Double gloving in the operating theatre: The benefits and the potential drawbacks
Tuesday, December 1st, 2015
There are potential benefits and drawbacks when double gloving in the operating theatre. Working in the operating room is associated with a high risk of contact with bodily fluids. To prevent breaches of surgical gloves in theatre it has been suggested in the literature that using two pairs of gloves (double gloving) could provide benefit. Double gloving reduces the amount of contact with the patient’s blood and is also effective at reducing the level of exposure to infectious material during needle stick injury. Double gloving also reduces the risk of perforation compared to single gloving. However, it is suggested that double gloving may actually compromise manual dexterity, tactile sensitivity and 2-point discrimination. In conclusion, double gloving does provide greater protection against infection transmission than ‘single gloving’ in relation to intraoperative glove perforation and needle stick injuries, and does not appear to compromise surgical performance.
Working in the operating room is associated with a high risk of contact with bodily fluids, especially for surgeons.  Transmission of an infection from a patient to a surgeon or other operating room staff occurs through mucocutaneous or percutaneous transmission, such as a needle stick injury.  Transmission of blood borne viruses such as hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV) are of particular concern to the occupational health and safety of surgical staff. Infection transmission from the surgical team to the patient may also be of concern.  For these reasons it is important to have measures in place for infection control. Use of intact surgical gloves is one way of preventing the transmission of these infections. However, breached gloves allow potential exposure to infectious material, especially if there are cuts or abrasions present. Breached gloves not only indicate potential for mucocutaneous transmission but also promote the possible inoculation of blood from a needle stick injury. 
To prevent breaches of surgical gloves in theatre it has been suggested in the literature that using two pairs of gloves (double gloving) is effective in reducing transmission of infection to surgeons and operating room staff. Double gloving is thought to be superior to ‘single gloving’ as it has a greater resistance to withstand breaches and perforation, lowering the probability of puncture.  Furthermore, double gloving is also understood to provide a lower dose of inoculated infectious fluid during needle stick injuries. 
This article will examine whether ‘double gloving provides greater protection against infection transmission than single gloving during intraoperative glove perforation and needle stick injury’.
Why surgeons double glove
Double gloving reduces the amount of contact with the patient’s blood. Blood borne infection may be transferred when bodily fluids and blood are transferred between the surgical staff and a patient, exacerbated by pre-existing cuts or abrasions already present on the skin. One study revealed that pre-operatively, 17.4% of surgeons had skin abrasions on their hands.  Furthermore, 38-50% of practicing surgeons may not be adequately immunised against HBV to prevent infection.  It has been estimated in a study that double gloving reduced the rate of blood contamination of the hands from 13% in the single glove group to 2% in the double glove group. 
Double gloving is also effective at reducing the level of exposure to infectious material during a needle stick injury. The risk of acquiring an infection from percutaneous exposure after a needle stick injury is 0.3-0.4% for HIV, 6-30% for HBV and 3-10% for HCV.  The volume of bodily fluid transferred by the needle itself in a needle stick injury is a predictor of the possibility of infection, with lower volumes providing a lower viral load.  A recent study used double gloving and single gloving techniques of the same collective thickness and glove material to determine the amount of contaminate transmitted during simulated needle stick injuries. The results supported that the double gloving technique provides greater protection, with lower levels of contaminate transmitted through the needle stick injury.  Hence, double gloving is likely to be effective at reducing the level exposure to contaminate on a needle and consequently may reduce the incidence of transmission of infection to surgical staff. Therefore double gloving reduces the exposure of infectious contaminate on a needle stick during an injury, and may help prevent establishment of an infection, improving occupational health and safety.
The risk of perforation when double gloving is lower than the risk of perforation compared to single gloving. Intact gloves prevent the transmission of infection and therefore are important in the control of infection and safety. An analysis of gloves post-operatively found that 20.8% of surgeons who had single gloved had perforations and exposure to potentially infectious material, but only 2.5% of surgeons that double gloved had tears in the inner and outer glove.  A systematic review, including 31 controlled trials, reported that there were significantly more perforations of the single glove than the innermost (closest to skin) of the double gloves (OR 4.10, 95% CI 3.30 – 5.09).  Additionally, using an indicator glove (coloured latex underneath a second glove) warns the surgical team of any perforations and allows a replacement of the outer glove, which reduces the probability of tearing both layers and exposure to infectious contaminate.  Therefore double gloving protects the surgical staff and the patient from any exposure to potentially infectious contaminate and improves occupational health in the operating room
Why surgeons may not double glove
On the contrary, it has been claimed that the use of ‘double gloving’ may actually compromise manual dexterity, tactile sensitivity and 2-point discrimination of the surgeon, therefore reducing the ability and quality of the surgeon’s performance.  Another problem may be that a decrease of manual dexterity may increase the rate of needle stick injuries. Additionally there is poor acceptance among surgeons to double glove including a regular habit of single gloving, comfort, and low risk of transmission. Furthermore, some choose not to double glove because they feel there is a lack of evidence supporting its protection. 
Double gloving diminishes the hand sensibility and moving two-point discrimination of surgeons compared to single gloving, both of these being important for a surgeon to perform to the highest standards. Studies have demonstrated that double gloving does indeed have an effect on hand sensibility when evaluating pressure sensitivity, when compared to a single glove and no glove. Furthermore double gloving was found to impair moving two-point discrimination, but not static two-point discrimination, when compared to single gloving.  For this reason some surgeons prefer not to use two pairs of gloves as it can affect their surgical performance in the operating room.
Double gloving does not appear to reduce manual dexterity. Of note, many surgeons that advocate single gloving argue that their dexterity decreases with fatigue. Manual dexterity is defined as the ability to move fingers skilfully, manipulate small objects rapidly and accurately. Some surgeons are also concerned that manual dexterity will be compromised if employing a double glove technique during an operation, and consequently may result in poor performance. However this has been challenged in the literature, which suggests there is no difference in dexterity whether single or double gloving techniques are employed. One study examined the knot tying abilities of individual surgeons wearing one and two layers of gloves and found that there was no statistically significant difference between them.  Another study found that there was no substantial impact on manual dexterity, measured by a Perdue Peg-board, in double, single and no glove groups.  Therefore the use of double gloving as protection does not impair the quality of the surgeon’s performance.
Double gloving does not increase the risk of injuries such as needle stick injuries. A decrease in the level of tactile sensibility and manual dexterity of the surgeon is thought to increase the frequency of needle stick injuries in theatre. However as stated previously, manual dexterity is not compromised by double gloving. Furthermore, a study found that there was no correlation with the frequency of actual injuries and glove perforations compared to the number of glove layers.  Double gloving is no more of a risk to injury than single gloving; hence there are no grounds for it to be an occupational hazard.
Double gloving is not universally accepted by surgeons due to a lack of information and misconceptions. A questionnaire completed by surgeons revealed that most (57%) do not double glove, and that the most common reason not to was because of a perceived loss of manual dexterity. After competing the survey, the participating surgeons were given evidence-based information on the potential occupational health benefits of double gloving and only 23% said they would change their practice.  Hence, the majority of surgeons do not accept double gloving even with current evidence and may be at unnecessary risk of infection transmission opportunity. Various surgical specialties have different views on double gloving. Orthopaedic surgeons almost universally utilise double gloving technique due to the inherent risks of mechanical injury,  whereas plastic surgeons tend to have lower double gloving rates.  Furthermore the age of the surgeon appears to have an impact on double gloving rates with older surgeons often opting for single gloves. Anecdotally most trainees now double glove.
In conclusion, ‘double gloving’ provides greater protection against infection transmission than ‘single gloving’ in relation to intraoperative glove perforation and needle stick injuries. The prevention of infection transmission between surgical staff and patients is an important aspect of the occupational health and safety of the operating room. There is clear evidence that double gloving reduces post-operative wound infection. In fact this is much more effective than a 5-minute hand wash. However, it is also important to consider the performance of the surgical team with double gloves. Although manual dexterity is not compromised, hand sensibility and moving 2-point discrimination may be impaired whilst double gloving. Furthermore, even when presented with strong evidence for its beneficial use in practice, surgeons still prefer not to double glove. In summary, there is considerable literature that suggests the use of double gloving reduces the probability of infection transmission in the operating room, and because infection is an occupational danger, it is recommended that surgical staff double glove while performing operations.
Conflict of interest
M Papageorgiou: email@example.com
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