Key Words: percutaneous exposure incident (PEI)
What are the benefits and harms of extra gloves for preventing percutaneous exposure incidents (PEI) compared to alternative interventions in healthcare workers?
Healthcare workers frequently experience percutaneous exposure to body fluids. These injuries place them at risk for infectious diseases including hepatitis B, hepatitis C and human immunodeficiency virus (HIV). Several interventions exist to prevent infection including the use of gloves as personal protective equipment. Wearing multiple gloves, gloves made from special materials, or gloves with an indicator system has the potential to prevent contaminant transmission. Because there are several ways to reduce percutaneous exposure incidents, it is important to know which are effective. In the operating room (OR), there are multiple preventative strategies for prevention of injury including double gloving and the use of special gloves.However, the question is which is most effective.
This summary is based on a Cochrane systematic review of 34 articles with 6,890 operations on 46 intervention-control glove comparisons involving patient contact. Study participants were mostly surgeons. Inclusion criteria included interventions to reduce exposure to body fluids through the use of extra gloves or special types of gloves. Interventions were categorized according to (a) increasing the number of layers of gloves; (b) using special or thicker gloves versus normal gloves; (c) using gloves with puncture indicator systems; or (d) using a combination of layers, special/thicker gloves, or puncture indicator systems. Participants were surgeons, with 27 studies including other surgical staff (e.g. nurses).
Primary outcomes included exposure to body fluids, needle stick or sharps injury, blood stains inside glove or on skin, or glove perforation that was self-reported, reported by the employer, or observed by researchers. Dexterity was a secondary outcome measured by the ratio of number of perforations in the outer glove when wearing two gloves.
Though the evidence included only randomized controlled trials, the quality of the evidence included in the review was moderate. This is a result of a majority of the studies being conducted by surgeons without the assistance of a research institute, unclear randomization methods and allocation concealment, differences in assessing potential exposure to blood and studies greater than 20 years old. Results of all trials were treated as dichotomous and used rate ratios because of the high prevalence of most outcomes.
Summary of Key Evidence:
Moderate quality evidence:
Double gloves significantly reduced the risk of glove perforation in the inner glove by 71% (rate ratio (RR) = 0.29, 95% confidence interval (CI) 0.23 to 0.37).
Double gloves significantly reduced the number of blood stains on the skin by 65% (RR = 0.35, 95% CI 0.17 to 0.70).
There was no loss of dexterity with double gloves (RR = 1.10, 95% CI 0.93 to 1.31).
Triple special gloves (Kevlar, steel, spectra polyethylene fiber) compared to double normal gloves reduced the risk of perforations by 76% (RR = 0.24, 95% CI 0.13 to 0.45).
Indicator gloves did not reduce the total number of inner glove perforations for one person during one operation compared to double gloves without the indicator system (RR = 0.72, 95% CI 0.36 to 1.42).
Low quality evidence:
Triple gloves compared to double gloves reduce the risk of glove perforation (RR = 0.03, 95% CI 0.00 to 0.52).
One fabric glove over one normal glove reduces perforations compared to two normal gloves (RR = 0.24, 95% CI 0.06 to 0.93).
Thicker gloves had a similar risk of inner glove perforations compared to thinner gloves (RR = 0.63, 95% CI 0.37 to 1.08).
Best Practice Recommendations:
Prevention of percutaneous exposure incidents can occur with an increase in the number of glove layers, rather than the thickness of gloves. Prevention can be increased by using two or more layers or by using special material gloves. Based on the evidence presented, further studies are not needed to show the preventative effect of double gloving during surgery. However, evidence is needed concerning the use of gloves and the effect of extra gloves for healthcare professionals outside of the OR.
Alyce S. Ashcraft, PhD, RN, CNE, ANEF
Professor and Associate Dean for Research
Texas Tech University Health Sciences Center
Alyce is a member of the Cochrane Nursing Care Field (CNCF)
Mischke, C., Verbeek, J., Saarto, A., Lavoie, M., Pahwa, M. & Ijaz, S. (2014). Gloves, extra gloves or special types of gloves for preventing percutaneous exposure injuries in healthcare personnel. Cochrane Database of Systematic Reviews, 3,(CD009573). DOI: 10.1002/14651858.CD009573.pub2.