Double gloving to reduce surgical cross-infection

 

Abstract

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 methods

For this second update we searched the Wounds Group Specialised Register (June 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2009), Ovid MEDLINE (1950 to May Week 5 2009), Ovid EMBASE (1980 to 2009 Week 22 ) and EBSCO CINAHL (1982 to May Week 4 2009).

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.

 

Plain language summary

Double gloving to reduce surgical cross-infection

Surgical operations are undertaken within a clean environment and with members of the surgical team wearing sterile gloves. Sterile surgical gloves aim to protect the patient from contamination with bacteria from members of the surgical team and protect the surgical team from the body fluids of the patient. Double-gloving (wearing two sets of gloves) is becoming more common, especially for surgery where sharp surfaces are formed (such as orthopaedic or dental surgery). The review found that a second pair of gloves does protect the inner pair, without apparently affecting surgical performance. A glove liner between the two pairs of gloves reduces breaks to the inner glove even further, and extra-thick gloves seem to be as good as two pairs.

 

摘要

背景

使用雙層手套以降低手術交叉感染

由於手術本身的侵入性使得接觸到血液的機會增加，意味著手術中有高度風險可能會傳播病原體。病原體可透過患者和醫護團隊間的接觸而傳播，造成患者術後或經血液的感染，而醫護團隊也同樣可能經由血液而被感染。患者和醫護團隊都需要防護以降低此種風險。一般可透過使用防護罩來降低感染風險，例如配戴手套就是一種方式。比起只用1副手套，1次戴2或3副手套、手套加上內襯、或在手套外包覆布料，被視為可提供額外的防護，並可進一步降低污染的風險。

目標

本份文獻回顧的主要目標是探討添加手套防護是否可降低患者或醫護團隊發生手術部位或經血液感染的次數。次要目標則是探討添加手套防護是否可以減少最內層的手套被刺穿的次數。比起最外層的手套，最內層(亦即最貼近皮膚)的手套被視為患者和醫護團隊之間的最後一道防護。

搜尋策略

我們搜尋了the Wounds Group Specialised Register (2006年1月) 以及the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005年第4期), 我們同時也聯繫了手套製造商以及專業團體。

選擇標準

探討以下主題的隨機對照試驗 (Randomised controlled trials;RCTs) 將被納入：單層手套、雙層手套、三層手套、手套內襯、外層針織手套、外層鋼製手套以及刺穿警示系統。

資料收集與分析

2位作者分別評估每項試驗的相關性以及品質。由1位作者負責摘錄資訊，並由另1位作者來確認其正確性。

主要結論

發現有2項試驗評估了主要的指標，亦即患者手術部位的感染，這兩項試驗都沒有發現有感染的形況發生。總有31項評估手套刺穿的隨機對照試驗，被納入本份文獻回顧中。我們把14項有關雙層手套 (戴兩層外科乳膠手套) 的試驗結果整合起來，發現單層手套發生刺穿的機會，明顯比雙層手套的內層被刺破的機會來得高 (OR 4.10, 95% CI 3.30 to 5.09) 。8項有關警示型手套 (在乳膠手套底下再加上有顏色的乳膠手套，可以讓醫護團隊更快警覺到手套被刺破了) 的試驗顯示，比起使用警示型手套，如果只戴1層手套或使用標準規格的雙層手套，則明顯較不容易發現到手套已被刺破 (OR 0.08, 95% CI 0.04 to 0.17) 。在2項探討手套內襯 (在2副乳膠手套中間縫入布料或聚合物) (OR 26.36, 95% CI 7.91 to 87.82) 、3項針織手套 (在乳膠手套的頂端套上針織手套) (OR 5.76, 95% CI 3.25 to 10.20) 、1項3層手套 (戴3副乳膠手套) (OR 69.41, 95% CI 3.89 to 1239.18) 的試驗中，全部都發現標準規格的雙層手套明顯比這些手套更容易會發生最內層被刺破的狀況。

作者結論

沒有直接證據顯示手術團隊採取額外手套防護可減少患者手術部位的感染，然而本份回顧對這項結果缺乏足夠的檢力。多戴1副手套可以顯著減少最內層手套被刺破的機會，使用3層手套、外層針織手套或手套內襯也有同樣的功效。刺穿警示系統明顯可以讓手術中最內層手套被刺破的情形更容易被偵測出來。

翻譯人

本摘要由成功大學附設醫院邱曉萱翻譯。

此翻譯計畫由臺灣國家衛生研究院 (National Health Research Institutes, Taiwan) 統籌。

總結

雙層手套可以降低最內層手套被刺破的機會，而最內層的手套被刺破也容易造成手術團隊和患者之間發生交叉感染。外科手術必須在乾淨的環境下進行，而醫護團隊也必須使用滅菌手套。使用滅菌外科手套的目的是希望能保護患者免於被醫護團身上的細菌感染，同時也可保護醫護團對不會被患者的體液感染。雙層手套的方式(戴兩副手套)已變得更加普遍，特別是進行有尖銳表面的手術(比方說整形外科或牙科手術)的時候更是如此。本份文獻回顧發現加上第2副手套確實可以保護到最內層的手套，且並未明顯影響到手術的進。在兩副手套中間加上內襯可以更進一步減少內層手套被割破的情形,而使用加厚的手套看起來則跟雙層手套的效果同樣良好。