outer gloves) by electroconductivity and saline solution load testing, respectively. There was no significant association between glove tears and the number of epithelial cells found on the suture (P > .05). CONCLUSIONS Epithelial cells were transmitted to the suture during simulated arthroscopic knot tying. However, despite multiple skin lacerations produced during knot-tying sessions, the number of cells transmitted was not significantly different when compared with the negative controls. The number of cells transmitted did not correlate with the number of knots tied and/or the presence of glove tears. CLINICAL RELEVANCE Skin lacerations on the surgeon's fingers are often noted after arthroscopic knot tying. However, despite these skin lacerations, no skin tissue is transferred across the surgical gloves to the suture itself.
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Affiliation(s)
- Matthew B Burn
- Department of Orthopedics & Sports Medicine, Houston Methodist Hospital, Houston, Texas, U.S.A
| | - Heidi L Holtorf
- Department of Pathology & Genomic Medicine, Houston Methodist Hospital, Houston, Texas, U.S.A
| | - Kevin M Smith
- Department of Orthopedics & Sports Medicine, Houston Methodist Hospital, Houston, Texas, U.S.A
| | - Derek T Bernstein
- Department of Orthopedics & Sports Medicine, Houston Methodist Hospital, Houston, Texas, U.S.A
| | - Domenica A Delgado
- Department of Orthopedics & Sports Medicine, Houston Methodist Hospital, Houston, Texas, U.S.A
| | - Nickarr Prudhomme
- Department of Orthopedics & Sports Medicine, Houston Methodist Hospital, Houston, Texas, U.S.A
| | - Michael T Deavers
- Department of Pathology & Genomic Medicine, Houston Methodist Hospital, Houston, Texas, U.S.A
| | - Patrick C McCulloch
- Department of Orthopedics & Sports Medicine, Houston Methodist Hospital, Houston, Texas, U.S.A
| | - Joshua D Harris
- Department of Orthopedics & Sports Medicine, Houston Methodist Hospital, Houston, Texas, U.S.A..
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Ali S, Wilson A. Effect of poly-hexamethylene biguanide hydrochloride (PHMB) treated non-sterile medical gloves upon the transmission of Streptococcus pyogenes, carbapenem-resistant E. coli, MRSA and Klebsiella pneumoniae from contact surfaces. BMC Infect Dis 2017; 17:574. [PMID: 28814284 PMCID: PMC5559802 DOI: 10.1186/s12879-017-2661-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 08/01/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Reduction of accidental contamination of the near-patient environment has potential to reduce acquisition of healthcare-associated infection(s). Although medical gloves should be removed when soiled or touching the environment, compliance is variable. The use of antimicrobial-impregnated medical gloves could reduce the horizontal-transfer of bacterial contamination between surfaces. AIM Determine the activity of antimicrobial-impregnated gloves against common hospital pathogens: Streptococcus pyogenes, carbapenem-resistant E.coli (CREC), MRSA and ESBL-producing Klebsiella pneumoniae. METHODS Fingerpads (~1cm2) of PHMB-treated and untreated gloves were inoculated with 10 μL (~104 colony-forming-units [cfu]) of test-bacteria prepared in heavy-soiling (0.5%BSA), blood or distilled-water (no-soiling) and sampled after 0.25, 1, 10 or 15 min contact-time. Donor surfaces (~1cm2 computer-keys) contaminated with wet/dry inoculum were touched with the fingerpad of treated/untreated gloves and subsequently pressed onto recipient (uncontaminated) computer-keys. RESULTS Approximately 4.50log10cfu of all bacteria persisted after 15 min on untreated gloves regardless of soil-type. In the absence of soiling, PHMB-treated gloves reduced surface-contamination by ~4.5log10cfu (>99.99%) within 10 min of contact-time but only ~2.5log10 (>99.9%) and ~1.0log10 reduction respectively when heavy-soiling or blood was present. Gloves became highly-contaminated (~4.52log10-4.91log10cfu) when handling recently-contaminated computer-keys. Untreated gloves contaminated "recipient" surfaces (~4.5log10cfu) while PHMB-treated gloves transferred fewer bacteria (2.4-3.6log10cfu). When surface contamination was dry, PHMB gloves transferred fewer bacteria (0.3-0.6log10cfu) to "recipient" surfaces than untreated gloves (1.0-1.9log10; P < 0.05). CONCLUSIONS Antimicrobial-impregnated gloves may be useful in preventing dissemination of organisms in the near-patient environment during routine care. However they are not a substitute for appropriate hand-hygiene procedures.
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Affiliation(s)
- S. Ali
- Clinical Microbiology and Virology, University College London Hospitals NHS Foundation Trust, London, UK
- UCLH Environmental Research Laboratory, University College Hospital, EGA Wing, Level -2, 235 Euston Road, London, NW1 2BU UK
| | - A.P.R. Wilson
- Clinical Microbiology and Virology, University College London Hospitals NHS Foundation Trust, London, UK
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Harnoss JC, Assadian O, Karl Diener M, Müller T, Baguhl R, Dettenkofer M, Scheerer L, Kohlmann T, Heidecke CD, Gessner S, Wolfgang Büchler M, Kramer A. Microbial Load in Septic and Aseptic Procedure Rooms. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 114:465-475. [PMID: 28764834 PMCID: PMC5545629 DOI: 10.3238/arztebl.2017.0465] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 11/25/2016] [Accepted: 05/02/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Highly effective measures to prevent surgical wound infections have been established over the last two decades. We studied whether the strict separation of septic and aseptic procedure rooms is still necessary. METHODS In an exploratory, prospective observational study, the microbial concentration in an operating room without a room ventilating system (RVS) was analyzed during 16 septic and 14 aseptic operations with the aid of an air sampler (50 cm and 1 m from the operative field) and sedimentation plates (1 m from the operative field, and contact culture on the walls). The means and standard deviations of the microbial loads were compared with the aid of GEE models (generalized estimation equations). RESULTS In the comparison of septic and aseptic operations, no relevant differences were found with respect to the overall microbial concentration in the room air (401.7 ± 176.3 versus 388.2 ± 178.3 CFU/m3; p = 0.692 [CFU, colony-forming units]) or sedimentation 1 m from the operative field (45.3 ± 22.0 versus 48.7 ± 18.5 CFU/m2/min; p = 0.603) and on the walls (35.7 ± 43.7 versus 29.0 ± 49.4 CFU/m2/min; p = 0.685). The only relevant differences between the microbial spectra associated with the two types of procedure were a small amount of sedimentation of Escherichia coli and Enterococcus faecalis in septic operations, and of staphylococcus aureus and pseudomonas stutzeri in aseptic operations, up to 30 minutes after the end of the procedure. CONCLUSION These data do not suggest that septic and aseptic procedure rooms need to be separated. In interpreting the findings, one should recall that the study was not planned as an equivalence or non-inferiority study. Wherever patient safety is concerned, high-level safety concepts should only be demoted to lower levels if new and convincing evidence becomes available.
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Affiliation(s)
- Julian-Camill Harnoss
- Department of General, Visceral and Transplantation Surgery and Study Center of the German Surgical Society (SDGC), University of Heidelberg
| | - Ojan Assadian
- Division for Hospital Hygiene, Vienna General Hospital, Medical University Vienna
| | - Markus Karl Diener
- Department of General, Visceral and Transplantation Surgery and Study Center of the German Surgical Society (SDGC), University of Heidelberg
| | - Thomas Müller
- Institute for Hygiene and Environmental Medicine, University of Greifswald
| | - Romy Baguhl
- Institute for Hygiene and Environmental Medicine, University of Greifswald
| | - Markus Dettenkofer
- Institute of Hospital Hygiene und Infection Prevention, Klinikum Konstanz
| | - Lukas Scheerer
- Department of General, Visceral and Transplantation Surgery and Study Center of the German Surgical Society (SDGC), University of Heidelberg
| | | | - Claus-Dieter Heidecke
- Clinic and Outpatient Clinic for Surgery—Department of General Surgery, Visceral, Thoracic and Vascular Surgery, University of Greifswald
| | - Stephan Gessner
- Institute for Hygiene and Environmental Medicine, University of Greifswald
| | - Markus Wolfgang Büchler
- Department of General, Visceral and Transplantation Surgery and Study Center of the German Surgical Society (SDGC), University of Heidelberg
| | - Axel Kramer
- Institute for Hygiene and Environmental Medicine, University of Greifswald
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Abstract
Sterile technique is an essential patient safety principle that reduces the risk of microbial transmission to patients during surgery. The ability to establish and maintain a sterile environment is an important skill for all perioperative team members. Understanding the principles of sterile technique is crucial for anyone entering the perioperative environment. This Back to Basics article reviews sterile technique and the importance of all perioperative team members adhering to aseptic principles.
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Zaatreh S, Enz A, Klinder A, König T, Mittelmeier L, Kundt G, Mittelmeier W. Prospective data collection and analysis of perforations and tears of latex surgical gloves during primary endoprosthetic surgeries. GMS HYGIENE AND INFECTION CONTROL 2017; 11:Doc25. [PMID: 28066701 PMCID: PMC5175006 DOI: 10.3205/dgkh000285] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Introduction: Surgical gloves are used to prevent contamination of the patient and the hospital staff with pathogens. The aim of this study was to examine the actual effectiveness of gloves by examining the damage (perforations, tears) to latex gloves during surgery in the case of primary hip and knee prosthesis implantation. Materials and methods: Latex surgical gloves used by surgeons for primary hip and knee replacement surgeries were collected directly after the surgery and tested using the watertightness test according to ISO EN 455-1:2000. Results: 540 gloves were collected from 104 surgeries. In 32.7% of surgeries at least one glove was damaged. Of all the gloves collected, 10.9% were damaged, mainly on the index finger. The size of the perforations ranged from ≤1 mm to over 5 mm. The surgeon’s glove size was the only factor that significantly influenced the occurrence of glove damage. Surgeon training level, procedure duration, and the use of bone cement had no significant influence. Conclusions: Our results highlight the high failure rate of surgical gloves. This has acute implications for glove production, surgical practice, and hygiene guidelines. Further studies are needed to detect the surgical steps, surface structures, and instruments that pose an increased risk for glove damage.
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Affiliation(s)
- Sarah Zaatreh
- Department of Orthopedics, University Medicine Rostock, Rostock, Germany
| | - Andreas Enz
- Department of Orthopedics, University Medicine Rostock, Rostock, Germany
| | - Annett Klinder
- Department of Orthopedics, University Medicine Rostock, Rostock, Germany
| | - Tony König
- Department of Orthopedics, University Medicine Rostock, Rostock, Germany
| | - Lena Mittelmeier
- Department of Orthopedics, University Medicine Rostock, Rostock, Germany
| | - Günther Kundt
- Institutes for Biostatistics and Informatics in Medicine and Ageing Research, University of Rostock, Rostock, Germany
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Bardorf MH, Jäger B, Boeckmans E, Kramer A, Assadian O. Influence of material properties on gloves' bacterial barrier efficacy in the presence of microperforation. Am J Infect Control 2016; 44:1645-1649. [PMID: 27388267 DOI: 10.1016/j.ajic.2016.03.070] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/13/2016] [Accepted: 03/14/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Medical examination gloves and surgical gloves protect the wearer directly and the patient indirectly from the risk of contamination. Because of concerns related to latex allergy, an increasing trend toward the use of synthetic gloves made of materials other than latex is observable. However, currently it is unknown if the physical properties of different materials may influence bacterial passage in case of a glove puncture. METHODS We examined 9 different medical examination gloves from various manufacturers made of nitrile (n = 4), latex (n = 3), or neoprene (n = 2). Additionally, 1 latex surgical glove each with and without antibacterial chlorhexidine gluconate coating and 1 synthetic surgical glove made of thermoplastic elastomer were included in the experiments. The studied materials were perforated following a standardized procedure, and direct bacterial passage was measured under dynamic conditions. Glove elasticity at 1 cm up to 2.5 cm elongation was measured following EN 455-2. RESULTS Nitrile gloves demonstrated higher material stiffness compared with latex gloves. Medical examination gloves made of nitrile and neoprene showed a 10-fold higher bacterial passage through a standardized puncture compared with latex gloves. All surgical gloves showed a lower bacterial passage compared with the tested examination gloves. CONCLUSION Bacterial passage through punctures is correlated with the stiffness or elasticity of the glove material. Therefore, gloves made of latex may have an increased protective effect in case of a glove breach. Whenever gloves are purchased and selected, a risk-benefit assessment should be conducted, balancing the risk of allergy against the degree of required protection in case of a glove puncture.
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Elce YA, Laverty S, Almeida da Silveira E, Piat P, Trencart P, Ruzickova P, Reardon RJM. Frequency of Undetected Glove Perforation and Associated Risk Factors in Equine Surgery. Vet Surg 2016; 45:1066-1070. [DOI: 10.1111/vsu.12562] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Accepted: 05/12/2016] [Indexed: 12/01/2022]
Affiliation(s)
| | - Sheila Laverty
- Department of Clinical Sciences; University of Montreal; St. Hyacinthe Canada
| | | | | | | | - Pavlina Ruzickova
- Department of Clinical Sciences; University of Montreal; St. Hyacinthe Canada
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Oliveira ACD, Gama CS. [Evaluation of adherence to measures for the prevention of surgical site infections by the surgical team]. Rev Esc Enferm USP 2016; 49:767-74. [PMID: 26516746 DOI: 10.1590/s0080-623420150000500009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 07/06/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Evaluate pre- and intraoperative practices adopted by medical and nursing teams for the prevention of surgical infections. METHOD A prospective study carried out in the period of April to May 2013, in a surgical center of a university hospital in Belo Horizonte, Minas Gerais. RESULTS 18 surgeries were followed and 214 surgical gloves were analyzed, of which 23 (10.7%) had postoperative glove perforation detected, with 52.2% being perceived by users. Hair removal was performed on 27.7% of patients in the operating room, with the use of blades in 80% of the cases. Antibiotic prophylaxis was administered to 81.8% of patients up to 60 minutes prior to surgical incision. An average of nine professionals were present during surgery and the surgery room door remained open in 94.4% of the procedures. CONCLUSION Partial adhesion to the recommended measures was identified, reaffirming a need for greater attention to these critical steps/actions in order to prevent surgical site infection.
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Affiliation(s)
| | - Camila Sarmento Gama
- Nursing School, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
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Makama JG, Okeme IM, Makama EJ, Ameh EA. Glove Perforation Rate in Surgery: A Randomized, Controlled Study To Evaluate the Efficacy of Double Gloving. Surg Infect (Larchmt) 2016; 17:436-42. [DOI: 10.1089/sur.2015.165] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jerry Godfrey Makama
- Department of Surgery, Ahmadu Bello University Teaching Hospital, Shika-Zaria, Nigeria
| | - Ibrahim Mohammed Okeme
- School of Post Basic Nursing Program, Ahmadu Bello University Teaching Hospital, Shika-Zaria, Nigeria
| | - Elizabeth Jerry Makama
- Department of Nursing Services, Ahmadu Bello University Teaching Hospital, Shika-Zaria, Nigeria
| | - Emmanuel Adoyi Ameh
- Department of Surgery, Ahmadu Bello University Teaching Hospital, Shika-Zaria, Nigeria
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Meakin LB, Gilman OP, Parsons KJ, Burton NJ, Langley-Hobbs SJ. Colored Indicator Undergloves Increase the Detection of Glove Perforations by Surgeons During Small Animal Orthopedic Surgery: A Randomized Controlled Trial. Vet Surg 2016; 45:709-14. [PMID: 27412490 PMCID: PMC4973670 DOI: 10.1111/vsu.12519] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 04/22/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether use of colored indicator gloves affects perforation detection rate and to identify risk factors for glove perforation during veterinary orthopedic surgery. STUDY DESIGN Prospective randomized controlled trial. SAMPLE POPULATION 574 double pairs of gloves worn during 300 orthopedic surgical procedures (2,296 gloves). METHODS Primary and assistant surgeons double-gloved for all orthopedic surgical procedures. Type of inner glove (standard or colored indicator) was randomized for the first 360 double pairs of gloves worn by surgeons during 180 procedures. Perforations detected by surgeons were recorded and gloves changed if requested. For a further 120 procedures, indicator gloves were used exclusively. All gloves were leak-tested after surgery to identify perforations. Association between potential risk factors and perforation was explored using multivariate logistical regression analysis. RESULTS Glove perforations occurred during 43% of surgeries with a mean of 2.3 holes/surgery. Inner gloves were intact in 63% of glove pairs where an outer perforation occurred. Intraoperative perforation detection was improved when colored indicator gloves were worn (83% sensitivity) vs. standard gloves (34% sensitivity; P<.001). Independent risk factors for perforation were placement of plates and/or screws (P=.001; OR=2.4; 95% CI, 1.4-4.0), placement of an external skeletal fixator (P=.002; OR=7.0; 95% CI, 2.1-23.8), use of orthopedic wire (P=.011; OR=2.4; 95% CI, 1.2-4.7), and primary surgeon being board-certified (P=.016; OR=1.9; 95% CI, 1.1-3.1). CONCLUSION Increased surgeon recognition of glove perforations through use of colored indicator gloves enables prompt change of gloves if perforation occurs and may reduce potential contamination of the surgical site.
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Affiliation(s)
- Lee B Meakin
- School of Veterinary Science, University of Bristol, Bristol, United Kingdom
| | - Oliver P Gilman
- School of Veterinary Science, University of Bristol, Bristol, United Kingdom
| | - Kevin J Parsons
- School of Veterinary Science, University of Bristol, Bristol, United Kingdom
| | - Neil J Burton
- School of Veterinary Science, University of Bristol, Bristol, United Kingdom
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Infektionsschutz und spezielle Hygienemaßnahmen in klinischen Disziplinen. KRANKENHAUS- UND PRAXISHYGIENE 2016. [PMCID: PMC7152143 DOI: 10.1016/b978-3-437-22312-9.00005-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Trindade JPDA, Serra JRD, Tipple AFV. INDEX OF PERFORATION OF PROCEDURE/SURGICAL GLOVES USED BY WORKERS IN THE PURGING OF A MATERIAL AND STERILIZATION CENTER. TEXTO & CONTEXTO ENFERMAGEM 2016. [DOI: 10.1590/0104-07072016001410015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT The objectives of this study were to identify the types of gloves the nursing team uses for the manual cleaning of health products and to identify the perforation rates in procedure/surgical gloves used for this purpose. Cross-sectional and descriptive, descriptive study with quantitative approach was developed at a large hospital in Goiânia, Goiás, Brazil. In total, 300 procedure/surgical gloves (Group A), 100 procedure and 100 new surgical gloves (Group B), and six nitrile gloves (Group C) were analyzed. Among the gloves in Group A, 135 (45.0%) were perforated. Superposition of gloves did not prevent perforations and, the longer they were used, the higher the index of perforation (p<0.05). No perforations were identified in Group B, whereas there were four perforations in 48 hours of use in Group C. This study reinforces the idea that procedure/surgical gloves are inappropriate for cleaning health products, representing an ineffective barrier for the safety of workers.
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Kim YG, Jeong IS, Park SM. Sharps injury prevention guidance among health care professionals: A comparison between self-reported and observed compliance. Am J Infect Control 2015; 43:977-82. [PMID: 26072716 DOI: 10.1016/j.ajic.2015.04.210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 04/29/2015] [Accepted: 04/30/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND This study was performed to compare self-report and observation methods for measuring compliance with double gloving (DG) and the hands-free technique (HFT). METHODS The participants were 81 health care professionals (29 nurses, 52 doctors) working in 22 operating rooms in a tertiary hospital in Busan (South Korea). All participants were asked to complete a self-report questionnaire. Additionally, compliance with DG and the HFT was observed from March-May 2014. Data were analyzed using descriptive statistics, χ(2) test, and κ statistic using SPSS version 18.0 (SPSS, Chicago, IL). RESULTS The participants who always complied with DG and the HFT were 30.9% and 7.7% according to the self-report method, respectively, and 30.9% and 0.0% according to direct observation, respectively. The κ value comparing the self-report and observation methods was 0.557 for all study participants, 0.259 for nurses, and 0.668 for doctors for DG. The κ value was 0.027 for all participants, 0.131 for nurses, and 0.020 for doctors for the HFT. CONCLUSION DG compliance and HFT compliance showed moderate and low levels of agreement between the 2 methods, respectively. Doctors showed higher agreement than nurses between the 2 methods for DG compliance but similar to nurses for HFT compliance. Therefore, the levels of compliance with DG may be measured by either the self-report or observation methods for doctors.
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Antimicrobial Sterile Gloves Reduce Pathogen Transmission in an In Vitro Glove Perforation Model. Infect Control Hosp Epidemiol 2015; 36:1249-50. [DOI: 10.1017/ice.2015.164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Leitgeb J, Schuster R, Yee BN, Chee PF, Harnoss JC, Starzengruber P, Schäffer M, Assadian O. Antibacterial activity of a sterile antimicrobial polyisoprene surgical glove against transient flora following a 2-hours simulated use. BMC Surg 2015; 15:81. [PMID: 26141495 PMCID: PMC4490737 DOI: 10.1186/s12893-015-0058-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 05/25/2015] [Indexed: 11/24/2022] Open
Abstract
Background A surgical glove will protect surgeons and patients only if the glove’s integrity remains intact. However, several studies have demonstrated that undetected micro-perforations of surgical gloves are common. Because of the possibility of surgical glove puncture, an antimicrobial surgical glove was developed. The aim of this laboratory based experimental study was to assess the antibacterial efficacy of the interior chlorhexidine-gluconate (CHG)-coat of an antimicrobial synthetic polyisoprene surgical glove by using a standardized microbiological challenge. Methods Sixteen healthy adult participants donned one antimicrobial surgical glove and one non-antimicrobial surgical glove randomly allocated to their dominant and non-dominant hand following a crossover design. During a 2-h wear time, participants performed standardized finger and hand movements. Thereafter, the interior surface of excised fingers of the removed gloves was challenged with 8.00 log10 cfu/mL S. aureus (ATCC 6538) or K. pneumoniae (ATCC 4352), respectively. The main outcome measure was the viable mean log10 cfu counts of the two glove groups after 5 min contact with the interior glove’s surface. Results When comparing an antimicrobial glove against an untreated reference glove after 2-h simulated use wear-time, a mean reduction factor of 6.24 log10 (S. aureus) and 6.22 log10 (K. pneumoniae) was achieved after 5 min contact. Conclusion These results demonstrate that wearing antibacterial gloves on hands does not negatively impact their antibacterial activity after 2-h of wear. This may have a potential benefit for patient safety in case of glove puncture during surgical procedures.
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Affiliation(s)
- Johannes Leitgeb
- Department for Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Rupert Schuster
- Department for Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Bit New Yee
- Science & Technology Innovation Centre, Ansell Shah Alam, 40000, Shah Alam, Selangor, Malaysia
| | - Pui Fong Chee
- Science & Technology Innovation Centre, Ansell Shah Alam, 40000, Shah Alam, Selangor, Malaysia
| | - Julian-Camill Harnoss
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, D-69120, Heidelberg, Germany
| | - Peter Starzengruber
- Department for Hospital Hygiene, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Michael Schäffer
- Department for General, Visceral, and Thoracic Surgery, Marienhospital Stuttgart, Böheimstrasse 37, D-70199, Stuttgart, Germany
| | - Ojan Assadian
- Institute for Skin Integrity and Infection Prevention, School of Human & Health Sciences, R1/29 Ramsden Building, University of Huddersfield, Huddersfield, HD1 3DH, UK.
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Pérez-Blanco V, García-Olmo D, Maseda-Garrido E, Nájera-Santos MC, García-Caballero J. Evaluación de un paquete de medidas para la prevención de la infección de localización quirúrgica en cirugía colorrectal. Cir Esp 2015; 93:222-8. [DOI: 10.1016/j.ciresp.2014.12.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 12/02/2014] [Accepted: 12/03/2014] [Indexed: 11/29/2022]
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Abstract
This article will present a critical review of the literature relating to the use of double gloves during surgery in order to identify best practice by using available resources and to improve health care. During surgery there is an increased risk of exposure to blood and, as a result, pathogens can be transferred through contact between the patient and surgical team. Health professionals working in the operating room are prone to frequent exposure to patients' blood and body fluids (Davanzo et al, 2008 ; Au et al, 2008 ; Myers et al, 2008). Several researchers have also demonstrated that the highest incidence of blood and body fluid exposure is in the operating room during surgical procedures (Ganczak et al, 2006 ; Myers et al, 2008 ; Naghavi and Sanati, 2009).
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Perforación de los guantes e infección de la herida de esternotomía en cirugía cardíaca con circulación extracorpórea. CIRUGIA CARDIOVASCULAR 2015. [DOI: 10.1016/j.circv.2014.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Verwilghen D, Singh A. Fighting surgical site infections in small animals: are we getting anywhere? Vet Clin North Am Small Anim Pract 2014; 45:243-76, v. [PMID: 25542615 DOI: 10.1016/j.cvsm.2014.11.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
A diverse array of pathogen-related, patient-related, and caretaker-related issues influence risk and prevention of surgical site infections (SSIs). The entire surgical team involved in health care settings in which surgical procedures are performed play a pivotal role in the prevention of SSIs. In this article, current knowledge of SSI risk factors and prevention methods is reviewed. Although new avenues that can be explored in the prevention of SSIs in veterinary medicine are described, the main conclusion drawn is that the best method for prevention of SSI is to adhere to what we already know.
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Affiliation(s)
- Denis Verwilghen
- Department of Large Animal Sciences, University of Copenhagen, Hojbakkegaerd Allé 5, Taatsrup 2630, Denmark.
| | - Ameet Singh
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, 50 Stone Road East, Guelph, Ontario N1G 2W1, Canada
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de Oliveira AC, Gama CS. Evaluation of surgical glove integrity during surgery in a Brazilian teaching hospital. Am J Infect Control 2014; 42:1093-6. [PMID: 25278400 DOI: 10.1016/j.ajic.2014.06.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 06/22/2014] [Accepted: 06/23/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND A cross-sectional study was conducted in a large university hospital in Belo Horizonte, Minas Gerais, Brazil to evaluate surgical glove integrity after use during surgery. METHODS This 6-month study was conducted by a gastroenterological, cardiovascular, and pediatric surgical team consisting of surgeons (main surgeon and first and second assistants), medical students, and scrub nurses. The gloves used during surgery were examined postsurgery for microperforations using the watertight test as described in European Norm EN 455-1. RESULTS A total of 116 medical professionals conducted the 100 surgeries monitored. Of the 1090 gloves analyzed, 131 (12%) had a perforation detected postsurgery, 39 of which (37.5%) were recognized by users at the time of occurrence. The highest incidence of perforations occurred among surgeons (P = .033) in the index finger, followed by the thumb of the nondominant hand; in outer gloves (76.9%) when double-gloving was used (P = .014); in open surgery (P = .019); and in surgeries lasting ≥ 150 minutes (P < .05). CONCLUSION These findings reaffirm the importance of double-gloving, using a perforation indicator system, and changing gloves in surgeries of ≥ 150 minutes duration, especially in procedures involving open incisions.
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Hayes GM, Reynolds D, Moens NM, Singh A, Oblak M, Gibson TW, Brisson BA, Nazarali A, Dewey C. Investigation of Incidence and Risk Factors for Surgical Glove Perforation in Small Animal Surgery. Vet Surg 2014; 43:400-4. [DOI: 10.1111/j.1532-950x.2014.12159.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 03/30/2012] [Indexed: 10/25/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | - Cate Dewey
- University of Guelph; Guelph Ontario Canada
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