The risks and challenges of surgical glove failure

AORN Journal, Nov, 1997 by Dietmar Rabussay, Denise M. Korniewicz

The primary reason for wearing surgical gloves in surgical settings is to prevent the transmission of infections between health care providers and patients. The ideal glove would

* provide total protection against injuries, infections, and toxic substances for several hours;

* ensure undiminished tactility, and

* prevent fatigue or sweating.

Today's gloves do not meet these criteria but are considered critical in protecting health care providers and patients nevertheless.(1) Health care personnel have been wearing medical gloves much more frequently, especially since the adoption of universal precautions in the late 1980s, to protect themselves and patients from AIDS and hepatitis and to avoid contact with toxic substances (eg, antineoplastic drugs, methylmethacrylate) and gross contamination from direct hand contact with body fluids and tissues.(2)

In the OR, exposure to fluidborne pathogens (eg, HIV, hepatitis B virus [HBV], hepatitis C virus [HCV]) may occur because

* gloves frequently fail and

* the rate of glove failures increases with the duration of surgery.(3)

The potential dangers to health care personnel and patients depend on the actual number of pathogens transmitted, the general health and immune functions of the people at risk, the nature and duration of the surgical procedure, and the quality and number of layers of gloves used.(4) This article will review the risks of infection by viral and bacterial pathogens, controversial issues associated with gloving practices in the surgical environment, and guidelines and recommendations on infection control practices and glove use.

CURRENT GUIDELINES

The Occupational Safety and Health Administration (OSHA) and the Centers for Disease Control and Prevention (CDC) have addressed the use of gloves in their bloodborne pathogen regulations and universal precautions.(5) The CDC also has published guidelines for the prevention and control of nosocomial infections in seven different documents, including one specifically aimed at reducing the risk of infection from HIV and HBV.(6)

The 1991 CDC guidelines are based on the premise that the risk of pathogen transmission is greatest during "exposure-prone" invasive procedures that include

digital palpation of a

needle tip in a body cavity or

the simultaneous presence

of the health care worker's

fingers and a needle, or

other sharp instruments or

objects in a poorly

visualized or highly confined

anatomic site.(7)

Health care personnel who perform or assist in such procedures should know their HIV and hepatitis B antigen (HBe) status. Those whose status is positive should not perform risk-prone procedures unless they have received guidance from an expert panel as to when and how they may do so without unduly compromising the safety of the patient. The guidelines do not demand suspension of surgical practice, but do require that patients be notified of the provider's infection status before undergoing specified procedures.

Regulations in the United Kingdom are more strict than in the United States, prohibiting HBe- and HIV-positive surgical personnel from performing procedures that carry a risk of exposing patients to the blood of such personnel.(8) In the United Kingdom, all health care providers at risk for HBV infection must be vaccinated and show a sufficient antibody titer against HBV surface antigen before they may perform risk-prone procedures.(9)

RISK FROM VIRUSES

The most feared pathogen in surgical settings is still HIV, although the number of confirmed infections due to occupational exposure is relatively low. As of Dec 31, 1996, 52 health care workers were confirmed to have contracted HIV on the job and an additional 111 possible transmissions also have been reported.(10) Despite a recent decline in deaths due to AIDS, the number of HIV-positive people is increasing in the United States and other countries. Except for accidents, the leading cause of death among people between the ages of 25 and 44 years in the United States is AIDS.(11) The total number of HIV-infected people in the United States may be as many as I million (Table 1).(12) Worldwide, AIDS cases in 1995 were estimated at 4.5 million. The number of HIV-infected people is expected to reach 40 million by the year 2000.(13)

[TABULAR DATA NOT REPRODUCIBLE IN ASCII]

Hepatitis B virus. Infections from HBV are the most numerous among the well-documented fluid-borne viral infections in the surgical environment. Statistics from the CDC report that approximately 18,000 health care providers have become infected per year, of whom 275 have died and 1,400 were at serious risk.(14) Approximately 1,900 of the 133,000 surgeons practicing in the United States are chronic HBV carriers.(15) The chronic infection rate among surgeons is approximately three times greater than that of the general population and varies greatly among surgical specialties.(16) The number of HBV-infected people in the US general population is estimated at 1.25 million chronic carriers. Another 140,000 to 320,000 people are infected with HBV annually and remain infectious for at least several months. Approximately 5,500 deaths per year in the United States are attributed to HBV.(17)