Aseptic Technique. Aseptic technique is vital in reducing the morbidity and mortality associated with surgical infections.

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1 By: BM Madisha, Phlebotomy facilitator (General nursing, community, psychiatry and midwifery) What is Aseptic technique? Aseptic Technique Aseptic technique is a set of specific practices and procedures performed under carefully controlled conditions with the goal of minimizing contamination by pathogens. Aseptic technique can be applied in any clinical setting. Why is Aseptic Technique important? 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, drains and collection of blood cultures. Aseptic technique is employed to maximize and maintain asepsis. Asepsis is 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. Regular practices such as cleaning (remove dirt and other impurities), sanitizing (reduce the number of microorganisms to safe levels), or disinfecting (remove most microorganisms but not highly resistant ones) are not sufficient to prevent infection. Aseptic technique is vital in reducing the morbidity and mortality associated with surgical infections. Where and when should the aseptic technique be applied? 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. However during blood culture collection aseptic technique must be used to reduce the likelihood of bacterial contamination. This technique is used to ensure quality of sample to be tested.

2 Aseptic non-touch technique (ANTT) Approximately 10% of all endemic infections in hospital are airborne. It would therefore seem reasonable to assume that the potential for harmful contamination via this route is small in comparison to direct contact. When introduced in the unit it heightens awareness of the basic principle of achieving asepsis. Because it is logical in its approach it is relatively easy to teach. To help address these types of problems the ANTT was developed. It is exactly what it says it is - a technique that maintains asepsis and is non-touch in nature. ANTT is supported by evidence and highlights the key components involved in maintaining asepsis and aims to standardize practice. The underlying principles of ANTT are: Always wash hands effectively; Never contaminate key parts (Those parts or sites that if contaminated with microorganisms increase the risk of infection, or pieces of equipment that come into direct contact with the patient and therefore have the potential to transmit bacteria and/or microorganisms e.g. patient skin, wounds, cotton wool/ gauze swabs, needle and syringe tips, etc.) Touch non-key parts with confidence; Take appropriate infective precautions. Compliance is a vital ingredient of any standardized practice. It is therefore essential that staff are well prepared and educated in ANTT before it is introduced. Many staff may hold the opinion that their practice is already aseptic. However, observation and assessment will often demonstrate to even experience staff that their practice could be improved. After implementation it is essential that compliance is monitored and audited on a regular basis. Hands Maintaining asepsis of key parts is achieved by preventing them coming into contact with a significant amount of potentially harmful organisms. This is difficult, as the very tools we use to perform ANTT are covered in bacteria - our hands. Pathogenic bacteria, such as pseudomonas and klebsiella, can be harbored on hands for months. A worrying trend in hospitals is the emergence of antibiotic-resistant organisms which can survive on the hands of health care workers. Many, if not most, hospital-acquired infections continue to be spread by direct contact by the hands of health care workers (Bauer et al, 1990).

3 Effective Hand-washing Technique is the most significant procedure in preventing cross infection. Organisms present on the hands are either resident or transient. Transient organisms are those that are not usually part of the skin flora. They are acquired by contact with infected patients or infected equipment. They can be easily removed by effective hand-washing techniques. Our own normal resident skin flora consists of mainly Staphylococcus epidermis and Staphylococcus aureus bacteria. These are normally deeply ingrained into the epidermis and cannot be totally removed by hand-washing, although effective hand-washing can reduce the number significantly. However, research continues to highlight that many health care workers fail to wash their hands effectively. Although bacteria can be reduced by effective hand-washing, it can re-establish quickly over the entire hand surface in the warm and damp environment created beneath gloves (Gould, 1991). This is an important fact, as a study by Stringer et al (1991) highlighted that failure to wash hands after glove removal was the most frequent breakdown in universal barrier precautions. Gloves Choosing between sterile, non-sterile or no gloves at all has become a contentious issue in IV therapy. The rationale for glove choice for the ANTT is based on the fact that there is no substantial evidence to prove that any particular type of glove reduces the incidence of IV-related infection. Also, COSHH regulations (1988) recommend protective clothing such as gloves for all procedures involving potentially hazardous substances. Ojajarvi (1980) highlighted the fact that colonisation of skin by transient bacteria is likely to result when skin is repeatedly moist or damaged. Shredded skin caused by such damage can transmit bacteria via the contact route. HCP often have moist and damaged hands owing to frequent washing and drying. Gloves may therefore serve as a barrier to prevent descaling of bacteria onto key parts. When the fundamental requirements of the ANTT are adhered to gloves become superfluous. However, as these two requirements cannot be guaranteed it would seem a sensible measure for gloves to be worn to protect the patient in case staff inadvertently touch key parts with poorly washed hands. The wearing of gloves for all procedures involving potential exposure to body fluids was recommended by the Center for Disease Control (1987) and was termed universal precautions.

4 Must the gloves be sterile? The use of sterile gloves for particularly difficult procedures or those that take a significant amount of time seem both sensible and logical precautions, as the potential for accidental direct/indirect contamination is increased. However, it can be a waste of money to wear expensive sterile gloves for simple procedures. After all, even sterile gloves cannot always be considered 100% sterile, due to a small but significant micro permeability and the potential for staff to contaminate them (DeGroot-Kosolcharoen and Jones, 1989). Aseptic fields A clean working environment is a sensible precaution. However, the need for sterile towels and dressing packs for all procedures is extravagant. For the majority of IV procedures the asepsis of only one or two small key parts is maintained. This can be achieved simply and effectively by the ANTT. However within Ampath the practice of using sterile/ dressing packs for blood culture collection is mandatory to minimize contamination of the sample. Risk factors To assess the degree of precautions required to maintain asepsis for any procedure HCP must be able to identify and consider the risk factors involved, such as the technical difficulty of the procedure, its duration, the environment and the number of key parts. Fundamental to the effectiveness of the technique will be the HCP s ability to identify the infection risks in every procedure. The HCP s can then counter these risks by utilizing appropriate aseptic precautions. Either a technique is aseptic or it is not. Aseptic precautions when collecting blood culture Preparation: Clean hands with alcohol solution on entry to the unit; Wipe a clean tray with an alcohol impregnated surface cleaner; Gather all equipment; While the tray dries wash hands with chlorhexidine solution and water; Prepare the equipment and arrange it on the tray tidily. Open the dressing/ sterile pack avoid touching the inside of the pack. Open syringes and needles onto the pack maintaining asepsis Take care to maintain the asepsis of all exposed key parts, such as protecting syringe tips with capped needles; Pour the skin cleaning solution on the cotton wool balls in the sterile pack, soak them with solution

5 Prepare the bottles aseptically; Flip open the bottle tops without touching the rubber septum and clean the rubber septum with webcol swab and let it air dry Enter the patient s room and prepare the patient and position the arm Select an appropriate vein, and apply the tourniquet cm proximal to the chosen site. Palpate the vein and identify its position carefully. Release the tourniquets leaving it on the arm. Surgically wash hands and dry with a sterile paper towel from the pack; Ask patient to lift arm and use the sterile towel in the pack to create a sterile area when collecting blood Prepare the skin or venepuncture site: Put on sterile gloves from the pack, avoid touching the outside of the gloves with ungloved hands Ideally the skin should be washed with soap and rinsed with sterile water. This should be followed by the application of Iodine-based solution, which should be washed off after 30 seconds of drying with 70% alcohol solution. Ampath protocol is vigorous cleaning of the skin (site of puncture) with alcohol based solution (0.5% Hibitane in 70% alcohol or D-germ). Repeated cleaning in circular motion and then let site to air dry. Iodine will then be used after alcohol has air dried, leave the iodine to air dry as well. Iodine can only be used if patient is not allergic to iodine. Venepuncture: Reapply the tourniquet using the sterile gauze from the pack, maintaining asepsis Do not touch or palpate the vein after swabbing, unless there is difficult venous access, in which case adopt full aseptic technique with sterile gloves and field and palpate above selected puncture area Use the 20mL syringes to withdraw blood samples. It is unnecessary to replace the needle after withdrawing blood and prior to inserting it in the culture bottles. This increases the risk of needle-stick injury and contamination. Insert the needle into the sterile septum of the blood culture bottle and inject at least 8mL of blood, starting with the aerobic bottle. Withdraw the needle and repeat for the anaerobic culture bottle. Avoid inoculating blood culture bottles as the last in line of a series of routine investigations. There will be a low rate of genuine positive results, and a high false positive rate due to skin contaminants.