- Email: [email protected]
Clinical Issues—October 2012
CONTINUING EDUCATION Clinical Issues
1.2
JOAN C. BLANCHARD, MSS, BSN, RN, CNOR, CIC; BYRON L. BURLINGAME, MS, BSN, RN, CNOR; MARY J. OGG, MSN, RN, CNOR
www.aorn.org/CE Continuing Education Contact Hours
Approvals
indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal, and completing the online Learner Evaluation at http://www.aorn.org/CE. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #12527 Session: #0001 Fee: Members $6, Nonmembers $12
Conflict of Interest Disclosures
The contact hours for this article expire October 31, 2015.
Purpose/Goal To educate perioperative nurses about providing safe nursing care throughout the perioperative continuum.
Objectives 1. Discuss practices that could jeopardize safety in the perioperative area. 2. Discuss common areas of concern that relate to perioperative best practices. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care.
Ms Blanchard, Mr Burlingame, and Ms Ogg have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2012.07.007
Ó AORN, Inc, 2012
October 2012
Vol 96 No 4
AORN Journal j 443
CLINICAL ISSUES
1.2
www.aorn.org/CE
This Month Cross contamination of paper forms used in health care facilities Key words: inoculate, cross contamination, paper forms.
Manual cleaning of flexible endoscopes Key words: flexible endoscope, endoscope washers, manual cleaning, reprocessor, endoscope reprocessor, automatic endoscope reprocessor.
Achieving a comfortable fit when double gloving Key words: double gloving, comfort, glove fit.
Cross contamination of paper forms used in health care facilities QUESTION: We have electronic health records for our patients, but we are still required to have paper documents such as consent sheets for our charts. Can pathogens adhere to paper, and is it possible for those pathogens to transfer to the hands of health care personnel and then to patients or surfaces? ANSWER: It is possible that paper could be a source of cross contamination and infection in a health care facility. Paper’s porous surface and its incompatibility with disinfectants makes it very difficult to disinfect.1 Many studies have examined the transmission of pathogens from hands to inanimate surfaces2-6; there have been fewer studies to determine how long bacterial pathogens survive on paper and whether the identified pathogens could be
transferred from hands to paper and back to hands.7,8 In one study, researchers conducted a twostep experiment of bacterial survivability and transmission for a “worst case scenario” on the spread of pathogens to paper.1 In one test they used Escherichia coli, Staphylococcus aureus, Pseudomonas aeruginosa, and Enterococcus hirae to inoculate sterile paper swatches. They tested these swatches for bacterial survival over seven days. The pathogens survived for different lengths of time, but all were stable for at least 72 hours and were still cultivatable after seven days. Of the test organisms that survived on the inoculated paper, P aeruginosa and E hirae were quite resistant to the laboratory room conditions and were only reduced 3 log10 (99%) after seven days. This means that what remains on the surface after seven days has been significantly
http://dx.doi.org/10.1016/j.aorn.2012.07.007
444 j AORN Journal
October 2012 Vol 96 No 4
Ó AORN, Inc, 2012
CLINICAL ISSUES
www.aornjournal.org
reduced but could still be a potential source of infection.1 The researchers performed a second test to determine bacterial transmissibility from hand to paper to another hand. They inoculated the fingertips of one group of volunteers with a nonpathogenic E coli strain and then pressed the volunteers’ fingertips onto sterile swatches. They then irrigated the fingertips of another group of volunteers with sterile saline and pressed them onto the contaminated swatches. The test pathogens that were transferred to paper were able to survive and contaminate the hands of the second group of volunteers. This study showed that bacteria could be transferred to paper, survive on it, and transfer to hands and contaminate them.1 Boyce et al9 recommend that thorough hand hygiene be performed to reduce pathogen transmission. Farrington et al10 showed that transient bacteria on hands are an important route of transmission, and paper can be a reservoir for cross contamination of resistant organisms. Electronic health records may reduce the amount of paper used in health care facilities but will not reduce the need for thorough hand hygiene. It is important to remember that computer keyboards and terminals also may serve as sources of contamination. JOAN C. BLANCHARD MSS, BSN, RN, CNOR, CIC
References 1. Hubner N-O, Hubner C, Kramer A, Assadian O. Survival of bacterial pathogens on paper and bacterial retrieval from paper to hands. Am J Nurs. 2011;111(12): 30-34. 2. Abad FX, Pint o RM, Bosch A. Survival of enteric viruses on environmental fomites. Appl Environ Microbiol. 1994; 60(10):3704-3710. 3. Ansari SA, Sattar SA, Springthorpe VS, Wells GA, Tostowaryk W. Rotovirus survival on human hands and transfer of infectious virus to animate and nonporous inanimate surfaces. J Clin Microbiol. 1988;26(8): 1513-1518. 4. Gwaltney JM, Hendley JO. Transmission of experimental rhinovirus infection by contaminated surfaces. Am J Epidemiol. 1982;116(5):828-833. 5. Sattar SA, Karim YG, Springthorpe VS, JohnsonLussenburg CM. Survival of human rhinovirus type 14 dried onto nonporous inanimate surfaces: effect of relative humidity and suspending medium. Can J Microbiol. 1987;33(9):802-806. 6. Scott E, Bloomfield SF. The survival and transfer of microbial contamination via cloth, hands and utensils. J Appl Bacteriol. 1990;68(3):271-278. 7. Basavarajappa KG, Rao PN, Suresh K. A study of bacteria, fungal, and parasitic contamination of currency notes in circulation. Indian J Pathol. 2005;48(2):278-279. 8. El-Dars FM, Hassan WM. A preliminary bacterial study of Egyptian paper money. Int J Environ Health Res. 2005;15(3):235-239. 9. Boyce JM, Pittet D. Guideline for hand hygiene in healthcare settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/ Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002;51(RR-16):1-45. 10. Farrington M, Ling J, Ling T, French GL. Outbreaks of infection with methicillin-resistant Staphylococcus aureus on neonatal and burns units of a new hospital. Epidemiol Infect. 1990;102(2):215-228.
Manual cleaning of flexible endoscopes QUESTION: We are having problems interpreting the recommendation V and VI.b.1 in the AORN “Recommended practices for cleaning and processing flexible endoscopes and endoscope accessories.” One group of employees states that cleaning of endoscopes can be done manually or performed automatically by the new automatic washers. Another group of employees states that cleaning of endoscopes can only be accomplished manually. Which is correct?
ANSWER: The “Recommended practices for cleaning and processing flexible endoscopes and endoscope accessories”1 does allow for the use of an automatic endoscope reprocessor for the endoscope cleaning process. The steps for using an automatic reprocessor are not specifically identified because of differences in manufacturer’s written instructions. The recommended practices direct that the endoscope be reprocessed in three steps as described below: precleaning, manual cleaning, and high-level disinfection.
AORN Journal j 445
October 2012 Vol 96
CLINICAL ISSUES
No 4
1. Precleaning occurs in the patient care area and consists of wiping off the outer portion of the endoscope tube and irrigating its channels with cleaning solution using suction, as described in recommendation II of the recommended practices.1 2. Manual cleaning occurs after proper transport of the endoscope to the decontamination area and after leak testing, if appropriate. Recommended practice V states, Following leak testing and before high-level disinfection using a manual process or an automatic endoscope reprocessor, flexible endoscopes and their accessories should be cleaned before any remaining organic material dries on the surface or in the channels of the endoscope.1(p502-503) 3. High-level disinfection, the third step, is described in recommendation VI. One step of this recommendation states, “Manual cleaning should be accomplished as described in recommendation V.”1(p503)
In the second step, manual cleaning describes a process that can be accomplished by following the steps described in recommendation V.a or by using an automatic endoscope reprocessor that has the ability to accomplish this. Key points to remember are that the reprocessor must have the ability to accomplish manual cleaning and the manufacturer’s written instructions must be followed when completing the process. In step three, the use of the term manual cleaning refers to the process and not to the steps described in recommendation V.a.1
BYRON L. BURLINGAME MS, BSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE
Reference 1. Recommended practices for cleaning and processing flexible endoscopes and endoscope accessories. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012:499-512.
Achieving a comfortable fit when double gloving QUESTION: How do you obtain a comfortable fit when double gloving?
n
ANSWER: Double gloving is a very important technique to reduce potential exposure to bloodborne pathogens (eg, hepatitis B, hepatitis C, HIV). A review by Tanner and Parkinson1 of double gloving to reduce surgical cross infection found that double gloving significantly reduces perforations of the innermost gloves. The key to finding a comfortable fit with double gloves is to experiment with different combinations of glove types and sizes. There are three different size combinations to try that include wearing
Several studies have reported preferences for each combination, indicating that this is a matter of personal choice and comfort.2-4 Novak et al4 conducted a survey of surgeons who always or usually double glove and reported that double glove size combinations were equally distributed among the participants. The distribution was as follows:
n
two of the same-sized gloves,
446 j AORN Journal
a half size larger than your usual size inner glove, and n a half size larger outer glove.
n
35% preferred the outer glove to be a half size smaller than the inner glove, n 31% preferred the outer glove to be a half size larger than the inner glove, and n 31% preferred wearing inner and outer gloves that were the same size.4
CLINICAL ISSUES The time individuals required to adapt to double gloving was highly variable and ranged from one to 120 days, with one day being the most frequent adaptation time.4 During a study of post-fellowship surgeons that assessed tactile discrimination and dexterity, researchers asked participants to assess the comfort of double gloving with the larger inner/smaller outer glove and the larger outer/smaller inner glove combinations.2 The majority thought that the larger inner glove method was the most comfortable.2 Fry et al3 published a study that advocated the use of the larger inner glove to prevent hand ischemia and impaired dexterity and to improve comfort. They also recommended an adjustment period to allow the surgeons to become accustomed to the feel of double gloves.3 The ASTM (formerly the American Society for Testing and Materials) develops and publishes international voluntary consensus standards for materials, products, systems, and services.5 Glove manufacturers follow ASTM’s “Standard specification for rubber surgical gloves,”6 which defines physical dimension requirements (ie, length, width, thickness) of gloves.6 There are minimum and maximum tolerances in the standard,6 which results in slight fit variations between different brands
www.aornjournal.org
(eg, brand A’s size seven glove may fit differently than brand B’s size seven glove). Glove material also may be a factor in how a glove fits. Natural rubber latex provides more elasticity than synthetic glove materials. Because of this variability, perioperative team members should determine the proper fit for the brand of glove that is currently provided within their health care organization and whenever the facility switches brands. MARY J. OGG MSN, RN, CNOR PERIOPERATIVE NURSING SPECIALISTS AORN CENTER FOR NURSING PRACTICE References 1. Tanner J, Parkinson H. Double gloving to reduce surgical cross-infection. Cochrane Database Syst Rev. 2009;3: CD003087. 2. Webb JM, Pentlow BD. Double gloving and surgical technique. Ann R Coll Surg Engl. 1993;75(4):291-292. 3. Fry DE, Harris WE, Kohnke EN, Twomey CL. Influence of double-gloving on manual dexterity and tactile sensation of surgeons. J Am Coll Surg. 2010;210(3):325-330. 4. Novak CB, Patterson JM, Mackinnon SE. Evaluation of hand sensibility with single and double latex gloves. Plastic Reconstr Surg. 1999;103(1):128-131. 5. ASTM Fact Sheet. ASTM International. http://www.astm .org/ABOUT/factsheet.html. Accessed May 3, 2012. 6. Standard Specification for Rubber Surgical Gloves. Designation: D3577-09. West Conshohocken, PA: ASTM International; 2009:1-4.
The authors of this column have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
AORN Journal j 447
LEARNER EVALUATION CONTINUING EDUCATION PROGRAM
Clinical Issues
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the Learner Evaluation online at http://www.aorn.org/CE. Rate the items as described below. PURPOSE/GOAL To educate perioperative nurses about providing safe nursing care throughout the perioperative continuum. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss practices that could jeopardize safety in the perioperative area. Low 1. 2. 3. 4. 5. High 2. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
448 j AORN Journal
October 2012 Vol 96 No 4
1.2 www.aorn.org/CE
6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 7. Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.) 7A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: ________________________________ 7B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: ________________________________ 8. Our accrediting body requires that we verify the time you needed to complete the 1.2 continuing education contact hour (72-minute) program: _________________________________
Ó AORN, Inc, 2012
1.2
JOAN C. BLANCHARD, MSS, BSN, RN, CNOR, CIC; BYRON L. BURLINGAME, MS, BSN, RN, CNOR; MARY J. OGG, MSN, RN, CNOR
www.aorn.org/CE Continuing Education Contact Hours
Approvals
indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal, and completing the online Learner Evaluation at http://www.aorn.org/CE. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #12527 Session: #0001 Fee: Members $6, Nonmembers $12
Conflict of Interest Disclosures
The contact hours for this article expire October 31, 2015.
Purpose/Goal To educate perioperative nurses about providing safe nursing care throughout the perioperative continuum.
Objectives 1. Discuss practices that could jeopardize safety in the perioperative area. 2. Discuss common areas of concern that relate to perioperative best practices. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care.
Ms Blanchard, Mr Burlingame, and Ms Ogg have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2012.07.007
Ó AORN, Inc, 2012
October 2012
Vol 96 No 4
AORN Journal j 443
CLINICAL ISSUES
1.2
www.aorn.org/CE
This Month Cross contamination of paper forms used in health care facilities Key words: inoculate, cross contamination, paper forms.
Manual cleaning of flexible endoscopes Key words: flexible endoscope, endoscope washers, manual cleaning, reprocessor, endoscope reprocessor, automatic endoscope reprocessor.
Achieving a comfortable fit when double gloving Key words: double gloving, comfort, glove fit.
Cross contamination of paper forms used in health care facilities QUESTION: We have electronic health records for our patients, but we are still required to have paper documents such as consent sheets for our charts. Can pathogens adhere to paper, and is it possible for those pathogens to transfer to the hands of health care personnel and then to patients or surfaces? ANSWER: It is possible that paper could be a source of cross contamination and infection in a health care facility. Paper’s porous surface and its incompatibility with disinfectants makes it very difficult to disinfect.1 Many studies have examined the transmission of pathogens from hands to inanimate surfaces2-6; there have been fewer studies to determine how long bacterial pathogens survive on paper and whether the identified pathogens could be
transferred from hands to paper and back to hands.7,8 In one study, researchers conducted a twostep experiment of bacterial survivability and transmission for a “worst case scenario” on the spread of pathogens to paper.1 In one test they used Escherichia coli, Staphylococcus aureus, Pseudomonas aeruginosa, and Enterococcus hirae to inoculate sterile paper swatches. They tested these swatches for bacterial survival over seven days. The pathogens survived for different lengths of time, but all were stable for at least 72 hours and were still cultivatable after seven days. Of the test organisms that survived on the inoculated paper, P aeruginosa and E hirae were quite resistant to the laboratory room conditions and were only reduced 3 log10 (99%) after seven days. This means that what remains on the surface after seven days has been significantly
http://dx.doi.org/10.1016/j.aorn.2012.07.007
444 j AORN Journal
October 2012 Vol 96 No 4
Ó AORN, Inc, 2012
CLINICAL ISSUES
www.aornjournal.org
reduced but could still be a potential source of infection.1 The researchers performed a second test to determine bacterial transmissibility from hand to paper to another hand. They inoculated the fingertips of one group of volunteers with a nonpathogenic E coli strain and then pressed the volunteers’ fingertips onto sterile swatches. They then irrigated the fingertips of another group of volunteers with sterile saline and pressed them onto the contaminated swatches. The test pathogens that were transferred to paper were able to survive and contaminate the hands of the second group of volunteers. This study showed that bacteria could be transferred to paper, survive on it, and transfer to hands and contaminate them.1 Boyce et al9 recommend that thorough hand hygiene be performed to reduce pathogen transmission. Farrington et al10 showed that transient bacteria on hands are an important route of transmission, and paper can be a reservoir for cross contamination of resistant organisms. Electronic health records may reduce the amount of paper used in health care facilities but will not reduce the need for thorough hand hygiene. It is important to remember that computer keyboards and terminals also may serve as sources of contamination. JOAN C. BLANCHARD MSS, BSN, RN, CNOR, CIC
References 1. Hubner N-O, Hubner C, Kramer A, Assadian O. Survival of bacterial pathogens on paper and bacterial retrieval from paper to hands. Am J Nurs. 2011;111(12): 30-34. 2. Abad FX, Pint o RM, Bosch A. Survival of enteric viruses on environmental fomites. Appl Environ Microbiol. 1994; 60(10):3704-3710. 3. Ansari SA, Sattar SA, Springthorpe VS, Wells GA, Tostowaryk W. Rotovirus survival on human hands and transfer of infectious virus to animate and nonporous inanimate surfaces. J Clin Microbiol. 1988;26(8): 1513-1518. 4. Gwaltney JM, Hendley JO. Transmission of experimental rhinovirus infection by contaminated surfaces. Am J Epidemiol. 1982;116(5):828-833. 5. Sattar SA, Karim YG, Springthorpe VS, JohnsonLussenburg CM. Survival of human rhinovirus type 14 dried onto nonporous inanimate surfaces: effect of relative humidity and suspending medium. Can J Microbiol. 1987;33(9):802-806. 6. Scott E, Bloomfield SF. The survival and transfer of microbial contamination via cloth, hands and utensils. J Appl Bacteriol. 1990;68(3):271-278. 7. Basavarajappa KG, Rao PN, Suresh K. A study of bacteria, fungal, and parasitic contamination of currency notes in circulation. Indian J Pathol. 2005;48(2):278-279. 8. El-Dars FM, Hassan WM. A preliminary bacterial study of Egyptian paper money. Int J Environ Health Res. 2005;15(3):235-239. 9. Boyce JM, Pittet D. Guideline for hand hygiene in healthcare settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/ Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002;51(RR-16):1-45. 10. Farrington M, Ling J, Ling T, French GL. Outbreaks of infection with methicillin-resistant Staphylococcus aureus on neonatal and burns units of a new hospital. Epidemiol Infect. 1990;102(2):215-228.
Manual cleaning of flexible endoscopes QUESTION: We are having problems interpreting the recommendation V and VI.b.1 in the AORN “Recommended practices for cleaning and processing flexible endoscopes and endoscope accessories.” One group of employees states that cleaning of endoscopes can be done manually or performed automatically by the new automatic washers. Another group of employees states that cleaning of endoscopes can only be accomplished manually. Which is correct?
ANSWER: The “Recommended practices for cleaning and processing flexible endoscopes and endoscope accessories”1 does allow for the use of an automatic endoscope reprocessor for the endoscope cleaning process. The steps for using an automatic reprocessor are not specifically identified because of differences in manufacturer’s written instructions. The recommended practices direct that the endoscope be reprocessed in three steps as described below: precleaning, manual cleaning, and high-level disinfection.
AORN Journal j 445
October 2012 Vol 96
CLINICAL ISSUES
No 4
1. Precleaning occurs in the patient care area and consists of wiping off the outer portion of the endoscope tube and irrigating its channels with cleaning solution using suction, as described in recommendation II of the recommended practices.1 2. Manual cleaning occurs after proper transport of the endoscope to the decontamination area and after leak testing, if appropriate. Recommended practice V states, Following leak testing and before high-level disinfection using a manual process or an automatic endoscope reprocessor, flexible endoscopes and their accessories should be cleaned before any remaining organic material dries on the surface or in the channels of the endoscope.1(p502-503) 3. High-level disinfection, the third step, is described in recommendation VI. One step of this recommendation states, “Manual cleaning should be accomplished as described in recommendation V.”1(p503)
In the second step, manual cleaning describes a process that can be accomplished by following the steps described in recommendation V.a or by using an automatic endoscope reprocessor that has the ability to accomplish this. Key points to remember are that the reprocessor must have the ability to accomplish manual cleaning and the manufacturer’s written instructions must be followed when completing the process. In step three, the use of the term manual cleaning refers to the process and not to the steps described in recommendation V.a.1
BYRON L. BURLINGAME MS, BSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE
Reference 1. Recommended practices for cleaning and processing flexible endoscopes and endoscope accessories. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012:499-512.
Achieving a comfortable fit when double gloving QUESTION: How do you obtain a comfortable fit when double gloving?
n
ANSWER: Double gloving is a very important technique to reduce potential exposure to bloodborne pathogens (eg, hepatitis B, hepatitis C, HIV). A review by Tanner and Parkinson1 of double gloving to reduce surgical cross infection found that double gloving significantly reduces perforations of the innermost gloves. The key to finding a comfortable fit with double gloves is to experiment with different combinations of glove types and sizes. There are three different size combinations to try that include wearing
Several studies have reported preferences for each combination, indicating that this is a matter of personal choice and comfort.2-4 Novak et al4 conducted a survey of surgeons who always or usually double glove and reported that double glove size combinations were equally distributed among the participants. The distribution was as follows:
n
two of the same-sized gloves,
446 j AORN Journal
a half size larger than your usual size inner glove, and n a half size larger outer glove.
n
35% preferred the outer glove to be a half size smaller than the inner glove, n 31% preferred the outer glove to be a half size larger than the inner glove, and n 31% preferred wearing inner and outer gloves that were the same size.4
CLINICAL ISSUES The time individuals required to adapt to double gloving was highly variable and ranged from one to 120 days, with one day being the most frequent adaptation time.4 During a study of post-fellowship surgeons that assessed tactile discrimination and dexterity, researchers asked participants to assess the comfort of double gloving with the larger inner/smaller outer glove and the larger outer/smaller inner glove combinations.2 The majority thought that the larger inner glove method was the most comfortable.2 Fry et al3 published a study that advocated the use of the larger inner glove to prevent hand ischemia and impaired dexterity and to improve comfort. They also recommended an adjustment period to allow the surgeons to become accustomed to the feel of double gloves.3 The ASTM (formerly the American Society for Testing and Materials) develops and publishes international voluntary consensus standards for materials, products, systems, and services.5 Glove manufacturers follow ASTM’s “Standard specification for rubber surgical gloves,”6 which defines physical dimension requirements (ie, length, width, thickness) of gloves.6 There are minimum and maximum tolerances in the standard,6 which results in slight fit variations between different brands
www.aornjournal.org
(eg, brand A’s size seven glove may fit differently than brand B’s size seven glove). Glove material also may be a factor in how a glove fits. Natural rubber latex provides more elasticity than synthetic glove materials. Because of this variability, perioperative team members should determine the proper fit for the brand of glove that is currently provided within their health care organization and whenever the facility switches brands. MARY J. OGG MSN, RN, CNOR PERIOPERATIVE NURSING SPECIALISTS AORN CENTER FOR NURSING PRACTICE References 1. Tanner J, Parkinson H. Double gloving to reduce surgical cross-infection. Cochrane Database Syst Rev. 2009;3: CD003087. 2. Webb JM, Pentlow BD. Double gloving and surgical technique. Ann R Coll Surg Engl. 1993;75(4):291-292. 3. Fry DE, Harris WE, Kohnke EN, Twomey CL. Influence of double-gloving on manual dexterity and tactile sensation of surgeons. J Am Coll Surg. 2010;210(3):325-330. 4. Novak CB, Patterson JM, Mackinnon SE. Evaluation of hand sensibility with single and double latex gloves. Plastic Reconstr Surg. 1999;103(1):128-131. 5. ASTM Fact Sheet. ASTM International. http://www.astm .org/ABOUT/factsheet.html. Accessed May 3, 2012. 6. Standard Specification for Rubber Surgical Gloves. Designation: D3577-09. West Conshohocken, PA: ASTM International; 2009:1-4.
The authors of this column have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
AORN Journal j 447
LEARNER EVALUATION CONTINUING EDUCATION PROGRAM
Clinical Issues
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the Learner Evaluation online at http://www.aorn.org/CE. Rate the items as described below. PURPOSE/GOAL To educate perioperative nurses about providing safe nursing care throughout the perioperative continuum. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss practices that could jeopardize safety in the perioperative area. Low 1. 2. 3. 4. 5. High 2. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
448 j AORN Journal
October 2012 Vol 96 No 4
1.2 www.aorn.org/CE
6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 7. Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.) 7A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: ________________________________ 7B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: ________________________________ 8. Our accrediting body requires that we verify the time you needed to complete the 1.2 continuing education contact hour (72-minute) program: _________________________________
Ó AORN, Inc, 2012