Exploring bacterial growth and recolonization after preoperative hand disinfection and surgery between operating room nurses and non-health care workers: a pilot study

Prevention of surgical site infections (SSIs) is important to avoid patient suffering and death and to lower the cost of health care providers [1]. Depending on where the SSI is located, an SSI can be devastating for the patient, as well as costly for society. For example, a severe SSI might be one that occurs after open heart surgery, where a deep sternal wound infection can double or even triple the usual cost of treatment [2‐4]. In an intraoperative environment causative bacteria for SSI often originate either from the patient’s skin or from the surgical team [5, 6]. The most common bacteria causing sternal infections are coagulase negative staphylococci, Staphylococcus aureus, and gram-negative bacteria [2, 6‐9].

There are different strategies to reduce SSIs in an operating room (OR), such as the use of basic hygiene procedures, controlled OR ventilation, normothermia, surgical techniques, sterile materials, prophylactic antibiotics, and preoperative skin disinfection [10]. A preventive method is to perform preoperative hand disinfection prior to wearing surgical gloves and to double glove for easy detection of puncture in the outer glove [11].

Strategies have been recommended to reduce the incidence of SSIs, and great attention has been focused on the liquid-proof barrier of the surgical gown and gloves [11]. Double gloving has become routine in many departments because of its effect of reducing the risk of transmitting bacteria through puncture of the gloves [11, 12]. Less focus has been centred on the largest hole in the glove, the glove cuff, the place at which the hand enters the glove. There are few studies that address this issue but these studies are not performed recently. However, the issue is nevertheless current because the problem still exists. If, while wearing a liquid-proof surgical gown and surgical gloves, the hands and arms were set under a water tap, the arms would get wet [13, 14]. It has been noted in clinical practice that during surgical procedures, the gloves will become moist at the end of the surgical glove cuff. Often the gloves will turn dark, indicating that fluid is present (Fig. 1), a process that can only be detected by using double gloves with an indicator system by which a darker colour appears. A question to be raised is if the fluid originates from the skin of the hand and if it may contain bacteria.

There may be differences in bacterial growth and recolonization on the hands of OR nurses compared to those of non-health care workers (non-HCWs), due to their frequently performed preoperative hand disinfection and frequent exposure to virulent bacteria [15‐19]. A need existed to investigate whether OR nurses had different amounts or type of bacteria present on their hands after preoperative hand disinfection and wearing surgical gloves compared to a control of non-HCWs. No previous study has investigated whether repetitive preoperative hand disinfection affects the results regarding bacterial growth and recolonization on the hands, both directly after the preoperative hand disinfection process and then after wearing surgical gloves.

The aim was to investigate if there were differences in bacterial growth and recolonization of hands between OR nurses and non-HCWs as well as to investigate if bacterial growth existed at the surgical glove cuff and gown interface during surgery.

Two of the 14 OR nurses were excluded due to use of another preoperative hand disinfection method, that is, chlorhexidine containing soap, resulting in a total of 12 OR nurses. One of the 14 non-HCWs was excluded because of nail extensions (Fig. 2), resulting in a total of 13 non-HCW. There were no significant differences between the groups except for the duration of time wearing the surgical gloves (Table 1).

This pilot study was conducted at one specific OR department and the group of non-HCW was the first author’s circle of friends. The selection of non-HCW’s focused on people not having contact with hospital environment and maintaining ordinary hand hygiene. Both groups were either work friends or personal friends which should not affect the bacterial flora of the participants. Nor was it suitable for the non-HCW’s to participate during surgical procedures, hence the design with different tasks for each group. The aim of preoperative hand disinfection is to eradicate transient flora and reduce resident flora of the hands and promote a prolonged effect [22]. The preoperative hand disinfection solution used in this study was approved according to EN Standard EN12791. The glove juice technique recommended in a Cochrane review was not applicable for this specific sample site [24]. The technique used in our present study was chosen to investigate if bacterial growth existed at the surgical glove cuff and gown interface. This means that the culture had to be sampled at the glove cuff and gown interface. It have been reported that recolonization occurs inside the gloves and that the bacterial counts on the hands increases with time [23, 24], suggesting that the skin disinfection reduce bacteria on the skin but that bacteria persists deeper down in the skin pores and hair follicles after the perioperative hand disinfection process. The amount of bacterial growth found at the glove cuff end were not very high compared to the amount of bacterial growth sometimes found on the hands after wearing gloves but this shows that the glove cuff end is a danger zone which can transfer bacterial growth, possibly from the hands, but the glove cuff may also be contaminated by the hands when donning the glove [25, 26]. In the present study the amount of bacteria was greater in OR nurses than in non-HCWs at the beginning of wearing gloves, whereas the opposite occurred after wearing surgical gloves. It seems as the recolonization rate was higher in the group consisting of non-HCWs. The duration of wearing gloves may have an impact on the recolonization rate [23]. Moreover, damaged skin is more likely to have a higher amount of bacteria compared to healthy skin [27]. The risk that more of the OR nurses had damaged skin than the non-HCWs are probable higher due to the extensive hand wash regime OR nurses perform every day at work. Considering that the OR nurses wore the surgical gloves for a significantly longer period of time and had a greater amount of bacteria on their hands at the start, they still had a lower bacterial recolonization compared to the non-HCWs. This may suggest that repeatedly performing hand disinfection inhibits the bacterial recolonization rate of the hands, but this has to be further investigated.

This pilot study was performed to investigate whether bacterial growth from the surgical glove cuff and gown interface could be found, since bacterial growth was suspected, and no previous study had addressed this issue. The bacteria present at the surgical glove cuff and gown interface were the types that could cause SSIs [6]. It is speculated that bacteria might migrate from the skin of the hands to the surgical glove cuff and further on to the sleeve of the sterile surgical gown. It is unlikely that bacteria will pass through the material of the gown when the gown used is liquid proof. The origin of the fluid is most likely to be sweat or evaporations from the user’s hands, but this was not tested in present study. It is also noted in clinical practice that the sleeves of the surgical gloves roll down and turn inside out. In some OR departments’ staff routinely seal the inner gloves with sterile sticky tape to prevent the insides of the gloves being exposed. Our study has indicated that bacterial growth seems to exist between the surgical glove cuff and gown interface. In an attempt to enhance the barrier, some clinicians put on the inner glove before the gown. When the sterile gown is on, they use sterile scissors to make a small hole in the gown cuff so that the thumb can pass through. When this is done the outer glove can be donned. This technique can be seen in a technical note by Fernandez and colleagues; note, however, that they use this technique for another reason and use only single gloves [28]. Sealing the inner glove and changing the order of gloves and gowns might prevent bacterial leakage; this has still to be investigated.

There is a need to develop surgical gloves with a secure interface between gloves and gowns. A suggestion is to develop a one-piece gown with sealed inner gloves attached directly to the gown. Gown size could follow the glove size. The limitation of a one-piece garment incorporating gown and gloves would be the capability of changing only outer gloves. Yet, a change of inner gloves is seldom needed [29].

Although the outcome data may be taken by caution, this pilot study showed bacterial growth existed at the glove cuff end, and that it mostly was the same bacteria as found on the hands which indicates a need for more secure surgical glove and gown interface to avoid cross contamination during surgery. It seems like OR nurses have a more difficult task eradicating bacterial growth with preoperative hand disinfection but on the other hand they have less bacterial recolonization rate compared to non-HCW. Both groups had significantly larger amount of bacterial growth after wearing sterile gloves compared to directly after the preoperative hand disinfection indicating rapid recolonization.