A systematic review of the literature addressing asepsis in wound management

Transcription

1 A systematic review of the literature addressing asepsis in wound management Haesler E, Thomas L, Morey P & Barker J ABSTRACT There has been extensive ongoing debate on the application of aseptic technique in wound management over the previous decades and changes to the way in which theory is applied to clinical practice have occurred regularly. Clinicians often express confusion over the way various techniques should be applied, particularly when practising in clinical settings in which maintenance of strict asepsis is inherently difficult (for example, community-based wound management). Wound cleansing, use of open but unused Emily Haesler* PhD, BN, PostGradDipAdvNurs(Gerontics) Adjunct Associate Professor Curtin University, School of Nursing, Midwifery and Paramedicine, WA, Australia Honorary Associate La Trobe University, Australian Centre for Evidence Based Aged Care, Vic, Australia Emily.Haesler@curtin.edu.au Tel Lyn Thomas RN, NP, BHlthSci(Nurs), MNP Community and Aged Care Services,Greater Newcastle Sector, Hunter New England Local Health District, NSW, Australia Pam Morey MN, NP, STN, PhD(C) Nurse Practitioner, Advanced Wound Assessment Service, Silver Chain Nurse Practitioner Course Coordinator Curtin University, WA, Australia Judith Barker RN, NP, BHlthSc(Nurs), MNP Nurse Practitioner Wound Management Adjunct Associate Professor, University of Canberra, Synergy: Research Centre for Nursing and Midwifery Practice, Canberra Canberra Hospital, ACT Health, ACT, Australia * Corresponding author wound dressings and storage of wound management equipment are frequent issues on which clinicians request guidance. A systematic review using Joanna Briggs Institute methods was undertaken in order to establish the current state of the scientific literature on this topic and inform the development of recommendations for practice in this field. All levels of evidence were included in the review, including opinion papers. Findings from the 20 quantitative studies were reported in narrative summary and findings from 37 qualitative research papers were aggregated in a thematic synthesis. Although high-level evidence on wound cleansing solutions was identified, the review concluded that there is a paucity of scientific literature on most topics related to asepsis in wound care. Keywords: Asepsis, wound cleansing, aseptic non-touch technique, handwashing, infection control. INTRODUCTION Wound infection has a large impact on individuals and the health care system. Precise incidence rates are difficult to determine due to the many types of wounds and various methods of diagnosing and tracking wound infection. As many as 60% of chronic wounds have infection in the form of demonstrated presence of surface bacteria or invasive biofilm 1,2. Rates of surgical site infection vary substantially based on surgical site 3 ; however, recent estimates suggest 10 12% of all surgical wounds become clinically infected 4. Infection rate in lacerations is cited at 5% 5, and rate of biofilm in all acute wounds is approximately 6% 2. Facility-acquired wound infection is of particular concern given the increasing significance of antibiotic-resistant bacteria. Infection control procedures are first-line strategy to prevent infection spread 6. Given the impact of wound infection and significance of infection control practices in reducing its incidence, it is important that clinicians understand the implementation of infection control procedures when managing wounds. Historically, there have been major changes to aseptic theory in wound management 7-9. Surveys indicate clinicians experience confusion about how to implement aseptic technique and other infection control principles 10,11. Within Australia, the introduction of a standard on health care-associated infection 12 and publication of a national 208

2 infection control policy 13 led to a demand for updated wound management procedures. Wounds Australia established a working party to develop clinical guidance on procedures associated with prevention and control of wound infection. To inform the development of this document, a systematic review (SR) was undertaken. AIMS The objective of this review was to identify the contemporary evidence addressing topics associated with aseptic technique and infection control in wound management. Specific aims were to identify evidence related to cleaning considerations when performing a wound procedure, techniques for wound cleansing, environmental considerations in performing wound management and ways in which wound dressings can be handled and stored aseptically. REVIEW METHODS The review was undertaken using methods published by the Joanna Briggs Institute (JBI) 14,15. An initial search was conducted in MEDLINE, CINAHL, EMBASE, Current Contents and the Cochrane library. All papers published in English up to October 2015 that related to topics outlined in the aims were eligible for inclusion. All research designs, qualitative research and opinion papers were eligible for inclusion; however, news items, letters and conference abstracts were excluded. Papers related to aseptic technique in the operating room, intravenous therapy or catheterisation were excluded. Search terms and MESH headings included: asepsis, non-touch technique, aseptic technique, steriliz/sation, disinfection, microbial and bacterial contamination, hospital, healthcare and community-acquired infection. These terms were used in combination with terms associated with wound care, wound dressings, equipment storage, cleansing, and equipment recycling. The working party reviewed the search strategy to ensure it captured the intended literature. On review of the evidence it was noted by the working party that significant changes in theory and practice have occurred in the field of aseptic technique. It was determined that inclusion would be limited to papers published between January 2000 to October 2015 in order that the review findings reflect contemporary knowledge. References cited in included manuscripts were also considered for inclusion. All papers meeting inclusion criteria were critically appraised by two independent reviewers using the JBI suite of appraisal tools. For randomised controlled trials (RCTs) and pseudo- RCTs, critical appraisal evaluated randomisation, blinding, allocation concealment, withdrawals, comparability and equivalent treatment of participants, outcome measurement and statistical analysis 14. Consistent with JBI appraisal, RCTs and pseudo-rcts were ranked as high quality or lower 15. For descriptive studies and case series, process for randomisation, sample inclusion, outcome measurement, management of confounders, participant withdrawal and data analysis were evaluated 14. These studies received a 209 ranking of low or very low quality 15. For interpretive and critical research, congruity of philosophies, methodology, research methods and analysis was evaluated, as well as reflexivity 14. Qualitative research was ranked as high quality or lower 15. Textual and opinion papers were evaluated based on source and logic of opinion and arguments, focus, referencing and support from peers 14 and ranked as low or very low quality 15. Data extraction used standardised JBI tools. Quantitative results were not appropriate for meta-analysis as they generally addressed different topics, had heterogeneous methods, or were meta-analyses. These results are reported in a narrative format. Qualitative studies and opinion papers were analysed to identify themes, concepts and meanings within the research 14, with identification of primary findings that were grouped in categories based on similarity in meaning. The categories were meta-aggregated in syntheses. IDENTIFIED RESEARCH The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram 16 is presented in Figure 1. The searches initially identified over 2,000 potential studies that was reduced to 57 papers that met inclusion criteria and were critically appraised. As indicated in Figure 1, most studies were excluded in the first review of the flagged references due to having insufficient focus on the topic of this review. Of the 57 included papers, 14 were quantitative research papers 17-30, six were SRs 31-36, three were qualitative research papers 10,11,37 and 34 papers were non-research articles 7-9, The quantitative research consisted of six RCTs 18,21,23,25,26,29 (level 1.c evidence) that were of low or moderate quality 15. There was one very low quality before/after study 22 (level 2.d evidence), five observational studies 17,19,20,28,30 (level 2 and 3 evidence), one very low quality cohort study 24 (level 3.c evidence) and a very low quality cross-sectional study 27 (level 4.b evidence). The SRs (level 1 evidence) ranged in quality from low to very high and the qualitative research 10,11,37 (level 3 evidence) was of moderate to high quality. The majority of findings in this review arose from textual papers providing low and very low quality evidence. Table 1 presents summaries of the research papers. Quantitative results from the literature Cleansing solutions and technique SRs and studies exploring irrigation fluids received the most attention in quantitative research. As the individual studies 18,19,21,23,26,29 (Table 1) were included in identified SRs, only SR results are reported below; however, none of the individual RCTs established significant differences in infection rates between wounds cleansed with sterile solutions versus tap water 18,19,21,23,26,29. A high quality SR 36 compared sterile saline (n=326) to tap water (n=257) for cleansing lacerations, acute and chronic wounds. Pooled results from two RCTs showed no significant Volume 24 Number 4 December 2016

3 Figure 1: PRISMA review flow Original references flagged in searches as potentially meeting inclusion criteria (n> 2,000) Excluded: duplicate references (majority of studies), not sufficiently related to topic (n>1,820) Review of title/abstracts against inclusion criteria (n=180) Excluded as not sufficiently related to topic, letters to editor, duplicate reports and conference abstracts (n=37) Full review against inclusion criteria and critically appraised (n=143) Included studies (n=57): Systematic reviews (n=6) Quantitative research (n=14) Qualitative studies (n=3) Non-research papers (n=34) Excluded: (n=86) Published prior to 2000 (n=33) No unique information, summarises studies already included (n=19) Not focused on aseptic technique (n=12) Letters, abstracts, duplicate reports (n=12) Low quality, including no methods or no results reported (n=5) Libraries unable to obtain (n=3) Not wound care related (n=3) difference in wound infection rates, with tap water slightly less likely to result in infection (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.36 to 1.72, p=0.55) 36. A moderate quality Cochrane SR 33 compared cleansing methods for lacerations, open fractures, chronic and surgical wounds. Infection rate in all wound types (3 RCTs) was not significantly different between tap water cleansing and no cleansing (relative risk [RR] 1.06, 95% CI 0.07 to 16.50, p=not significant [ns]). There was no difference in infection rates in all acute sutured wounds (3 RCTs) between tap water versus sterile saline irrigation (RR 0.66, 95% CI 0.42 to 1.04, p=ns). Cost-effective analyses favoured tap water 33. This Cochrane review reached the same conclusions as earlier systematic reviews by the same research team 34,35. A low quality SR compared tap water to sterile saline. Significantly more wounds cleansed with sterile saline became clinically infected (saline 7.1% versus tap water 4.3%, RR 0.62, 95% CI 0.39 to 1.01, p=0.05). There was no significant difference in wounds with positive cultures (saline 3.1% versus tap water 4.4%, RR 1.53, 95% CI 0.79 to 2.99, p=0.21) 31. A low quality SR compared bathing to no bathing for postsurgical foot wounds. Normal hygiene groups showered at 1 5 days postoperative (n=1,639). Patients abstaining from foot hygiene waited until sutures/staples removal (n=511). There were no significant differences in surgical site infection rates in any study 32. Although confounding factors are noted (for example, administration of saline at cooler temperatures than water) when controlled for these factors the outcomes did not change. Findings from the high-level evidence 31,33-36 indicated no increase in wound infection rates associated with cleansing wounds in tap water. Reuse of wound dressing products A moderate quality observational study investigated rate of contamination of opened hydrogel products. The products were opened after handwashing, using clean gloves and away from direct patient care. After 28 days, one package from 60 random samples returned a positive bacterial culture. The sample collection technique may not reflect clinical practice 17. A very low quality observational study reported contamination rates for opened dressings and reusable equipment stored in different containers in patients homes. After 14 days, 75% of samples (n=21) were contaminated 30. Another low quality observational study investigated contamination rates for randomly selected multi-use saline flasks stored in hospital settings. Approximately half of the samples were found to be contaminated 20. Wound dressing practice In a low quality RCT, leaving surgical wounds uncovered after surgery (n=235) was compared to wound dressings applied in the operating theatre (n=216). Patients were reviewed after seven days for clinical signs of infection and no significant difference in infection rates was found (exposed wounds 1.7% versus covered wounds 1.4%, p=ns)

4 A very low quality cohort study compared sterile (n=1,070 admissions) and clean (n=963 admissions) dressing procedures for surgical wounds. The outcome measure was positive wound culture established by wound swab. There was no significant difference in surgical site infection rates (0.84% versus 0.83%, p=ns) and the clean procedure was faster (10 minutes versus 13 minutes) 24. Aseptic technique education and behaviours A very low quality before/after study investigated an education program delivered to medical students. The course was based on principles associated with handwashing and dressing procedures. After 10 weeks, there was a significant decline (p<0.001) in the ratio of students who were able to achieve a pass mark in the assessment, indicating the education had no prolonged influence on practice. Poor role modelling and lack of resources were identified as contributing to poor outcomes 22. A very low quality observational study reported clinical practice amongst nurses in community settings. Practice was established through direct observation and validated in interviews with participants. As many as 40% of nurses did not engage in handwashing before a procedure 28. Qualitative results from the literature Three hundred and eighty-six findings were extracted from qualitative studies and non-research articles. Using the JBI ratings 15, 60 of the findings were rated as unequivocal, 218 were rated as credible and 20 findings were rated as unsupported, generally where an assertion was made without any supporting reference. These findings were grouped in 65 categories and aggregated into 23 syntheses (Figure 2). Current evidence base Synthesis 1: Research on wound cleansing and aseptic technique is insufficient and that which is available is poorly translated into practice. There is a lack of research on aseptic techniques 9,65. Inconsistencies in terminology and practice guidance, and ongoing change to theory interpretation has a negative impact on compliance 7-9. The need for more research on aseptic technique, including translation to different clinical settings was highlighted 38,44,48. Handwashing practices Six categories aggregated into two syntheses represented textual findings on handwashing. Synthesis 2: Liquid alcohol rub, antimicrobial hand wash or soap and water can be used for washing hands. When hands are visibly soiled, use soap and water. Articles referred to three handwashing solutions: alcoholbased rubs, antiseptic/antimicrobial hand washes and soaps/ detergents. Alcohol rub has broad spectrum activity 51 and is quick to apply without the need for water 8,40,45,50,51,55,57,59. A small risk of fire from alcohol exposed to a heat source before complete evaporation 45 and potential for dry hands are 211 reported. Some texts suggest alcohol-based hand rubs are not appropriate when hands are visibly soiled 40,55. Antiseptic or antimicrobial hand wash with water is suggested for cleaning visibly dirty hands 40,45,51,55 although it may be more expensive or cause irritation 51. Antimicrobial-impregnated towels are an alternative for visibly clean hands, but not a replacement for soap and water 40,45,55. Opinion articles agreed that soap and water is appropriate for visibly soiled hands 40,49,51,55,64. Synthesis 3: Handwashing should occur before and after patient contact, regardless of the use of gloves, and consist of vigorous rubbing for at least 15 to 30 seconds. Hands should be washed before/after patient contact, or after contact with body fluids, to prevent crosscontamination 7,40,55,56,64. Use of gloves does not preclude the need to wash hands 40,55-57,59 because hands may become contaminated when removing gloves 56. Handwashing should be a vigorous process covering all hand surfaces using soap and water or an alcohol rub 40,55,59. Most papers suggested that handwashing should take at least 15 seconds 40,55 ; however, one suggested at least 30 seconds 59. Gloves and personal protective equipment Three syntheses related to the use and selection of gloves, and one related to other personal protective equipment. Synthesis 4: Gloves are required to prevent contamination and cross-infection; however, they do not replace routine handwashing. Textual findings highlighted that the primary purpose of gloves is to prevent contamination, between the patient and the nurse, or cross-infection between different anatomical sites on the same patient 40,44,51,55,59. It was suggested that gloves are worn when there is a risk of coming into contact with bodily fluids or non-intact skin 40,55 ; when removing old wound dressings 45 ; and for invasive activities 51. Use of gloves does not preclude handwashing 45,57, regardless of the implementation of double-gloving 45. Findings suggested gloves be removed immediately following care 40,55. Synthesis 5: Selection of gloves is guided by the procedure to be performed, risk of contamination, latex allergies and cost. Synthesis 6: Sterile gloves are required for surgical aseptic non-touch technique, surgery and invasive aseptic procedures and clean gloves are for non-sterile procedures/standard aseptic non-touch technique. Level of expected direct contact with susceptible sites 44,53,57 should guide glove selection. Latex allergy influences glove choice 44,50,59, and some texts identified the increased cost of sterile gloves as a factor in selection 59,62. There was agreement that sterile gloves are required for sterile procedures 44,48,51,57,61. Within the literature sterile procedures referred to invasive activities 44,51 surgical procedures 44, aseptic technique 44, Volume 24 Number 4 December 2016

5 aseptic non-touch technique (ANTT) requiring direct contact with key parts 61, and delivering sterile pharmaceuticals 44. Clean, non-sterile gloves were suggested for removing old wound dressings 48, performing clean procedures 48 and performing procedures that do not require direct contact with the key parts 61. Synthesis 7: Wearing appropriately selected personal protective equipment helps to reduce the risk of cross-infection from exposure to body fluids or airborne contamination. Personal protective equipment is designed to reduce the risk of contamination for both the patient and clinician 57,64. When protective equipment is used, the clinician is protected from body fluid exposure (for example, blood splashes) 51,57 and the patient is protected from the clinician as a source of infection risk 59. Textual findings focused on using plastic aprons 51,59 with selection of equipment based on the level of risk of body fluid exposure 64. Wound management environment Two syntheses addressed the general and specific environment in which wound management is conducted. Synthesis 8: Actions should be taken to reduce airborne and other infection risks in the home and hospital to ensure wound care is conducted in a clean environment. The requirement for a clean environment, free from airborne and other infection risks was described 51,61,64. The risk posed by carpets, soft furnishings and pets was reported 64. Strategies to reduce environmental risk included reporting infection risk in the home to authorities 64, ensuring there are cleaning routines that incorporate the ventilation and water supplies 64 ; reducing airborne infection by closing windows, reducing foot traffic and turning off fans 64 ; leaving the wound exposed for the shortest time 64 ; and disposing of waste promptly and appropriately 64. Synthesis 9: A wound management field can be established on a clean surface in a space at low risk of environmental contaminants. Once established, introduction of contaminated external objects should be avoided. The importance of establishing a sterile local field on a clean surface 8,57,64 was discussed. Strategies for establishing a sterile field in a clean environment included using a visually clean dressing trolley 57 or cleaning a hard surface with a broad spectrum disinfectant 64. In the community, a plastic apron or lid could be used 8,64. Considering the wound, an extension of the wound management field was suggested 7, as was ensuring the wound management field remains sterile 57. Findings were consistent that objects external to the wound and field should not contaminate the wound management field 7,57,61. Clinicians could use either a critical aseptic field into which only sterile equipment is introduced (for example, for an invasive or extensive procedure) or a general aseptic field in which key parts are individually protected within the field (for example, for a simple wound procedure) 61. Cleansing solutions and technique Eighteen categories were aggregated into six syntheses related to wound cleansing. Synthesis 10: An ideal wound cleanser should adequately clean the wound, not cause cell damage or sensitivity and have a long shelf life. The principle of doing no harm and preventing infection were highlighted as guiding the choice of wound cleanser 9. Consideration to the toxicity of a cleanser and its potential to cause sensitivity was highlighted 42,63. Using an expired product should be avoided 57 by selecting a wound cleanser with a long shelf life 42,63. The ability to effectively remove organic material and reduce bioburden are other considerations 42,63. Synthesis 11: An assessment should be conducted by the interdisciplinary team to determine if a wound bed should be cleansed, and if so, the cleansing process to use. Not all wound beds require cleansing as a wound may heal without disruption if there are no visual contaminants or signs of infection 39,58. The wound management team could work together to determine the best approach for individual patients 9,39,58. Synthesis 12: Normal saline, potable tap water, sterile water and low concentration antimicrobial solutions are safe and effective wound cleansers. Antiseptics are not a good choice for wound cleansing. Sterile saline is an isotonic solution that has no impact on tissue repair processes 42,46 ; therefore it is a safe and traditional option 62, particularly in hospital environments 46 or for vulnerable wounds 9. Tap water, sterile water and normal saline were all reported as safe; however, none of these solutions reduces bioburden in the wound 42,46,56,57,67. Antimicrobial solutions reduce bioburden 63,67, although concentrations should be selected carefully in light of potential cell toxicity 63,67. Use of skin cleaners and antiseptics in wound cleansing is warned against 39,42,58,63. Cell toxicity 42,58,63, potential carcinogenicity 41, insufficient contact time with the wound to effectively reduce bacteria levels 39 and association with antibiotic-resistant bacteria 39 were concerns. Synthesis 13: Apply a wound cleanser at a lukewarm temperature with consideration to the potential for crossinfection and using low pressure to irrigate the wound bed. Irrigation at a low pressure (4 to 15 pounds per square inch) using a syringe or faucet tubing is suggested for promoting debris removal without disrupting granulating tissue 42,56,62,65. Applying fluid at lukewarm temperature avoids vasoconstriction that lowers tissue healing capacity 9,45,46,54,62,66. The potential for cross-infection between patients, or contaminated water from dirty body areas flowing over a wound are considerations when washing in a shower 9,54,58. Directing fluid flow appropriately when irrigating 54 was noted as another strategy to prevent cross-infection. 212

6 Synthesis 14: Good quality tap water is a cost-effective option for cleansing dirty wounds, chronic wounds and wounds with closed or sutured edges, although it may cause pain. Benefits and disadvantages of tap water were discussed 39,42,46,54,56,58,62,66. Water was noted as acceptable for sutured 39, sacral/perineal 56, open traumatic 56, and chronic 56 wounds, and wounds with sealed edges 39. Ensuring high quality water is important 54,56,62,66, although commentators noted that in cities with monitored and drinkable tap water it is sufficiently safe for wounds 54,56,62,66. Texts suggested using running tap water for at least 30 seconds 62 or soaking wounds in a bucket 58. Higher, constant pressure 62, large fluid volumes 62, patient satisfaction 66 and reduced time 66 are advantages of water. Lack of additional equipment (for example, syringes) contributes to the cost-effectiveness of water 46,54,62,66. However, there is potential that water may cause pain due to increasing osmotic pressure 46. Synthesis 15: Precautions can be taken to reduce the risk of potential contamination of water sources. Another disadvantage is the potential for contaminated tap water 9,41. One commentator suggested a risk of acquiring virulent pathogens or biofilm from hospital water 41. This risk may be higher for immunocompromised patients 41. However, precautions can be taken 41,42,56. Water filters 41, running taps for a few minutes before using the water 42 and evaluating the water storage and delivery before use 9 were suggested. Selecting wound care technique and equipment Four syntheses addressed selection of wound care techniques and equipment. Synthesis 16: Selection of sterile/surgical ANTT or clean/ standard ANTT is determined by the level of risk posed to the patient by his or her health status, the environment, factors associated with the wound and the type of wound management procedure being performed. The infection risk from the surrounding environment is one consideration in selecting a wound management technique 7,37,44,57,60,61,68. Findings illustrated that both the health care setting 7,37,44,68 and the storage of equipment 68 influences the ability to maintain a sterile or aseptic environment. The complexity of the procedure is a contributing factor, for example extensive debridement, wound packing and necessity to touch key parts were considered more invasive and requiring greater precautions 44,51,57,60,61,68. Patient-related factors (for example, immune status) may also contribute to the risk of infection from a dressing procedure 7,44,57,60,68. The chronicity, depth and location of the wound also contribute to selection of a technique 7,44,50,56,57,68. Rigorous asepsis was considered to be inappropriate for chronic wounds 50,56,57,68. Synthesis 17: Simple wound management procedures on low-risk patients can be performed with non-sterile but clean equipment, solutions and gloves. More complex procedures or procedures in higher risk patients require surgical aseptic 213 non-touch technique, using sterile gloves, solutions and equipment. Textual findings referred to clean technique/standard ANTT and aseptic technique/surgical technique/surgical ANTT. The first technique is appropriate for routine dressing changes without surgical conservative debridement and simple procedures lasting less than 20 minutes 37,61,68. This technique was reported to involve a clean surface, non-sterile gloves and clean equipment and irrigation fluids (for example, tap water) 37,61,68. The surgical ANTT requires sterile gloves and equipment and a sterile irrigation fluid, with a strict aseptic field 37,56,57,61,68. The findings suggested this procedure was appropriate for patients at high infection risk, wounds requiring surgical conservative debridement, complex/ invasive procedures with many key parts or procedures lasting longer than 20 minutes 56,57,61,68. One commentator suggested that this should be standard practice 56. Synthesis 18: Wound management equipment should be single use or cleaned with alcohol preparations. Using cleansers and wound dressings in smaller packages reduces waste and contamination risk. Ensuring products are cleaned appropriately via sterilisation, disinfection or decontamination is important 57,61,64. Using alcohol preparations or wipes and vigorously rubbing equipment to remove visual soiling cleans reusable products 61,64, although single-use products may be easier, especially in community settings 64. Wastage of excess products was noted as a concern, especially from dressing packs with pre-selected materials that are not always appropriate for the procedure 8,11. Selecting smaller packages to reduce waste or risk of contamination from reusing products was suggested 45,65. Synthesis 19: When performing surgical ANTT the wound management field must remain free of non-sterile items, including equipment, cleansing fluids and gloved hands that have touched a non-sterile object. Commentary highlighted the importance of all sterile equipment being free from potentially contaminated objects, including water that had touched surrounding skin during washing or forceps that had touched the wound bed 7,8,43,51,68. One text referred to a dirty hand or forceps/a clean hand or forceps 7. The difficulty clinicians have in manoeuvring forceps was raised 7,56, and using a gloved hand for parts of a procedure was proposed as an optional wound management method 7,8,56, if the potentially contaminated hand could be maintained away from the wound management field 7,68. Managing patients with known infection Synthesis 20: Extra infection control precautions should be taken for people with known infection. One opinion article addressed infection control for patients with known methicillin-resistant Staphylococcus aureus (MRSA) 49. Findings indicated that clinicians should take Volume 24 Number 4 December 2016

7 additional precautions by thoroughly disinfecting surfaces, putting down plastic sheeting and using disposable equipment when possible 49. Reusable equipment could be cleaned immediately 49. Double-bagging waste products before disposal may reduce cross-infection 49. Diligence is required in handwashing and the use of personal protective equipment 49. Product storage Synthesis 21: Wound management products should be stored in dry, clean environments to reduce risk of contamination and cleansers should be dated on opening and discarded if visually contaminated or according to organisation policy. Storing dressing products in a clean, dry space was suggested 56,64. Wound cleansers should be dated and refrigerated on opening, although there is no set time frame after which they should be disposed 45. One commentator mentioned discarding fluids if there is visual contamination, or to follow the organisation policy 45. Risks posed by storing gloves in a manner that attracts mould or contamination were noted 50,62. Structural support Two syntheses summarised eight categories related to structural support for aseptic technique and infection control. Synthesis 22: Staff education that incorporates skills practice, simulation learning, theoretical knowledge update and procedures for different clinical settings is essential in promoting best practice in aseptic technique and infection control. Importance of education was highlighted 8,11,38,39,44,49-51,57,59,64. Some references suggested that clinicians develop ritualistic practice and may not fully understand theoretical concepts 8,11,39. Qualitative studies indicated that community nurses experience frustration and have fatalistic attitudes 11 that may influence the way in which they perform wound care 10. Ongoing reinforcement of knowledge and skills through regular education using simulation learning 53,57, visual feedback (for example, dye in handwashing exercises) 59, hands-on practice with feedback 64 and didactic lectures 53 is suggested. Synthesis 23: Best practice in aseptic technique and infection control procedures is promoted through development of facility policies, regular risk surveillance, annual auditing of staff practice, engaging with staff and patients and provision of acceptable hand hygiene products. Regular risk surveillance 7,50,59,64 promoting a culture of clinicians identifying risks 50, and root cause analysis 64 were highlighted as promoting quality improvement. Engaging with staff and patients by working with a wound champion to promote best practice 38,64, empowering patients to ask clinicians about hand hygiene 59 and ensuring adequate staffing levels may promote best practice 51. Commentators proposed incorporating annual handwashing audits into quality improvement programs 8,38,40,55,59. The importance of local policies and procedures was raised 8,48,61, especially for topics for which there is insufficient evidence to make recommendations 48. Finally, provision of products that are acceptable to clinicians (for example, low allergen) may promote handwashing 40,55. DISCUSSION There was general agreement between the quantitative and qualitative/textual findings in this review. Use of potable tap water for irrigation received the most attention, and findings from SRs, RCTs and non-research articles were in agreement that for many wound types, cleansing with goodquality, lukewarm tap water does not increase risk of wound infection 18,20,21,23-26,29,32-36,39,42,46,54,56,58,62,66. This evidence should be considered when selecting appropriate and cost-effective wound management techniques. Limited evidence was available on other topics of interest. No significant evidence was identified regarding strategies for managing opened wound dressing packages and minimal commentary on the advantages and risks of this practice was identified. One moderate quality study 17 suggested reusing hydrogel products may be safe if the product was dispensed in controlled conditions. A very low quality study suggested contamination of opened wound dressings is an issue in community settings 30 and commentators suggested using smaller packages to reduce waste 45,65. There was also limited evidence on methods of performing aseptic technique, with technique details often derived from unreferenced opinion sources 61. There is a strong need for well-designed studies exploring these issues. There was a paucity of evidence on environmental factors in conducting wound care identified in the available literature. There was agreement that the environment in which wound care is conducted should be clean 51,61,64, with guidance generally focused on strategies to address the potential risk from airborne contamination 51,61,64. Practical solutions for maintaining asepsis in home care settings were provided 8,51,61,64 ; however, the evidence supporting these practices was at best minimal. This review is not without limitations. Foremost, the literature search was limited to journal articles. Reports 12 and guidelines 13,69 also inform this topic; however, these resources are developed from the existing body of evidence and are not specific to wound management. The search terms used for this review focused specifically on asepsis in wound management. It is probable that evidence on some included topics is available in the broader literature. Except for evidence related to irrigation, the evidence was primarily from non-research texts of low and very low quality and this should be considered when evaluating the adoption of the suggestions into practice. It should be noted that theory and translation in this field has changed substantially over time. The reviewers attempted to identify a cut-off date in order 214

8 to exclude outdated concepts; however, given that much of the findings were opinion, some ideas may be anachronous. CONCLUSIONS The findings of this systematic review highlighted the lack of high-level evidence in many clinical areas associated with aseptic wound management practice. There is a need for further research in this field to establish with certainty the procedures that are necessary to prevent and control wound infection. Until such research exists, guidance based on the current evidence base, evidence derived from other clinical procedures (for example, intravenous therapy), broader guidelines 12,13,69 and expert opinion is required to assist facilities in developing local policies and procedures. ACKNOWLEDGEMENTS Sue Atkins and Liz Howse undertook second review of some papers included in this systematic review. Wounds Australia contributed to the funding of the systematic review. Figure 2: Thematic analysis of qualitative research and textual findings (Level 1 findings) (Level 2 findings) (Level 3 findings) Finding 1 Inadequate advice on translating evidence into practice has led to variety in ways clinicians incorporate wound cleansing into aseptic technique. 8 [C] Finding 2 There is inconsistency in irrigation technique between trials, particularly with respect to volume and pressure. 9 [UE] Finding 3 Research conducting on irrigating acute wounds may cannot be extrapolated to diabetic foot ulcers, especially those with exposed tendon and bone. 9 [C] Finding 4 Changes in wound care theory and practice can cause confusion for students and practising health professionals. 7 [UE] Finding 5 Debate over use of clean versus aseptic technique have a negative impact on compliance with standardised technique. 8 [C] Category 1 Inconsistencies and changes in interpretation of evidence and theory related to wound cleansing into clinical practice has a negative impact on compliance. Synthesis 1 Research on wound cleansing and aseptic technique is insufficient and that which is available is poorly translated into practice Finding 6 Previous evidence on optimal pressure for removing bacteria while preventing contamination and disruption to wound healing is based on small studies and may not be reliable. 65 [C] Finding 7 Studies investigating cleansing have inadequate sample sizes and have methodological limitation (e.g. do not ensure cleansers are equivalent temperature). 9 [C] Finding 8 There is insufficient evidence to provide comprehensive recommendations for appropriate cleansing methods for traumatic wounds. 65 [C] Category 2 There is insufficient good quality existing evidence on wound cleansing. Finding 9 More research is needed on how nurses currently perform wound care and the effectiveness of different wound care strategies. 48 [UE] Finding 10 More research on the effectiveness and implications of different dressing technique is required. 38 [C] Finding 11 Further research and evidence is required on influence of clean vs sterile gloves in aseptic techniques. 48 [C] Category 3 More research is required on aspects of performing aseptic technique. [UE] unequivocal [C] credible [US] unsupported 215 Volume 24 Number 4 December 2016

9 (Level 1 findings) (Level 2 findings) (Level 3 findings) Finding 12 Alcohol rub cannot remove spores, does not have persistent antibacterial activity, is flammable, does not remove soiling and can cause dry hands if used frequently. 51 [C] Finding 13 When hands are not visibly soiled they can be cleaned with an alcohol-based hand rub. 40,55 [C] Finding 14 Alcohol rub has broad spectrum activity that is simple, has fast action, is cost effective and contains emollient. 51 [C] Finding 15 When using alcohol-based hand rubs, rub hands together after application until all alcohol has evaporated to reduce the small risk of fire. 45 [C] Finding 16 Alcohol rub is faster to use than soap and water. 59 [C] Finding 17 Alcohol based hand gels can be used as often as required without the need for soap and water washes in between applications. 45 [C] Finding 18 Use an alcohol based hand rub. 57 [C] Finding 19 Liquid aqueous alcohol rub can be used for hand washing instead of soap and water. 50 [C] Finding 20 In the community setting, alcohol gels can be used for effective hand hygiene. 8 [C] Category 4 Liquid alcohol rub can be used for washing hands, ensuring the all alcohol evaporates after application. Synthesis 2 Liquid alcohol rub, antimicrobial hand wash or soap and water can be used for washing hands. When hands are visibly soiled, use soap and water. Finding 21 Antiseptic hand wash, warm water and paper towel remove visible soiling, and have residual activity against microbes for approximately 6 hours. 51 [C] Finding 22 Antiseptic hand wash, warm water and paper towel is expensive, require nearby sink and waste bin, is time consuming and may irritate the skin. 51 [C] Finding 23 When hands are visibly soiled they can be cleaned with antimicrobial soap and water. 40,55 [C] Finding 24 Antimicrobial impregnated towels are not an acceptable replacement for alcohol based hand rubs or antibacterial soap. 45 [C] Finding 25 Antimicrobial impregnated wipes are an alternative to non-antimicrobial soap and water but are not a replacement for alcohol hand rub or antimicrobial soap and water. 40,55 [C] Category 5 Antimicrobial hand wash can be used to wash hands that are visibly soiled. Finding 26 Visibly dirty hands or those contaminated with protein material should be washed with soap and water. 40,55 [UE] Finding 27 Wash visibly soiled hands with soap and water rather than alcohol rub. 49 [UE] Finding 28 Hand hygiene can be achieved through washing with either soap and water or using alcohol decontaminant. 64 [UE] Finding 29 Plain detergent, warm water and paper towels remove visible soiling and reduce skin irritation. 51 [UE] Category 6 Regular soap and water can be used to wash visibly soiled hands. 216

10 (Level 1 findings) (Level 2 findings) (Level 3 findings) Finding 30 Preventing contamination of the wound from dirty hands by implementing rigorous handwashing is the most effective way to prevent wound infection. 7 [UE] Finding 31 Hands should be washed before direct contact with patients, after contact with patients and after contact with body fluids, including wound dressings. 40,55 [C] Finding 32 Hands should be washed when moving from a contaminated part of the patient to a noncontaminated part of the patient during care. 40,55 [C] Finding 33 Handwashing frequency should be determined based on patient and clinician factors. 56 [C] Finding 34 Hands should be washed before and after touching the patient, before and after aseptic procedures, after body fluid exposure and after touching patient surroundings. 64 [UE] Category 7 Hands should be washed before and after patient care to prevent contamination. Synthesis 3 Hand washing should occur before and after patient contact, regardless of the use of gloves, and consist of vigorous rubbing for at least 15 to 30 seconds. Finding 35 Wash hands before and after using sterile gloves. 57 [C] Finding 36 Handwashing should be conducted before and after procedures, even if gloves are worn. 59 [UE] Finding 37 Hands should be washed after wearing gloves because hands could become contaminated under the gloves or when the gloves are removed. 56 [C] Finding 38 Hands should be washed after removing gloves. 40,55 [UE] Category 8 Hands should be washed before and after wearing gloves. Finding 39 When using soap and water, hands should be rubbed together vigorously covering all surfaces for at least 15 seconds. 40,55 [C] Finding 40 When using alcohol-based hand rub hands should be rubbed together, covering all surfaces until the hands are dry. 40,55 [C] Finding 41 Hand disinfectants should be used for at least 30 seconds. 59 [UE] Category 9 Hands should be rubbed vigorously for 15 to 30 seconds, covering all hand surfaces. 217 Volume 24 Number 4 December 2016

11 (Level 1 findings) (Level 2 findings) (Level 3 findings) Finding 42 Gloves should be worn when contact with blood or non-intact skin could occur. 40,55 [UE] Finding 43 Gloves should be changed when moving from a contaminated patient site to a non-contaminated patient site. 40,55 [C] Finding 44 Gloves should be removed when patient care is completed. 40,55 [UE] Finding 45 Gloves are required for all procedures to protect nurses and patients from infection. 59 [C] Finding 46 Aim of wearing gloves is to reduce cross infection, reduce contamination of hands or to protect the hands from chemicals. 48 [UE] Finding 47 Gloves must be worn when removing an old dressing to prevent risk of cross-contamination. 45 [C] Finding 48 Sterile gloves are required for invasive activities to protect the patient and health professional. 51 [C] Category 10 Gloves prevent contamination and cross infection. Synthesis 4 Gloves are required to prevent contamination and cross infection; however, they do not replace routine handwashing. Finding 49 After removing gloves, wash hands with either antiseptic hand wash or antiseptic rub. 45 [C] Finding 50 Double gloving is not an acceptable replacement for washing hands (with either soap and water or an antiseptic rub) and donning new gloves. 45 [C] Finding 51 Gloves are not a substitute for hand hygiene. 57 [C] Category 11 Gloves do not replace hand washing. Finding 52 If forceps are used sterile gloves are not required for aseptic non touch technique. 53 [C] Finding 53 Selection of gloves should be based on their purpose. 48 [C] Finding 54 Selection of clean versus sterile gloves should be determined by level of expected contact with the wound. 57 [C] Finding 55 Selection of gloves should be guided by a risk assessment that includes assessment of contact with susceptible sites or devices, type of potential contamination and whether it is a sterile or a non-sterile task. 48 [C] Category 12 The type of procedure, level of contact and risk of contamination influence the choice of glove types. Synthesis 5 Selection of gloves is guided by the procedure to be performed, risk of contamination, latex allergies and cost. Finding 56 Selection of gloves should be based on any allergies of nurse and patient. 48 [C] Finding 57 Selection of gloves should be considered carefully due to latex allergy risks. 59 [C] Finding 58 Before using latex gloves, assess the risk of latex allergy of the nurse and the patient. 50 [UE] Category 13 Latex allergy is a consideration in selecting gloves. Finding 59 Selection of gloves should be considered carefully due cost factors. 59 [C] Finding 60 Sterile gloves are costly and may lead to requiring an assistant. 62 [C] Category 14 Cost is a consideration in selecting gloves. 218

12 (Level 1 findings) (Level 2 findings) (Level 3 findings) Finding 61 Sterile gloves should be worn for surgical wound dressings and surgical procedures. 48 [C] Finding 62 Sterile gloves should be worn for procedures requiring aseptic technique. 48 [C] Finding 63 Sterile gloves should be worn for invasive procedures and insertion of invasive devices, especially in immune compromised patients. 48 [C] Finding 64 Sterile gloves should be worn for administering sterile pharmaceutical preparations. 48 [C] Finding 65 Sterile gloves are required for invasive activities to protect the patient and health professional. 51 [C] Finding 66 Sterile gloves are required for invasive activities to protect the patient and health professional. 51 [UE] Finding 67 When performing sterile procedure, sterile gloves are used to apply the new dressing. 48 [C] Finding 68 Do not touch non-sterile items after donning sterile gloves. 57 [UE] Finding 69 Use sterile gloves for aseptic non-touch techniques if there is a need to touch key parts. 61 [US] Category 15 Sterile gloves are required for surgery, aseptic procedures, invasive procedures, procedures in which the wound will be touched and for inserting invasive devices or sterile pharmaceuticals. Synthesis 6 Sterile gloves are required for surgical aseptic non-touch technique, surgery and invasive aseptic procedures and clean gloves are for non-sterile procedures/ standard aseptic non-touch technique. Finding 70 When performing sterile procedure, clean gloves are used for removing the old dressing. 48 [C] Finding 71 Clean gloves may be contaminated from other staff taking gloves from the box; however, evidence shows this risk does not influence wound infection rates. 62 [C] Finding 72 When performing clean procedure, two pairs of clean gloves are required, one for removing the old dressing and one for applying a new dressing. 48 [C] Finding 73 Clean, non-sterile gloves may be an acceptable alternative to sterile gloves. 56 [C] Finding 74 Use clean non-sterile gloves if there is no requirement to touch key parts in an aseptic non-touch technique. 61 [US] Category 16 Clean gloves are worn as an alternative to sterile gloves for removing old dressings and for aseptic non-touch technique (ANTT) where there will be no requirement to touch the wound or key parts. 219 Volume 24 Number 4 December 2016

13 (Level 1 findings) (Level 2 findings) (Level 3 findings) Finding 75 Personal protective equipment is designed to prevent transmission from patient to healthcare professional. 64 [UE] Finding 76 Use personal protective equipment when there is a risk of contamination to the caregiver, including contact with body fluids. 51 [UE] Finding 77 Personal protective equipment should be used to prevent cross contamination and/or exposure to body fluids. 57 [UE] Finding 78 Uniforms and jewellery are source of potential contamination. 59 [C] Finding 79 Disposable plastic apron should be worn when undertaking tasks that risk contaminating the wearer s clothing (e.g. splash back from irrigation). 51 [C] Finding 80 Plastic aprons should be used to reduce cross infection and changed between patients. 59 [C] Finding 81 Selection of personal protective equipment is determined by the level of risk, including exposure to body fluids and airborne infections. 64 [UE] Category 17 Personal protective equipment is used to reduce the risk of cross infection. Category 18 Selection of personal protective equipment should be guided by the level of risk of exposure to body fluids and airborne infection. Synthesis 7 Wearing appropriately selected personal protective equipment helps to reduce the risk of cross infection from exposure to body fluids or airborne Finding 82 Cleanliness of the care environment influences actual and perceived risk of infection and should be maintained in all care environments. 64 [C] Finding 83 Do not undertake aseptic procedures at times when environmental risk is higher, such as during housekeeping. 51 [C] Finding 84 The environment in which aseptic non-touch technique is performed should be clean and dust free. 51 [C] Finding 85 Infection sources include the health professional and the immediate environment. 61 [US] Finding 86 Carpets and soft furnishings may be a source of infection. 64 [UE] Finding 87 Consider the implications for cleanliness of pets in the home. 64 [UE] Category 19 Environment in which wound care is attended must be clean. Category 20 The home can be a source of contamination. Synthesis 8 Actions should be taken to reduce airborne and other infection risks in the home and hospital to ensure wound care is conducted in a clean environment. Finding 88 If a home environment poses significant infection risk, assistance should be provided to reduce the risk and when high the risk should be reported to local and environmental agencies. 64 [C] Finding 89 Cleaning schedules and standards and the ventilation and water supplies should be monitored regularly. 64 [C] Finding 90 Reduce airborne infection risk by closing windows, turning off fans, completing housework before undertaking wound care, restricting foot traffic around wound care, exposing wound for the shortest time possible, dress clean wounds before infected wounds, dispose of old dressings in sealed waste bags. 64 [C] Finding 91 The environment can be cleaned through disinfection or decontamination. 64 [UE] Category 21 Effort should be made to reduce infection sources (including airborne infection sources) in the area in which wound care is performed. 220

14 (Level 1 findings) (Level 2 findings) (Level 3 findings) Finding 92 Chlorine is recommended for surface cleaning due to its broad spectrum action. 64 [C] Finding 93 If using a dressing trolley, ensure it is clean before use. 57 [C] Finding 94 In the community setting, the nurse should place the sterile field at a height that prevents contamination with skin scales and fibres. 64 [C] Finding 95 In the community setting, the nurse should establish the sterile filed on either a clean table or on a plastic surface to prevent wicking. A plastic apron could be utilised.8 [C] Finding 96 The plastic lid of a storage container can be wiped and used as a clean surface on which to set up a sterile surface for a procedure in a home setting. 64 [C] Finding 97 Community nurses choose clean hard surfaces at wound height to create a sterile field, however this is often on the floor for a leg ulcer dressing. 11 [C] Finding 98 Application of wound field principle treats the wound as an extension of the dressing field. 7 [C] Finding 99 Wound field concept is guided by the principle that wounds themselves are not sterile, and products from a wound cannot contaminate itself; however external objects can contaminate the wound. 7 [C] Finding 100 Maintain a sterile field by only placing sterile objects within it, considering everything outside the field to be contaminated and not returning items to the field once they leave the field. 57 [UE] Finding 101 Use a critical aseptic field into which only sterile equipment is introduced for open, invasive or technical procedures. 61 [US] Finding 102 Use a general aseptic field in which key parts can be individually protected for non-invasive basic wound care. 61 [US] Category 22 The surface on which a sterile field will be set up should be clean and free from sources of contamination Category 23 Once established, the wound management field must not be contaminated. Synthesis 9 A wound management field can be established on a clean surface in a space at low risk of environmental contaminants. Once established, introduction of contaminated external objects should be avoided. Finding 103 A wound cleanser should be non-toxic and not cause sensitivity. 63 [UE] Finding 104 Wound cleansers may be toxic to cells and their use should be carefully considered. 63 [C] Finding 105 Wound cleaners should be non-toxic and not cause sensitivity to tissue. 42 [C] Finding 106 Use the principle of do no harm and prevent infection when selecting an irrigation solution. 9 [UE] Finding 107 Wound cleaners should have a long shelf life. 42 [C] Finding 108 Wound cleaners should have a long shelf life. 63 [C] Finding 109 Do not use expired or damaged irrigation fluids. 57 [UE] Finding 110 A wound cleanser should be effective in the presence of organic material and reduce microorganisms. 63 [UE] Finding 111 Wound cleaners should reduce microorganisms and remove organic material effectively. 42 [UE] Category 24 A wound cleanser should not cause damage or sensitivity. Category 25 A wound cleanser should have a long shelf life. Category 26 A wound cleanser should adequately clean the wound. Synthesis 10 An ideal wound cleanser should adequately clean the wound, not cause cell damage or sensitivity and have a long shelf life Volume 24 Number 4 December 2016

15 (Level 1 findings) (Level 2 findings) (Level 3 findings) Finding 112 Only cleanse wounds that are visibly contaminated with debris, excess exudate, necrotic tissue or slough, because these encourage infection. 39 [C] Finding 113 Only remove bacteria from a wound through cleansing in the presence of clinical signs of infection. 39 [US] Finding 114 When no contaminants are present, a wound may heal better without cleansing. 58 [US] Finding 115 The interdisciplinary care team should work together to determine the best wound cleansing options for specific individuals. 58 [C] Finding 116 Decisions about cleansing strategy for patients with DFU should be made by the multidisciplinary collaborative team. 9 [C] Finding 117 Assess whether a wound needs cleansing. 39 [C] Category 27 Wound beds only need cleansing in the presence of visible contamination or signs of infection. Category 28 The interdisciplinary team should assess if and how a wound should be cleansed. Synthesis 11 An assessment should be conducted by the interdisciplinary team to determine if a wound bed should be cleansed, and if so, the cleansing process to use. Finding 118 Normal saline is the only completely safe wound cleanser as it is isotonic and does not draw fluid from the wound. 42 [C] Finding 119 As an isotonic solution, saline does not impact osmotic pressure or impede normal healing as it has no impact on blood flow, granulation tissue, collagen formation or DNA synthesis. 46 [C] Finding 120 Sterile saline should be the preferred irrigation fluid in hospital settings. 46 [C] Finding 121 The choice of saline for wound irrigation is based on tradition rather than evidence. 62 [C] Finding 122 Use sterile saline solution for complex and vulnerable wounds. 9 [C] Finding 123 Use tap water or normal saline to cleanse wounds because antiseptics are ineffective and can delay healing. 56 [C] Finding 124 Appropriate irrigation fluids include normal saline and sterile water. 57 [UE] Finding 125 Water may be the best option for irrigation when using dressing products with which saline is contraindicated. 46 [C] Finding 126 Tap water is an acceptable alternative to saline. 42 [C] Finding 127 Water and saline are ineffective cleansers for reducing the wound bioburden or improving wound healing. 67 [C] Finding 128 All antimicrobials are effective in reducing wound contamination. 67 [C] Finding 129 Polyhexamethylene biguanide (PHMB), povidone-iodine, and ionised silver are wound cleaners that are effective for promoting wound healing. 67 [C] Finding 130 All antimicrobials are toxic to wounds (PHMB has lowest toxicity). 67 [UE] Finding 131 Antimicrobials (e.g. Dakin solution and povidone-iodine) are toxic to cells and if used as a wound cleanser the concentration should be carefully considered. 63 [C] 222 Category 29 Normal saline is a safe and traditional wound cleansing solution. Category 30 Tap water, sterile water or normal saline are acceptable options for wound cleansing, although they do not reduce bioburden. Category 31 Antimicrobial solutions are effective cleansers that play a role in reducing bioburden, although they are toxic in higher concentrations. Synthesis 12 Normal saline, potable tap water, sterile water and low concentration antimicrobial solutions are safe and effective wound cleansers. Antiseptics are not a good choice for wound cleansing. 8

16 (Level 1 findings) (Level 2 findings) (Level 3 findings) Finding 132 Antiseptics should be used with caution for wound cleansing, particularly those deemed toxic or carcinogenic to tissues. 42 [UE] Finding 133 Using antiseptics to cleanse wounds is controversial because they can negatively influence wound healing. 63 [C] Finding 134 Skin cleansers are cytotoxic to cells and are not appropriate wound cleansers. 63 [C] Category 32 Antiseptics and skin cleansers are toxic to wound healing and not appropriate for wound cleansing. Finding 135 Antiseptics are not in contact with a wound surface sufficiently long to reduce bacteria. 39 [C] Finding 136 Antiseptics can damage healing wounds. 39 [UE] Finding 137 Excessive use of antiseptics may be associated with antibiotic resistant bacteria. 39 [C] Finding 138 Using antiseptics for wound cleansing can be detrimental to the wound healing process. 58 [C] Finding 139 Low pressure irrigation using normal saline and a syringe is the preferred method for wound cleansing. 42 [US] Finding 140 Irrigation is the preferred cleansing method. 56 [C] Finding 141 When irrigating with tap water, use tubing attached to the faucet if the wound cannot be placed under the tap. 62 [C] Finding 142 When cleansing or irrigating, suitable pressure to remove exudate, loose tissue and contaminants should be applied. However, pressure should not be high enough to disrupt granulation. 65 [C] Finding 143 When irrigating with tap water ensure it is lukewarm. 62 [C] Finding 144 Rewarm refrigerated wound cleansing fluids before use. 45 [UE] Finding 145 Cooler irrigation fluids may lead to impaired healing associated with local vasoconstriction. 66 [UE] Finding 146 Because wound healing optimally occurs at 33 C, irrigation fluids should be warmed to between 37 C and 42 C before use. 46 [UE] Finding 147 Consider refrigerating wound cleansers after opening to reduce bacterial growth. 45 [C] Finding 148 Cleansing with cool fluids can increase risk of infection as the body s defence mechanisms are lower due to vasoconstriction. 9 [C] Finding 149 Fluid temperature should be considered when selecting a cleansing method. 54 [C] Category 33 Low pressure irrigation removes debris without disrupting granulation. Category 34 A wound cleanser should be lukewarm on application. Synthesis 13 Apply a wound cleanser at a lukewarm temperature with consideration to the potential for cross infection and using low pressure to irrigate the wound bed. Finding 150 Cross infection risk should be considered when deciding if cleansing a wound in a shower is appropriate. 58 [C] Finding 151 The practicalities of cleansing techniques, including the difficulty in managing fluid flow direction should be considered when selecting a cleansing method. 54 [C] Finding 152 Consider cross infection risk when determining if a person with a diabetic foot ulcer can cleanse a wound in a shower (particularly in a multi-dwelling residence). 9 [UE] Category 35 There is a risk of cross infection when cleansing a wound Volume 24 Number 4 December 2016

17 (Level 1 findings) (Level 2 findings) (Level 3 findings) Finding 153 Soap and water is acceptable for cleansing sutured wounds. 39 [C] Finding 154 Bathing and showering can be undertaken once wound edges are sealed. 39 [C] Finding155 Water should only be used occasionally. 42 [US] Finding 156 Tap water has the advantage of providing a greater volume of fluid, at a constant high pressure when provided from city water mains. 62 [C] Finding 157 Soaking the leg in a bucket of water is an option for cleansing legs with venous ulcers. 58 [C] Finding 158 Tap water is sufficient for cleansing sacral, perianal wounds, open traumatic wounds and leg ulcers. 56 [C] Finding 159 Soap and water are sufficient for removing transient flora in wounds. 56 [C] Finding 160 When irrigating with tap water, place the wound under running water for 30 seconds. 62 [C] Category 36 Running tap water or water in a bucket is sufficient for cleansing dirty wounds, chronic wounds and wounds with closed or sutured edges. Synthesis 14 Good quality tap water is a cost effective option for cleansing dirty wounds, chronic wounds and wounds with closed or sutured edges, although it may cause pain. Finding 161 Quality of drinking water should be considered when determining where to use it for wound cleansing. [UE] Finding 162 Tap water should be from a clean, monitored supply. 56 [C] Finding 163 It is safe to use clean uncontaminated tap water to cleanse wounds. 54 [C] Category 37 The quality of water used for wound cleansing is important. Finding 164 In major cities tap water is chlorinated therefore the risk from pathogens is minimal. 62 [US] Finding 165 Tap water is cheaper than saline and eliminates the need for additional equipment including syringes. 62 [C] Finding 166 Using tap water for wound cleansing is likely to have a large financial benefit. 54 [C] Finding 167 Patient satisfaction, time and cost effectiveness should all be considered when selecting a wound cleanser. 66 [UE] Finding 168 Water may be more cost-effective than saline. 46 [C] Finding 169 As a hypotonic solution, water can increase osmotic pressure within wounds and may be detrimental to cells during healing due to potential of excessive moisture absorption and exudate production. 46 [C] Finding 170 Irrigating wounds with water can cause pain. 46 [C] Finding 171 Irrigating wounds with water can cause loss of intracellular fluid and substances that promote wound healing. 46 [C] Finding 172 Water may cause wound pain because it is hypotonic and therefore causes cells within the tissue to swell and rupture. 42 [US] Category 38 It is cost effective to use tap water for wound cleansing. Category 39 Tap water may cause pain or damage cells due to its hypotonicity. 224

18 (Level 1 findings) (Level 2 findings) (Level 3 findings) Finding 173 The risk of potential infection from tap water, particularly in immunocompromised patients and in the hospital environment should be considered when determining how to cleanse a wound. 41 [UE] Finding 174 Biofilm in pipes, faucets and sinks are a potential source of contamination of running tap water. 41 [C] Finding 175 Exposure to tap water during bathing (either from direct contact or inhalation) is a potential source of infection in hospitals. 41 [C] Finding 176 Pseudomonas Aeruginosa, Acanthamoeba, Mycobacteria and Leptospira are common water-related pathogens that be transmitted via contact with water. 41 [UE] Finding 177 More virulent bacteria may enter water sources in hospital environments. 41 [C] Finding 178 When determining the infection risk of tap water, consider how the water was stored and delivered (consider the variation in water purity in different geographic locations and clinical settings). 9 [UE] Finding 179 Hospitals do not always have high quality water. 41 [C] Finding 180 Tap mounted water filters reduce the number of microorganisms in tap water. 41 [C] Finding 181 Holy water should be autoclaved due to risk of pathogens. 56 [C] Finding 182 A tap should be run properly for a few minutes before the water is used for wound cleansing, to reduce risk of bacterial contamination. 42 [US] Category 40 Tap water may be a source of contamination in homes and hospitals. Category 41 Filters, autoclaving and running the faucet to remove bacteria can reduce the risk of contamination from water supply. Synthesis 15 Precautions can be taken to reduce the risk of potential contamination of water sources. 225 Volume 24 Number 4 December 2016

19 (Level 1 findings) (Level 2 findings) (Level 3 findings) Finding 183 The use and storage of dressing supplies and solutions influences the type of dressing technique selected. If materials are not stored in a way to ensure sterility, conditions for sterile and no touch techniques cannot be met. 68 [UE] Finding 184 In selecting a dressing technique consider the clinical setting (e.g. surrounding environment, health professional skills). 68 [UE] Finding 185 Aseptic non touch technique framework is based on assessing the risk the patient faces of infection from the health professional and environment. 60 [C] Finding 186 Decision regarding technique is guided by the environment. 57 [C] Finding 187 In deciding between clean and aseptic technique consider the healthcare setting. 48 [C] Finding 188 Assess risks of contamination from the local environment. 60 [C] Finding 189 Concern about potential infection is a barrier to uptake of clean technique in community settings. 37 [C] Finding 190 Not all care environments require the strict asepsis that was developed for sterile operating rooms. 7 [C] Category 42 Selection of technique for performing a wound dressing should be guided by the risk to the patient of infection from the surrounding environment. Synthesis 16 Selection of sterile /surgical ANTT or clean/standard ANTT is determined by the level of risk posed to the patient by his or her health status, the environment, factors associated with the wound and the type of wound management procedure being performed. Finding 191 Decision regarding technique is guided by complexity of the procedure. 57 [C] Finding 192 In selecting a dressing technique consider the invasive level of the procedure. 68 [UE] Finding 193 Selection of dressing technique should be guided by the intervention required to the wound. 68 [C] Finding 194 In deciding between clean and aseptic technique consider the level of invasion of procedure (e.g. extensive debridement or packing). 48 [C] Finding 195 Determine the level of risk of contamination with consideration to level of contact with the patient, when selecting a hand hygiene methods. 51 [C] Finding 196 In deciding what technique to use, assess the complexity of the procedure and necessity to touch key parts. 60 [US] Finding 197 Aseptic non touch technique (ANTT) framework is based on assessing the risk the patient faces of infection from the procedure. 60 [C] Finding 198 In selecting a dressing technique consider patient factors (e.g. immune status, acuity). 68 [C] Finding 199 In deciding between clean and aseptic technique consider the patient s immune status. 48 [C] Finding 200 Consider the patient s context when selecting appropriate dressing technique. 7 [C] Finding 201 Historically the selection of technique has been based on perceived patient risk of infection. 60 [C] Finding 202 Patient-related factors to consider when determining technique include immune status; age; use of steroids patient lifestyle; concurrent skin conditions; nutritional and status. 57 [C] Category 43 Selection of the technique for performing a wound dressing should be guided by the complexity or invasiveness of the procedure being performed. Category 44 Selection of the technique for performing a wound dressing should be guided by patient factors that influence infection risk

20 (Level 1 findings) (Level 2 findings) (Level 3 findings) Finding 203 In deciding between clean and aseptic technique consider the type of wound (e.g. acute vs chronic) and its location and depth. 48 [C] Finding 204 In selecting a dressing technique consider wound factors (e.g. acuter versus chronic, depth, location). 68 [C] Finding 205 Consider the wound history when selecting appropriate dressing technique. 7 [C] Finding 206 Chronic wounds cannot become contaminated from clean products because they are already colonised with microbes. 50 [US] Category 45 Selection of the technique for performing a wound dressing should be guided by the type and condition of the wound. Finding 207 Clean technique may be more appropriate than rigorous asepsis in caring for chronic wounds. 57 [C] Finding 208 Clean wound care technique using non-sterile gloves and tap water could be used for some wound types. 56 [C] Finding 209 Patient factors to consider when determining technique type of wound; depth, location and size of wound. 57 [C] Finding 210 Use clean technique (handwashing, clean gloves, solutions, equipment maintained as clean) for dressing changes with mechanical, chemical or enzymatic debridement. 68 [C] Finding 211 Use clean technique (handwashing, clean gloves, solutions and equipment maintained as clean) for routine dressing changes without debridement. 68 [C] Finding 212 Use standard aseptic non-touch technique, critical micro-field and non-sterile gloves with a nontouch technique for a simple wound dressing that is less than 20 minutes in duration. 61 [US] Finding 213 Clean technique allows irrigation or bathing with saline or tap water and use of a clean surface. 37 [C] Finding 214 Use clean technique (handwashing, clean gloves, solutions and equipment maintained as clean) for irrigating wounds. 68 [C] Finding 215 Use sterile technique (handwashing, sterile gloves, sterile solutions and equipment) for routine dressing changes with sharp conservative debridement. 68 [C] Finding 216 Aseptic wound care using sterile equipment and wound cleansers prevents transmission of bacteria and is the standard recommended practice. 56 [US] Finding 217 Surgical aseptic technique or aseptic non-touch technique is required when undertaking an invasive procedure when the patient s defences are compromised. 57 [C] Finding 218 Surgical aseptic technique or aseptic non-touch technique is required when undertaking an invasive procedure that breaches the skin. 57 [C] Finding 219 Use surgical aseptic non-touch technique with an aseptic field, sterile gloves and barrier precautions for attending a complex or large dressing with key parts that require asepsis or procedures longer than 20 minutes. 61 [US] Finding 220 Aseptic technique requires a sterile dressing pack and sterile cleansing solution. 37 [C] Finding 221 Sterile technique is the most appropriate technique for patients at high infection risk. 68 [C] Category 46 Clean technique/standard ANTT is appropriate for irrigating and wound dressings without debridement. It requires clean gloves and equipment and cleansing solutions maintained as clean. Category 47 Sterile/ surgical ANTT is appropriate for individuals at infection risk due to compromised immunity, and/or when the procedure is invasive, complex or breaches the skin (e.g. sharp debridement) or is of longer duration. It requires sterile gloves, sterile equipment and sterile cleansing solutions. Synthesis 17 Simple wound management procedures on low risk patients can be performed with non-sterile but clean equipment, solutions and gloves. More complex procedures or procedures in higher risk patients require surgical aseptic non-touch technique, using sterile gloves, solutions and equipment Volume 24 Number 4 December 2016

21 (Level 1 findings) (Level 2 findings) (Level 3 findings) Finding 222 Equipment can be cleaned through sterilization, disinfection or decontamination. 64 [UE] Finding 223 Decontamination of equipment can be performed with detergent and water, or with alcohol wipes. 64 [C] Finding 224 When cleaning equipment use 70% alcohol /2% chlorhexidine impregnated wipe and scrub the equipment hard using different parts of the wipe. 61 [US] Finding 225 Single use equipment can be more practical in homecare environments where there is not ready access to facilities to adequately sterilise reusable equipment. 64 [C] Finding 226 Consider cleaning the sachet before opening irrigation fluids. 57 [C] Finding 227 Sterile packs that contain standardised equipment choices and/or gloves of the incorrect size leave community nurses at risk of contaminating the sterile field. 8 [C] Finding 228 Lack of choice in dressing packs from the formulary hinders the performance of asepsis in community settings. 11 [C] Finding 229 Use a secondary container for fluids being used in a procedure to avoid contaminating a larger container with syringes. 45 [C] Finding 230 Pressurised multi dose canisters can be used for sterile solution irrigation and reduce risks associated with using needle/ syringe or cotton/gauze. 65 [C] Finding 231 Open wound cleaner containers without contaminating the inside of the bottle, place the cap face up when using the container and replace the cap as soon as possible. 45 [C] Finding 232 To reduce risk of contamination of irrigation containers used in home care settings, use smaller containers. 45 [C] Category 48 Wound management equipment should be single use or decontaminated using detergent and water or alcohol preparations. Category 49 Pre-packaged, standardised dressing packs can be wasteful or increase risk of contamination. Category 50 Use wound cleansers from smaller containers to prevent contaminating the wound cleanser supplies. Synthesis 18 Wound management equipment should be single use or cleaned with alcohol preparations. Using cleansers and wound dressings in smaller packages reduces waste and contamination risk. 228

22 (Level 1 findings) (Level 2 findings) (Level 3 findings) Finding 233 In aseptic non touch technique used equipment must not re-enter the sterile field. 51 [C] Finding 234 When implementing sterile technique, sterile objects must not touch non-sterile objects. 68 [UE] Finding 235 An aseptic technique requires all objects and fluid that come on touch with the wound to be sterile. 7 [UE] Finding 236 To perform aseptic technique the health professional must: understand when an object is or is not sterile; maintain the dressing field separate from the wound; remove contaminated or nonsterile items from the field; ensure non-sterile items do not cross into to the sterile field and correct infractions if the sterile field becomes contaminated. 7 [UE] Finding 237 The concept of clean and dirty (hands and/or forceps) is incorporated into aseptic techniques. 7 [UE] Finding 238 To maintain aseptic technique the process of cleansing with tap water and washing the surrounding skin (e.g. VLU leg) should be separate from applying a dressing. 8 [C] Finding 239 Equipment that only touches the wound or the sterile field cannot be a source of contamination to the wound. 43 [C] Category 51 In sterile/surgical aseptic non-touch techniques the wound management field must remain free of non-sterile items, including equipment and cleansing fluids. Synthesis 19 When performing sterile/surgical ANTT the wound management field must remain free of non-sterile items, including equipment, cleansing fluids and gloved hands that have touched a nonsterile object. Finding 240 Gloves have replaced the use of sterile forceps. 56 [C] Finding 241 Use a dressing aid to remove the old wound dressing and use gloves and a clinical sheet to dry the leg, before commencing aseptic technique. 8 [C] Finding 242 Forceps are difficult to manoeuvre and health professionals often become confused or are unable to prevent contamination of the clean forceps by the dirty forceps when applying aseptic non-touch technique. 7 [UE] Category 52 Because using forceps can be difficult, some clinicians use gloved hands in the wound dressing procedure. 229 Volume 24 Number 4 December 2016

23 (Level 1 findings) (Level 2 findings) (Level 3 findings) Finding 243 In a home with an MRSA infected wound, disinfect surfaces with bleach and water or an appropriate detergent. 49 [C] Finding 244 When caring for a wound infected with MRSA, clean reusable equipment with an intermediate disinfectant before returning it the bag. 49 [C] Finding 245 Dispose of MRSA-infected waste at the patient s home, using double-bagging and labelling as hazardous waste if there is significant wound drainage. 49 [C] Finding 246 When caring for a wound infected with MRSA, use disposable equipment where possible to prevent MRSA spread. 49 [C] Category 53 Strategies to prevent contamination of equipment should be taken if a patient has MRSA. Synthesis 20 Extra infection control precautions should be taken for patients with known infection. Finding 247 To prevent spread of MRSA in the community place a plastic sheet underneath the equipment bag when caring for a patient with MRSA. 49 [C] Finding 248 In a home with an MRSA infected wound, the health professional should avoid using the patient s soap or towels. 49 [C] Finding 249 Use personal protective equipment when caring for a wound infected with MRSA 49 [C] Finding 250 When caring for an MRSA infected wound, hand washing and gloves are important in preventing the spread of MRSA in the community. 49 [UE] Category 54 Pay extra attention to personal hygiene to prevent cross infection when a patient has MRSA. Finding 251 Dressing packs should be stored in a clean, dry place and not used if they are damaged or soiled. 56 [C] Finding 252 Support the strategies patients develop for storing equipment in a way that reduces contamination. 64 [US] Finding 253 There is no set timeframe after which an opened irrigation solution needs to be disposed. 45 [C] Finding 254 If using larger irrigation fluid containers reduce the risk of contamination by dating on opening, discarding according to organisation policy and destroying any fluid containers that visually appear contaminated. 45 [C] Finding 255 Gloves should be used and stored in a way that reduces risk of damage. 50 [C] Finding 256 Gloves from damp boxes are at risk of contamination from mould. 62 [US] Category 55 Wound products and equipment should be stored in a clean dry place that reduces risk of contamination. Category 56 Wound cleaners should be dated on opening and destroyed when they are visually contaminated. Category 57 Gloves should be stored in a manner that reduces contamination. Synthesis 21 Wound management products should be stored in dry, clean environments to reduce risk of contamination and cleansers should be dated on opening and discarded if visually contaminated or according to organisation policy. 230

24 (Level 1 findings) (Level 2 findings) (Level 3 findings) Finding 257 Ongoing education is required to improve asepsis skills. 48 [C] Finding 258 Regular infection control training should include hand hygiene, asepsis, decontamination and cleaning, waste and laundry disposal, sharps management and use of personal protective equipment. 64 [C] Finding 259 Education is an effective strategy in promoting best hand hygiene practice. 64 [C] Finding 260 All health professionals involved in wound care should be offered training, regardless of discipline. 38 [C] Finding 261 Nurses often have superficial and incomplete knowledge of principles underpinning wound care and this leads to ritualistic practice. 39 [C] Finding 262 Education is an important factor in reducing hospital acquired infection. 51 [UE] Finding 263 Good base knowledge and ongoing education are important to ensure health professionals have perform good handwashing technique. 50 [UE] Finding 264 Provide education to the patient and caregivers on preventing spread of MRSA. 49 [UE] Finding 265 Regular education contributes to improving infection control behaviour and compliance in hand hygiene. 59 [C] Finding 266 Clinical staff require education and training in aseptic technique. 8 [UE] Finding 267 Community nurses display confusion regarding clean technique and the use of tap water, often leading to sterile field contamination due to failure to separate wound washing from aseptic procedure. 11 [C] Finding 268 Community nurses receive no guidance in how to adapt the principles of aseptic technique to the home setting and patient preferences. 11 [C] Finding 269 Aseptic technique principles are ingrained in initial nurse training and community nurses maintain knowledge of important principles. 11 [C] Finding 270 Appropriate education, training and skill assessment is required for all health professionals undertaking aseptic technique. 57 [UE] Category 58 Staff education, including education on application in different clinical settings, is an essential component in ensuring best practice in aseptic technique and infection control. Synthesis 22 Staff education that incorporates skills practice, simulation learning, theoretical knowledge update and procedures for different clinical settings is essential in promoting best practice in aseptic technique and infection control. Finding 271 District nurses are aware that performing aseptic technique in community settings is a challenge. 11 [C] Finding 272 Community nurses perceive they have a lack of control over cleanliness and therefore risk of infection. 10 [C] Finding 273 Community nurses use the term aseptic technique vaguely as they perceive asepsis as impossible in the home environment. 10 [C] Finding 274 Some community nurses view infection as unavoidable. 10 [C] Category 59 Nurses in the community experience frustration and fatalism when negotiating aseptic procedures. 231 Volume 24 Number 4 December 2016

25 (Level 1 findings) (Level 2 findings) (Level 3 findings) Finding 275 Students should first learn clean and aseptic wound care in simulation. 57 [C] Finding 276 Observing clinical practice to provide feedback is an effective strategy in promoting best hand hygiene practice. 64 [C] Finding 277 Students require a combination of didactic theory and opportunities for practical simulation to learn aseptic non touch technique. 53 [C] Category 60 Skills practice and simulation learning can be used for infection control training and education. Finding 278 Visual education strategies such as coloured dye and talcum powder activities helps health professionals visualise the spread of infection. 59 [C] 232

26 (Level 1 findings) (Level 2 findings) (Level 3 findings) Finding 279 Health professionals have a responsibility to identify infection risks and intervene to reduce that risk. 50 [UE] Finding 280 Assessments of infection risk should be conducted in health facilities. 59 [C] Finding 281 Continuous quality improvement through regular auditing, risk assessment and education is essential in maintaining appropriate wound care practices. 7 [C] Finding 282 Infection surveillance and quality improvement using root cause analysis is essential for continuous quality improvement. 64 [C] Finding 283 Engaging wound champions are a strategic strategy to promote infection control and appropriate dressing practices. 38 [C] Finding 284 Quality practice can be achieved using linkage programs through which infection champions disseminate key messages. 64 [C] Finding 285 Partnership and understanding between the individual, informal carers and health professionals is essential to ensure effective infection prevention and control. 64 [C] Finding 286 Patients could be empowered to promote hand hygiene by asking health professionals about their practice. 59 [C] Finding 287 Adequate staffing is an important factor in reducing hospital acquired infection. 51 [C] Category 61 Regular risk surveillance within a health service promotes continuous improvement in aseptic technique and infection control procedures. Category 62 Engaging with staff members and patients promotes best practice in aseptic technique and infection control procedures. Synthesis 23 Best practice in aseptic technique and infection control procedures is promoted through development of facility policies, regular risk surveillance, annual auditing of staff practice, engaging with staff and patients and provision of acceptable hand hygiene products. Finding 288 Annual assessment of dressing technique should be a required organisational policy. 38 [C] Finding 289 Ongoing practice audits contribute to improving infection control behaviour. 59 [C] Finding 290 Auditing of practice increases compliance with the standardised aseptic technique. 8 [C] Finding 291 Facilities should periodically monitor hand hygiene. 40,55 [C] Finding 292 Annual auditing of aseptic non touch technique practises should be conducted a part of continuous quality improvement. 38 [C] Category 63 Annual auditing clinical practice of staff contributes to continuous improvement in aseptic technique and infection control procedures. Finding 293 Standardising the technique used in a facility is one way to prevent and control hospital acquired infection. 8 [C] Finding 294 There is insufficient evidence to make recommendations on approach to wound care therefore facilities should develop their own policies regarding wound care. 48 [C] Finding 295 Health professionals should continue current practice consistent with their facility policies. 48 [C] Finding 296 Standardising aseptic care reduces infection. 61 [C] Category 64 Standardised policies and procedures increase compliance with best practice in aseptic technique and infection control procedures Volume 24 Number 4 December 2016

27 (Level 1 findings) (Level 2 findings) (Level 3 findings) Finding 297 Plain detergent, warm water and paper towels reduce skin irritation and increase acceptability of handwashing. 51 [C] Finding 298 Providing efficacious hand hygiene products with low irritancy and favourable aesthetics increases compliance with hand washing. 40,55 [C] Category 65 Providing low irritant products increases compliance with hand washing. 234

28 Table 1: Summary of research papers Ref Type of Study Cleansing solutions Sample Intervention(s) Outcome Measures & Length of Follow-up Bansal, 2002 Fernandez, Giffiths 2001 and Fernandez, Griffiths 2004 RCT comparing irrigation with normal saline to irrigation with tap water for management of lacerations in children Systematic review of controlled clinical trials exploring efficacy of cleansing solutions and techniques In 2001 review, 9 RCTs included In 2004, 14 RCTs included Paediatric patients recruited in US emergency room (n=45) Inclusion criteria: children aged 1 to 18 years presented within 8 hours of injury simple laceration (no muscle, bone or joint involvement) Exclusion criteria: laceration from dog bite hand laceration currently taking antibiotics Characteristics: age range 2 to 15 sharp and blunt injury lacerations 64% of laceration 3 cm and 7% >6cm 64% located on leg, 22% located on arm, 11% located on foot, 4% located on hand The included trials were conducted in adults and children in Australia, Sweden, Tanzania and UK Inclusion criteria: Adults or children with wounds (excluding burns) Characteristics: 4 studies included people with lacerations 1 trial each for traumatic wounds, open fractures or ulcers 7 trials post- op surgical wounds All participants had a wound swab conducted pre and post irrigation All lacerations were sutured, had antibiotic cream and dressing applied Patients were randomised to receive: o Group 1: irrigation of the laceration with normal saline at a pressure of 25 to 40 psi (n=24) or o Group 2: irrigation of the laceration with tap water at a pressure of 25 to 40 psi (n=21) Participants re- attended ER in 48 hours to assess for complications Comparisons of different cleansing solutions Comparison of showering versus non showering Wound culture performed post irrigation Infection rate at 48 hours using the following criteria to define a laceration as infected: o cellulitis or erythema of the wound margin of more than 4 mm with tenderness, o purulent discharge from the wound, o ascending lymphangitis, o dehiscence of the wound with wound separation of >2mm Infection rates Wound dehiscence Wound healing Cost Results Positive post irrigation wound culture (threshold: any growth) No significant difference between groups in post- irrigation wound cultures: normal saline 29% versus tap water 51%, p=0.20 Infected laceration at 48 hours No significant difference in infected lacerations at 48 hours: normal saline 8% versus tap water 10%, p=ns Tap water versus normal saline Infection in acute wounds (1 RCT): favours tap water odds ratio (OR) 0.52 (95% confidence interval [CI] 0.28 to 0.96), p=0.04 Infection in chronic wounds (1 RCT): no significant difference; OR 0.14 (95% CI 0.01 to 2.94), p=0.21 Infection in children with lacerations (2 RCTS): no significant difference, OR 1.07 (95% CI 0.42 to 2.75), p=0.89 Infection in all types wounds (4 RCTs): favours tap water, OR 0.60 (95% CI 0.37 to 0.99), p=0.05 Cost analysis: normal saline $1.43 vs tap water $1.16/dressing (currency not reported) Showering/bathing versus no showering Infection in post- operative wounds (5 RCTs): no significant difference, OR 0.80 (95% CI 0.29 to 2.23), p=0.67 Wound healing in post- operative wounds (3 RCTs): no significant difference, OR 1.21 (95% CI 0.29 to 5.10), p= c Moderate 1.a Moderate 235 Volume 24 Number 4 December 2016

29 Ref Type of Study Fernandez and Giffiths 2012 Systematic review of RCTs and quasi- RCTs exploring efficacy of water for cleansing 11 RCTs included Sample Intervention(s) Outcome Measures & Length of Follow-up Trials were primarily conducted in emergency rooms (10/11) Participant characteristics: Age range 2 to 95 years Wound types: 5 trials lacerations, 1 trial open fractures; 1 trial - chronic wounds; 4 trials surgical wounds 3 trials compared tap water to no cleansing 8 trials compared tap water to other cleansing solution Wound infection Wound dehiscence Wound healing Cost Results Wound dehiscence in post- operative wounds (1 RCT): no significant difference, OR 1.14 (95% CI 0.10 to 12.69), p=0.91 1% povidone- iodine versus normal saline Infection rate in lacerations/ postop wounds in small trials (2 RCTS): favours povidone- iodine, OR 0.15 (95% CI 0.05 to 0.43) p<0.05 Infection rate in lacerations and postop wounds in large trials (1 RCT): no significant difference, OR 0.62 (95% CI 0.25 to 1.53) p=0.29 Wound healing in post- operative wounds (1 RCT): favours normal saline, OR 4.46 (95% CI 1.45 to 13.68) p<0.05 1% povidone- iodine versus no cleansing Infection in contaminated traumatic wounds (1 RCT): no significant difference, OR 1.00 (95% CI 0.05 to 19.3), p=1.00 Tap water versus no cleansing Wound infection (3 RCTs): no significant difference, relative risk (RR) 1.06, 95% CI 0.07 to Wound dehiscence (2 RCTs ): no significant difference, RR 1.26, 95% CI 0.18 to 8.66 Tap water versus saline Wound infection in acute wounds that were sutured (3 RCTs): no significant difference, RR 0.66, 95% CI 0.42 to 1.04, p=0.16 Wound infection in chronic wounds that were not sutured (1 RCT): no significant difference, RR 0.16, CI 0.01 to 2.96, p=0.22 Wound healing in chronic wounds that were not sutured 1 RCT): no significant difference, RR 0.57, CI 0.30 to 1.07, p=ns Cost analysis (2 RCTs): both found reduction in costs associated with tap water Distilled water vs cooled boiled water Wound infection in open fractures (1 RCT): no significant difference, RR 1.69, 95% CI 0.68 to 4.2, p=ns Distilled water versus isotonic saline 1.a Moderate 236

30 Ref Type of Study Lakshmi et al 2011 RCT comparing tap water and sterile saline for cleansing chronic wounds Valente, 2003 RCT comparing tap water and sterile saline for cleansing simple lacerations in children presenting to an emergency department (ED) Sample Intervention(s) Outcome Measures & Length of Follow-up Participants recruited in outpatients and surgical wards in India (n=82 recruited, n=61 completed) Inclusion criteria: Chronic wound of 3 weeks Up to date tetanus immunisation Exclusion criteria: Serious medical disorder Malnutrition (BMI <15 or >36) Immuno- compromised pressure ulcer diabetic foot ulcers with osteomyelitis Patient characteristics: mean age 46 years comparable biochemical parameters except tap water group had significantly higher total protein (p=0.02) most wounds were VLUs mean ulcer duration approx. 49 days (not different between groups) Saline group had significantly larger mean wound length at baseline (4cm vs 2.94cm, p<0.05) Convenience sample of children with lacerations presenting at an ED (586 eligible, 530 randomised, 490 completed follow up, equivalent loss to follow up between groups) Inclusion criteria: Aged 1 to 7 years Simple wounds of < 8 hours duration Wound located on face, scalp, trunk or extremity Participants were randomised to receive: o Saline group: wound irrigation with sterile saline delivered in a 50ml syringe and needle at pressure of 8ppi (n=39 commenced, n=30 completed and reported) or o Tap water: drinkable quality tap water delivered to wound via PVC pipe and irrigated 10 mins after running the tap for 5 mins to clear potential contamination (n=43 commenced, n=31 completed and reported) All wounds treated with povidone- iodine impregnated gauze and secondary sterile gauze pad. All participants received anaesthesia as appropriate After irrigation wound were repaired with staples, sutures or skin glue Participants were randomised to receive: o Minimum 100 ml saline solution irrigation using a 30-60mL syringe (271 randomised, 251 completed follow up) Infection rate measured with culture taken at 0 weeks and completion of follow up (5-6 weeks) Rate of healing measured as percent decrease in wound area at 2 weekly intervals and measured with ruler and tracings Development of wound infection assessed at 48 to 72 hours in person by blinded clinicians using clinical signs and symptoms. For patients unable to return, a phone interview with parent was conducted to determine infection (ED review: 165 saline irrigation group versus Results Wound infection in open fractures (1 RCT): no significant difference, RR 0.49, 95% CI 0.19 to 1.26, p=ns Cooled boiled water versus isotonic saline Wound infection in open fractures (1 RCT): no significant difference, RR 0.83, 95% CI 0.37 to 1.87, p=ns Distilled or cooled, boiled water versus normal saline Wound infection in open fractures (1 RCT): no significant difference, RR 0.65, 95% CI 0.31 to 1.37, p=ns Wound healing rate No significant difference in wound healing rate between groups at week 2, week 4 or week 5-6. End trial result: normal saline 45.34% (mean size: 8.42±6.57) versus tap water % (mean size of 5.36±7.89), p=ns Post irrigation culture No significant difference between groups Saline group 64.51% versus tap water group 58.06%, p=0.40 Participants with a pre- irrigation negative culture and a post- irrigation positive culture did not differ (saline 13.3% versus tap water 9.6%) Development of infection No significant differences between groups, saline group 2.8% (95% CI 1.1 to 5.7%) versus tap water group 2.9% (95% CI 1.2 to 5.9%) Based on wound location, foot wounds were 4.4 times more likely to be infected if irrigated with tap water (relative risk 4.4, 95% CI 0.6 to 33.1, p=not reported) Volume of fluid used 1.c Low 1.c Moderate 237 Volume 24 Number 4 December 2016

31 Ref Type of Study Bee, 2009 Systematic review including 4 RCTs comparing tap water to saline for wound cleansing 4 RCTs included (all included in other SRs and this review) Dayton, 2013 Systematic review including 9 studies that compared bathing to not bathing post surgical foot wounds (9 case series or prospective observational studies) Sample Intervention(s) Outcome Measures & Length of Follow-up Requiring sutures, staples or skin glue Exclusion criteria: Immunocompromised Complicated lacerations (e.g. joints; tendon,cartilage, fascia or muscle involvement; viscous cavity, genitourinary, eyelids, mouth, fractures, foreign bodies) Current or prophylactic use of antibiotics Participant characteristics: No significant difference in age, gender, ethnicity, wound duration, wound mechanism, type of anaesthesia or type of wound closure. Tap water group had more hand lacerations (9.2% versus 21.3%) Trials were primarily conducted in emergency rooms in Australia, US and Sweden Study inclusion: Limited to RCTs and quasi- RCTs 4 RCTs comparing use of tap water with use of sterile saline were identified for inclusion No exclusion criteria based on participant characteristics Participant characteristics: Total 1228 participants across 4 studies (636 treated with saline, 592 treated with tap water) Wounds varied between studies but covered acute, chronic and soft tissue wounds, simple wounds and traumatic lacerations Location not reported. Study inclusion: Limited to case series and prospective observational studies Studies compared normal hygiene to abstaining from bathing following surgery on foot or ankle Search included research focused on different soap products but results not presented Participant characteristics: Not reported o Minimum of 10 seconds (a4pprox. 1.5 ml) tap water irrigation, with tap run for 30 seconds before commencing irrigation and wound placed directly under faucet or when not possible, tubing from faucet was used to irrigate wound over a basin (259 randomised, 239 completed follow up (151 in ED and 88 by phone) Tap water cleansing versus sterilesaline cleansing Normal hygiene versus abstaining from washing following surgery The normal hygiene groups ranged from immediate permission to wash to waiting up to 5 days, although most studies had a time period of washing within 1-2 days (n=1639 participants) The control groups generally abstained from washing until after staples/sutures were removed (n=511 participants) Studies appeared to use tap water but no specific details were provided 152 in tap water group; phone review 86 in saline irrigation group versus 88 in tap water group) Positive wound culture Wound infection identified via objective or subjective outcome measures Surgical site infection the method of assessing was not reported Results More fluid was used in the tap water group 7,140mL (interquartile range [IQR] 3,570 to 14,280) compared with the saline group 300mL 25% to 75% (IQR 180 to 400) Positive wound culture (2 RCTs, n = 662) No significant heterogeneity Non- significant favouring of Saline (3.1% versus 4.4%, relative risk [RR] 1.53, 95% CI 0.79 to 2.99, p=0.21) Infected wound (4 RCTs, n=1228) No significant heterogeneity Significant favouring of tap water (4.3% versus 7.1%, RR 0.62, 95% CI 0.39 to 1.01, p=0.05) Surgical site infection There was no significant difference in infection rates between washing the surgical site in tap water with bandage removed to abstaining from hygiene in any of the 9 included studies 1.a Low 1.b Low 238

32 Ref Type of Study Quieros, 2014 Systematic review comparing sterile saline with tap water for reducing wound infection and promoting healing 3 RCTs included Griffiths, 2001 RCT comparing tap water to normal saline for irrigating wounds Sample Intervention(s) Outcome Measures & Length of Follow-up The studies were RCTs conducted in US and Australia. Participants were adults with lacerations, acute or chronic wounds presenting in an emergency department in two studies. Inclusion criteria: Both studies only included wounds without significant complication (e.g. not full thickness, not involving joints, not requiring surgical debridement) Exclusion criteria: In both studies patients with significant comorbidities (e.g. diabetes, immunosuppressed) were excluded Patients taking antibiotics were excluded Sterile saline wound irrigation (n=326) versus Tap water irrigation (n=357) In one study, fluids were at room temperature In both studies, fluid was delivered with force using syringe Wound infection (the trials used different criteria to define infection) Participants were recruited from two community health centres in Australia (n=43 patients with 60 wounds randomised, n=35 patients with 49 wounds completed follow up) Inclusion criteria: Acute or chronic non- sutured wound of Grade II (partial thickness skin loss down to epidermis and/or dermis) or Grade III (full thickness skin loss down to but not including fascia) Exclusion criteria: Immunosuppressed Existing infected wound Skin graft, skin graft donor sites, wounds with sinus, unbroken skin wounds, full thickness wounds extending into muscle, bone or supporting structures Use of antibiotics Participant characteristics: Mean age 78.9 years (SD 12.63) Mean wound duration (range 3 to 365) days in tap water group and (range 14 to 2098) days in saline group Mean wound size mm2 (range 9 to 2123) in tap water group and mm2 (range 14 to 1695) in saline group More laceration in saline group (16 versus 8) All wounds received irrigation via syringe and cannula with fluid at wound temperature All wounds had exudate removed with gauze prior to cleansing Participants were randomised to receive either: o Cleansing with tap water dispensed from the health centre faucet within the previous 24 hours and stored in an empty, cleaned saline bottle (n=23 wounds) o Normal saline stored in the same type bottle that had its seal removed within the previous 24 hours (n=26 wounds) Wounds were dressed with appropriate dressings and patients kept dressing dry Assessment of wound at baseline and 6 weeks by researcher and by community nurse at each dressing change using a standardised tool Assessment of healing done with a wound grid and a cotton bud to measure depth Wound classified as healing when epithelial tissue present Wound infection was determined using Cutting s criteria and purulent exudate was considered to indicate infection Results Wound infection rate (2 RCTs, n=683) Tap water was more effective than saline in preventing wound infection, however the result was not significant (OR 0.79, 95% CI 0.36 to 1.72, p=0.55) Wound infection rate at 6 weeks Overall incidence 6.1% (all in saline group) No significant difference in infection rate between groups (p>0.05) Wound healing at 6 weeks No significant difference in complete healing between healing in tap water group versus saline group (34.7% versus 61.5%, p>0.05) Amount of irrigation fluid used No significant difference between volume of water used compared to saline (p>0.05) 1.a High quality 1.c Moderate quality 239 Volume 24 Number 4 December 2016

33 Ref Type of Study Fellows, 2006 An observational study exploring contamination rate of home- made saline solution Sample Intervention(s) Outcome Measures & Length of Follow-up More venous ulcers and pressure injuries in tap water group (11 versus 7) Samples were prepared in a home health agency and tested by a registered hospital laboratory Samples were made of saline using a 1- gallon (3.78 litres) bottle of distilled water with 8 teaspoons of table salt to make isotonic saline Storage: 2 bottles were stored in the refrigerator at 9 C and 5 bottles were stored at room temperature (26 C) Samples were cultured weekly for 4 weeks at a hospital laboratory Moscati, 2007 RCT exploring infection rate in wound irrigated with sterile saline versus tap water Participants were a non- consecutive sample of people attending emergency departments (ED) in three hospitals in US (n=711 randomised, n=634 completed follow- up and analysed) Inclusion criteria: Aged 18 years Uncomplicated skin laceration requiring sutures or staple repair Exclusion criteria: Puncture wounds, self- inflicted wounds Wound 8 hours old on presentation Wound involving tendon, joint or bone Wound with gross contamination requiring scrubbing or debridement Peripheral vascular disease, immunocompromised, corticosteroids Pregnancy Taking antibiotics Participant characteristics: Approximately 27% wounds on head/neck, 66% on upper extremity, 7% on lower extremity Primarily sharp force injuries Mean wound length 2.8 to 3cm (range 0.5 to 15) Reuse of wound dressing products (including reusing irrigation fluids) Aras and Sussman, 2000 Observational study exploring the contamination of Samples of three products: Hydrogel in a plastic pack with long nozzle with snap tip (Instrasite) Amorphous gel in a plastic tube with screw All participants received anaesthesia prior to irrigation and closure of wound with sutures or staples following irrigation No participants received antibiotics Participants were randomised to receive: o Tap water irrigation directly under faucet (extremities) or using a clean tube. Participants attended own irrigation and were instructed to irrigate under tap water for a minimum of 2 minutes (n=300) o Irrigation by clinician with sterile saline via 35mL syringe and splash shield (n=334) Twenty packs of each item were opened after hand washing and using clean disposable latex gloves and away from the patient Wound infection assessed at follow- up between 5 and 14 days later assessed in ED by blinded health professionals or, for patients not returning to ED, assessed over the phone by blinded callers Cost of intervention, estimated based on cost of supplies at one of the centres Amount of bacterial growth compared to a control growth environment Results Culture results room temperature At 1 week the saline at room temperature 50% contained 6000 cfu/ml bacillus species At 2 weeks 50% samples contained 50%>50,000 cfu/ml Pseudomonas pickettii and 50% contained >25,000 cfu/ml bacillus species Culture results refrigerator No growth until 4 weeks At 4 weeks 1 sample contained 600 cfu/ml Pseudomonas species Wound infection rate Sterile saline 3.3% versus tap water 4.0% Difference in wound infection rate was 0.7% (95% CI 2.25% to 3.64%, p=not significant) Relative risk for infection in tap water group was 1.21 (95% CI 0.5 to 2.7) Irrigation costs Including costs for equipment, water and additional use of antibiotics associated with higher infection rate, costs of tap water was estimated at $US 0.91/patient versus $US 9.11 for sterile saline No contamination in any packs on day 1 On day 14, on pack of intrasite gel that had been used on day 1 and 7 had 3.e Low quality 1.c Moderate quality 2.c 240

34 Ref Type of Study hydrogels after opening Zwanziger and Roper, 2002 Observational study exploring contamination of reusable products stored in patient homes Gouveia, 2007 Observational study investigating level of contamination on reused saline flasks Wound dressing practice Lawson, 2003 Cohort study comparing sterile versus clean dressing procedure for open surgical wounds Sample Intervention(s) Outcome Measures & Length of Follow-up on cap (Solugel) Hyroactive gel with metal tub and plastic screw on cap (Duoderm hydroactive gel) Convenience sample of 17 home sites within one homecare agency in the US Samples: 47 wound care products were selected for inclusion in the study. Small sample placed on a tongue depressor for application Package recapped and put into original packaging Procedure repeated on days 1, 7, 14, 21 (note, procedure was in front of patient on day 21) On day 7,14,21 and 28 a sterile syringe was used to withdraw a 1ml sample from the packaging of 5 of the 20 packs for testing for contamination Supplies were used in the home setting by nurses, caregivers and patients. Supplies were either: o opened, unused items (e.g. gauze squares, irrigation solution) (n=12) or o reusable items such as scissors, plastic wound measure guides that were cleaned with alcohol between uses. (n=35) Equipment was stored in the home in a variety of different containers Swabs were taken from the products in the home on day 7 (n=26) and day 14 (n=21) Swabs were taken from 3 control products (unopened gauze) stored at the home agency office. Sterile equipment, procedure and storage used to attain samples for testing. Culture swabs were taken from all products. Convenience sample of randomly selected saline bottles in 22 health care centres in Spain (n=44) Saline flasks were randomly selected from the emergency room (ER) and an outpatient clinic at 22 centres Saline solution flasks were mixed, the top was disinfected with sodium hypochlorite and 5 ml samples removed with a syringe and needle. Swabs were also taken from the saline flask transfers Samples were seeded on sterile agar plates Level of contamination (colony forming units [CFU]/ml) Participants were gastrointestinal, trauma, transplant, general surgery and urology adult patients Inclusion criteria: open surgical wound healing via secondary intention Dressing changes three times daily with In the first 3 month period nurses were attending open surgical wounds using sterile technique (not described but procedure required sterile gloves, scissors or bowls) (1,070 admissions, unknown how many had open surgical wound) Wound swab for cultures unclear how it was determined if a wound should be swabbed Results growth On day 21 no samples had growth On day 28 no samples had growth Control samples No bacterial colony growth found in control. Samples from home sites Day 7 5 types of organisms identified in cultures Day 14 7 types of organisms identified 75% of samples were contaminated The longer the sample was stored in the home, the more contaminants found More virulent bacterial strains were located on reusable products (e.g. scissors) 54.5% of saline solution flasks were contaminated (CFU/ml ranged from 1 to 230) 50% samples contaminated in saline solutions, 37.5% contaminated on transfer and 12.5% contaminated at both sources ER flasks were significantly more likely to be contaminated compared to outpatient flasks (p=0.01) Contamination is likely due to the use of the saline flasks for multiple patients Surgical site infection rate identified via wound culture through infection control tracking was not significantly different (0.84% versus 0.83%, p=ns) Surgical supply budget was $380 less in one unit of three months Time to attend dressings decreased from Moderate quality 3.e Very low quality 3.e low quality 3.c Very low 241 Volume 24 Number 4 December 2016

35 Ref Type of Study Mercei, 2004 RCT comparing dressing versus no dressing following surgery Selim 2001 Action research qualitative study aimed at promoting effective clinical practice with respect to cleansing wounds in the community Poole and Coughlan, 2002 Cross- sectional survey on change in practice for aseptic technique normal saline Exclusion criteria: None stated Participant characteristics: None supplied Sample Intervention(s) Outcome Measures & Length of Follow-up Consecutive sample of children undergoing surgery over a 4 year period in a hospital in Jordan (n=451) Inclusion criteria: Clean surgical wound Exclusion criteria: Central venous catheter insertion Participant characteristics: 11.3% abdominal wounds, 80% groin wounds, 6.4% head and neck wounds, 2.2% thoracic wounds No further demographics reported Three community nursing regions in Australia Commenced with 7 participants but decreased to 3-4 members after initial meetings. Participants were community health nurses engaged in the research and quality improvement process. Convenience sample of 2 general practices in UK (total population served, n=23,150) Inclusion criteria: Prescribed for district nurses, practice nurses and at least one nursing home with > 60 beds Able to provide data from computer In the second 3 months nurses received education in attending clean dressings and used this technique for open surgical wounds (not described but procedure did not require sterile gloves, scissors or bowls) (963 admissions, unknown how many had open surgical wound) Participants were randomized by birth date to: Wound dressing following surgery (n=216) Wound left exposed following surgery (n=235) Participants with exposed wounds were permitted to shower, does not report if those with dressings also showered. Participatory action research including literature review, focus groups, surveys and attempted RCT. Data is reported as a commentary of the action research process and includes some quantitative reporting of survey results and some qualitative/opinion evidence on rationale for changing practice and effectiveness of education. Education session delivered to nurses in the sample practices on a changed procedure for aseptic technique that requires use of a sterile plastic field and sterile gloves in place of a dressing pack. Nurses were given 3 months to Follow- up was conducted in the outpatient department 1 week after discharge from hospital but within 30 days of surgery For patients not presenting to outpatients, follow- up was via telephone consultation Definition of a wound infection was not reported Results approximately 13 mins to approximately 10 mins Wound infection rate There was no significant difference in infection rate between wound left exposed and wounds covered (1.7% versus 1.4%. p=ns) N/A Major findings Aseptic technique requires a sterile dressing pack and sterile cleansing solution.[c] Clean technique allows irrigation or bathing with saline or tap water and performing using a clean surface for dressing equipment.[c] Patients with VLUs may feel more comfortable when the whole leg is washed with warm tap water rather than confining cleansing to the wound bed. [C] Concern about potential infection is a barrier to uptake of clean technique in community settings. [C] Influencing sustained change in dressing technique practice requires long term strategies. [UE] Survey collected data for the 3 month prior to practice change and 3 month after practice change. Data included: o Number dressing packs used Dollars spent on dressing Number of dressing packs used Reduced in both practices following change of procedure (practice one from 240 to 10 dressing packs, practice 2 from 405 to 130 dressing packs) Money spent on dressing packs Reduced in both practices following change 1.c Low 3 (meaningfuln ess) High quality 4.b Very low quality 242

36 Ref Type of Study Education in aseptic technique Sample Intervention(s) Outcome Measures & Length of Follow-up system Participant characteristics: No description of participants or wounds involved in this study Results implement new practice packs of procedure (practice one from 154 to 23 UK pounds, practice 2 from 261 to 130 UK pounds) Jackson 2012 Before/after study investigating effectiveness of aseptic technique education and factors influencing knowledge Ribu, 2003 Observational study exploring the ways in which nurses attend leg ulcers in community care Medical students in ne medical school in UK were invited to participate (phase 1 total 112 students, phase 2 total 72 students) Inclusion and exclusion criteria not reported Participant characteristics: Year 3 and Year 5 medical students Participants were recruited in a municipality in Norway. Inclusion criteria (patients, n=32): Adults 21 years Living at home and receiving home care one leg or foot ulcer Inclusion criteria (nurses, n=31): Registered nurse in community care Treated foot/leg ulcer during study Participant characteristics: Patient mean age 79±0.47 years Ulcer duration ranged 6 weeks to 20 yrs Nurses had mean practical experience ranging 3 months to 32 yrs Nurse mean age range 23 to 54 Phase one: Year 3 medical student participants were trained and assessed in aseptic non touch technique in week 1 of clinical placement. A sub- sample were reassessed and interviewed in week (n=112, assessed in week 1 and n =46 underwent reassessment in week 10) Phase two: Years 3 and 5 students participated in a written questionnaire on aseptic technique during final exams (n=72). Focus group was held with 4 students and interviews with 3 nurse educators/manager Content of education program was not detailed in depth but was based on 4 key principles: o always wash hands effectively o touch non- key parts with confidence o take appropriate infective precautions o never contaminate key parts Student nurses (n=30) volunteered to be observer data collectors, working in pairs Observers received training in the observation tool (n=35 wound care events observed) Observation of clinical procedure using a non- validated tool with 11 items. Students given a pass or fail grade (uncertain how this score was determined) Questionnaire in phase 2 had 63 items with strong internal consistency of α=0.76 Methods for interviewing not described in detail. Semi- structured observational instrument developed to audit actual practice against recommended practice Data included handwashing and aseptic technique, as well as care practice for ulcers Data was collected by 2 raters in pairs who observed the same procedure then completed the data collection tool independently (overall, 89% observations were in agreement, 83% hand washing observations were in Phase one results two cohorts There was a significant decrease in pass rate from week 1 to week 10 (cohort 1: 95% vs 9%, p<0.001; cohort 2: 96% vs 33%, p<0.001) Most common error leading to failure was failure to use clean surface 46% of participants stated in interview that a contributing factor to failure was not using aseptic non touch technique in daily practice Phase two questionnaire and interviews 9.7% had not received formal aseptic non touch technique training Students exhibited doubt about the validity of aseptic non touch technique Students expressed difficulty in remembering steps of aseptic non touch technique Poor role modelling was identified as a contributing factor to failure to perform aseptic non touch technique correctly Lack of resources was identified as a contributing factor to failure to perform aseptic non touch technique correctly Wound cleansing 63% used normal saline to cleanse ulcer 20% cleansed with tap water Hand washing 43% washed hands before and after procedures 60% washed hands before procedure 60% washed hands after procedure Approximately 10% of nurses with poor hand hygiene explained it as a result of the unhygienic nature of the patient home 2.d Very low quality 3.e Very low quality 243 Volume 24 Number 4 December 2016

37 Ref Type of Study Staff attitudes and behaviours Sample Intervention(s) Outcome Measures & Length of Follow-up agreement) Data was qualified with interviews after the procedure Results Unsworth and Collins 2011 Qualitative study exploring how nurses negotiate performing aseptic technique in community settings Nurse practitioners in community settings (n=10) Inclusion criteria: nurse practitioner qualification minimum of 2 years experience performs aseptic technique in community setting Participant characteristics: median age 44.8 yrs (range 33-58) Initial training in asepsis conducted mean 26 yrs prior (range 12 to 34 yrs) All participants were interviewed regarding how they adapt their clinical care and negotiate the home setting to maintain asepsis Researchers observed each nurse attending procedures requiring aseptic technique for three different patients Researchers used an auditing tool based on the standardised procedure manual to document ways nurses problem solved performing aseptic technique N/A Major findings District nurses are aware that performing aseptic technique in community settings is a challenge.[c] Aseptic technique principles are ingrained in initial nurse training and community nurses maintain knowledge of important principles.[c] Community nurses receive no guidance in how to adapt the principles of aseptic technique to the home setting and patient preferences. [C] Lack of choice in dressing packs from the formulary hinders the performance of asepsis in community settings. [C] Community nurses choose clean hard surfaces at wound height to create a sterile field, however this is often on the floor for a leg ulcer dressing. [C] Community nurses display confusion regarding clean technique and the use of tap water, often leading to sterile field contamination due to failure to separate wound washing from aseptic procedure.[c] Hallett 2000 Qualitative research exploring fatalistic attitudes to aseptic technique Community health nurses in the UK (n=7) Inclusion criteria: Not reported Participant characteristics: Nurses were from a range of different experience levels Participants were selected to engage in semi- structured interviews with 4 researchers Fatalistic philosophical perspective, phenomenological methodology, semi- structured interviews and interpretative data analysis using a predetermined stance of fatalism N/A Major findings Community nurses perceive they have a lack of control over cleanliness and therefore risk of infection. [C] Community nurses use the term aseptic technique vaguely as they perceive asepsis as impossible in the home environment. [C] Asepsis is viewed as both a process that includes specific behaviours and practices (e.g. sterile field and gloves) and a phenomenon (being contaminant free). [C] Some community nurses view infection as unavoidable. [C] Aseptic technique is a term used to describe a routinized practice that includes identifying a dirty hand and a clean hand. [C] 3 (meaningfulness) Moderate quality 3 (meaningfulness) Moderate quality 244

38 REFERENCES 1. Ngo QD, Vickery K, Deva AK. The effect of topical negative pressure on wound biofilms using an in vitro wound model. Wound Repair Regen 2012;20(1): James GA, Swogger E, Wolcott R et al. Biofilms in chronic wounds. Wound Repair Regen 2008;16(1): Sandy-Hodgetts K, Carville K, Leslie G. Determining risk factors for surgical wound dehiscence: a literature review. Int Wound J 2015;12: Leaper D, Ousey K. Evidence update on prevention of surgical site infection. Curr Opin Infect Dis 2015;28(2): Roodsari GS, Zahedi F, Zehtabchi S. The risk of wound infection after simple hand laceration. World J Emerg Med 2015: DOI /wjem.j Sarwat T, Rashid M, Rastogi V, Chander Y. A comparative study of antibiogram of Pseudomonas aeruginosa in hospital- and community-acquired infections. Int J Curr Microbiol App Sci 2015;1: Gillespie BM, Fenwick C. Comparison of the two leading approaches to attending wound care dressings. Wound Practice & Research 2009;17(2): Unsworth J. District nurses and aseptic technique: where did it all go wrong? Br J Community Nurs 2011;16(1): Watret L, McClean A. Cleansing diabetic foot wounds: tap water or saline? Diabetic Foot Journal 2009;12(3):5p. 10. Hallett CE. Infection control in wound care: a study of fatalism in community nursing. J Clin Nurs 2000;9(1): Unsworth J, Collins J. Performing an aseptic technique in a community setting: fact or fiction? Prim Health Care Res Dev 2011;12(1): Australian Commission on Safety and Quality in Health Care (ACSQHC), Standard 3: Preventing and Controlling Healthcare Associated Infection. Safety and Quality Improvement Guide. Sydney: ACSQHC: National Health and Medical Research Council. Australian Guidelines for the Prevention and Control of Infection in Healthcare. Commonwealth of Australia, Joanna Briggs Institute. Reviewers Manual Adelaide: Joanna Briggs Institute, Joanna Briggs Institute, Reviewers Manual 2014: Summary of Findings Tables for Joanna Briggs Systematic Reviews. Adelaide: Joanna Briggs Institute, Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 2009;6(6):e Aras PS, Sussman G. The clinical contamination of amorphous hydrogels. Primary Intention 2000;8(4): Bansal BC, Wiebe RA, Perkins SD, Abramo TJ. Tap water for irrigation of lacerations. Am J Emerg Med 2002;20(5): Fellows J, Crestodina L. Home-prepared saline: a safe, costeffective alternative for wound cleansing in home care. J Wound Ostomy Continence Nurs 2006;33(6): Gouveia JCF, Miguéns CIM, Nogueira CLS, Alves MIP. Is it safe to use saline solutions to clean wounds? EWMA J 2007;7(2): Griffiths RD, Fernandez RS, Ussia CA. Is tap water a safe alternative to normal saline for wound irrigation in the community setting? J Wound Care 2001;10(10): Jackson D, Wall D, Bedward J. The sociocultural contribution to learning: why did my students fail to learn Aseptic Non- 245 Touch Technique? Multidimensional factors involved in medical students failure to learn this skill. Med Teach 2012;34(12):e Lakshmi R, Andrews R, Chumber S. A study to compare the effectiveness of normal saline vs tapwater in irrigation of chronic wounds. Int J Nurs Educ 2011;3(1): Lawson C, Juliano L, Ratliff CR. Does sterile or nonsterile technique make a difference in wounds healing by secondary intention? Ostomy Wound Manage 2003;49(4): Merei JM. Pediatric clean surgical wounds: is dressing necessary? J Pediatr Surg 2004;39(12): Moscati RM, Mayrose J, Reardon RF, Janicke DM, Jehle DV. A multicenter comparison of tap water versus sterile saline for wound irrigation. Acad Emerg Med 2007;14(5): Poole M, Coughlan A. Use of sterile dressing packs: challenging tradition. Nurs Times 2002;98(25): Ribu E, Haram R, Rustøen T. Observations of nurses treatment of leg and foot ulcers in community health care. J Wound Ostomy Continence Nurs 2003;30(6): Valente JH, Forti RJ, Freundlich MS, Zandieh SO, Crain EF. Wound irrigation in children: saline solution or tap water? Ann Emerg Med 2003;41(5): Zwanziger PJ, Roper S. Bacterial counts and types found on wound care supplies used in the home setting. J Wound Ostomy Continence Nurs 2002;29(2): Bee TS, Maniya S, Fang ZR et al. Wound bed preparation cleansing techniques and solutions: a systematic review. Singapore Nursing Journal 2009;36(1): Dayton P, Feilmeier M, Sedberry S. Does postoperative showering or bathing of a surgical site increase the incidence of infection? A systematic review of the literature. Foot Ankle Surg 2013;52(5): Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev 2012(2). 34. Fernandez R, Griffiths R, Ussia C. Effectiveness of solutions, techniques and pressure in wound cleansing. JBI Reports 2004;2(7): Fernandez RS, Griffiths RD, Ussia C. Wound cleansing: which solution, what technique? Primary Intention 2001;9(2): Queirós P, Santos E, Apóstolo J, Cardoso D, Cunha M, Rodrigues M. The effectiveness of cleansing solutions for wound treatment: a systematic review. JBI Database of Systematic Reviews & Implementation Report 2014;12(10): Selim P, Bashford C, Grossman C. Evidence-based practice: tap water cleansing of leg ulcers in the community. J Clin Nurs 2001;10(3): Aziz AM. Variations in aseptic technique and implications for infection control. Br J Nurs 2009;18(1): Blunt J. Wound cleansing: ritualistic or research-based practice? Nurs Stand 2001;16(1): Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee. Society for Healthcare Epidemiology of America. Association for Professionals in Infection Control. Infectious Diseases Society of America. Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol 2002;23(12 Suppl):S Clark AP, John LD. Legal and ethical. Nosocomial infections and bath water: any cause for concern? Clin Nurse Spec 2006;20(3): Volume 24 Number 4 December 2016

39 42. Cunliffe PJ, Fawcett TN. Wound cleansing: the evidence for the techniques and solutions used. Prof Nurse 2002;18(2): Ellis T. CPD: understanding the act of contamination in wound dressing procedure... including commentary by Dreimanis D and Rice J. Collegian 2004;11(3): Flores A. Sterile versus non-sterile glove use and aseptic technique. Nurs Stand 2008;23(6): Friedman MM. Infection control update for home care and hospice organizations. Home Healthc Nurse 2003;21(11): Gannon R. Wound cleansing: sterile water or saline? Nurs Times 2007;103(9): Gilmour D. Is aseptic technique always necessary? Journal of Community Nursing 2000;14(4): Gray M, Doughty DB. Clean versus sterile technique when changing wound dressings. J Wound Ostomy Continence Nurs 2001;28(3): Grossman S, Mager DD. Managing the threat of methicillinresistant Staphylococcus aureus in home care. Home Healthc Nurse 2008;26(6): Hampton S. Nurses inappropriate use of gloves in caring for patients. Br J Nurs 2003;12(17): Hart S. Using an aseptic technique to reduce the risk of infection. Nurs Stand 2007;21(47): Karch AM, Karch FE. Clean vs sterile : are sanitary napkins and diapers acceptable as wound dressings? Am J Nurs 2001;101(4): Lewis G. ANTT clinical competencies for nursing students... aseptic non touch technique (ANTT). Australian Nursing Journal 2009;17(4): O Neill D. Can tap water be used to irrigate wounds in A&E? Nurs Times 2002;98(14): World Health Organisation. WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care. Switzerland: WHO, Parker L. Applying the principles of infection control to wound care. Br J Nurs 2000;9(7): Pegram A, Bloomfield J. Wound care: principles of aseptic technique. Mental Health Practice 2010;14(2): Platt C. Wound cleansing: is tap water best? Primary Health Care 2005;15(5): Preston RM. Aseptic technique: evidence-based approach for patient safety. Br J Nurs 2005;14: Rowley S, Clare S. ANTT: a standard approach to aseptic technique. Nurs Times 2011;107(36): Rowley S, Clare S, Macqueen S, Molyneux R. ANTT v2: an updated practice framework for aseptic technique. Br J Nurs 2010;19(Supp 1):S Schremmer RD. New concepts in wound management. Clin Pediatr Emerg Med 2004;5(4): Spear M. Wound care management. Wound cleansing: solutions and techniques. Plast Surg Nurs 2011;31(1): Swanson J, Jeanes A. Infection control in the community: a pragmatic approach. Br J Community Nurs 2011;16(6): Towler J. Cleansing traumatic wounds with swabs, water or saline. J Wound Care 2001;10(6): Whaley S. Tap water or normal saline for cleansing traumatic wounds? Br J Community Nurs 2004;9(11): Wilkins RG, Unverdorben M. Wound cleaning and wound healing: a concise review. Adv Skin Wound Care 2013;26(4): WOCN Wound Committee. Clean vs. sterile dressing techniques for management of chronic wounds: a fact sheet. J Wound Ostomy Continence Nurs 2012;39(2S):S30 s Rowley S, Clare S. ANTT Core Clinical Guidelines 2016, Association for Safe Aseptic Practice: about.html. Wound Practice and Research THANK YOU On behalf of the Editorial Board, Joint Editors Allison Cowin and Michael Woodward sincerely thank all reviewers who contributed to the 22 manuscripts that were published this year in Volume 24. Thank you to Donna Angel, Judith Barker, Keryln Carville, Kerrie Coleman, Ann Marie Dunk, Kathleen Finlayson, Laurence Foley, Nikki Frescos, Anne Gardner, Chris Jackson, Chloe Jansz, Donald MacLellan, Kerry May, William McGuiness, Sue McLennan, Katy Melrose, Charne Miller, Julie Miller, Stuart Mills, Pam Morey, Geraldine Moses, Rachael Murray, Jenny Prentice, Tabatha Rando, Jan Rice, Dianne Smith, Terry Swanson, Sue Templeton and Lyn Thomas. Special thanks to those who reviewed multiple manuscripts. The voluntary contribution that each reviewer makes contributes greatly to the high standards that Wound Practice and Research strives to achieve. 246