Aseptic technique

Definition

Aseptic technique is a set of specific practices and procedures performed under

carefully controlled conditions with the goal of minimizing contamination by
pathogens.

Purpose

Aseptic technique is employed to maximize and maintain asepsis, the absence of

pathogenic organisms, in the clinical setting. The goals of aseptic technique are
to protect the patient from infection and to prevent the spread of pathogens.
Often, practices that clean (remove dirt and other impurities), sanitize (reduce the
number of microorganisms to safe levels), or disinfect (remove most
microorganisms but not highly resistant ones) are not sufficient to prevent
infection.

The Centers for Disease Control and Prevention (CDC) estimates that over 27
million surgical procedures are performed in the United States each year.
Surgical site infections are the third most common nosocomial (hospital-
acquired) infection and are responsible for longer hospital stays and increased
costs to the patient and hospital. Aseptic technique is vital in reducing the
morbidity and mortality associated with surgical infections.

Description

Aseptic technique can be applied in any clinical setting. Pathogens may

introduce infection to the patient through contact with the environment,
personnel, or equipment. All patients are potentially vulnerable to infection,
although certain situations further increase vulnerability, such as extensive burns
or immune disorders that disturb the body's natural defenses. Typical situations
that call for aseptic measures include surgery and the insertion of intravenous
lines, urinary catheters, and drains.
Asepsis in the operating room

Aseptic technique is most strictly applied in the operating room because of the
direct and often extensive disruption of skin and underlying tissue. Aseptic
technique helps to prevent or minimize postoperative infection.

PREOPERATIVE PRACTICES AND PROCEDURES. The most common source

of pathogens that cause surgical site infections is the patient. While
microorganisms normally colonize parts in or on the human body without causing
disease, infection may result when this endogenous flora is introduced to tissues
exposed during surgical procedures. In order to reduce this risk, the patient is
prepared or prepped by shaving hair from the surgical site; cleansing with a
disinfectant containing such chemicals as iodine, alcohol, or chlorhexidine
gluconate; and applying sterile drapes around the surgical site.

In all clinical settings, handwashing is an important step in asepsis. The "2002

Standards, Recommended Practices, and Guidelines" of the Association of
Perioperative Registered Nurses (AORN) states that proper handwashing can be
"the single most important measure to reduce the spread of microorganisms." In
general settings, hands are to be washed when visibly soiled, before and after
contact with the patient, after contact with other potential sources of
microorganisms, before invasive procedures, and after removal of gloves. Proper
handwashing for most clinical settings involves removal of jewelry, avoidance of
clothing contact with the sink, and a minimum of 10–15 seconds of hand
scrubbing with soap, warm water, and vigorous friction.

A surgical scrub is performed by members of the surgical team who will come
into contact with the sterile field or sterile instruments and equipment. This
procedure requires use of a long-acting, powerful, antimicrobial soap on the
hands and forearms for a longer period of time than used for typical
handwashing. Institutional policy usually designates an acceptable minimum
length of time required; the CDC recommends at least two to five minutes of
scrubbing. Thorough drying is essential, as moist surfaces invite the presence of
pathogens. Contact with the faucet or other potential contaminants should be
avoided. The faucet can be turned off with a dry paper towel, or, in many cases,
through use of a foot pedal. An important principle of aseptic technique is that
fluid (a potential mode of pathogen transmission) flows in the direction of gravity.
With this in mind, hands are held below elbows during the surgical scrub and
above elbows following the surgical scrub. Despite this careful scrub, bare hands
are always considered potential sources of infection.

Sterile surgical clothing or protective devices such as gloves, face masks,

goggles, and transparent eye/face shields serve as barriers against
microorganisms and are donned to maintain asepsis in the operating room. This
practice includes covering facial hair, tucking hair out of sight, and removing
jewelry or other dangling objects that may harbor unwanted organisms. This garb
must be put on with deliberate care to avoid touching external, sterile surfaces
with nonsterile objects including the skin. This ensures that potentially
contaminated items such as hands and clothing remain behind protective
barriers, thus prohibiting inadvertent entry of microorganisms into sterile areas.
Personnel assist the surgeon to don gloves and garb and arrange equipment to
minimize the risk of contamination.

Donning sterile gloves requires specific technique so that the outer glove is not
touched by the hand. A large cuff exposing the inner glove is created so that the
glove may be grasped during donning. It is essential to avoid touching nonsterile
items once sterile gloves are applied; the hands may be kept interlaced to avoid
inadvertent contamination. Any break in the glove or touching the glove to a
nonsterile surface requires immediate removal and application of new gloves.

Asepsis in the operating room or for other invasive procedures is also maintained
by creating sterile surgical fields with drapes. Sterile drapes are sterilized linens
placed on the patient or around the field to delineate sterile areas. Drapes or
wrapped kits of equipment are opened in such a way that the contents do not
touch non-sterile items or surfaces. Aspects of this method include opening the
furthest areas of a package first, avoiding leaning over the contents, and
preventing opened flaps from falling back onto contents.

Equipment and supplies also need careful attention. Medical equipment such as
surgical instruments can be sterilized by chemical treatment, radiation, gas, or
heat. Personnel can take steps to ensure sterility by assessing that sterile
packages are dry and intact and checking sterility indicators such as dates or
colored tape that changes color when sterile.

INTRAOPERATIVE PRACTICES AND PROCEDURES. In the operating room,

staff have assignments so that those who have undergone surgical scrub and
donning of sterile garb are positioned closer to the patient. Only scrubbed
personnel are allowed into the sterile field. Arms of scrubbed staff are to remain
within the field at all times, and reaching below the level of the patient or turning
away from the sterile field are considered breaches in asepsis.

Other "unscrubbed" staff members are assigned to the perimeter and remain on
hand to obtain supplies, acquire assistance, and facilitate communication with
outside personnel. Unscrubbed personnel may relay equipment to scrubbed
personnel only in a way that preserves the sterile field. For example, an
unscrubbed nurse may open a package of forceps in a sterile fashion so that he
or she never touches the sterilized inside portion, the scrubbed staff, or the
sterile field. The uncontaminated item may either be picked up by a scrubbed
staff member or carefully placed on to the sterile field.

The environment contains potential hazards that may spread pathogens through
movement, touch, or proximity. Interventions such as restricting traffic in the
operating room, maintaining positive-pressure airflow (to prevent air from
contaminated areas from entering the operating room), or using low-particle
generating garb help to minimize environmental hazards.

Other principles that are applied to maintain asepsis in the operating room
include:
 • All items in a sterile field must be sterile.
• Sterile packages or fields are opened or created as close as possible to
time of actual use.
• Moist areas are not considered sterile.
• Contaminated items must be removed immediately from the sterile field.
• Only areas that can be seen by the clinician are considered sterile (i.e.,
the back of the clinician is not sterile).
• Gowns are considered sterile only in the front, from chest to waist and
from the hands to slightly above the elbow.
• Tables are considered sterile only at or above the level of the table.
• Nonsterile items should not cross above a sterile field.
• There should be no talking, laughing, coughing, or sneezing across a
sterile field.
• Personnel with colds should avoid working while ill or apply a double
mask.
• Edges of sterile areas or fields (generally the outer inch) are not
considered sterile.
• When in doubt about sterility, discard the potentially contaminated item
and begin again.
• A safe space or margin of safety is maintained between sterile and
nonsterile objects and areas.
• When pouring fluids, only the lip and inner cap of the pouring container is
considered sterile; the pouring container should not touch the receiving
container, and splashing should be avoided.
• Tears in barriers and expired sterilization dates are considered breaks in
sterility.

Other clinical settings

A key difference between the operating room and other clinical environments is
that the operating area has high standards of asepsis at all times, while most
other settings are not designed to meet such standards. While clinical areas
outside of the operating room generally do not allow for the same strict level of
asepsis, avoiding potential infection remains the goal in every clinical setting.
Observation of medical aseptic practices will help to avoid nosocomial infections.
The application of aseptic technique in such settings is termed medical asepsis
or clean technique (rather than surgical asepsis or sterile technique required in
the operating room).

Specific situations outside of the operating room require a strict application of

aseptic technique. Some of these situations include:

• wound care
• drain removal and drain care
• intravascular procedures
• vaginal exams during labor
• insertion of urinary catheters
• respiratory suction

For example, a surgical dressing change at the bedside, though in a much less
controlled environment than the operating room, will still involve thorough
handwashing, use of gloves and other protective garb, creation of a sterile field,
opening and introducing packages and fluids in such a way as to avoid
contamination, and constant avoidance of contact with nonsterile items.

General habits that help to preserve a clean medical environment include:

• safe removal of hazardous waste, i.e., prompt disposal of contaminated

needles or blood-soaked bandages to containers reserved for such
purposes
• prompt removal of wet or soiled dressings
• prevention of accumulation of bodily fluid drainage, i.e., regular checks
and emptying of receptacles such as surgical drains or nasogastric suction
containers
• avoidance of backward drainage flow toward patient, i.e., keeping
drainage tubing below patient level at all times
• immediate clean-up of soiled or moist areas
 • labeling of all fluid containers with date, time, and timely disposal per
institutional policy
• maintaining seals on all fluids when not in use

The isolation unit is another clinical setting that requires a high level of attention
to aseptic technique. Isolation is the use of physical separation and strict aseptic
technique for a patient who either has a contagious disease or is
immunocompromised. For the patient with a contagious disease, the goal of
isolation is to prevent the spread of infection to others. In the case of respiratory
infections (i.e., tuberculosis), the isolation room is especially designed with a
negative pressure system that prevents airborne flow of pathogens outside the
room. The severely immunocompromised patient is placed in reverse isolation,
where the goal is to avoid introducing any microorganisms to the patient. In these
cases, attention to aseptic technique is especially important to avoid spread of
infection in the hospital or injury to the patient unprotected by sufficient immune
defenses. Entry and exit from the isolation unit involves careful handwashing,
use of protective barriers like gowns and gloves, and care not to introduce or
remove potentially contaminated items. Institutions supply specific guidelines that
direct practices for different types of isolation, i.e., respiratory versus body fluid
isolation precautions.

In a multidisciplinary setting, all personnel must constantly monitor their own

movements and practices, those of others, and the status of the overall field to
prevent inadvertent breaks in sterile or clean technique. It is expected that
personnel will alert other staff when the field or objects are potentially
contaminated. Health care workers can also promote asepsis by evaluating,
creating, and periodically updating policies and procedures that relate to this
principle.

PRINCIPLES

1. Only sterile items are used within the sterile field.

2. Gowns are considered sterile only from waist to shoulders level in front and
the sleeves.

3. Tables are sterile only at table level.

4. Persons who are sterile touch only sterile items or areas; persons who are not
sterile touch only unsterile items or areas.

5. Unsterile persons avoid reaching over a sterile field; sterile persons avoid
leaning over an unsterile area.

6. Edges of anything that encloses sterile contents are considered unsterile.

7. Sterile field is created as close as possible to time of use.

8. Sterile areas are continuously kept in view.

9. Sterile persons keep well within the sterile area.

10. Sterile persons keep contact with sterile areas to a minimum.

11. Unsterile persons avoid sterile areas

12. Destruction of integrity of microbial barriers results in contamination.

13.Microorganisms must be kept to an irreducible minimum

Aseptic Technique
Asepsis and Aseptic Technique

“Asepsis is the method by which we prevent microbial contamination during

invasive procedures or care of breaches in the skin’s integrity“ (ICNA 2003).
Two types of asepsis can be classified: medical and surgical asepsis (Ayliffe,
2000).

Medical asepsis aims to reduce the number of organisms and prevent their
spread and is mainly employed in ward areas and some other treatment areas,
e.g. outpatient clinics.

Surgical asepsis is a strict process and includes procedures to eliminate

micro-organisms from an area and is practised by nurses and other health care
workers in operating theatres and some other treatment areas (Royal Marsden
Manual, p.50). It is also appropriate in wards and other departments for
invasive procedures such as the insertion of a central venous catheter.
An aseptic technique is the method employed to help prevent contamination
of wounds and other susceptible sites by organisms that could cause infection,
by ensuring that only uncontaminated equipment and fluids come into contact
with sterile/susceptible body sites during certain clinical procedures. It should
be used during any procedure that bypasses the body’s natural defences.
Organisms can be transferred from one person to another if techniques to
prevent such spread are not adopted.
This policy aims to focus upon medical asepsis and the procedures that are
currently carried out in ward and other treatment areas, using an aseptic,
nontouch
technique (ANTT). It should be noted that only staff who have received
appropriate training and have been assessed as competent should carry out an
aseptic procedure.

3 Aims of an Aseptic Technique

• To prevent the introduction of potentially pathogenic micro-organisms into
susceptible sites such as wounds or the bladder.
• To prevent the transfer of potentially pathogenic micro-organisms from one
patient to another.
• To prevent staff from acquiring an infection from the patient.

4 Indications for Aseptic Technique:

• Care of wounds healing by primary intention, e.g. surgical incisions and
fresh breaks.
• Suturing of wounds.
• Insertion of urinary catheters.
• Insertion, re-siting or dressing intravenous cannulae or other intravascular
devices, such as CVP lines, Hickman lines and Arterial lines.
• Insertion of gastrostomy and jejunostomy tubes.
• Insertion of tracheostomy tubes or chest drains.
• Vaginal examination using instruments (e.g. smear taking, high vaginal
swabbing, colposcopy).
• Assisted delivery (e.g. forceps and ventouse).
• Biopsies.
The timing of procedures such as re-dressing wounds in a ward area, can be
an important factor in helping to reduce the risk of infection. They should not be
carried out when tasks such as bed-making are taking place, due to the risk of
micro-organisms being dispersed into the air and potentially contaminating the
sterile equipment or wound. Ideally, these should be carried out at a time when
ward activities are less and cleaning activities suspended. Clean, non-infected
wounds should be dressed first; colostomies and infected wounds should be
dressed last, to minimise environmental contamination and cross-infection.

5 Principles of Aseptic Non-Touch Technique

The principles of carrying out an aseptic technique remain the same, but
components of the technique may vary according to the degree of risk.
• Assess the individual patient’s infection risk, and plan appropriate care:
Consider:
Is the patient at increased risk of acquiring an infection from others or the
environment?
Does the patient pose an infection risk to those around them? Are they
currently colonised or infected with bacteria or a multi-resistant organism?
Does the patient have any invasive devices?
Consider the patient’s age: the elderly and neonates are more at risk as their
immune systems are less efficient.
Does the patient suffer from an underlying disease, i.e. a severe debilitating or
malignant disease?
Consider the patient’s prior drug therapy – the use of immunosuppressive
drugs or broad-spectrum anti-microbials can increase the risk of infection.
Is the patient undergoing surgery or has the patient undergone surgery?
(HCAIs are known to present in surgical incision wounds, accounting for 10 –
30% of all HCAIs).
What is the patient’s general health status?
What is the patient’s nutritional state?
Has the patient previously been exposed to infection, or does the patient suffer
from an existing infection?
• Inform the patient and obtain consent.
• Collect appropriate PPE for the task.
• Select appropriate dressings/devices.
• Prepare the area.
• Decontaminate your hands (Section H/I, Infection Control Manual).
• Carry out the procedure (See Appendix 2).
• Ensure the correct disposal of any waste (section U, Infection control
Manual.
• Document the procedure undertaken.

6 Aseptic Non-Touch Technique

The Aseptic Non-Touch Technique (ANTT) is a a standard for safe and
effective practice that can be applied to all aseptic procedures such as
intravenous therapy, wound care and urinary catheterisation. It standardises
practice and rationalises the many different techniques currently in use. The
ANTT is rolling out nationally to all areas and will soon be audited by the DOH.
An ANTT means that when handling sterile equipment, only the part of the
equipment not in contact with the susceptible site is handled (Hart, 2007).
It is essential to ensure that hands, even though they have been washed, do
not contaminate the sterile equipment or the patient.

The aim is for asepsis not sterility. The individual healthcare professionals need
to decide between sterile or non sterile field/gloves and simply ask themselves ‘
can I do this procedure without touching key-parts?’
If the answer is NO – they use a sterile dressing pack and sterile gloves.
If YES – they wear non-sterile gloves.
The principle is that you cannot infect a key part if it is not touched. Any key
part must only come into contact with other key parts (ie syringe tip and needle
hub); non-key parts should be touched with confidence.
● Always wash hands effectiveley
● Never contaminate key parts
● Touch non key - parts with confidence
● Take appropriate infective precautions

7 Clean Technique – What Is It?

‘A clean technique is a modified aseptic technique and aims to avoid
introducing micro-organisms to a susceptible site and also to prevent
crossinfection
to patients and staff’ (Royal Marsden Manual). It differs from an
aseptic technique, as the use of sterile equipment and the environment are not
as crucial as would be required for asepsis. The non-touch technique is
incorporated as part of a clean procedure i.e. the ends of sterile connections
should not be touched or other items that could contaminate a susceptible site.
Clean, single-use gloves are worn rather than sterile gloves.

8 When Could a Clean Technique Be Used?

• Dressing procedures for wounds that are healing by secondary intention
such as chronic leg ulcers.
• Tracheostomy site dressings.
• Removing drains or sutures.
• Endotracheal suction.
NB: if wounds enter deep, sterile body areas, then an aseptic technique must
be used.
Issue Number 2 Page 5 of 9 Section G
Issue Date: March 2008 Review Date March 2010 Ref: IC:G:02
Issued by the Infection Control Department
INFECTION
Infection is the ‘invasion and multiplication of micro-organisms within tissue,
which
then results in destruction of the tissue’ (ICNA 2003). It is part of a chain of
events
that can occur within the healthcare setting.

The Chain of Infection

Links in the Chain of Infection
• Infectious agents such as bacteria, viruses, fungi or parasites.
• A reservoir that supports the infectious agent, allowing it to survive and
multiply.
• A portal of exit that allows the infectious agent to leave the reservoir.
• A mode of spread i.e. through direct or indirect contact or via airborne
droplets.
• A portal of entry – often the same route as the portal of exit e.g. the skin,
respiratory, gastrointestinal, circulatory, urinary or reproductive system.
• A susceptible host – i.e. a person at risk of infection. People are more
vulnerable to infection when the balance of the body’s defence system is upset,
due to disease or devices that breach the body’s defences.
Breaking any link in the chain will assist in preventing the spread of
microorganisms
(ICNA 2003).
Techniques used to contribute to breaking the links of the chain are:
A) Standard Precautions (formerly Universal Precautions - see Section C of the
Infection Control Manual): hand hygiene; wearing personal, protective
equipment; aseptic techniques; safe handling of sharps, waste and linen.
B) Decontamination of patient care equipment

Appendix 1
C) Environmental cleanliness – ensuring that standards of hygiene and
cleanliness adhere to local and national guidelines, as outlined in the Infection
Control Manual. Various policies contain specific information regarding
environmental cleaning, including Section C - Standard Precautions; Section F -
Decontamination and Disinfection Policy; Section K – Isolation Policy; Section L
– Laundry Policy; Section S – TB Policy; Section T – Management of patients
colonised or infected with multi-resistant organisms.
The most usual means for spread of infection include:
Direct contact – e.g. the hands of others.
Indirect contact – objects such as instruments, clothes and equipment.
Dust particles or droplet nuclei suspended in the atmosphere.
HAND HYGIENE
Hand hygiene is a means of achieving a reduction in, or removal of, visible
soiling
and transient or resident micro-organisms.
Transient micro-organisms are picked up during daily activities and shed on skin
scales. They can be effectively removed, or reduced to a low level by hand
washing.
Resident micro-organisms are permanently resident on the skin and can only be
reduced to a low level for a short time.
Hand washing is the single most important means of preventing the spread of
HCAIs.
PERSONAL PROTECTIVE EQUIPMENT (PPE)
Gloves must be worn for invasive procedures, contact with sterile sites, non-
intact
skin or mucous membranes, and all activities where a risk assessment indicates
that
exposure to blood, body fluids, secretions, excretions and contaminated
instruments
can occur. Wearing PPE, such as gloves and apron will provide a barrier
between
micro-organisms present on hands and clothing and the susceptible site.
It has been reported that prolonged glove use can produce occlusion conditions
that
encourage the rapid growth of skin flora on nurses’ hands. It is therefore
essential to
clean hands both before applying gloves and following their removal (Pereira et
al,
1997).
When performing an aseptic technique, the health care practitioner should
ensure
that all his/her actions minimise the likelihood of potentially pathogenic
microorganisms
being introduced to the site, or being spread to other patients or
colleagues.

Appendix 2
GUIDELINES FOR CARRYING OUT A WOUND DRESSING USING AN
ASEPTIC
TECHNIQUE
1. Explain and discuss the procedure with the patient, ensuring privacy as much
as possible.
2. Trolleys should be cleaned with detergent and water then dried to remove any
debris, alternatively wipe using a detergent wipe.
3. Assemble all necessary equipment, make sure that all the packaging of sterile
equipment is intact and in date.
4. A dispenser of alcohol hand gel should be placed on the lower shelf of the
trolley, to allow hands to be decontaminated during the aseptic procedure.
5. Prepare the area.
6. Position the patient.
7. Decontaminate hands
8. Apply disposable apron.
9. Apply clean gloves if required.
10. Loosen the dressing tape.
11. Remove gloves (if used); wash and dry hands or use alcohol gel to cleanse
hands.
12. Open the dressing pack and, using the corners of the paper, create a sterile
field. A hand may be placed in the sterile, disposable bag in order to arrange
the contents of the dressing pack. This may then be used to carefully remove
the used dressing (a large amount of micro-organisms are shed into the air).
13. Invert the bag, ensuring that the contents remain within, and attach to the
dressing trolley, using the adhesive strip. Decontaminate hands again if
required.
14. Ensure that all necessary items are assembled onto the sterile field including
any lotions that may be required. Tip fluids/lotion into containers on the sterile
field using a non-touch technique. Ensure that sterile gloves are available and
ready for use.
15. Put on sterile gloves.
16. Carry out the procedure.
17. Remove gloves and wash hands.
18. Ensure that all waste is disposed of according to the waste disposal policy
(section U Infection Control manual).
19. Make sure that the patient is comfortable.
20. Wash and dry hands thoroughly.
21. Document the procedure.
NB: Additional steps may be required in the aseptic technique procedure; a risk
assessment carried out prior to the procedure will define these e.g. is a wound
swab
required?
Full details of Clinical Nursing Procedures can be found in the Royal Marsden
Hospital Manual of Clinical Nursing Procedures (6th edition). An up-to-date copy
of
this manual should be kept in all clinical areas.

Appendix 3
GLOSSARY OF TERMS
Aseptic Non-Touch Technique (ANTT).
Asepsis – the complete absence of bacteria, fungi, viruses or other micro-
organisms
that could cause disease.
Aseptic Technique – a method developed to ensure that only uncontaminated
objects / fluids make contact with sterile / susceptible sites.
Clean Technique – a modified aseptic technique.
Decontamination – the process of rendering an article safe to handle, by cleaning
with or without disinfection or sterilization.
HAI – Hospital Acquired Infection.
HCAI – Health Care Associated Infection.
Infection – the invasion and multiplication of micro-organisms within tissue which
then results in destruction of the tissue.
Invasive – involving puncture or incision of the skin or insertion of an instrument
or
foreign material into the body.
Non-touch technique (NTT) – identifying the ‘key parts’ of a procedure and not
touching them either directly or indirectly.
Primary Intention – where wound edges are brought together and held in place
by
mechanical means, e.g. adhesive strips, staples or sutures.
Risk assessment – the method used to quantify the risk to human health and the
environment.
Secondary Intention – where the wound is left ‘open’ (although usually covered
with
an appropriate dressing) and the edges come together naturally by means of
granulation and contraction.
Standard precautions – infection control precautions that should be applied as
standard principles by all healthcare staff to the care of all patients at all times.
(See
Section C of the Infection Control Manual).