critical thinking activities medical and surgical asepsis

6.2 Asepsis and PPE

Learning objectives.

By the end of this section, you will be able to:

• Define the two types of asepsis
• Recognize the negative implications healthcare-associated infections have on healing
• Correlate appropriate personal protective equipment with their necessary uses

Nurses in all roles are in a unique position to create a safe patient care environment. From bedside nurses to executives, fostering safe healthcare environments can prevent the transfer of pathogens and the spread of infection. With evidence-based practices, nurses can facilitate a patient’s plan of care and recovery while minimizing risks and complications related to infections. Proper use of infection-control measures can directly affect patient morbidity and mortality.

The state of being free from disease-causing contaminant is referred to as asepsis . These contaminants include bacteria , viruses, fungi, and parasites. The term asepsis can also refer to the process of preventing infection by minimizing the number of contaminants present and decreasing the ability to transport pathogens. The two types of asepsis include medical and surgical ( Table 6.3 ). Furthermore, medical asepsis has three degrees: sanitization , antisepsis, and disinfection. An example of sanitization is physically removing microorganisms by cleaning linen. An example of antisepsis would be preoperative skin cleansing. Disinfection kills microorganisms on objects such as tables or blood pressure cuffs that come into contact with the patient or patients. This process utilizes strong chemicals called disinfectants, which should not be used on skin.

Medical Asepsis

The techniques and procedures used to decrease the potential for the spread of microorganisms and infection is called medical asepsis . Medical asepsis is also referred to as “clean technique” in the healthcare environment because it is a standard practice used to avoid spreading infection from one person to another throughout a facility. The core practices of medical asepsis include hand hygiene , environmental cleanliness, and the use of protective equipment and isolation.

Surgical Asepsis

The absence of all microorganisms within any type of invasive procedure is called surgical asepsis . Maintaining surgical asepsis requires the use of sterile technique, a set of specific practices and procedures that are performed to make an environment and equipment in that environment free of all microorganisms. Principles of sterile technique help control and prevent infection. Sterile technique is discussed in depth in 6.3 Sterile Technique .

Hand Hygiene

The term hand hygiene refers to the act of handwashing, hand rubbing (using alcohol-based hand sanitizer), or surgical hand antisepsis. Hand hygiene is regarded as one of the most important elements in the prevention and control of infections. Hand hygiene that is timely and effective protects patients, healthcare workers, and the healthcare environment from the spread of infection. Hand hygiene should be performed when arriving and leaving a patient care unit, before direct contact with a patient, before and after removing gloves , after contact with patient’s skin, and when hands are visibly dirty or soiled with blood or bodily fluids. Healthcare providers may be required to wash their hands as many as 100 times in a twelve-hour shift, depending on the number and acuity of patients.

Link to Learning

The World Health Organization has created the Five Moments of Hand Hygiene to help healthcare workers improve understanding of hand hygiene and the five moments when it is required.

Cleaning hands using an alcohol-based sanitizer is an effective form of hand hygiene if the hands are not visibly soiled. The advantages of alcohol-based hand hygiene are that it takes only twenty to thirty seconds, can be completed directly at the point of care, and does not require a sink, water, or towel. Alcohol-based hand sanitizers can kill most pathogens. Keep in mind, however, that certain bacteria are not removed by hand sanitizers. These bacteria are only removed by handwashing. One example of bacteria that is only removed with soap and water is Clostridioides difficile ( C. diff ). Nurses who take care of patients with C. diff or other stubborn bacteria will usually be told before they commence care. When these instances occur, the nurse will know to avoid the hand sanitizer and choose to wash their hands with soap and water instead. When in doubt, washing your hands is the best choice.

Washing hands with soap and water is recommended if the hands are visibly dirty, soiled, or are contaminated with blood or other bodily fluids. It is essential to spend the proper amount of time on handwashing; washing hands for at least thirty seconds removes up to ten times the number of bacteria as does washing for fifteen seconds.

Patient Conversations

Understanding when to use soap and water for hand hygiene.

Scenario: The nurse is entering a patient’s room to complete q4h vital signs. This patient is currently positive for Clostridioides difficile . After donning personal protective equipment, the nurse enters the room.

Nurse: Hi, Ms. Lee, it’s your nurse Bryan. I’m here to get your vital signs. Let me wash my hands, and we will get started. How are you feeling?

Patient: I’m doing okay, I suppose. I’m not in any pain right now, so that’s good news.

Nurse: That’s excellent. Let me just put on a pair of gloves, so I can verify your name on your wristband. Can you tell me your name, date of birth, and if you have any allergies?

Patient: Yang Lee, 03/27/1942. I’m allergic to iodine. Why did you wash your hands when you came in here when there’s hand sanitizer over by the door?

Nurse: Performing proper hand hygiene is a critical component of preventing the spread of infections, especially in the hospital. Alcohol-based hand sanitizers are a great method for cleaning your hands, but there are times when it is not effective.

Patient: Is getting my vital signs one of those times?

Nurse: The stool sample that was sent to the lab on Monday came back positive for a bacteria called Clostridioides difficile , or C. diff . Alcohol alone cannot kill C. diff spores, and studies have shown soap and water to be much more effective at removing them. In order to prevent the spread of infection, you’ll notice that all of the healthcare workers will be washing their hands with soap and water when they enter and exit your room.

Patient: So, should I wash my hands too?

Nurse: Since you already have C. diff , you cannot infect or re-infect yourself. However, washing your hands will prevent you from getting bacteria such as C. diff in the future. Additionally, washing your hands will help prevent spread to others inside and outside of the hospital. Nurses always wash our hands frequently because it washes away all kinds of bacteria. It really is the best way to prevent spreading bacteria.

Patient: That makes sense. I wouldn’t want anyone else to get sick from what I have. Thank you for being so careful.

Healthcare-Associated Infections

Healthcare-associated infections (HAIs), also known as nosocomial infections, are infections acquired while receiving medical treatment in a healthcare facility. Although preventable, HAIs are some of the most common complications for patients within a healthcare setting and can prolong hospital stays and recovery time. According to the CDC, one in every twnty-five hospitalized patients will contract an HAI (CDC, 2022). The most common HAIs are associated with invasive devices such as catheter-associated urinary tract infections (CAUTIs), central line–associated bloodstream infections (CLABSIs), ventilator-associated pneumonia (VAP), and surgical site infections (SSIs).

The risk for developing an HAI is dependent on the infection-control policies within a facility and the degree of adherence to them. Additional risk factors include a patient’s immune status, age, underlying comorbidities, and the prevalence of pathogens within the environment. Length of hospitalization, number of invasive procedures, and amount of antibiotic therapy received all increase a patient’s risk for acquiring an HAI.

The Global Alliance for Infections in Surgery has outlined seven strategies to prevent healthcare-associated infections in the healthcare setting.

Preventing Healthcare-Associated Infections

Nurses are at the front line for preventing the transmission of pathogens through infection-control policies and procedures. These evidence-based prevention strategies and control practices can directly reduce HAIs. Appropriate hand hygiene and glove usage heavily contributes to an increase in patient safety and the prevention of HAIs. Keeping a healthcare environment clean by disinfecting equipment between patients is an additional vital prevention measure. Additionally, the use of proper personal protective equipment can prevent the transmission of pathogens. Nurses must stay current with how to protect themselves from newly identified pathogens and adhere to the protocols put in place. In recent history, viruses such as Ebola and the coronavirus that caused the COVID-19 pandemic all required specific infection-control measures. Healthcare providers were and still are on the front lines in these instances and must also educate the public and their patients about necessary protocols.

Clinical Safety and Procedures (QSEN)

Qsen competency: safety: preventing hais.

Definition: Quality and Safety Education for Nurses (QSEN) competencies were designed to emphasize key elements that pre-licensure nursing students should be competent in at the time of graduation. Safety is defined as minimizing risk of harm to patients through both systems effectiveness and individual performance.

Knowledge: Students will examine human factors and other basic safety design principles as well as commonly used unsafe practices, using evidence-based sources to enhance knowledge.

Skills: Students will demonstrate effective use of strategies to reduce risk of harm to self or others.

Attitudes: Students will value their own role in preventing errors and reducing the spread of infections.

Clinical scenario: A new nurse is working on a medical-surgical unit. Bedside shift report is beginning, and the nurse notices a sign on one patient’s door stating that the patient is on airborne precautions. The box of masks located outside the patient’s room is empty.

Step 1: The nurse uses knowledge to recognize that the patient’s condition warrants airborne precautions and that masks are the first line of defense for reducing the spread of airborne pathogens. The nurse uses knowledge of evidence-based sources to confirm that entering the room without a mask would place themselves and other patients on the unit at risk for exposure to the identified pathogen.

Step 2: The nurse identifies the skill of replacing the empty box before anyone can enter the room as an effective use of infection-control strategies to reduce risk of harm to self or others.

Step 3: The nurse stops and replaces the supplies outside the patient’s room before continuing with the morning report. The nurse can now begin the shift with a positive attitude , knowing value is placed on their role in reducing the spread of infection and providing quality, competent nursing care.

Reporting Healthcare-Associated Infections

As part of its mission in healthcare safety, the CDC has developed the National Healthcare Safety Network (NHSN), the nation’s most widely used system for tracking and surveillance of HAIs (CDC, 2022). More than 38,000 healthcare facilities provide data to the NHSN, which are, in turn, used for analysis and development of prevention initiatives by states, regions, and national public health agencies. These agencies include acute care/critical access hospitals, long-term care facilities, ambulatory surgery centers, long-term acute care facilities, inpatient psychiatric facilities, inpatient rehabilitation facilities, and dialysis facilities. The report provides data on CLABSIs, CAUTIs, ventilator-associated events (VAEs), SSIs, methicillin-resistant Staphylococcus aureus (MRSA) bloodstream events, and C. diff events. Federal government bodies such as the Centers for Medicare and Medicaid Services (CMS) use these data to determine performance incentives. Community members can use this information to select the healthcare facilities that they feel best fits their needs.

Personal Protective Equipment

Healthcare workers use personal protective equipment (PPE) as a means of barrier protection for their eyes, nose, mouth, and skin from exposure to blood and other potentially infectious bodily fluids and materials. The most commonly worn PPE includes gloves , gowns, face masks, protective eyewear, and face shields. These barriers are used in both standard precaution s as well as in transmission -based precautions. Every nurse must be knowledgeable about the appropriate PPE to wear in various situations. Simply wearing all available PPE is not appropriate practice and is wasteful considering healthcare resources.

Clinical Judgment Measurement Model

Take action: initiating the use of additional personal protective equipment.

This scenario requires a nurse to take action to prevent infection from spreading. A nurse is reviewing a patient’s morning laboratory results. The nurse notes that the patient’s stool culture has come back positive for vancomycin-resistant Enterococci (VRE). Knowing the method of transmission of VRE (contaminated equipment, surfaces, hands), the nurse analyzes these data and prioritizes how they will be incorporated into the patient’s care. The nurse knows that additional interventions will need to be implemented.

The nurse hangs a contact isolation sign on the door and places a PPE cart next to the room. The cart contains masks, gloves, face shields, hand sanitizer, and disinfectants, among other PPE items. When the nurse enters the patient’s room, they don the appropriate PPE per facility policy. They also provide the patient with education regarding why they will be seeing staff wearing additional PPE.

The use of gloves in the healthcare setting prevents contamination of the hands and reduces the likelihood of the transmission of pathogens ( Figure 6.5 ). Medical gloves should be worn when providing care to protect the healthcare provider as well as the patient. Further, sterile gloves should be worn for procedures that pose greater risk of contamination to the patient, which are indicated as sterile procedures. Gloves are only effective in infection prevention if they are used properly, and the wearer performs proper hand hygiene before and after wear. Gloves should be removed and hand hygiene should occur once contact with blood or bodily fluids has ended, once contact with a single patient has ended, when leaving a patient’s room, and when there is a need for hand hygiene. The same pair of gloves should never be worn more than once.

A medical isolation gown is a long-sleeved garment that covers the body front and back from the neck to the thighs, overlaps or meets in the back, fastens at the neck and waist, and is easy to put on and take off. They are used in the healthcare setting as a broad barrier against blood or bodily fluids. Gowns are used for patients who are on contact and droplet precaution s and for any potentially splash-generating procedures. Medical isolation gowns must be removed before leaving an individual patient area and hand hygiene must occur. A surgical gown is worn by healthcare personnel during a surgical procedure to protect both the patient and the personnel from transmission of pathogens. Examples of gowns can be seen in Figure 6.6 .

Healthcare workers should wear a mask when caring for a patient on droplet precautions or when providing care to patients who are immunocompromised. A surgical mask is worn over the nose and mouth to prevent the transmission of large particle droplet matter generated through coughing or splash-generating procedures. These masks have either ear loops or ties and can be either pleated or made of molded material. An N95 respirator mask is a tight-fitting cover that, when properly fitted, protects the wearer from very small particles that float in the air, such as tuberculosis (TB), measles, chickenpox, and COVID-19 ( Figure 6.7 ). When properly worn, an N95 mask can block at least 95 percent of non-oil-based particles that are 0.3 microns or larger. Any time a mask becomes wet from exhaled moist air, it weakens the integrity of the mask, warranting a mask change.

Eyewear and Shields

The use of eyewear and shields form a barrier and protect the membranes of the eyes, nose, and mouth when performing tasks that could produce splashes of bodily fluids or blood. Goggles should fit snugly around the eyes and protective face shields should cover the entire forehead, extend past the chin, and wrap around the sides of the face ( Figure 6.8 ).

Donning PPE

The type of PPE used in a healthcare setting is based on the level of precaution and isolation that is required. The meticulous use of PPE is a vital step to reduce contamination and transfer of infectious diseases. The CDC recommends a standardized procedure for donning, or applying, PPE, but the procedure should always be tailored to the specific type of PPE being used. Prior to donning PPE, always perform hand hygiene . The steps for donning PPE should follow the guidelines outlined by the CDC.

QSEN Competency: Donning Personal Protective Equipment, Evidence-Based Practice

Definition: Quality and Safety Education for Nurses (QSEN) competencies were designed to emphasize key elements that pre-licensure nursing students should be competent in at the time of graduation. Employing evidence-based practice means “integrating best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.”

Clinical scenario: Here are some evidence-based steps issued by the CDC (n.d.) on donning PPE:

Step 1: An isolation gown should be donned first. The gown should be picked up by the shoulders, which allows it to fall open without touching the floor. The gown should be positioned to fully cover the torso (from the neck to the knees) and arms (to wrists), and it should wrap around the back. Fasten the ties at the neck and the waist.

Step 2: After securing the gown, don the face mask or N95 mask. Ensure that the ties or elastic band fits at the middle of the head and neck. The mask should be snug to the face and below the chin. N95 masks should be fit checked to ensure proper seal.

Step 3: Once the face mask is in place, goggles will be placed over the top of the edge of the mask. A face shield is placed over the eyes.

Step 4: The final step for donning PPE is the application of gloves. The glove cuff should extend over the gown cuff. Ensure that the correct size gloves are selected to prevent them from falling off or ripping.

Doffing and Disposal of PPE

Once patient care is completed, all PPE except for a respirator will be removed, or doffed, prior to exiting a patient’s room. All PPE is discarded in the appropriate receptacle as outlined by facility policy. Following the removal of PPE, perform hand hygiene immediately. The steps for doffing PPE should follow the guidelines outlined by the CDC.

QSEN Competency: Hand Hygiene and Donning and Doffing PPE

See the competency checklist for Hand Hygiene and Donning and Removing PPE. You can find the checklists on the Student resources tab of your book page on openstax.org.

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4.3 Aseptic Technique

In addition to using standard precautions and transmission-based precautions, aseptic technique (also called medical asepsis) is the purposeful reduction of pathogens to prevent the transfer of microorganisms from one person or object to another during a medical procedure. For example, a nurse administering parenteral medication or performing urinary catheterization uses aseptic technique. When performed properly, aseptic technique prevents contamination and transfer of pathogens to the patient from caregiver hands, surfaces, and equipment during routine care or procedures. The word “aseptic” literally means an absence of disease-causing microbes and pathogens. In the clinical setting, aseptic technique refers to the purposeful prevention of microbe contamination from one person or object to another. These potentially infectious, microscopic organisms can be present in the environment, on an instrument, in liquids, on skin surfaces, or within a wound.

There is often misunderstanding between the terms aseptic technique and sterile technique in the health care setting. Both asepsis and sterility are closely related, and the shared concept between the two terms is removal of harmful microorganisms that can cause infection. In the most simplistic terms, asepsis is creating a protective barrier from pathogens, whereas sterile technique is a purposeful attack on microorganisms. Sterile technique (also called surgical asepsis) seeks to eliminate every potential microorganism in and around a sterile field while also maintaining objects as free from microorganisms as possible. It is the standard of care for surgical procedures, invasive wound management, and central line care. Sterile technique requires a combination of meticulous hand washing, creation of a sterile field, using long-lasting antimicrobial cleansing agents such as betadine, donning sterile gloves, and using sterile devices and instruments.

Principles of Aseptic Non-Touch Technique

Aseptic non-touch technique (ANTT) is the most commonly used aseptic technique framework in the health care setting and is considered a global standard. There are two types of ANTT: surgical-ANTT (sterile technique) and standard-ANTT.

Aseptic non-touch technique starts with a few concepts that must be understood before it can be applied. For all invasive procedures, the “ANTT-approach” identifies key parts and key sites throughout the preparation and implementation of the procedure. A key part is any sterile part of equipment used during an aseptic procedure, such as needle hubs, syringe tips, needles, and dressings. A key site is any nonintact skin, potential insertion site, or access site used for medical devices connected to the patients. Examples of key sites include open wounds and insertion sites for intravenous (IV) devices and urinary catheters.

ANTT includes four underlying principles to keep in mind while performing invasive procedures:

• A lways wash hands effectively.
• N ever contaminate key parts.
• T ouch non-key parts with confidence.
• T ake appropriate infective precautions.

Preparing and Preventing Infections Using Aseptic Technique

When planning for any procedure, careful thought and preparation of many infection control factors must be considered beforehand. While keeping standard precautions in mind, identify anticipated key sites and key parts to the procedure. Consider the degree to which the environment must be managed to reduce the risk of infection, including the expected degree of contamination and hazardous exposure to the clinician. Finally, review the expected equipment needed to perform the procedure and the level of key part or key site handling. See Table 4.3 for an outline of infection control measures when performing a procedure.

Table 4.3 Infection Control Measures When Performing Procedures

Use of Gloves and Sterile Gloves

There are two different levels of medical-grade gloves available to health care providers: clean (exam) gloves and sterile (surgical) gloves. Generally speaking, clean gloves are used whenever there is a risk of contact with body fluids or contaminated surfaces or objects. Examples include starting an intravenous access device or emptying a urinary catheter collection bag. Alternatively, sterile gloves meet FDA requirements for sterilization and are used for invasive procedures or when contact with a sterile site, tissue, or body cavity is anticipated. Sterile gloves are used in these instances to prevent transient flora and reduce resident flora contamination during a procedure, thus preventing the introduction of pathogens. For example, sterile gloves are required when performing central line dressing changes, insertion of urinary catheters, and during invasive surgical procedures. See Figure 4.15 [1] for images of a nurse opening and removing sterile gloves from packaging.

See the “ Checklist for Applying and Removing Sterile Gloves ” for details on how to apply sterile gloves.

Applying Sterile Gloves on YouTube [2]

• “Book-pictures-2015-199-001-300x241.jpg,” “Book-pictures-2015-215.jpg,” and “Book-pictures-2015-219.jpg” by British Columbia Institute of Technology  are licensed under CC BY 4.0 . Access for free at https://opentextbc.ca/clinicalskills/chapter/sterile-gloving/ ↵
• RegisteredNurseRN. (2017, April 28). Sterile gloving nursing technique | Don/donning sterile gloves tips. [Video]. YouTube. All rights reserved. Video used with permission. https://youtu.be/lumZOF-METc ↵

The purposeful reduction of pathogen numbers while preventing microorganism transfer from one person or object to another.

A state of being free of disease-causing microorganisms.

Techniques used to eliminate every potential microorganism in and around a sterile field while maintaining objects and areas as free from microorganisms as possible.

A standardized technique, supported by evidence, to maintain asepsis and standardize practice.

A key part is any sterile part of equipment used during an aseptic procedure, such as needle hubs, syringe tips, dressings, etc.

A key site is the site contacted during an aseptic procedure, such as non-intact skin, a potential insertion site, or an access site used for medical devices connected to the patients.

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Chapter 1. Infection Control

1.2 Infection Prevention and Control Practices

Infection prevention and control (IPAC) practices  are evidence-based procedures and practices that can prevent and reduce disease transmission, and eliminate sources of potential infections (PIDAC, 2012). When used consistently,  IPAC practices will prevent the transfer of  health care associated infections (HAIs)  in all health care settings. HAIs, also known as   nosocomial infections , are infections that occur in any health care setting as a result of  contact with a pathogen that was not present at the time the person infected was admitted (World Health Organization[WHO], 2009a).

Two types of techniques are used to prevent infection in the hospital setting. The first, medical asepsis , or clean technique , has been used in the past to describe measures for reducing and preventing the spread of organisms (Perry, Potter & Ostendorf, 2014). The second, sterile technique , also known as sterile asepsis , is a strict technique to eliminate all microorganisms from an area (Perry et al., 2014). When a patient is suspected of having or is confirmed to have certain pathogens or clinical presentations, additional  precautions  are implemented by the health care worker, in addition to routine practices (PIDAC, 2012). These additional precautions are based on how an infection is transmitted, such as by contact, droplet, or air. Additional precautions use personal protective equipment (PPE), such as gowns, eyewear, face shields, and masks, along with environmental controls to prevent transmission of infection.

To reduce, and prevent the spread of, HAIs, routine practices , a system of recommended IPAC practices, are to be used consistently with all patients at all times in all health care settings (Public Health Agency of Canada [PHAC], 2012b). The principles of   routine practices are based on the premise that all patients are potentially infectious, even when asymptomatic, and IPAC routine practices should be used to prevent exposure to blood, body fluids, secretions, excretions, mucous membranes, non-intact skin, or soiled items (PIDAC, 2012).

To learn the steps for routine practices, see Checklist 1.

Critical Thinking Exercises

• Name four environmental procedures that can break the chain of infection.
• What types of patents are at an increased risk for an HAI?
• How can health care providers reduce patient susceptibility to infection?

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Principles of asepsis 1: the rationale for using aseptic technique

14 April, 2020

Aseptic technique is a core competency for many nurses and is required for everyday procedures such as catheterisation and wound dressing. This first article in a two-part series outlines the principles of medical asepsis

Aseptic technique is a core competency for many nurses. This article, the first in a two-part series, describes the principles of asepsis and part 2 will describe the procedure for changing a simple wound dressing.

Citation: Denton A, Hallam C (2020) Principles of asepsis 1: the rationale for using aseptic technique. Nursing Times [online]; 116: 38-41.

Authors: Andrea Denton and Carole Hallam are independent nurse consultants, AC Independent Nursing Consultants.

• This article has been double-blind peer reviewed
• This article is open access and can be freely distributed
• Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser)
• Read part 2 of this series here

Introduction

It is estimated that 300,000 patients each year in England will develop a healthcare-associated infection (HCAI) (National Institute for Health and Care Excellence, 2012). These infections are more likely to occur in patients with invasive devices, such as peripheral canulas, vascular access devices or urinary catheters in situ, or after invasive procedures (NICE, 2012).

To reduce patients’ risk of developing a HCAI, it is vital to prevent the transmission of micro-organisms between staff and patients when undertaking any invasive procedure (Loveday et al, 2014); this can be achieved by asepsis. The term asepsis means “the absence of potentially pathogenic micro-organisms” (Loveday et al, 2014). It could be suggested that understanding the principles of asepsis goes back as far as Florence Nightingale, who made the links between good hand hygiene and reduction in wound infections in 1855 (Rowley et al, 2010). Indeed, as far back as the mid-1800s, the association between good hand hygiene and reduced infection rates was identified by Ignaz Semmelweis (Wilson, 2019). With the increased focus on antimicrobial resistance (AMR) there is also a need to carefully consider antibiotic usage, and prevention of infection can help to reduce the need for antimicrobials in the first place (HM Government, 2019).

What is asepsis?

Aseptic technique is a process or procedure used to achieve asepsis to prevent the transfer of potentially pathogenic micro-organisms to a susceptible site that may result in the development of infection (Wilson, 2019). An aseptic technique is required for many clinical interventions including wound dressing and insertion of invasive devices, as well as the maintenance of these devices (Loveday et al, 2014). Healthcare workers who perform an aseptic technique should receive training in how to correctly perform the procedure; this should include a competency assessment (Loveday et al, 2014).

A variety of terms are used to refer to aseptic technique; this can be confusing for frontline healthcare staff (Loveday et al, 2014). Medical asepsis – sometimes referred to as standard aseptic technique (Association of Safe Aseptic Practice, 2015) – aims to reduce the number of organisms and prevents their spread by use of standard principles of infection prevention (Loveday et al, 2014). Surgical asepsis includes procedures to eliminate, rather than reduce, micro-organisms from an area and is practised by surgical teams and nurses in operating theatres and procedure areas, including interventional radiology (NICE, 2012). The term ‘clean technique’ is often used to describe the procedure for dressing chronic wounds; it includes hand hygiene, preparation of a clean area with use of clean gloves and sterile instruments, such as scissors and forceps (Wound, Ostomy and Continence Nursing Society, 2012). A ‘clean technique’ can be classed as medical asepsis or standard aseptic technique, as it uses the same principles.

Rowley et al (2010) recognised the need for a systematic and robust approach to aseptic technique that aims to prevent the contamination of wounds or other susceptible sites by removing variation in practice (Rowley et al, 2010). The ANTT® (aseptic non-touch technique) framework was developed to provide consistent step-by-step guidance for an aseptic non-touch technique that can be applied to several invasive procedures, including insertion of urinary catheters and peripheral cannulas, phlebotomy and administration of intravenous drugs (Box 1) (Rowley et al, 2010). It provides a comprehensive set of principles including ANTT, which aims to achieve surgical asepsis; the ANTT approach is widely used in hospitals and community settings (NICE, 2012).

Box 1. Examples of when to use a medical aseptic technique

• Dressing a leg ulcer
• Dressing a surgical wound
• Inserting a peripheral cannula
• Redressing of vascular access devices
• Venepuncture
• Inserting a urinary catheter
• Administrating intravenous drugs
• Administrating of enteral feeds

Principles of asepsis

The fundamental principle of an aseptic technique/ANTT incorporates protecting key elements of the equipment that should remain free from micro-organisms, for example, the inside of a sterile dressing or the barrel of a sterile needle (NICE, 2012). These ‘key parts’ or ‘key sites’ are crucial components of any invasive procedure. If they become contaminated, this can result in the patient acquiring a preventable infection. Key parts are defined as the parts of the equipment used in the procedure that come into direct or indirect contact with another key part or site. Key sites are defined as open wounds, including insertion sites and puncture sites. Both key parts and key sites always need to be protected (Rowley et al, 2010), which can be achieved by not touching the key part and by using caps and covers, such as the sterile wrapper of a syringe to protect the key part of the syringe before use.

Risk assessment before the procedure will direct the practitioner as to whether the key parts and key sites can be protected by non-touch or whether the procedure will require the use of sterile gloves, such as for the insertion of a urinary catheter or for taking blood when the re-palpation of the puncture site is required (ASAP, 2015).

Medical asepsis can be used in procedures that:

• Are considered technically simple;
• Are short in duration (usually less than 20 minutes);
• Involve small sites such as puncture sites;
• Have a minimal numbers of key parts (usually considered to be less than five although there is no evidence to support this).

Surgical aseptic technique should be used when procedures are technically complex and invasive, involve extended procedure time (more than 20 minutes) or a large, open key site and large or numerous key parts. The main aseptic field needs to be managed as a critical aseptic field (a controlled working space that ensures asepsis by providing protection from the procedure environment – typically by using a sterilised drape), using sterile gloves and often with full barrier precautions to include sterile gown, mask and cap (ASAP, 2015). For the purpose of this article all references to aseptic technique refer to medical/standard aseptic technique.

Stages of medical aseptic technique

Hand hygiene.

There are a number of stages and principles for aseptic technique (Table 1); the fundamental initial stage is hand hygiene, which must be performed before any aseptic technique (World Health Organization, 2019; Loveday et al, 2014). Hands can be decontaminated by washing with soap and water or by use of alcohol-based handrub (Loveday et al, 2014). Hand hygiene must be performed before preparation of the sterile equipment to avoid contamination of the equipment, and may need to be repeated immediately before the procedure if the hands have become contaminated (Loveday et al, 2014). It must also be performed after the procedure (WHO, 2019).

Storage of equipment

All sterile equipment should be stored in a clean and dry environment (National Health and Medical Research Council, 2019). The sterile packages should not be allowed to become wet or damaged as this affects the sterility of the equipment inside. Ideally the equipment should be kept out of direct sunlight as this could also affect the packaging, as well as the quality of the sterile products of the equipment. It is also sensible to store the equipment in a manner that enables staff to locate it easily, preventing wasted time.

Preparing equipment

Preparation of aseptic technique equipment before performing a procedure should be done in a clean area. A suitable surface should be prepared, such as a dressing trolley or a procedure tray, by cleaning it with a detergent wipe or according to local policy (Loveday et al, 2014). Ideally, preparation should be undertaken far enough away from hand washbasins to prevent droplets from the sink outlet contaminating the prepared equipment (Centers for Disease Control and Prevention, 2019). Each sterile package should be inspected to ensure the packaging is still intact with no visible damage; the expiry date must be checked to ensure the equipment is still in date (Lloyd Jones, 2014). All equipment required should be gathered at this point and laid out in a manner to protect key parts using sterile packets, covers and caps (Rowley et al, 2010). Alternatively, a sterile field can be created using a sterile dressing pack (Lloyd Jones, 2014).

It is important to inform the patient before undertaking any procedure and to obtain consent, allowing time to explain the specific procedure and to help reduce any anxieties the patient may have (Royal College of Nursing, 2017). Where the patient has capacity, this can usually be done verbally and then documented in the patient’s record (RCN, 2017). A best-interest decision may need to be made for a patient who is unable to give consent and this decision needs to be clearly documented in the patient’s record (NHS, 2018).

Environment

The procedure should be carried out in a location that maintains the patient’s privacy and dignity, such as a treatment room, at the bedside with the curtains drawn or in the patient’s own home (Lloyd Jones, 2014). To reduce the risk from airborne dispersal of micro-organisms, the procedure area should be prepared by closing windows, turning off any fans that are in use and avoiding any bed making being undertaken in close proximity (Lloyd Jones, 2014).

Use of gloves and aprons

A clean disposable apron provides an ideal barrier between potentially contaminated uniforms and the procedure, reducing any contamination that may arise from the procedure. The decision as to whether single-use sterile or single-use non-sterile examination gloves should be worn, or whether gloves are required at all, should be based on a risk assessment (NHMRC, 2019; Loveday et al, 2014). Single-use non-sterile gloves should be worn to protect the healthcare worker when there is a risk of contact with blood or body fluids during any procedure (Loveday et al, 2014). Where there is a risk that key parts or key sites cannot be protected, for example, during urinary catheter insertion, sterile gloves should be worn (NHMRC, 2019; Rowley et al, 2010). It is important to remember that the single-use gloves, whether sterile or non-sterile, should be applied immediately before beginning the procedure; applying them before this point is likely to contaminate sterile gloves and/or prevent an opportunity for hand hygiene (NICE, 2012).

Maintaining a sterile field

During the procedure, the sterile field needs to be maintained; this can be achieved by careful opening of the sterile packets to avoid contamination of the sterile equipment and the sterile surfaces of the inside packaging. If a sterile dressing pack is being used, care should be taken to ensure that only the corners are used when opening out the sterile field. Carefully open any other sterile equipment and gently place it onto the sterile field, avoiding any contamination of the sterile surfaces of the equipment (Lloyd Jones, 2014).

Equipment disposal

At the end of the procedure, all waste must be disposed of in the appropriate waste stream bin, such as a healthcare waste bin. Sharps, including needles, suture cutters, scissors and blades must be disposed of at the point of use in an approved sharps container (Loveday et al, 2014). The remaining waste, including aprons and gloves, should be disposed of according to local policy (Loveday et al, 2014). When all the waste has been disposed of safely and apron and gloves, if worn, have been removed hands should be decontaminated (Loveday et al, 2014). Once you have clean hands, the procedure should be clearly documented in the patient’s records (Nursing and Midwifery Council, 2018).

Asepsis is an essential component of infection prevention and control practice to protect patients from potential HCAIs (Loveday et al, 2014). All steps in a non-touch aseptic technique should be seen as an opportunity to reduce the transfer of pathogenic organisms. Healthcare workers should be educated and trained in an aseptic technique that should include competency assessment (Loveday et al, 2014) and should be considered a core competency for many nurses. NICE guidance (2012) suggests that the ANTT framework provides a possible approach to standardised aseptic technique removing ambiguity and variance that allows a process for audit and assurance. It is vitally important that nurses understand the principles of asepsis, and the ANTT framework may provide a way of implementing the principles.

• The term asepsis means the absence of potentially pathogenic micro-organisms
• Aseptic technique is used to achieve asepsis in order to prevent the transfer of potentially pathogenic micro-organisms to a susceptible site
• Medical asepsis aims to reduce the number of organisms and prevent their spread by use of standard principles of infection prevention
• An aseptic technique is required for many clinical interventions including wound dressing, peripheral cannula or other vascular access device insertion
• Prevention of infection can help to reduce the requirement for antimicrobial prescribing

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Chapter 1. Infection Control

1.5 Principles of Asepsis

Asepsis refers to the absence of infectious material or infection. Surgical asepsis is the absence of all microorganisms within any type of invasive procedure. Sterile technique  is a set of specific practices and procedures performed to make equipment and areas free from all microorganisms and to maintain that sterility (Centre for Disease Control, 2007). In the literature, surgical asepsis and sterile technique are commonly used interchangeably, but they mean different things (Kennedy, 2013). Principles of sterile technique help control and prevent infection, prevent the transmission of all microorganisms in a given area, and include all techniques that are practised to maintain sterility.

Sterile technique is most commonly practised in operating rooms, labour and delivery rooms, and special procedures or diagnostic areas. It is also used when performing a sterile procedure at the bedside, such as inserting devices into sterile areas of the body or cavities (e.g., insertion of chest tube, central venous line, or indwelling urinary catheter). In healthcare, sterile technique is always used when the integrity of the skin is accessed, impaired, or broken (e.g., burns or surgical incisions). Sterile technique may include the use of sterile equipment, sterile gowns, and gloves (Perry et al., 2014).

Sterile technique is essential to help prevent surgical site infections (SSI) , an unintended and oftentimes preventable complication arising from surgery. It is simply post op infection that occurs at the surgical site (CDC, 2014). Preventing and reducing SSI are the most important reasons for using sterile technique during invasive procedures and surgeries.

Principles of Surgical Asepsis

All personnel involved in an aseptic procedure are required to follow the principles and practice set forth by the Association of periOperative Registered Nurses (AORN). These principles must be strictly applied when performing any aseptic procedures, when assisting with aseptic procedures, and when intervening when the principles of surgical asepsis are breached. It is the responsibility of all healthcare workers to speak up and protect all patients from infection.

Critical Thinking Exercises

• When should a sterile field be opened (under normal circumstances)?
• What part of the sterile field is considered non-sterile?

Clinical Procedures for Safer Patient Care Copyright © 2018 by Thompson Rivers University is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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