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Double-Gloving:
The Power of Two

An Online Continuing Education Activity

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Welcome to

Double-Gloving:
The Power of Two

(An Online Continuing Education Activity)

CONTINUING EDUCATION INSTRUCTIONS

This educational activity is being offered online and may be completed at any time.
Steps for Successful Course Completion
To earn continuing education credit, the participant must complete the following steps:
1. Read the overview and objectives to ensure consistency with your own learning needs and objectives. At the end
of the activity, you will be assessed on the attainment of each objective.
2. Review the content of the activity, paying particular attention to those areas that reflect the objectives.
3. Complete the Test Questions. Missed questions will offer the opportunity to re-read the question and answer
choices. You may also revisit relevant content.
4. For additional information on an issue or topic, consult the references.
5. To receive credit for this activity complete the evaluation and registration form.
6. A certificate of completion will be available for you to print at the conclusion.

Pfiedler Enterprises will maintain a record of your continuing education credits and provide verification, if
necessary, for 7 years. Requests for certificates must be submitted in writing by the learner.

If you have any questions, please call: 720-748-6144.

CONTACT INFORMATION:

2016
All rights reserved
Pfiedler Enterprises, 2101 S. Blackhawk Street, Suite 220, Aurora, Colorado 80014
www.pfiedlerenterprises.com
Phone: 720-748-6144 Fax: 720-748-6196

Overview

As the requisite use of protective barriers has evolved over the years, the use of gloves also has become more prevalent
as a key strategy for reducing the risk of an exposure incident. Perioperative personnel use gloves on a daily basis to
protect themselves from exposure to blood and other potentially infectious materials in the surgical practice setting. In
todays healthcare environment, new pathogens, in addition to well-known pathogens that have developed resistance to
therapeutic modalities, have given greater awareness to the use of gloves as a primary protective barrier for perioperative
staff members. Paralleling these developments is the practice of double-gloving. Therefore, it is imperative that members
of the surgical team understand the role of protective barriers, as well as the practice of double-gloving as an exposure
risk reduction strategy. This continuing education activity will provide a historical review of the evolution of the use of
gloves as a protective barrier. The current impact of occupational exposure on healthcare workers will be presented. The
contemporary literature citing the practice of double-gloving as an effective risk reduction strategy also will be reviewed.
Recommendations promulgated by professional associations will be outlined. The implications of double-gloving in the
surgical practice setting, including approaches to implement a change in practice and the identification of perceived
barriers, will be discussed. Finally, selected case studies will provide the participant with the opportunity to synthesize the
information and evaluate workplace scenarios with regard to double-gloving practices and policies.

Learner Objectives

Upon completion of this continuing education activity, the learner should be able to:
1. Outline the evolution of the use of gloves as protective barriers.
2. Describe the impact of occupational exposure on healthcare workers today.
3. Discuss the efficacy of double-gloving as an occupational exposure risk reduction strategy as cited in the literature.
4. Identify professional recommendations supporting the practice of double-gloving.
5. Discuss the implications of double-gloving in the surgical practice setting.
6. Critique workplace scenarios regarding the implementation of a double-gloving policy as a strategy to reduce the risk
of an exposure incident.

Intended Audience

This continuing education activity is intended for perioperative nurses, surgical technologists, and other healthcare
professionals who participate in surgical or invasive procedures and are interested in learning more about the practice of
double-gloving as a strategy to reduce the risk for an exposure incident.

CREDIT/CREDIT INFORMATION
State Board Approval for Nurses
Pfiedler Enterprises is a provider approved by the California Board of Registered Nursing, Provider Number CEP14944, for
2.0 contact hour(s).
Obtaining full credit for this offering depends upon attendance, regardless of circumstances, from beginning to end.
Licensees must provide their license numbers for record keeping purposes.
The certificate of course completion issued at the conclusion of this course must be retained in the participants
records for at least four (4) years as proof of attendance.

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RELEASE AND EXPIRATION DATE

This continuing education activity was planned and provided in accordance with accreditation criteria. This material was
originally produced in February 2016 and can no longer be used after February 2018 without being updated. This continuing
education activity expires in February 2018.

DISCLAIMER

Accredited status as a provider refers only to continuing nursing education activities and does not imply endorsement of any
products.

SUPPORT

Grant funds for the development of this activity were provided by Cardinal Health.

authors/PLANNING COMMITTEE/Reviewers

Rose Moss, RN, MN, CNOR Westcliffe, Colorado

Nurse Consultant/Author
Moss Enterprises, LLC
Judith I. Pfister, RN, BSN, MBA Aurora, Colorado
Program Manager/Planner
Pfiedler Enterprises
Julia A. Kneedler, RN, EdD Aurora, Colorado
Program Manager/Reviewer
Pfiedler Enterprises

DISCLOSURE OF RELATIONSHIPS WITH COMMERCIAL ENTITIES FOR THOSE IN A POSITION TO

CONTROL CONTENT FOR THIS ACTIVITY

Pfiedler Enterprises has a policy in place for identifying and resolving conflicts of interest for individuals who control content
for an educational activity. Information listed below is provided to the learner, so that a determination can be made if
identified external interests or influences pose a potential bias of content, recommendations or conclusions. The intent is full
disclosure of those in a position to control content, with a goal of objectivity, balance and scientific rigor in the activity.
Disclosure includes relevant financial relationships with commercial interests related to the subject matter that may be
presented in this educational activity. Relevant financial relationships are those in any amount, occurring within the past 12
months that create a conflict of interest. A commercial interest is any entity producing, marketing, reselling, or distributing
health care goods or services consumed by, or used on, patients.
Activity Planning Committee/Authors/Reviewers:
Julia A. Kneedler, RN, MS, EdD
No conflict of interest
Rose Moss, RN, MN, CNOR
No conflict of interest
Judith I. Pfister, RN, BSN, MBA
No conflict of interest

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PRIVACY AND CONFIDENTIALITY POLICY

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continuing education. The information we collect is never shared with other organizations for commercial purposes. Our
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Phone:

720-748-6144

Email:

registrar@pfiedlerenterprises.com

Postal Address:

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Aurora, Colorado 80014

Website:

www.pfiedlerenterprises.com

Page 3

INTRODUCTION

Healthcare facilities are inherently dangerous places for their employees. Exposure to bloodborne pathogens is a serious
occupational risk for all healthcare workers, but especially for operating room (OR) personnel, who face the risk of exposure
to potentially hazardous substances on a daily basis. Gloves play an important role in minimizing the exposure risk.
For over 100 years, healthcare workers have worn gloves to reduce the risk of transmitting bloodborne pathogens and
other microorganisms. The practice of wearing gloves has never been more important than it is today, especially as new
pathogens and well-known pathogens that have developed resistance to therapeutic treatment options have emerged as
significant threats. In light of these developments, the practice of double-gloving is taking on greater importance.

THE USE OF GLOVES AS PROTECTIVE BARRIERS: A HISTORICAL REVIEW

In the 1890s, Dr. William Halstead introduced gloves into the surgical theater in order to protect the hands of nurses and
surgical assistants from harsh disinfecting agents and other caustic chemicals. It soon became apparent that wearing
gloves also reduced the rate of postoperative infections among patients and decreased mortality.1
In the late 1980s, the Centers for Disease Control and Prevention (CDC) instituted universal precautions to prevent the
transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV) and other bloodborne pathogens when
providing first aid or health care. Under universal precautions, blood and certain body fluids of all patients are considered
potentially infectious for HIV, HBV and other bloodborne pathogens. Universal precautions involve the use of protective
barriers such as gloves, gowns, aprons, masks, or protective eyewear, which can reduce the risk of exposure of the
healthcare workers skin or mucous membranes to potentially infective materials. In addition, under universal precautions,
it is recommended that all healthcare workers take precautions to prevent injuries caused by needles, scalpels, and other
sharp instruments or devices.2
With the institution of universal precautions, the use of examination gloves escalated and became the most common barrier
used outside the surgical arena. The evolution of pathogens, including HIV, HBV and hepatitis C virus (HCV), as well as
the emerging issues of antimicrobial resistance, have led healthcare professionals to demand that their barriers perform
effectively, for the safety of both their patients and themselves.3 In 1991, the Occupational Safety and Health Administration
(OSHA) issued the Bloodborne Pathogens Standard (29 CFR 1910.1030) to protect workers from the risk of occupational
exposure to bloodborne pathogens, including HBV, HCV, and HIV/acquired immune deficiency syndrome (AIDS).4 This
regulation required employers to develop a written exposure control plan that is designed to reduce or eliminate employee
exposure; at a minimum, the plan must address:
yy Engineering and work practice controls designed to eliminate risk;
yy A personal protective equipment (PPE) program (where occupational exposure remains after institution of engineering
and work practice controls);
yy Decontamination and removal procedures for regulated waste;
yy Annual employee education;
yy A vaccination program against the hepatitis B virus (HBV) for at-risk employees;
yy Evaluation and follow-up of employees post-exposure; and
yy Record-keeping procedures.
However, even after implementation of the OSHA Bloodborne Pathogens Standard, occupational exposure to bloodborne
pathogens from accidental sharps injuries in healthcare and other occupational settings continued to be a serious problem;
therefore, Congress felt that a modification to the Bloodborne Pathogens Standard was appropriate to outline in greater
detail, and also make more specific, OSHAs requirement for employers to identify, evaluate, and implement safer medical
devices designed to eliminate or minimize occupational exposure to bloodborne pathogens.5 To address these issues, on
November 6, 2000, the Needlestick Safety and Prevention Act (NSPA) was signed into law. In 2001, in response to the
NSPA, OSHA revised the Bloodborne Pathogens Standard. The revised standard clarifies the need for employers to select
safer needle devices and to involve employees (ie, non-managerial staff) in identifying and choosing these devices. The
updated standard also requires employers to maintain a log of injuries from contaminated sharps.
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RISKS TO HEALTHCARE WORKERS6

Occupational exposures occur through contact of the eye, nose, mouth, or skin with a patients blood or through
needlesticks or cuts from other sharp instruments contaminated with an infected patients blood. Significant factors that
influence the overall risk for occupational exposures to bloodborne pathogens include the number of infected individuals in
the patient population as well as both the number and type of blood contacts.
The risk of infection after an occupational exposure is relatively small. Healthcare workers who have received hepatitis B
vaccine and have developed immunity to the virus are at virtually no risk for infection. For a susceptible person, the risk from
a single needlestick or cut exposure to HBV-infected blood ranges from 6-30% and is dependent upon on the hepatitis B e
antigen (HBeAg) status of the source individual. Hepatitis B surface antigen (HBsAg)-positive individuals who are HBeAg
positive have more virus in their blood and therefore are more likely to transmit HBV than those who are HBeAg negative.
While there is a risk for HBV infection from exposures of mucous membranes or nonintact skin, there is no known risk for
HBV infection from exposure to intact skin.
The average risk for infection after a needlestick or cut exposure to HCV-infected blood is approximately 1.8%. The risk
following a blood exposure to the eye, nose or mouth is unknown, but is believed to be very small; however, HCV infection
from blood splash to the eye has been reported. While there also has been a report of HCV transmission that may have
resulted from exposure to nonintact skin, there is no known risk from exposure to intact skin.
The average risk of HIV infection after a needlestick or cut exposure to HlV-infected blood is 0.3% (ie, three-tenths of one
percent, or about 1 in 300). Alternatively stated, 99.7% of needlestick or cut exposures do not lead to infection. The risk after
exposure of the eye, nose, or mouth to HIV-infected blood is estimated to be, on average, 0.1% (1 in 1,000). The risk after
exposure of non-intact skin to HlV-infected blood is estimated to be less than 0.1%. A small amount of blood on intact skin
most likely poses no risk at all. There have been no documented cases of HIV transmission due to an exposure involving a
small amount of blood on intact skin (ie, a few drops of blood on the skin for a short period of time).
According to the CDC, the annual number of occupational infections has decreased 95% since the hepatitis B vaccine
became available in 1982: from greater than 10,000 in 1983 to less than 400 in 2001. While there are no precise estimates
of the number of healthcare personnel who are occupationally infected with HCV, studies have shown that 1% of hospital
healthcare personnel have evidence of HCV infection (in comparison, about 3% of the U.S. population has evidence
of infection). The number of these healthcare workers who may have been infected through an occupational exposure
is unknown. As of December 2001, the CDC had received reports of 57 documented cases and 138 possible cases of
occupationally acquired HIV infection among healthcare personnel in the United States since the reporting began in 1985.
Prevention is a key factor in healthcare worker safety. The hepatitis B virus is essentially preventable through vaccination.
However, for HBV, HCV, and HIV, preventing occupational exposures to blood can prevent occupational infections with HBV,
HCV, and HIV. This includes using appropriate barriers such as gown, gloves and eye protection as appropriate, safely
handling needles and other sharp instruments, and using devices with safety features.

THE EVOLUTION OF DOUBLE-GLOVING: A REVIEW OF THE LITERATURE

Gloves are designed to protect healthcare workers from exposure to bloodborne pathogens and infectious diseases.
Wearing a single pair of gloves provides the necessary protection from bloodborne pathogens and is the standard of
practice. However, greater awareness of the advantages of double-gloving for operative and invasive procedures and
when needles and sharps are involved, is contributing to a reevaluation and evolution in gloving practices by perioperative
personnel. Today, double-gloving in the healthcare industry is emerging as the new standard of practice; the literature is
replete with evidence supporting this evolution. A synopsis of several research studies conducted across multiple surgical
specialties, which demonstrate the clinical benefits of double-gloving, is presented below.
Research on the protective effects of double-gloving provides compelling evidence that surgical personnel should doubleglove during all surgical procedures.7 As far back as the early 1990s, studies were being conducted that demonstrated the
effectiveness of double-gloving as a risk reduction strategy.

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Quebbeman et al noted that healthcare workers, in particular surgeons, understand the importance of preventing
contamination from the blood of patients infected with deadly viruses; the most common areas of contamination are the
hands and fingers due to the failure of glove protection.8 In addition, there are varying opinions with regard to the frequency
of glove failure, the necessity of wearing two gloves for added protection, as well as the ability to operate when wearing two
pairs of gloves. The authors conducted a prospective, randomized, trial of 143 procedures involving 284 people to address
these three questions for surgeons and first assistants. Overall, the glove failure rate (ie, blood contamination of the fingers)
was 51% when one glove was worn and 7% when two gloves were worn. Acceptability was 88% in the group who agreed
to wear two gloves, and 88% of these did not perceive that tactile sense was significantly impaired. The authors concluded
that double-gloving should be, and can be, used routinely during major surgical procedures to protect surgeons from blood
contamination.
Cohen et al noting that most dermatologists do not routinely double-glove when performing surgical procedures because
it reduces manual dexterity and increases costs, undertook a study to determine whether double-gloving should be
routinely practiced in dermatologic surgery.9 They collected the pairs of sterile surgical gloves worn during the week at their
universitys dermatologic surgery clinics over a 3 month period and examined them for perforations. The procedures that
these gloves were used for ranged from excision of benign lesions (lasting 15 minutes) to hair transplants (lasting 3 hours).
Upon completion of the procedures, 8 (5.5%) of 144 pairs of single gloves, 2 (3.7%) of 54 pairs of double inner gloves, and
3 (5.5%) of 54 pairs of double outer gloves were found to have perforations. They did not find any instances of both the
double outer and the double inner gloves having perforations when worn on the same hand. The authors concluded from
these results that double-gloving offers a protective advantage by providing extra protection for both the surgeon and the
patient during dermatologic surgery.
Chapman and Duff conducted a prospective investigation to first, assess the frequency of glove perforations and
subsequent blood contact associated with selected obstetric procedures, and second, to assess the relative risk of
perforation among various members of the surgical team and determine if the time of day or urgency of the procedure
affected the frequency of perforation.10 For a three-month period, obstetric personnel placed their gloves in plastic bags and
indicated the type of procedure, time of day, and their role on the surgical team; they also noted whether they were aware
of a glove tear and, if so, whether blood or fluid was on their hands. Gloves were then tested for injury by two methods:
by inflating them with air and subsequently immersing them in water to detect air bubbles and by directly filling them with
water to observe for leaks. A total of 540 glove sets (2,160 individual gloves) were examined; 407 sets were from cesarean
deliveries, 65 from puerperal tubal ligations, and 68 from vaginal deliveries. Sixty-seven of the sets (12.4%) had at least one
hole; the total number of holes was 78. Sixty-six holes were in the outer glove only, and 7 were in the inner glove only. In
five sets (0.9%) there were matching holes in the outer and inner gloves. In two of these cases (0.4%), the surgeons noted
blood on their hands at the conclusion of the procedure. The difference in frequency of injury in outer versus inner gloves
was highly significant (p < 0.005). Forty-six of the 78 holes (59%) were on the thumb or first two fingers of the nondominant
hand. Only 2 (3%) of the glove tears were recognized by the surgeon. There was no difference in frequency of glove tears
when cesarean sections were classified as urgent versus nonurgent. There also was no difference in the frequency of glove
tears in procedures performed at night when compared with those performed during the day. Surgical nurses had 36% of all
glove injuries and were more likely than physicians or medical students to sustain perforations. Primary surgeons and first
assistants were more likely than second assistants to sustain injuries from glove perforations. For primary surgeons and first
assistants, the level of training did not significantly affect the frequency of glove perforations. The authors concluded that
glove perforations occur in approximately 12% of obstetric surgical procedures, with surgical nurses being at greatest risk
for perforation. Double-gloving reduced the likelihood of a penetrating injury to the inner glove and subsequently, the risk of
blood contact.
Greco and Garza noted that the potential for blood contact with nonintact skin increases the risk of exposure to bloodborne
pathogens in OR personnel. Frank needlestick injury to the surgeon has been shown to occur once in every 20 to 40
procedures and blood contact exposure during aesthetic surgery occurs in 32% of the operations in which a single pair of
surgical gloves is used (surgeon - 39.7%; assistants - 23%).11 The reduction of blood contact exposure during aesthetic
surgical procedures through double-gloving was tested and demonstrated. Perforations to the outer glove occurred in 25.6%
of the cases, while inner glove perforations occurred in only 10% of the cases (surgeon - 8.7%, assistant - 3.5%). All of the
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inner glove perforations occurred during procedures that lasted over two hours, and in no case was there an inner-glove
defect without a corresponding outer glove perforation. The nondominant index finger was the most common perforation
location (33%). The authors concluded that double-gloving during aesthetic procedures reduced the operating room
personnels risk of blood contact exposure by 70% when compared with single glove use.
Hollaus, et al., reported on glove perforation rates in open lung surgery.12 In open lung surgery, the surgical access is
encircled by the ribs, which should result in a high glove perforation rate as compared with other surgical specialties.
They conducted a prospective study in which the surgeon, first and second assistant, and the scrub nurse wore double
standard latex gloves during 100 thoracotomy procedures. The parameters recorded were: procedure performed, number
of perforations, localization of perforation, the seniority of the surgeon, maneuver performed at the moment of perforation,
immediate cause of perforation, procedure time, performance of rib resection during thoracotomy and time of occurrence
of the first three perforations. One thousand, six hundred and seventy-three gloves (902 outer, 771 inner) were tested.
The results indicated that perforations occurred in 78 procedures; there were 150 outer glove perforations (8.9%) and 19
inner glove perforations (1.13%). Cutaneous blood exposure was prevented in 78% of all operations and in 87% of all
perforations. Rib resection and a procedure lasting over two hours resulted in a significant rise of glove perforation rate.
The personal experience of the surgeon and the type of operation did not correlate with glove perforation. The immediate
cause leading to perforation was named in only 17 cases (13.7%) and comprised contact with bone (7), a needle stitck (7)
and a production flaw (3). Leaks were localized mostly on the first finger (18%), second finger (39%), palm and dorsum
of the hand (16%). The average occurrence of all first perforations was 38.7 minutes (range was 3 to 190 minutes) after
the beginning of surgery, and the second after 63.2 minutes (range was 10 to 195 minutes). Fifty-four first perforations
(50.5%) were found during the first 30 minutes of the procedure. The authors concluded that double-gloving effectively
prevented cutaneous blood exposure and therefore should become a routine for the thoracic surgeon in order to prevent the
transmission of infectious diseases from the patient to the surgeon.
Naver and Gottrup investigated the incidence of glove perforations during various types of gastrointestinal surgery in order
to record the incidence of blood contamination of the hands and also to evaluate the protective effect of double-gloving.13
They conducted a randomized, prospective trial of 566 pairs of gloves tested on surgeons, assistants, and scrub nurses.
The participants were assigned to wear either single gloves or colored double-gloves. The number of glove perforations and
the incidence of blood contamination of the hands were measured. The results showed that the perforation rate in single
gloves was 53 out of 306 (17%), and that of both outer and inner colored gloves at corresponding sites was 6 out of 260
(2%). Double-gloving reduced the rate of blood contamination of the hands among surgeons from 15 out of 115 (13%) to 2
out of 98 (2%). These authors concluded that the use of colored double-gloves is recommended in gastrointestinal surgery
because of the appreciable protection against blood contamination that they offer.
Aarnio and Laine completed a study to compare puncture rates between the double-gloving color system and single-use
gloves and also to determine the extent to which glove perforations remain undetected during the course of vascular
surgical operations.14 The study included all gloves used in vascular surgical operations at their hospital for a period of two
months. Gloves were tested immediately after the surgical procedure using the approved standardized water-leak method.
With this method the glove is filled with water using a special filling tube, and the water-filled glove is then checked for two
minutes to detect any holes. The gloves used in this study were either double-gloves with color, or the standard glove used
at the hospital. In 73 procedures, 200 gloves were tested; half of these were double-gloves and half were single gloves.
The results indicated that perforation occurred in the double-gloves 3 times and with single gloves 12 times. The overall
perforation rate was 15 out of 200 gloves (7.5%). The detection of perforation during surgery was 60%. Most frequently,
(9 out of 15 perforations) the perforation was located on the second finger of the left hand. The authors concluded that, in
view of the critical importance of preventing transmitting pathogens from the skin of the surgeon to the wound as well as
transmitting bloodborne pathogens from the patient to the surgeon, it is very important to use double-gloving at least for
procedures where there is a high risk of glove perforation.
Thomas et al noting that breaches in gloving material may expose OR staff members to the risk of infections from patients
blood and body fluids, conducted a prospective randomized study to assess the effectiveness of the practice of doublegloving in comparison with single-gloving in decreasing finger contamination during surgery.15 In 66 consecutive surgical
procedures included in the study, preoperative skin abrasions were detected on the hands of 17.4% of the surgeons.
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When double-gloving was used, 32 glove perforations were observed; of these, 22 were in the outer glove and 10 were in
the inner glove. Only four outer glove perforations had matching inner glove perforations, thereby indicating that in 82%
of cases in which the outer glove is perforated, the inner glove will protect the surgeons hand from contamination. The
presence of visible skin contamination was also higher in perforation with single glove use (42.1%) than with double-gloving
(22.7%). An overwhelming majority of glove perforations (83.3%) went unnoticed. The practice of double-gloving was
accepted by the majority of surgeons, particularly with repeated use. The authors recommended that double-gloves be used
routinely in all surgical procedures in light of the significantly higher protection provided.
In 2002, Tanner and Parkinson completed a search of the Cochrane Wounds Group Specialized Register, the Cochrane
Central Register of Controlled Trials Register, MEDLINE, CINAHL, and EMBASE; they also contacted glove manufacturers
and professional organizations to determine if double-gloving, rather than single-gloving, reduces the number of
postoperative or bloodborne infections in surgical patients or bloodborne infections in the surgical team; the secondary
objective of this review was to determine if double-gloving, rather than single-gloving, reduces the number of perforations to
the innermost pair of surgical gloves, since the innermost pair of surgical gloves is considered to be the last barrier between
the patient and the surgical team.16 Randomized, controlled trials involving single-gloving, double-gloving, glove liners or
colored puncture systems were conducted. Both reviewers independently assessed the relevance and quality of each trial.
Trials to be included were cross-checked and authenticated by both reviewers. Data were extracted by one reviewer and
then cross-checked for accuracy by the second reviewer. The authors concluded that wearing two pairs of latex gloves
significantly reduces the number of perforations to the innermost glove; this evidence comes from trials undertaken in
low risk surgical specialties, that is, specialties that did not include orthopaedic joint surgery. Further, wearing two pairs
of latex gloves does not cause the glove wearer to sustain more perforations to their outermost glove. Wearing double
latex-colored gloves enables the glove wearer to detect perforations to the outermost glove more easily than when wearing
double latex gloves of the same color. However, wearing two different colored latex gloves will not assist with the detection
of perforations to the innermost glove, nor will it reduce the number of perforations to either the outermost or the innermost
glove. Wearing a glove liner between two pairs of latex gloves to perform joint replacement surgery significantly reduces
the number of perforations to the innermost glove, compared with double latex gloves only. Wearing cloth outer gloves to
perform joint replacement surgery significantly reduces the number of perforations to the innermost glove compared with
wearing double latex gloves. Wearing steel weave outer gloves to perform joint replacement surgery does not reduce the
number of perforations to innermost gloves as compared to double latex gloves.
In 2004, Laine and Aarnio assessed the frequency of perforation of surgical gloves during orthopaedic and trauma surgery
and compared the efficiency of single- and double-gloving.17 The authors examined all the gloves used by surgeons for a
two month period; there were 1,769 gloves from 349 operations. Perforations occurred in 18.5% of conventional and 5.8%
of arthroscopic procedures. The risk of contamination from blood was 13 times higher when using single as compared
with double-gloves. Surprisingly, the combination of two regular gloves was much less efficient than double colored gloves
when comparing the rate of perforation of the inner glove when the outer glove had been damaged (24% versus 4.9%). The
authors recommend double-gloving in orthopaedic surgery in general, and also in long arthroscopic procedures.
Florman et al undertook a double-blind, randomized study to evaluate the ability of participants to locate 30-micron laser
holes in surgical gloves while performing simulated surgery and to evaluate a colored glove system that reveals punctures.18
Twenty glove configurations (eight single, twelve double) were tested, half of which had laser-created holes. Each of the
25 participants randomly tested and evaluated 20 configurations. The simulated surgical procedure was terminated when
a hole was identified by the participant or at the end of two minutes, whichever occurred first. Participants also rated
their perceptions of each gloves features on questionnaires, all of which were returned, with 95.8% being complete. The
participants found 84% and 56% of the holes in the two colored systems, latex and synthetic, in an average of 22 seconds
and 42 seconds, respectively. In the worst-performing latex and synthetic glove configurations, participants found only 8%
and 12% of the holes at an average of 47 seconds and 67 seconds, respectively. The colored gloves were highly rated for
comfort and ease of use. The authors concluded that double-gloving with a colored system provides the best protection and
allows the timeliest identification of perforations; participants failed to identify most of the holes in the non-colored gloves.
Sadat-Ali et al compared double gloves (DGs) with single gloves (SGs) during orthopedic and trauma surgery in the
prevention of blood contact between patients and surgeons.19 DGs and SGs were collected after orthopedic operations,
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tested for size, site, and number of perforations; the medical records were reviewed for age, sex, type of operation,
duration, and postoperative wound infection. Five hundred seven procedures yielded 1,204 DGs and 830 pairs of SGs. In
DGs, perforations were detected in 220 outer gloves and 39 inner gloves (10.7%). In SGs, 226 perforations were detected
(13.3%). The incidence of perforations in inner gloves of the double colored glove was 1.6%. During surgery, perforations
were recognized in DGs 67% of the time, as compared to 12% in SGs. The authors concluded that this study confirms that
double gloves form an efficient barrier between patients and surgeons.
Hagen and Arntzen, recognizing that the increasing prevalence of bloodborne viral diseases has focused more attention
to the barrier between the hands of surgical personnel and the patients body fluids during surgery, conducted a study to
estimate and compare the perforation risk in different categories of surgery.20 In a series of 655 surgical operations covering
five main surgical specialties, all detected glove perforations were recorded and analyzed. Perforations were found in
203 out of 655 operations (31%). The observed perforation frequency was 44.5% in gastrointestinal surgery, 34.7% in
orthopaedic surgery, 31.1% in gynecology, 18.6% in vascular surgery and 9.2% in general surgery; in some subcategories,
the frequencies were even higher. The authors noted that perforations in single gloves are often not detected during
operations; this factor may increase the risk of transmission of bloodborne infections, particularly because the time of
exposure may be long. Double colored gloves make the intraoperative detection of perforations easier. Additionally, doublegloving is known to significantly reduce the perforation risk. Therefore, the use of double colored gloves is recommended in
all categories of surgery.
Lancaster and Duff conducted a study to compare the relative frequency of glove perforations in double-glove versus singleglove sets in obstetric and gynecological procedures.21 In their prospective cohort study, surgeons single- or double-gloved
for pelvic surgery procedures at their own discretion. The gloves were collected at the end of each procedure and evaluated
for perforations. The authors tested 1,000 sets of gloves: 675 double-glove sets and 325 single-glove sets. The highest rate
of perforation (19%) occurred during major gynecologic procedures. Surgical nurses were the most likely member of the
surgical team to sustain a glove injury. There was no significant difference in the total perforation rate between double and
single glove sets (10% vs. 11%). However, there was a significantly greater potential for blood-skin exposure in the single
glove sets. Eleven percent of the single glove sets contained a perforation, whereas only 2% of double-glove sets contained
a corresponding defect in the inner and outer gloves. The authors concluded that surgeons should double glove for all pelvic
surgery procedures.
Gaujac, et al conducted a prospective, randomized study to comparatively evaluate two double-gloving techniques for
providing protection during arch bar placement for intermaxillary fixation.22 A total of 42 consecutive patients in whom
application of an Erich bar was indicated for intermaxillary fixation were equally divided into two groups: in group 1, two
sterile surgical gloves were used; in group 2, a nonsterile disposable inner glove was used under a sterile surgical glove. A
total of 103 perforations were found in the outer gloves (47 in group 1 and 56 in group 2), along with 5 perforations in inner
gloves in both groups. No significant statistical difference was found between groups in terms of inner glove perforations.
The nondominant hand had the majority of the perforations (70.9%). The authors concluded that both double-gloving
techniques were found to provide effective protection for the clinician. The use of a nonsterile disposable glove under the
surgical glove is possible for less-invasive procedures, offering the same safety as using two pairs of sterile surgical gloves
while decreasing operational costs. However, this method does not eliminate the need to change gloves when a perforation
is suspected or noted during a procedure.
Ersozlu, et al assessed the frequency of glove perforation during major and minor orthopaedic procedures in order to
determine the effectiveness of double-gloving.23 A total of 1,528 gloves (622 inner and 906 outer) used in 200 procedures
(100 major and 100 minor), and 100 pairs of unused gloves were examined. The glove perforation rate, incidence among
the surgical team, and the location of the perforation and duration of the procedure were compared. The overall perforation
rate was 15.8%. The perforation rates for major versus minor surgical procedures were 21.6% and 3.6%, respectively. The
perforation rate for the unused control group was 1% (2 out of 200). Inner-outer gloves perforation rates were 3.7% (23 out
of 622) and 22.7% (206 out of 906), respectively. Surgeons had a higher perforation rate as compared with the other staff
members. The right thumb and left index finger had more punctures than other fingers. The authors concluded that the
routine use of double-gloving during orthopaedic procedures is recommended, because this practice significantly reduces
the perforation of inner gloves.
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Srensen et al performed a study to determine to what extent gloves become contaminated during neurosurgical shunt
surgery, since bacterial infection is a major cause of shunt dysfunction.24 Gloves used during shunt implantation were
examined in ten surgical procedures. Shunt implantation was performed by surgeons experienced in shunt surgery, using
recommended precautions to avoid infection, including prophylactic antibiotics and double-gloving. Surgical incision,
dissection and tunneling were completed; then the surgeon, the scrub nurse and, in three cases, the assistant, made an
imprint of their outer gloves on agar plates. Hereafter, they changed the outer pair of gloves before handling the shunt and
completing the procedure. The agar plates were then cultured for six days, in both aerobic and anaerobic environments. In
all cases, the surgeons gloves were contaminated; in six cases the nurses gloves, as well as those of all the assistants,
were also contaminated. Propionebacterium acnes was cultured from gloves in all ten procedures and coagulase-negative
Staphylococci were found in eight of the operations. While these results are preliminary, they are nevertheless alarming.
Despite the use of recommended precautions to avoid infections, the authors found that a substantial numbers of gloves
from the surgeon, scrub nurse and assistant were contaminated with microorganisms less than 15 minutes after surgery
began and before the shunts were handled. The authors concluded that this study offers a feasible, simple, and logical
explanation of how shunts may become contaminated and infected: a simple preventative measure would be to change
the outer pair of gloves prior to handling the shunt material during surgery, as was done in this study, where non-shunt
infections were observed. An earlier study of 863 patients conducted by Tulipan and Cleves to determine the effect of
double-gloving on cerebrospinal fluid (CSF) shunt infection rates demonstrated that double-gloving while performing shunt
surgery appeared to reduce the incidence of postoperative shunt infection by more than 50%.25
More recently, Naava et al, noting the increased tendency toward double-gloving by general surgeons in their practice,
conducted a study to compare the relative frequency of glove puncture in single-glove versus double-glove sets in general
surgical procedures, and also to determine if the duration of the surgical procedure affects the perforation rate.26 Surgeons
either single-gloved or double-gloved at their discretion, for general surgical procedures. All of the gloves used by the
surgeons were assessed immediately after surgery for perforation. A total of 1,120 gloves were tested, of which 880
were double-glove sets and 240 were single-glove sets. There was no significant difference in the overall perforation rate
between single and double-glove sets (18.3% versus 20%). However, only 2.3% had perforations in both the outer and inner
gloves in the double-glove group; therefore, there was significantly higher risk for blood-skin exposure in the single-glove
sets. The perforation rate also was significantly greater during surgical procedures lasting one hour or more, as compared to
those lasting less than one hour. The authors concluded that double-gloving reduces the risk of blood-skin contamination in
all general surgical procedures, particularly so in procedures lasting one hour or more.
Wittmann et al, noting that the risk of infection after a needlestick injury during surgery depends significantly on the
quantity of pathogenic germs transferred at the point of injury, measured the quantity of blood transferred at the point of a
percutaneous injury by using radioactively labeled blood in order to evaluate the risk of infection through blood contact by
simulating surgical needlestick injuries in an artificial envionroment.27 The tests were conducted by puncturing single and
double latex gloves with various sharp devices and objects that were contaminated with Technetium solution-labeled blood.
A mean volume of 0.064 L of blood was transferred in punctures with an automatic lancet at a depth of 2.4 mm through
1 layer of latex. When the double-gloving colored technique was used, a mean volume of only 0.011 L of blood was
transferred (median, 0.007 L). The study results demonstrated that double-gloving leads to a significant reduction in the
quantity of blood transferred during needlestick injury.

PROFESSIONAL RECOMMENDATIONS

In light of the published research data supporting key safety aspects of double-gloving, several professional organizations
continually revise and update their recommendations regarding the practice of double-gloving. The Association of
periOperative Registered Nurses (AORN) Recommended Practices Advisory Board updated its Guideline for Prevention of
Transmissible Infections in 2012. Recommendation VI of the revised guideline includes:28
yy Perioperative team members should wear two pairs of gloves, one over the other, during surgical and other invasive
procedures with the potential for exposure to blood, body fluids, or other potentially infectious materials. When double
gloves are worn, perforation indicator systems should be used.

Page 10

yy When the invasive procedure is completed, perioperative personnel should remove both pairs of gloves, discard
them, and perform hand hygiene.
The revisions to the recommended practices were based on a systematic literature review of clinical trials of various gloving
practices, which demonstrated that double-gloving minimizes the risk of exposure of healthcare workers to blood during
invasive procedures; these studies found the following: 29
yy Perforation rates of the glove closest to the skin are significantly less when wearing double-gloves compared to single
gloves.
yy Perforation rates are no different when wearing single gloves compared to the outer gloves when two pairs are worn.
yy More glove perforations are detected when using a colored under-glove system when compared to two pairs of
standard latex gloves.
yy Wearing two pairs of gloves significantly reduces the number of perforations to the innermost glove, when compared
to the outer glove or single gloves.
yy Wearing one pair of standard thickness gloves on top of a pair of standard thickness colored gloves facilitates the
wearers rapid recognition of perforations to the outer glove.
Studies have also indicated that powdered gloves should not be worn, especially as an outer glove. Powder introduces the
potential for granulomas in patients.
The American College of Surgeons (ACS) also supports and recommends the practice of double-gloving in its 2007
Statement on Sharps Safety.30 It notes that sharps injuries and surgical glove tears continue to expose surgeons and
OR personnel to the risk of HIV, viral hepatitis B, viral hepatitis C, and bacterial infections from patients. Patients blood
makes contact with the skin or mucous membranes of OR personnel in as many as 50% of surgical procedures, with cuts
or needlesticks occurring in as many as 15% of operations. Surgeons and first assistants are at highest risk for injury,
sustaining up to 59% of the injuries in the OR. Scrub personnel have the second highest frequency of injuries in the OR
(19%), followed by anesthesiologists (6%) and circulating nurses (6%). For surgeons, suture needles are the most frequent
source of sharps injuries. The recommended OR work practices related to gloving practices outlined in the statement
include:
yy Double-gloving. Glove barrier failure is common; perforation rates as high as 61% for thoracic surgeons and 40%
for scrub personnel have been reported. Double-gloving decreases the risk of exposure to patient blood by as much
as 87% when the outer glove is punctured; however, double-gloving has certain disadvantages, such as decreased
tactile sensation. In certain types of surgery (eg, neurosurgical procedures), where delicate manipulation of
instruments and tissues is required, double-gloving may impair the surgeons ability to safely perform the procedures.
yy The ACS recommends the universal adoption of the double-glove (or underglove) technique in order to reduce
body fluid exposure caused by glove tears and sharps injuries in surgeons and scrub personnel. In certain delicate
operations, and in situations where it may compromise the safe conduct of the operation or safety of the patient, the
surgeon may decide to forgo this safety measure.
In June 2008, the American Academy of Orthopaedic Surgeons (AAOS) revised its Information Statement on Preventing
the Transmission of Bloodborne Pathogens with an updated overview of strategies to reduce the risk of transmitting
bloodborne pathogens in various orthopaedic settings.31 Due to the nature of the procedures that they perform, orthopaedic
surgical staff members have high rates of exposure to blood and other body fluids. The recommendations for safety during
procedures and examinations regarding gloving practices include:
yy Gloves should be worn during any procedure that may result in contact with a patients blood or other body fluids.
This is particularly important for surgical staff, as frequent scrubbing may cause abrasions on the skin that pose an
increased risk for transmission through skin exposure. Gloves should also be worn when handling needles or other
sharp instruments. It has been shown that the volume of blood transmitted by a needle-stick is reduced by 50% when
the needle first passes through a glove. Double-gloving is recommended.
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yy Proper surgical garb must be worn during any surgical procedure:

o Double gloves may be worn during all surgical procedures. The outer pair should be changed at least every
two hours to prevent skin exposure from perforations that may occur in the gloves with use over time.
During procedures where sharp instruments and devices are used, or when bone fragments are likely to be
encountered, the surgeon may consider the use of reinforced gloves that offer more protection.
yy At the completion of the case, the surgeon should take care not to contaminate areas outside of the surgical field with
blood:
o The outside layer of gloves should be changed and the dressing applied while the outer pair of gloves is
clean.
o The contaminated drapes should be removed and discarded into an appropriate biohazard container.
o The surgeon should then remove the surgical gown and gloves.
o Clean, non-sterile gloves should be used to handle any operating equipment that is not grossly
contaminated. Afterwards, these gloves should be removed and the surgeons hands washed.
o All contaminated clothing should be removed in a manner that avoids contact with the blood.
o Care must be taken not to contaminate other areas with bloody shoe covers, gloves or scrub clothes.
In its Guideline for Prevention of Surgical Site Infection, 1999 the CDC also notes that:32
yy Sterile gloves are worn to minimize transmission of microorganisms from the hands of team members to patients and
to prevent contamination of team members hands with patients blood and body fluids.
yy If the integrity of a glove is compromised (eg, punctured), it should be changed as promptly as safety permits.
yy Wearing two pairs of gloves (ie, double-gloving) has been shown to reduce hand contact with patients blood and
body fluids when compared to wearing only a single pair.

IMPLICATIONS OF DOUBLE-GLOVING IN THE SURGICAL PRACTICE SETTING

As noted, both the research data and safety recommendations promulgated by professional associations support and
recognize the practice of double-gloving. However, despite the large body of evidence documenting the benefits of
double-gloving, this technique has not received wide acceptance in the surgical practice setting by surgeons or operating
room personnel. One possible reason for this may be that the research does not also inform healthcare personnel of the
consequences of blood and body fluid contamination by reporting on postexposure seroconversion after injuries and blood
exposures.33 Therefore, it is imperative that healthcare personnel fully appreciate the true risk of exposure as well as the
likelihood of postexposure seroconversion should a barrier breach in the gloves occur through injury or blood contamination
on broken or chapped skin. Additionally, in many cases, a period of adaptation and retraining seems to be required before
practitioners feel comfortable with the new technique.34
Double-gloving requires a change in practice. Any change in practice is often hard and typically not well received
especially when it comes to gloves. Glove preference is subjective acceptance of new gloves or a change in gloving
practices is based solely on the personal perception of the wearer. The wearer also needs time to get comfortable and
accustomed with new donning practices and to the fit and feel of two gloves versus one. The surgical professionals must be
willing to invest in both the change and the time.
When first using double-gloves, the wearer or practitioner must be committed to persevere through the length of the
evaluation or trial period.35 One survey reported that surgeons who always or usually double-glove report that a period of
1 to 120 days (2 days in most cases) is required to fully adapt to its use and surgeons who routinely double-glove report
decreased hand sensation much less frequently than those who do not.36

Page 12

The fit of the two gloves is essential to provide the wearer the dexterity and tactility desired. It is important to trial different
glove combinations. For example, if you wear a size 7 when single gloved, you may want to trial the following size
combinations:
yy Size 7 top (second layer) and bottom (first layer, closest to the skin) same glove size you are used to.
yy Size 7 bottom, size 7.5 top size up on the second layer to accommodate the first layer.
yy Size 7.5 bottom, size 7 top for a snug fit, closely conforms to the hand.
As noted, Quebbemans study found an 88% acceptance rate in the group that wore double-gloves; of those, 88% did not
perceive any decrease in tactile sensitivity.37 Webb and Pentlow compared double-gloving and single-gloving and the effects
on tactile sensitivity and dexterity. The testing included three scenarios: wearing the same glove size inside and out, the
larger glove on the inside, and the larger glove on the outside. Surgeons were evaluated on their ability to tie surgical knots
and with the moving two-point discrimination test. The Dellon test identifies when a glove wearer feels sensation in different
areas of the hand and fingers. The findings showed no alteration in the ability to tie knots or in the discrimination test. In
addition, the consensus found that wearing the larger glove on the outside was more comfortable.38 Edlich, et al, concluded
that the surgeon who is just beginning to use double-gloves should try various combinations; when a comfortable fit is found,
perceived hand sensitivity will likely improve with increased experience using double-gloves.39
One can also combine gloves of different thicknesses. Two thin or micro gloves will provide enhanced tactile sensitivity. A
micro glove as the first layer also can be combined with a standard or thicker glove on top. Undergloves also are available to
enhance the double-gloving experience. These specialized gloves are typically a micro-thin layer with a smooth or polished
surface to allow for easy donning and removal. The underglove also may include an emollient coating applied to the inside
of the glove to aid in skin wellness and to support hand hygiene protocols. Undergloves can be colored (ie, blue, brown or
green) to aid in the identification and detection of perforations to the outer layer, as well as to easily identify the wear order of
the two gloves: ie, first layer is the glove with color.
Healthcare practitioners hands are their livelihood. They need to be cared for and protected in order to provide essential
care to patients. Wearing gloves (one layer) is standard operating practice, but research has demonstrated that doublegloving offers more protection in the surgical practice setting. Injuries from sharps and needle sticks can and do happen. As
noted, cuts or needlesticks may occur in as many as 15% of operations.40,41 Suture needles are the most frequent source
of injury and are involved in as many as 77% of injuries; in addition, while most injuries are self-inflicted, a notable number,
perhaps as many as 24%, are inflicted by a co-worker.42 Up to 16% of injuries occur while passing sharp instruments handto-hand; most, if not all, surgeons have encountered blood on their hands or fingers at the conclusion of a procedure without
awareness of suffering an injury or the occurrence of a breach of the glove barrier by any other method (eg, glove puncture,
tear, or failure).43
The practice of wearing two pairs of gloves offers a high degree of protection from this common event.

SUMMARY

Two gloves are better than one.44 Operating room team members are faced with the occupational risk of exposure to blood
and other potentially hazardous substances daily. The risk of infection is a consideration for all OR personnel. Wearing
reliable and efficacious surgical gloves is one risk reduction strategy; today, double-gloving takes this strategy one step
further, as this practice provides personnel with better protection from sharps injuries and also reduces the risk of exposure
to infections than does wearing a single pair of gloves. It is well documented in the literature that double-gloving is clearly
safer than single-gloving. New developments and strategies, such as colored systems that allow for more timely recognition
of perforations and specially designed undergloves, improve both the comfort and safety aspects of double-gloving, as
well as its acceptance by surgeons and OR personnel. Although the practice of double-gloving is optional in many surgical
practice settings, for many staff members, double-gloving has become the standard of practice, protecting them from
exposures to patients blood and body fluids. Making the transition to the practice of double-gloving will take time, patience
and determination, but in the end, the power of two will enhance the safety of OR personnel and their patients.

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CASE STUDIES

The following case studies are presented to allow the learner to synthesize and apply the concepts discussed in the study
guide to workplace scenarios. Read the scenarios carefully, integrating the data and information to discuss the points to
consider.
Case Study 1: To Double-Glove or Not to Double-Glove?
Pam Jones, RN is a recent graduate who is a perioperative nursing intern at St. Marks Hospital, a 200-bed suburban
community hospital. She is very enthusiastic about perioperative nursing and actively researches issues as she encounters
them. During her orthopaedic surgery rotation, she noticed that the surgeons and their assistants wore two pairs of gloves
during all of their procedures, but that most of the OR staff did not routinely do so. She consulted the department policy
and procedure manual, where it stated that double-gloving was recommended, but not required; it was left to the staffs
discretion. When she questioned her preceptor, Sue Taylor, RN, BSN, CNOR, about it, Sue replied that the practice is not
required at this time because they are still doing research and that many of the staff dont like wearing two gloves. Revising
the current double-gloving policy and procedure was one of the projects with which Sue was assisting the educator, Tom
Williams, RN, MSN, CNOR. Sue asked Pam if she wanted to help with the policy revision, reviewing the literature and
conducting staff interviews and Pam agreed.
Points to Consider:
1. What are the advantages of double-gloving that the staff may cite?
2. What are some of the barriers to double-gloving that Pam might discover in her conversations with the staff?
3. What recommendations should Pam make to Sue and Tom regarding revisions to the double-gloving policy and
procedure?
Discussion of Points to Consider:
1. What are the advantages of double-gloving that the staff may cite?
- Its protection in case one glove breaks or is compromised on the field.
- I still have a second pair.
- It provides a backup layer of protection in case the outer glove becomes compromised.
- It protects me from exposure to blood during a case.
- Its safer for me and the patients.
2. What are some of the barriers to double-gloving that Pam might discover in her conversations with the staff?
- I cant move my hands.
- I lose my tactile sensation.
- It is hard to pick up items or load fine sutures.
- It feels differently at first.
- The gloves cost more.
- I just dont like it.

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3. What recommendations should Pam make to Sue and Tom regarding revisions to the double-gloving policy and
procedure?
- Use gloves that are specifically designed for double-gloving; these gloves are of equal thickness, and
generally are more comfortable to use.
- Wear two pairs of gloves consistently; try different sizes, wearing a smaller glove on top to get a closer fit.
- Ask the glove manufacturer to professionally size the gloves.
- Use a colored glove system, with a green or blue glove next to the skin and an off-white glove on the
outside; that way, when the outer glove becomes compromised, the colored underglove shows through;
then, the surgical team member knows to change his/her gloves.
Case study 2: Revising the Double-Gloving Policy
Tom Williams, RN, MSN, CNOR, is the Perioperative Educator for St. Marks Hospital. As noted, he has been asked to
revise the departments policy and procedure on double-gloving; one of the preceptors, Sue Taylor, RN, BSN, CNOR, is
assisting him. He wants to make the transition as smooth as possible for everyone concerned, ie, the OR staff and the
surgeons; therefore, he thought that having Pam Jones, one of the perioperative interns, assist with this project by talking to
the staff about double-gloving was a good idea.
Points to Consider:
1. What statistics/literature should Tom and Pam review in this process?
2. How should he address the staff concerns discussed with Pam related to double-gloving?
3. How should Tom revise the double-gloving policy and procedure?
4. What are the expectations for the staff?
Discussion of Points to Consider:
1. What statistics/literature should Tom and Pam review in this process?
- Current department statistics on incidents of exposure to blood during surgery or other invasive procedures,
including needlesticks.
- Current literature citing studies that demonstrate:
o Decreased perforation rate of the glove closest to the skin when wearing double-gloves.
o More glove perforations are detected when using a colored under-glove system when compared to
two pairs of standard gloves.
o Wearing two pairs of gloves significantly reduces the number of perforations to the innermost
glove.
o Wearing two pairs of gloves does not increase the likelihood of increased perforation to the
outermost glove.
o Wearing one pair of standard thickness gloves over a pair of standard thickness colored gloves
facilitates the wearers rapid recognition of perforations to the outer glove.
- Organizations that support the practice of double-gloving, eg, the Centers for Disease Control and
Prevention (CDC), American Academy of Orthopedic Surgeons (AAOS), American College of Surgeons
(ACS), and the Association of periOperative Registered Nurses (AORN).
Page 15

2. How should he address the staff concerns discussed with Pam related to double-gloving?
- He should recognize the staffs various concerns, ie, loss of tactile sensation, different feel, hard to pick up
fine items.
- He should present the results of his research demonstrating that the practice of double-gloving minimizes
the risk of exposure of healthcare workers to blood, including needlesticks, during invasive procedures.
- Tom should institute a trial period, realizing that changing the practice may be difficult; acceptance of new
gloves or the change in practice is based on the personal perception of the staff members. The staff will
need time to become accustomed to the new practice and to the fit and feel of two gloves versus one.
3. How should Tom revise the double-gloving policy and procedure?
- While the hospital currently lets the staff decide whether or not to double-glove, it should be mandatory,
citing the evidence from the literature review and professional recommendations, as noted above.
4. What are the expectations for the staff?
- Tom should ask the staff for feedback and their commitment to the change and time involved during the trial
period.
- 100% compliance with double-gloving should be the standard of practice once the new policy is approved
and disseminated; compliance should be monitored and enforced for the safety of all staff members.
Case Study 3: Monitoring Compliance
It has been two weeks since the double-gloving policy has been revised, disseminated to the staff at the last staff meeting,
and implemented. Pam is assigned to circulate for general surgery cases in OR # 3. Melissa Cooper, CST is the surgical
technologist also assigned to the room; Melissa has just recently confirmed that she is two months pregnant. After opening
and setting up, when Pam comes back into the room to count, she notices that Melissa is not wearing two pairs of gloves.
When she asks Melissa about it, Melissa tells her that her hands are a little swollen this morning and wearing two pairs of
gloves is uncomfortable for her now and she feels that they really hinder her ability to work effectively. She also doesnt think
the change in policy was necessary.
Points to Consider:
1. How should Pam respond to Melissa?
2. What should Pam do in this case?
Discussion of Points to Consider:
1. How should Pam respond to Melissa?
- She should point out that the practice of double-gloving is supported by research studies that demonstrate
it improves healthcare worker safety; the policy change was mandated for her safety, which is even more
important for Melissa, now that she is pregnant.
- She should also ask Melissa what double-gloving strategies she used during the trial period worked for her.

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2. What should Pam do in this case?

- Pam should offer Melissa either undergloves or larger pairs of gloves that would be more comfortable and
facilitate her manual dexterity.
- Pam should discuss the situation with Sue or Tom in the interest of compliance with the policy for Melissas
safety.

Page 17

Glossary of Terms
Barrier Breach

A puncture, perforation, hole, or compromise in the integrity of glove

material that renders it ineffective as a barrier to blood, body fluids, or
chemicals.

Bloodborne Pathogens

Pathogenic microorganisms that are present in human blood and can

cause disease in humans. These pathogens include, but are not limited
to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV).

Dexterity

Skill and ease in using the hands; expertness in manual acts: dexterity
with a scalpel.

Double-Gloving

The practice of wearing two pairs of gloves, one over the other.

Exposure Incident

A specific eye, mouth, other mucous membrane, non-intact skin, or

parenteral contact with blood or other potentially infectious materials that
results from the performance of an employees duties.

Hand Hygiene

A generic term that applies to hand washing either with a plain or

antimicrobial soap or use of an alcohol-based, antiseptic hand rub
product.

Invasive Procedures

The surgical entry into tissue, cavities, or organs or repair of major

traumatic injuries.

Microorganisms

Organisms (eg, bacteria, fungi, viruses, protozoa) that are too small to
be seen with the naked eye.

Occupational Exposure

Reasonably anticipated skin, eye, mucous membrane, or parenteral

contact with blood or other potentially infectious materials that may result
from the performance of an employees duties.

Pathogen

A microorganism that causes disease.

Personal Protective Equipment (PPE)

Specialized clothing or equipment worn by an employee for protection

against a hazard. General work clothes (eg, uniforms, pants, shirts or
blouses) not intended to function as protection against a hazard, are not
considered to be personal protective equipment.

Potentially Infectious Material

Blood; all body fluids, secretions, and excretions (except sweat),

regardless of whether they contain visible blood; nonintact skin;
mucous membranes; and airborne, droplet, and contact-transmitted
epidemiologically important pathogens.

Sharps

Sharps include, but are not limited to, suture needles, scalpel blades,
hypodermic needles, electrosurgical needles and blades, safety pins,
and instruments with sharp edges or points.

Page 18

Surgical Gloves

Gloves intended for use in surgical procedures; they are manufactured

to a higher acceptable quality level for holes than exam gloves.

Tactile Sensitivity

The ability to sense, discriminate, and feel through pressure receptors

located in the skin of the hands.

Universal Precautions

A prudent approach to infection control. According to the concept

of Universal Precautions, all human blood and certain human body
fluids are treated as if known to be infectious for HIV, HBV, and other
bloodborne pathogens.

Page 19

References

1. Twomey CL. Double-gloving: a risk reduction strategy. Jt Comm J Qual Saf. 2003; 29(7): 369-378.
2. CDC. Perspectives in disease prevention and health promotion update: universal precautions for prevention of
transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care
settings. http://www.cdc.gov/mmwr/preview/mmwrhtml/00000039.htm. Accessed February 3, 2016.
3. Twomey CL. Infection control today - does double-gloving double the protection? http://www.infectioncontroltoday.com/
articles/2000/05/infection-control-today-does-double-gloving-doubl.aspx. Accessed February 3, 2016.
4. US Department of Labor. OSHA. Regulations (Standards 29 CFR). Bloodborne pathogens. 1910.1030. https://
www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051. Accessed February 3,
2016.
5. US Department of Labor. OSHA. Frequently asked questions. What is the Needlestick Safety and Prevention Act?
https://www.osha.gov/needlesticks/needlefaq.html. Accessed February 3, 2016.
6. CDC. Exposure to blood: what health care personnel need to know. http://www.cdc.gov/HAI/pdfs/bbp/Exp_to_Blood.
pdf. Accessed February 3, 2016.
7. Thomas-Copeland J. Do surgical personnel really need to double-glove? AORN J. 2009; 89(2): 322-328.
8. Quebbeman EJ, Telford GL, Wadsworth K, Hubbard S, Goodman H, Gottlieb MS. Double-gloving: protecting surgeons
from blood contamination in the operating room. Arch Surg. 1992; 127(2): 213-217.
9. Cohen MS, Do JT, Tahery DP, Moy RL. Efficacy of double-gloving as a protection against blood exposure in
dermatologic surgery. J Dermatol Surg Oncol. 1992;18(10): 873-874.
10. Chapman S, Duff P. Frequency of glove perforations and subsequent blood contact in association with selected
obstetric surgical procedures. Am J Obstet Gynecol. 1993; 168(5): 1354-1357.
11. Greco RJ, Garza JR. Use of double-gloves to protect the surgeon from blood contact during aesthetic procedures.
Aesthetic Plast Surg. 1995; 19(3): 265-267.
12. Hollaus PH, Lax F, Janakiev D, Wurnig PN, Pridun NS. Glove perforation rate in open lung surgery. Eur J Cardiothorac
Surg. 1999; 5(4): 461-464.
13. Naver LP, Gottrup F. Incidence of glove perforations in gastrointestinal surgery and the protective effect of doublegloves: a prospective, randomised controlled study. Eur J Surg. 2000;166(4): 293-295.
14. Aarnio P, Laine T. Glove perforation rate in vascular surgery--a comparison between single and double-gloving. Vasa.
2001;30(2): 122-124.
15. Thomas S, Agarwal M, Mehta G. Intraoperative glove perforation single versus double-gloving in protection against
skin contamination. Postgrad Med J. 2001;77(909):458-460.
16. Tanner J, Parkinson H. Double-gloving to reduce surgical cross-infection. Cochrane Database of Syst Rev. 2002;(3):
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