EVIDENCE FOR PRACTICE. Evidence Appraisal Score: II A

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1 EVIDENCE FOR PRACTICE Evidence appraisal of Bekele A, Makonnen N, Tesfaye L, Taye M. Incidence and patterns of surgical glove perforations: experience from Addis Ababa, Ethiopia. BMC Surg. 2017;17(1): Evidence Appraisal Score: II A Editor s note: Reading research and incorporating valid research results into practice is a vital part of ensuring that perioperative nursing practice is evidence based. The AORN Research Evidence Appraisal Tools can help perioperative nurses evaluate research. There are three tools for evaluation of the different types of evidence: the Research Evidence Appraisal Tool Study, the Research Evidence Appraisal Tool Summary, and the Non-Research Evidence Appraisal Tool. These tools are used to evaluate the evidence upon which AORN s guidelines are based. The tools can be used to appraise the level of evidence and quality of evidence for a single research study, a summary of multiple research studies, or non-research evidence. Each section of the tool is discussed to help readers understand why the study received a particular appraisal score and what that rating means to perioperative nursing practice. Clinical judgment should be used to determine whether the findings of an individual study are of value and relevance in a particular setting or patient care situation. Individuals intending to put this study s findings into practice are encouraged to review the original article to determine its applicability to their setting. Gloves are vital in protecting patients from outside contamination; clinicians began wearing gloves in the late 1800s. Surgical gloves are also the main barrier between the patient and the surgical team; however, if a glove becomes perforated, that break in the barrier can allow microorganisms to pass through. Glove perforation is common, especially during emergency procedures. One technique that is helpful to reduce the risk of infection in the case of glove perforation is to wear two pairs of gloves instead of one. Past studies have demonstrated that when double gloves were used, the inner glove was found to have fewer perforations, thereby reducing the instances of cross- infection. AORN, Inc, 2018 AORN Journal 269

2 Evidence for Practice February 2018, Vol. 107, No. 2 Researchers in Ethiopia have conducted few studies on glove perforation. However, two of these studies have shown a very high rate of intraoperative accidents involving the operating team as a result of glove perforation and needle sticks. The main objectives of the current study were to describe the prevalence of surgical glove perforation during surgical procedures and to compare the perforation rates between emergency and elective surgeries at one of the main hospitals in Addis Ababa, Ethiopia. The authors believe this to be the first of such reports from Ethiopia and that it may serve as a baseline for the publication of subsequent wider studies. Because this is the report of a single research study, the AORN Research Evidence Appraisal Tool Study was used for the evidence appraisal (Figure 1). LEVEL OF EVIDENCE Using the AORN Research Evidence Appraisal Tool Study, this study was classified as Level II for level of evidence because it was a controlled trial intervention without randomization. The rationale for this classification is explained in the following sections. Intervention/manipulation. This was a single- center prospec tive interventional study. The study supported the research aim and there were sufficient details to allow replication. Control/comparison group. Not applicable to this study. Random assignment. Not applicable to this study. QUALITY OF EVIDENCE Using this AORN Research Evidence Appraisal Tool Study, this study was classified as A for quality of evidence. The rationale for this classification is explained in the following sections. Purpose/background. The purpose of the study was clearly defined, the research question was clear, and the researchers identified what was known and not known about the research question and how the study would address the lack of information on this topic in Ethiopia. The researchers received permission and ethical clearance from the Research and Publication Committee of the Department of Surgery at Addis Ababa University. There were 26 references in this research report, but only three were published within the last five years. Nevertheless, all of the articles were pertinent, and the lack of recent publications adds weight to the need for this present study. Randomization. Not applicable to this study. Control. Not applicable to this study. Intervention(s). The intervention supported the research question. The intervention was the collection of surgical gloves for analysis and contained enough information to be replicated. Sample size. This was a prospective study performed at the Minilik II referral hospital of Addis Ababa University, Ethiopia. The Minilik hospital is an affiliate hospital of Addis Ababa University, where surgical residents and consultant surgeons are involved in the care of surgical patients on a regular basis. The hospital houses 110 surgical beds and six operating theaters, and staff members perform approximately 60 procedures every week. The researchers tested 2,634 gloves: 1,588 from elective procedures and 1,046 from emergency procedures. All gloves were collected during the trial period and the convenience numbers were adequate for the study. All gloves were accounted for in the data collection and analysis. Data collection. The authors collected gloves worn during all of the major surgical procedures (emergency and elective) from June 1 through July 20, After each procedure, the researchers collected and stored the gloves used by each health care professional separately in a labeled collecting box and analyzed them immediately after surgery; they also collected data regarding the specific surgical procedure using a preapproved, structured format. During the study period, the researchers noted that different brands of surgical gloves from different manufacturers were used; no specific selection was made among the different brands. 270 AORN Journal

3 February 2018, Vol. 107, No. 2 Evidence for Practice Figure 1. AORN Journal 271

4 Evidence for Practice February 2018, Vol. 107, No. 2 Figure 1. continued 272 AORN Journal

5 February 2018, Vol. 107, No. 2 Evidence for Practice After end- of- procedure glove collection, the gloves were removed from the OR for testing. The researchers used standardized visual and hydro- insufflation techniques to test the gloves for perforations: Visual: Each glove was inspected visually for perforations. The examiner was blinded to the surgery type. Hydro-insufflation: Each glove underwent a standard ized water-leak test. The gloves were filled with 1000 ml of water and methylene blue solution, followed by manual compression on the wrist of the glove for one minute to reveal any holes. The leaking of blue water indicated perforation. After testing, the researchers recorded the number of perforations in each glove, the perforated layer of the glove, and the location of the perforations. They analyzed the data using the chi- square test and set statistical significance at P <.05. Results/conclusions. The authors presented two tables and one figure, all of which supported and clarified the narrative of the article. The two tables and one figure presented the following data, respectively: rate of glove perforation among the operating team during elective surgery, rate of glove perforation among the operating team during emergency surgery, and rates of glove perforation segregated according to the type of procedure. The researchers analyzed perforation in 2,634 gloves and obtained two sets of data for testing. The first set (ie, Set I) comprised 1,588 gloves (794 pairs) obtained from elective procedures and the second set (ie, Set II) comprised 1,046 gloves (523 pairs) obtained from emergency operations. Of the total gloves collected from Set I, 436 were used by the first surgeons, 414 by the first assistants, 306 by the second assistants, 30 by the third assistants, and 402 by the scrub persons. The results determined that during elective procedures, 546 gloves (34.3%) were perforated. Of the total gloves collected from Set II, 270 were used by the first surgeons, 288 by the first assistants, 212 by the second assistants, and 276 by the scrub persons. The results determined that during emergency procedures, 465 gloves (44.4%) were perforated. The researchers summarized their additional findings as follows. Higher rates of perforation were found among first surgeons (n = 176; 40.4%) and scrub persons (n = 156; 38.8%) compared with first assistants (n = 120; 28.9%), second assistants (n = 90; 29.4%), and third assistants (n = 4; 13.3%). This difference was statistically significant (P <.05). The index and middle fingers of the left-hand gloves were commonly perforated during elective procedures (most participants were right-handed). Orthopedic and cardiothoracic procedures were associa ted with significantly more perforations compared with other procedures, occurring in 44 (47.8%) and 86 (46.2%) of the gloves, respectively. The conclusions of the researchers were consistent with the results of the study. There was a notably high rate of surgical glove perforation, especially during emergency procedures. According to the authors, most of the emergency procedures were performed by surgical residents with relatively limited surgical experience, which can potentially lead to higher rates of perforation. Therefore, it may be necessary for perioperative staff members to examine the quality and fit of gloves used for surgery before starting all procedures. Additionally, the authors recommended postprocedural glove checks in instances of suspected glove perforation, thereby allowing surgical staff members to take the necessary steps to avoid contamination and infection. Limitations/future research. The researchers did not specifically discuss the limitations of their study. However, they believe the following factors may have played a significant role in the increased rate of glove perforations found in their study. Most, if not all, emergency procedures were performed by surgical residents with relatively limited surgical experience, which may have potentially led to higher perforation rates. During the study period, there was a serious lack of variety in glove size. Because there were limited glove size options, some surgical team members used gloves that were either too big or too small. The use of AORN Journal 273

6 Evidence for Practice February 2018, Vol. 107, No. 2 inappropriately sized gloves might have contributed to the increased rate of glove perforations. Developing countries like Ethiopia depend on the import of cheap and lower-quality products; therefore, manufacturing-related perforations may have played a role. However, the authors recommend that additional studies be conducted to confirm the role of glove quality in rates of glove perforation. The authors also pointed out that the surgical workforce in Ethiopia is commonly and repeatedly at a high risk for exposure to blood as a result of needle sticks, cuts with sharp objects, and splashes to the face and eyes. Additionally, they noted that it has been documented that most of the surgeons in Ethiopia are not fully vaccinated against hepatitis B. In addition to the importance of protecting the patients and the health of surgeons, the authors noted that the country should also protect its entire surgical workforce. This study lays the groundwork for additional research on this topic. Bias. Bias was not discussed, but it is clear the researchers believe that the present surgical working conditions in Ethiopia are not acceptable. Validity. Standardized visual and hydro- insufflation techniques were used to test the gloves for perforations. Generalizability. Although the study topic is generalizable to every surgical suite in the world, the findings are not applicable to other populations. APPRAISAL RESULTS The AORN Research Evidence Appraisal Tool Study was used to score this study as II A. The study was scored as II for level of evidence because it was a controlled prospective interventional study without randomization. The study was scored as A for quality of evidence because it included a clear purpose, intervention, and sample; clear data collection; and clear results and conclusions. A score of II A indicates that it is appropriate for perioperative nurses to consider this evidence coupled with other sources of primary and secondary evidence when developing or designing policies and procedures for the perioperative process. PERIOPERATIVE IMPLICATIONS Glove perforations during routine and emergency procedures continue to occur today in most ORs. Perioperative nurses should remember that these perforations can occur quickly and easily and should be prepared to reglove immediately anyone on the surgical team at any time during the surgery if necessary. This also serves as a reminder to every person on the surgical team to be aware of perforations and possible perforations, and to speak up to allow regloving. Because glove perforations are such a common and well- known problem, they are often overlooked or ignored in today s surgical arenas. Glove perforations can put both patients and surgical personnel at risk and cause potential harm. Although surgical site infections in patients are most often bacterial in origin, viral infections (eg, human immunodeficiency virus, hepatitis B, hepatitis C) tend to affect surgical staff members the most severely. By using improved gloving techniques, it is possible to create a safer perioperative workspace. This article was appraised by Nancy Girard, PhD, RN, FAAN, consultant/owner, Nurse Collaborations, Boerne, TX. Dr Girard has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. 274 AORN Journal