The potential for contamination

A pilot study of open and

closed surgical gloving

Rosemary Ann Roth, RN James Whitbourne

Prescript: Project #80-6-R of the Guthrie Foundation for Medical Research, Sayre, Pa, and the Association of Operating Room Nurses.

0 pen and closed surgical gloving 1 techniques-routinely used by operating room personnel-were

investigated by the AORN Recom- mended Practices Subcommittee of the Technical Practices Coordinating Committee. The charge of the Recom- mended Practices Subcommittee is to draft recommended practices that the AORN membership can use as a guideline for formulating policies and procedures in their operating room suites. The recommended practices are written as optimal achievable state- ments.

With closed gloving technique, the scrubbed person keeps prepped hands within the sleeves of the surgical gown until the glove is pulled on, then pushes the hands through the gown wrist cuffs. In this method, bare hands do not come in contact with the sterile exterior of the gown. With open gloving technique, the scrubbed person slips prepped hands through the gown cuffs prior to gloving, touching only the everted cuff of the surgical gown, then places the glove on a clenched hand and pulls it on with the opposite hand.

Personnel take care not to touch the glove’s exterior and to ensure that the cuff of the glove completely covers the cuff of the gown. Both techniques repre- sent accepted practice, but closed glov- ing is more frequently used for initial gloving, while open gloving is used for changing a contaminated glove during the procedure.

When the committee attempted to es- tablish practices for surgical gloving in 1976, a literature search of clinical data revealed that documentation did not exist on which method, open or closed surgical gloving, was aseptically more

AORN Journal, October 1982, Vol36, No 4 51 1

appropriate. Without such information, the proposed recommended practice could not be drafted. A pilot study was undertaken at the Guthrie Clinic in Sayre, Pa, in cooperation with the operating room staff and Sterilization Technical Services, a firm specializing in the sterilization and sterility testing of medical devices. Test results were ob- tained on May 12, 1980.

For this test, we used Bacillus stea- rothermophi2us (BSTM) spores on the glove user's hands as a tracer and com- pared the two methods of gloving under actual conditions. This tracer method was chosen because it represented a means of challenging the gloving tech- niques with actual bacteria that could easily be differentiated, based upon in-

Rosemary Ann Roth

Rosemary Ann Roth, RN, CNOR, MSN, is assistant director nursing practice OR/RR, Genesee Hospital, Rochester, NY. She is also senior associate on the nursing faculty at the University of Rochester. A member of the AORN Board of Directors, she is chairman of the AORN Technical Practices Coordinating Committee. A graduate of the St Joseph's Hospital School of Nursing, Syracuse, NY, Roth has a BS and MSN from the University of Rochester.

James Whitbourne, BS, is president of the Sterilization Technical Services, Rochester. He has a BS from the University of Georgia, Athens.

cubation temperature, from contami- nants that might appear from other sources. Materials used in the study were: 0 B stearothermophilus spores (Sterili-

zation Technical Services, Inc, Rochester, NY)

0 sterile surgical gloves 0 sterile surgical gowns, masks, and

hoods sterile saline, pipettes, swabs, and col- lection tubes tryptic soy broth (Difco Laboratories, Detroit, Mich)

0 Standard Methods Agar (Difco Laboratories). The first phase of the research study

involved the development of a metho- dology to determine if a glove would be- come contaminated as a result of con- tact with the hand(s) of the individual donning the glove. To demonstrate this,

criteria must be met: The contamination resulted from contact with the glove. Contact of hand to glove will transfer contamination at a suffi- ciently sensitive level. Under the conditions of testing, assessment of contamination must be sufficiently sensitive to detect contamination at a low order of magnitude.

With respect tothe first criteria, we chose to use spores of the bacteria B stearothermophilus as a tracer because:

(1) These spores are resistant to dry- ing and would remain stable dur- ing the course of the investiga- tion.

(2) They are not a common environ- mental contaminant.

(3) The minimum culturing temper- ature of approximately 48 "C for this thermophilic organism will not permit growth of the vast majority of normal environmen- tal flora. This fact precluded ad- ventitious Contamination.

572 AORN Journal, October 1982, Vol36, No 4

Table 1

Actual No No BSTM Expected No Theoretical BSTM BSTM spores spores recovered BSTM spores concentrationlrnl foundlrnl by swabbing recovered YO recovery

2 2 0 0.76' - 4 5 2 1.00 100% 6 0 3 2.00 100% 16 20 5 6.40 77%

*The expected number is the actual number found in the bath multiplied by 0.362 mi.

By using this stable spore prepara- tion foreign to the environment and a selective culturing requirement, we are assured that detection of an organism(s) will be a direct consequence of an event that is part of the methodology.

Phase I. The sensitivity of transfer- ring spores from hand to glove was as- sessed as follows. A subject dipped tips of the fingers and thumb of one hand into a solution containing 4 x lo3 spores/ml. After drying in the air stream of a laminar flow hood, finger tips were swabbed. The swab samples were then enumerated by standard plate count procedure. The procedure was repeated a total of three times on three consecutive days. A day was per- mitted to elapse between each dip pro- cedure to allow sufficient time for the spores to be washed and/or sloughed from the subject's finger tips.

In a second procedure, the same sub- ject aseptically donned a surgical glove on one hand and dipped the other hand in the bath and permitted it to dry in the air stream. The fingers of the ungloved hand were then pressed against the finger tips of the gloved hand in a man- ner that ensured that all of the spore- contaminated part of the fingers con- tacted the glove. Contact time was 2 seconds. The glove finger tips were then swabbed, and the swab samples were

enumerated by standard plate count procedure. Before each dip, the finger tips were swabbed to establish baseline data on the presence of B stearothermo- philus spores.

The recovery sensitivity of the swab- bing procedure was established using the following test procedure. A pre- weighed surgical glove was placed in water permitting only the exterior sur- face to become wetted. The surgical glove was subsequently removed, the exterior surface drained, and the glove reweighed. The results of three trials demonstrated that 0.362 g of water on the average adhered to the outer surface of the glove. This is approximately equal to a volume of 0.362 ml of water.

A bath containing 500 ml of sterile water was prepared and a known amount of BSTM spores was added to this to yield a final concentration of ap- proximately two spores/ml. The actual value present in the bath was deter- mined by plating 10 ml of the solution on Standard Methods Agar and incubat- ing the plate at 55 "C to 60 "C until col- onies had developed. A glove was don- ned, and the individual placed the gloved hand in the bath, removed it, and allowed it to air dry. A moistened swab was run over the entire surface of the dry glove and then placed in 10 ml of sterile saline. The saline tube contain-

AORN Journal, October 1982, Val 36, No 4 573

Table 2 Finger tips of hand

152 spores recovered Finger tips of glove 34 spores recovered

ing the swab was vortexed for 1 minute and the entire contents, including the swab, was poured into a Petri dish. This dish was then overpoured with agar and incubated. The procedure was repeated for increased levels in the bath of 4, 6, and 16 sporedml.

These results in Table 1 demonstrate that B stearothermophilus cells, dried no longer than 15 minutes on surgical gloves, can be effectively recovered by swabbing.

An additional test was performed to determine the quantitative level of spores transferred from the hand to the glove. A bath was prepared containing approximately 4 x lo3 spores/ml. The tips of an individual’s fingers were swabbed following immersion in the bath and air drying. The individual again placed a hand in the bath, re- moved it, and allowed it to air dry. When dry, the tips of the fingers were momentarily pressed against the glove tips of an aseptically applied glove worn on the other hand. The glove tips were then swabbed and all of the swabs as- sayed by standard plate count proce- dure. Results are shown in Table 2.

Phase 11. Actual testing of the open versus closed gloving technique pro- ceeded as follows. A bath containing 500 ml of sterile water was inoculated with 9 ml of a suspension of B stearo- therrnophilus containing approximate- ly los spores per ml. A culture was drawn with a sterile pipette for later testing. Two subjects bathed their hands in the bath and allowed them to air dry. Before beginning the gloving procedure, a swab of the subjects’ palms

was made and was placed in sterile saline for later enumeration. The two subjects then proceeded through the gowning and gloving procedures. One always used the open technique, and the other always used the closed gloving technique. After the sixth glove change, the subjects again dipped their hands, allowed them to dry, and proceeded with more glove tests. After each gowning, the subjects’ gloves were swabbed, and the swab was held in 10 ml of sterile saline. The gowning, gloving, and swabbing were repeated ten times. Swabbing was done by two individuals who alternated between the open and closed glove users.

The individuals who conducted the gloving procedures were experienced operating room nurses. They performed a scrubbing procedure before the first donning but did not scrub between changes.

Table 3 Bath before inoculation-negative Bath after inoculation-I .7 x 1 @/ml Subject A palm (swab)-1.50 x 10Yarea

Subject B palm (swab)-1.75 x 1 OYarea

Bath after second hand dip-1.9 x 1 OYmI

sampled

sampled

Glove technique analysis Subject A

Sample open No technique

I Negative 2 Positive 3 Negative 4 Negative 5 Negative 6 Negative 7 Negative 8 Negative 9 Negative

10 Negative

Subject B closed technique Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative

574 AORN Journal, October 198.2, Vol36, No 4

The swab samples were transported t o the laboratories of Sterilization Technical Services where they were stored at 38 "F for approximately 18 hours before further treatment.

Treatment of test material. The sam- ples from the bath and palm were di- luted with sterile water and appropriate dilutions were made for transfer to sterile Petri dishes. The Petri dishes were overpoured with Standard Methods Agar, swirled, and incubated at 55 "C to 58 "C until colonies appeared. The swab samples from the gloves were set in vortex. The entire contents were poured into a Petri dish, which was then overpoured with Standard Methods Agar and incubated at 55°C to 58°C for up to seven days. Results are shown in Table 3.

Discussion. In comparing the two techniques, only one positive culture was found in the open gloving proce- dure, while none was found in the closed gloving procedure. The organism found was positively identified as B stearo- thermophilus, and the level of trans- ferred contamination was found to be two spores. This low number ofpositives and transferred spores demonstrates that the two techniques are not subject to significant contamination. It would require a greater number of tests to de- termine if there is any significance to finding one positive using the open glov- ing technique.

This result does assume that the ex- perimental design is sfiiciently sensi- tive to pick up any breaches of asepsis. The level of organisms used in the Anger-to-glove transfer tests was one order of magnitude less than the level used in the technique comparison test. In the transfer test, approximately one in four spores were transferred from the hand to the glove by touch. This ratio would not be expected to change at the higher concentration, but the prob- ability of transfer would increase by a

factor of ten. The area of contact in the transfer test

was approximately 1 sq in, and assum- ing a limit of detection of two spores in the swab recovery method, 3412 = 17 and 1 sq id17 = 0.059 sq in of contact x 4 = 0.236 sq in of contact area would be re- quired to produce a transfer of two or more spores. Since the test showed that the level of B stearothermophilus con- taminating the hands was a factor often higher, we could reasonably expect that the area of contact necessary to result in a positive culture would be 0.0236 sq in.

Although the preceding computation is an approximation, it does serve to es- tablish the order of magnitude regard- ing the size area contacted that may result in contamination transfer. As a point of reference, 0.0236 sq in is com- parable to the size of a pin head.

Other factors contribute to transfer of contaminants by touch. As seen in these studies, approximately 25% of the po- tentially transferable spores were ac- tually passed from the hand to the glove. Typical flora found on operating room personnel would react in a similar fashion. Scrubbing before the donning of gloves has been shown to reduce the microbial load present on hands and would tend to remove those which would be most easily transferred by touch. The subjects in this study were donning gloves on hands that were highly contaminated and intended to accentuate contact transfer.

Microbial contamination during surgery, when it does occur, can be con- sidered a quantitative factor. In this pilot study, the one positive culture il- lustrated that it is possible to transmit two spores of B stearothermophilus de- spite careful aseptic technique. The mode by which this organism reached the glove surface was not identified. If contact was the means of transference, the number of organisms identified should have been greater than was

AORN Journal, October 1982, Val 36, No 4 575

actually found. tamination. Although no definit ive findings re-

sulted from the comparison o f the two techniques, it has been demonstrated

lenged biologically are not prone to con-

The question-how significant i s the one positive finding on the open gloving technique-cannot be resolved based

0 tha t both methods when severely chal- upon the data base used.

New monitoring device detects anoxia quickly The operating room staff at Duke University Medical Center, Durham, NC, is using a noninvasive brain monitor that detects anoxia in two or three seconds. The device-Near InfraRed Oxygen Sufficiency Scope (NIROSC0PE)-works on the principle that brain tissue absorbs infrared light depending on the amount of oxygen available.

Physiologist Frans Jobsis vander Wet developed the brain monitor. The advantages of NIROSCOPE, as compared with conventional monitoring devices, were cited in Medical World News by Michael H Mitnick, MD, physiology research assistant. Dr Mitnick said, “Heart rate, blood pressure, and electrocardiograms all have drawbacks. They are indirect, intermittent measures of oxygen in the brain. This is the first method to provide continuous, instantaneous readouts during an operat ion.”

The device has been used to monitor 40 patients at Duke Medical Center. Other monitoring equipment was also used during the procedures. One patient experienced complications during a neck dissection for a suspected thyroid mass. A sudden drop in blood pressure was detected by NIROSCOPE in ten seconds. The other monitoring equipment also detected the drop in blood pressure, but Dr Mitnick said, “by the time the change was indicated by that system, we were already remedying the situation.”

None of the 40 patients has had any negative effects from the new monitoring device. The amount of infrared radiation to the patient is one sixth the amount permitted. A Duke anesthesiologist compared the amount of radiation received

during monitoring to the amount received while “walking on a sunny day.”

The primary disadvantage of NIROSCOPE is that it is unwieldy. It shows on a four-line printout sheet measurements of oxygenated hemoglobin, disoxygenated hemoglobin, cytochrome oxidase, and the brain’s blood volume. Dr Mitnick hopes that the device can be improved to give a digital readout and to sound an alarm automatically if deficiencies occur. For now, the surgeon must check the printout and sound an alarm himself.

The possible uses for NIROSCOPE are many. Clinical studies will be conducted for each situation before widespread use is allowed, but the device may be used in the delivery room, critical care unit, and neonatal intensive care unit. Also, the device may show when and how brain damage occurred during an operation. Such information would be helpful when lawsuits are brought against hospitals or surgeons. The inventor of the device hopes it will be available in 1983.

Program promotes nursing leadership An office for professional development has been formed at the Parkland Memorial Hospital, Dallas. Its purpose is to coordinate nursing research and publication support for health care professionals at Parkland Memorial Hospital. It is also intended to improve the quality of nursing care by reinforcing nursing interventions and adding knowledge to nursing science literature. The office’s coordinator is Marilyn Bache Chassie, a doctoral candidate at the University of Texas at Dallas.

576 AORN Journal, October 1982, Vol36, No 4