Surgical glove perforations in otolaryngology: prevention with cut-resistant gloves

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Occupational health risks of pathologists--results from a nationwide online questionnaire in Switzerland

BACKGROUND

Pathologists are highly trained medical professionals who play an essential part in the diagnosis and therapy planning of malignancies and inflammatory diseases. Their work is associated with potential health hazards including injuries involving infectious human tissue, chemicals which are assumed to be carcinogenic or long periods of microscope and computer work. This study aimed to provide the first comprehensive assessment of the health situation of pathologists in Switzerland.

METHODS

Pathologists in Switzerland were contacted via the Swiss Society of Pathologists and asked to answer an ethically approved, online anonymous questionnaire comprising 48 questions on occupational health problems, workplace characteristics and health behaviour.

RESULTS

163 pathologists participated in the study. Forty percent of pathologists reported musculoskeletal problems in the previous month. The overall prevalence was 76%. Almost 90% of pathologists had visual refraction errors, mainly myopia. 83% of pathologists had experienced occupational injuries, mostly cutting injuries, in their professional career; more than one fifth of participants reported cutting injuries in the last year. However, long lasting injuries and infectious diseases were rare. Depression and burnout affected every eighth pathologist. The prevalence of smoking was substantially below that of the general Swiss population.

CONCLUSIONS

The results of this study suggest that more care should be taken in technical and personal protective measures, ergonomic workplace optimisation and reduction of work overload and work inefficiencies. Despite the described health risks, Swiss pathologists were optimistic about their future and their working situation. The high rate of ametropia and psychological problems warrants further study.

Scalpel safety in the operative setting: a systematic review

BACKGROUND

The complex environment of the operative setting provides multiple opportunities for health care workers to sustain scalpel injuries; scalpels are the second most frequent source of sharps injuries in this setting. Little evidence has been published detailing the effectiveness of proposed safety procedures and devices.

METHODS

A systematic search strategy was used to identify relevant studies. Studies were included based on the application of a predetermined protocol, an independent assessment by 2 reviewers, and a consensus decision. Nineteen articles formed the evidence base for this review.

RESULTS

Little high-level evidence was available. The results of studies reporting on 5 different devices/procedures were identified: the use of cut-resistant gloves/liners decreased the number of glove perforations in comparison with double latex gloves alone but lessened the wearer's dexterity and tactile sensation; the benefit derived from the use of the hands-free passing technique seemed equivocal; "sharpless surgery" was found to be feasible; a single-handed blade remover prevented at least as many injuries as a safety scalpel; and some shoe materials provided superior foot protection.

CONCLUSION

The lack of available evidence highlights the need for the generation of a methodologically rigorous, clinically relevant, and statistically valid body of primary research in this area to support appropriate and effective safety interventions.

Cut-resistant protective gloves in pathology--effective and cost-effective

Cutting injuries and needle-stitch injuries constitute a potentially fatal danger to both pathologists and autopsy personnel. We evaluated such injuries in a large German institute of pathology from 2002 to 2007 and analysed the effect of the introduction of cut-resistant gloves on the incidence of these injuries. In the observation period, 64 injuries (48 cutting injuries and 16 needle-stitch injuries) were noted in the injury report books. Most injuries were located at the non-dominant hand, preferentially at the index finger and the thumb. Around one fifths of the injuries were at the side of handedness. The average number of injuries per month was 1.22 for the 50 months prior to the introduction of cut-resistant gloves, more than seven times higher than after their introduction (0.158; 19 months; p < 0.001). Considering the medical and administrational costs of such injuries, cut-resistant protective gloves are an effective and cost-effective completion of personal occupational safety measures in surgical pathology and autopsy. We strongly recommend the use of such gloves, especially for autopsy personnel.

Double gloving to reduce surgical cross-infection

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Direct bonded orthodontic brackets for maxillomandibular fixation

OBJECTIVES/HYPOTHESIS

Mandibular fracture treatment often includes arch bar maxillomandibular fixation (MMF), either alone or in combination with open reduction/internal fixation (ORIF) techniques. The glove perforation rate associated with arch bar placement, the incidence of blood-borne pathogen positivity in facial fracture patients, and the injurious effects of arch bars on dental enamel and gingiva have prompted the development of safer alternatives to arch bar MMF. This study evaluates the efficacy, ease of use, and safety profile of one such alternative: orthodontic direct bonded bracket fixation (MMF/DBB).

STUDY DESIGN

Prospective study of consecutive mandible fracture patients treated with MMF/DBB.

METHODS

Thirty-two patients with mandibular fractures were evaluated from January 1994 to July 1997. Fourteen were appropriate for treatment with MMF/DBB (12 men and two woman; mean age, 24.6+/-7.2 y; range, 16-42 y). Fracture sites included symphysis, angle, condylar neck, coronoid, and body. Nine patients underwent MMF/DBB alone; five underwent MMF/DBB with subsequent ORIF.

RESULTS

No infection, malocclusion, malunion/nonunion, or enamel/ gingiva injury occurred. Mean follow-up was 6 months (range, 1-12 mo). Oral hygiene with MMF/DBB was superior to historical controls using arch bars.

CONCLUSIONS

MMF/DBB can serve as the single treatment method with satisfactory results in patients with favorable, less complicated mandible fractures, although with increased experience, we have treated several more complex cases with MMF/DBB alone. In cases necessitating ORIF, MMF/DBB can be performed preoperatively to align fracture segments and reestablish occlusion. This facilitates placement of osteosynthesis plates and reduces ORIF operative time. MMF/DBB is an economical, safe technique that minimizes blood-borne-pathogen risk to the operative team, eliminates periodontal injury, facilitates postoperative dental hygiene, and is painless to apply and remove.

Outer gloves in orthopaedic procedures: a polyester/stainless steel wire weave glove liner compared with latex

OBJECTIVE

To compare the efficacy of traditional double latex gloving with that of a highly cut-resistant polyester/stainless steel wire weave glove (PSSWWG) over a single latex inner glove for the prevention of perforation of the inner latex glove.

DESIGN

The primary surgeon and first assistant were involved in a prospective randomized study. Group I consisted of twenty-five procedures in which double latex gloves were used. Group II consisted of twenty-five procedures in which a PSSWWG liner was worn over an inner latex glove. All inner gloves were tested for perforations; all gloves exchanged that were presumed to have a perforation were noted and also tested. The type and length of the procedure were recorded. The dominant hand was recorded for all participants, along with their comments on the PSSWWG liner's performance.

SETTING

Orthopaedic Trauma Service, Hospital for Special Surgery. New York.

PATIENTS/PARTICIPANTS

Major operative cases, November 1996 to February 1997.

MAIN OUTCOME MEASUREMENTS

Inner latex glove perforations.

RESULTS

With the use of PSSWWG liners, the percentage of inner gloves found with a perforation dropped from 19 percent in the double latex group to 15 percent in the PSSWWG liner group (not statistically significant, p = 0.4). Two thirds of the perforations were in the primary surgeon's gloves, located in either the index finger or thumb. Nearly 80 percent of all perforations went unrecognized in both groups. Ninety-five percent of all perforations were in gloves that had been in use for more than 120 minutes (statistically significant, p = 0.01).

CONCLUSIONS

The particular cut-resistant glove studied (Sceptor) did not significantly reduce the rate of inner glove perforations. Other studies with different cut-resistant glove types and protocols have proven the liners effective. We would still recommend using outer cloth or cut-resistant type gloves when bone fragments are being manipulated or when using sharp implants or saws. At a minimum, surgical gloves should be changed every two hours.

A prospective study of the efficacy of various gloving techniques in the application of Erich arch bars

PURPOSE

This is a prospective study of the efficacy of three different techniques of triple gloving during the application of Erich arch bars. Two different cut-resistant glove liners and three layers of latex gloves were compared with double gloving.

METHODS AND MATERIALS

Thirty patients underwent Erich arch bar placement from first molar bilaterally on both arches. Two surgeons per case were arbitrarily placed into one of four groups that included double latex gloving, triple gloving with kevlar or stainless steel glove liners, or triple layer latex gloving, based on the availability of glove liners. All gloves were collected postoperatively and tested for perforation using water insufflation.

RESULTS

One hundred eight of 120 outer gloves were perforated. There were 16 perforations in 11 inner gloves of the double latex glove group, but no perforations in the inner gloves of the triple latex glove group. There were two inner gloves with one perforation each in the stainless steel group and one glove with a perforation in the kevlar group. All techniques of triple gloving were found to be superior to double gloving. There was no difference between the techniques of triple gloving.

CONCLUSION

During certain high-risk procedures greater protection to the surgeon can be obtained by triple gloving. The use of cut-resistant glove liners or triple layer latex gloving is superior to double layer latex gloving.