ASEPTIC NON - TOUCH TECHNIQUE (ANTT) Procedure ICPr014

Transcription

1 ASEPTIC NON - TOUCH TECHNIQUE (ANTT) Procedure ICPr014 version.icpr014 review March 20

2 Version Date Date of Next Reason for Change (eg. full rewrite, No. Ratified/ Implementation Review amendment to reflect new Amended Date legislation, updated flowchart, minor amendments, etc.) 1 01/03/16 Changed from policy to procedure 2 01/03/ /03/2020 Review of procedure no changes version.icpr014 review March 20

3 TABLE OF CONTENTS INTRODUCTION... 4 ASEPTIC NON TOUCH TECHNIQUE (ANTT)... 4 WHEN SHOULD AN ANTT BE USED?... 5 EQUIPMENT REQUIRED FOR ANTT:... 5 CLEAN DRESSING TECHNIQUE... 8 WHO SHOULD UNDERTAKE AN ANTT OR CLEAN TECHNIQUE?... 9 Community Setting... 9 Using Saline Aerosols, Saline Pods, Creams and Ointments... 9 Microbiology of your Hands... 9 Resident Skin Flora:... 9 Transient Skin Flora:... 9 EQUALITY CONSIDERATIONS REFERENCES AND BIBLIOGRAPHY Appendix 1 - Competency for Aseptic Non Touch Technique (ANTT) in Wound Management Page 3

4 INTRODUCTION Aseptic technique is the methods developed to keep the patient as free from infections as possible by ensuring that only uncontaminated equipment and fluids make contact with sterile or susceptible body sites during certain clinical procedures. The aim also is to prevent transfer of micro-organisms from one person to another or from one site of the patient s own body to another of their more susceptible body site (Endogenous infections). Aseptic technique should be used during any procedure which bypasses the body s natural defences therefore should be used where sterile body areas are entered, there is tracking to deeper areas or when the patient is immuno-compromised. Consider the following as high risk of infection requiring the use of an ANTT: Urinary catheterisation (except in cases where the patient performs Intermittent Self Catheterisation (ISC) when it is then a clean procedure) Surgical Wounds (up to 48 hours post op) Dressing an invasive device, e.g. intravenous line, wound drain Insertion of intrauterine device/system Insertion/removal of contraceptive implant Burns Deep wounds into sterile areas Bones / tendons exposed Patients with arterial insufficiency (ischaemic / arterial ulceration) Immuno-compromised patients e.g. Diabetes, receiving chemotherapy, high dose steroids Babies Patients with chronic disease or poor nutritional status A Clean Technique is a modified ANTT. Sterile materials are required, but the dressing technique can be simplified. A Clean Technique adopts the same aim and objectives as an ANTT, but uses clean rather than sterile single use gloves and potable (drinking) tap water. A risk assessment must be undertaken to ensure this process is appropriate for the patient and type of wound being dressed. A Clean technique may be considered to dress wounds healing by secondary intention e.g. surgical wounds (over 48 hours post op), pressure ulcers or leg ulcers, simple grazes, staple or suture removal. If these wounds enter deeper sterile body areas or the patient is immune-compromised, then an ANTT must be used. ASEPTIC NON TOUCH TECHNIQUE (ANTT) ANTT is a method used to prevent contamination of wounds and other susceptible sites by ensuring that only sterile objects and fluids come into the contact with these sites and that the risk of contamination is minimised. Aseptic technique requires adequate hand decontamination, the use of appropriate personal protective equipment, preparation of the environment and maintenance of a sterile field at all times. It is important that all sterile packaged equipment is stored in a clean, dry, dust free environment. A clean technique is a modified aseptic technique. Sterile materials are required, but the dressing technique can be Page 4

5 simplified. A Clean Technique adopts the same aim and objectives as an ANTT, but uses clean rather than sterile single use gloves and potable (drinking) tap water. A risk assessment must be undertaken to ensure this process is appropriate for the patient and type of wound being dressed. Qualified clinical staff or assistants who are assessed as competent should perform an ANTT or clean technique Competency Document Appendix 1. If a qualified nurse delegates wound management to an assistant, they retain responsibility and accountability for that delegation (NMC, 2008). The dressing trolley or surface used should be cleaned with detergent and water and then wiped with an alcohol wipe before and after each use that day. However, if contaminated with any body fluids between use the trolley should again be washed with detergent and water before using alcohol wipe. If procedure is done in the patient s own home then the surface used should be as clean as possible. Aseptic technique where hands although clean, do not contaminate the sterile field can be achieved by using a no-touch technique by using sterile forceps or sterile gloved hands. WHEN SHOULD AN ANTT BE USED? When a clean technique is insufficient in relation to the patient s risk assessment, e.g. sterile body areas are entered, there is tracking to deeper areas or the patient is immunocompromised. Consider the following as high risk of infection requiring an ANTT: Sutured or stapled surgical wounds (up to 48 hours post op) When dressing an invasive device, e.g. intravenous line, wound drain Burns Bones / Tendons exposed Deep wounds into sterile areas Patients with arterial insufficiency (ischaemic / arterial ulceration) Immuno-compromised patients e.g. diabetes, receiving chemotherapy, high dose steroids Babies Patients with chronic disease or poor nutritional status EQUIPMENT REQUIRED FOR ANTT: Sterile dressing pack containing plastic tray, gauze swabs, gloves, apron, wound measure, sterile field, disposable bag e.g. Softdrape or Dressit (Richardson Healthcare) or Nitrile Lilac Polyfield Patient Pack (Premier) Sterile fluids for cleansing and / or irrigation Hypo-allergenic tape (if non-adhesive dressings) Page 5

6 Appropriate dressing (See Northants Dressing Formulary on Intranet) Alcohol hand gel Extra equipment that may be needed during procedure, e.g. sterile scissors for cutting primary dressings 70% alcohol wipes and paper towels for cleaning trolley Action 1 Always read care/plan documentation available prior to procedure 2 Explain and discuss the procedure with the patient 3 Wash hands with liquid soap and dry with paper towels (recommended) AND apply alcohol gel to all areas of physically clean hands 4 Clean trolley (if available) with soap and water (dry with paper towels). Apply 70% alcohol solution and allow to dry 5 Place all the equipment required for the procedure on the bottom shelf of the clean dressing trolley 6 Position the patient comfortably. Ensure the area is easily accessible without exposing the patient unduly Rationale Essential to the provision of safe and effective care To ensure that the patient understands the procedure and gives his or her valid consent Clean hands before and after every patient contact and before commencing ANTT, to prevent cross-infection To provide a clean working surface To allow the top shelf to be used as a clean working surface To allow any airborne organisms to settle before the sterile field and the wound is exposed. Maintain the patient's dignity and comfort 7 Clean hands with alcohol hand gel To reduce the risk of wound infection 8 Check the dressing pack is sterile i.e. the pack is undamaged, intact and dry. Open the outer cover of the sterile pack and slide the contents onto the top shelf of the trolley. 9 Open the sterile field using only the corners of the paper 10 Check other packs are sterile and open by carefully tipping their contents onto the centre of the sterile field To ensure that only sterile products are used So that areas of potential contamination are kept to a minimum To prepare the equipment and reduce the amount of time that the wound is exposed. This reduces the risk of infection and drop in wound temperature, which may delay wound healing To reduce the risk of cross infection 11 Put on a disposable plastic apron from the dressing pack 12 Clean hands with alcohol gel Hands may become contaminated by handling outer packets, etc. Page 6

7 Action 13 Place hand inside disposable bag and arrange contents of dressing pack 14 Remove used dressing, hand covered with the disposable bag, invert bag and stick to trolley or if dressing too complex e.g. leg ulcer, use non-sterile gloves without touching the surface of the wound 15 If using saline sachets, swab along the tear area with 70% alcohol wipe. Tear open sachet and pour saline into indented plastic tray 16 Put on sterile gloves, touching only the inside of the wrist end- NB: At this point if i.e. inserting a urinary catheter continue as Urinary catheter procedures for inserting catheter 17 If signs of clinical infection, take a wound swab. Cleanse wound first if contaminated by debris / exudates. Use swab in a zigzag movement across the wound to yield sufficient growth for culture 18 If using saline pods or aerosol, creams or ointments, do not touch containers with contaminated gloves. If containers are handled, do not continue dressing the wound without new sterile gloves. 19 Redress wound with appropriate dressings 20 Ensure the patient is comfortable 21 Remove gloves. Dispose of waste as per Trust Policy - Waste Management Procedure Guidelines FIN 03a - Plastic bags should not be left in patient room in the mental health wards. 22 Clean trolley with soap and water (dry with paper towels). Check that the trolley is dry and physically clean 23 Wash hands with liquid soap and dry with paper towels 24 Document procedure and update care plans appropriately in patient records Rationale To maintain sterility of items in dressing pack To minimise risk of contamination, by containing dressing in bag To minimise risk of contamination of sachet To reduce the risk of infection. Gloves provide greater sensitivity than forceps and are less likely to cause trauma to the wound To remove colonising bacteria. To determine correct antibiotic therapy Do not use antiseptic solution (e.g. Octenilin) prior to taking a wound swab as this may impact on the result To prevent cross infection To prevent wound infection See Northants Dressing Formulary To prevent environmental contamination To reduce the risk of spreading infection To reduce the risk of spreading infection Essential to the provision of safe and effective care Page 7

8 CLEAN DRESSING TECHNIQUE This is a modified technique that can be used for wounds healing by secondary intention, e.g. pressure ulcers, leg ulcers, dehisced surgical wounds (over 48 hours post op wounds that break open), simple grazes, staple or suture removal. However, a risk assessment must be undertaken to ensure this process is appropriate for the type of wound being dressed and if these wounds enter deeper sterile body areas or the patient is immuno-compromised, then an ANTT must be used. The advice of a specialist Tissue Viability Nurse should be sought when dealing with chronic pressure ulcers or other complicated wounds. The basic principles of ANTT must be adopted and sterile dressing pack and sterile dressing materials used: Dressing trolley must be cleaned before use Clean gloves rather than sterile gloves can be used Good quality drinking (potable) water or cooled boiled water can be used instead of sterile saline Preventing infection is as important as when using ANTT therefore use a Non touch technique where possible Table - 1 Differences between clean technique and ANTT ANTT Areas When used During any procedure that bypasses the body s natural defence, such as where sterile body areas are entered, there is tracking to deeper areas or when the patient is immunocompromised. Hand Wash with liquid soap and dry decontamination with paper towels (recommended) AND apply alcohol gel to all areas of physically clean hands Clean Technique Gloves Sterile Non-sterile For wounds healing by secondary intention, e.g. pressure ulcers, leg ulcers, dehisced surgical wounds, simple grazes, and staple or suture removal. Wash with liquid soap and dry with paper towels recommended) AND alcohol gel to all areas of hands if physically clean Buckets / bowels can be used for washing ulcerated legs using a clean technique. The purpose is personal hygiene of the lower leg and foot. Avoid aggressive washing of the wounds when possible. Do not use this technique if patient develops a fungal foot infection as there is potential to spread infection to ulcerated areas. Keep the bucket / bowl exclusively for this purpose, line with a clean plastic bag and wash with hot soapy water between uses. Dry thoroughly and store upside down. Page 8

9 WHO SHOULD UNDERTAKE AN ANTT OR CLEAN TECHNIQUE? Qualified clinical staff or assistants who are assessed as competent should perform an ANTT or Clean Technique (Competency Document - Appendix 2). If a qualified nurse delegates wound management to an assistant, they retain responsibility and accountability for that delegation (NMC, 2008). Community Setting When carrying out dressing procedures in patients homes, the healthcare worker does not have specific equipment as in a hospital / clinic setting e.g. a dressing trolley. Therefore adaptations and creativity are often required to ensure the environment is conducive to the procedure being performed and the equipment remains sterile or clean. The use of a clean surface such as table or a chair should be used to arrange the dressing equipment. Using Saline Aerosols, Saline Pods, Creams and Ointments Saline aerosols, saline pods, creams and ointments all carry the risk of cross infection if used incorrectly. All of the above should be Single Patient Use Only in all care settings. For example, a tub of Aqueous Cream should not be used for multiple patients, even with the use of wooden spatulas. The outside of tubs, aerosols, pods and tubes cannot be classed as clean. When using these items, ensure you don t touch them with dirty gloves as this increases the risk of cross infection. If you touch the containers with clean gloves, ensure you do not then touch a patient s open wound. Microbiology of your Hands Your hands are colonised by resident and transient bacteria. Resident Skin Flora: These comprise mainly Gram-positive organisms of low pathogenicity, e.g. diphtheroids, micrococci, coagulase negative staphylococci (S. epidermidis). Their function is mainly protective and they are difficult to remove without the use of a disinfectant hand wash. HOWEVER, these organisms are opportunists and may cause infection if introduced into a wound. Alcohol hand gel will slow down bacterial growth. Transient Skin Flora: These comprise of Gram-negative and positive organisms, many of which are harmful to man if introduced into a susceptible site or to a susceptible person, e.g. coliforms - Klebsiella, Proteus, Acinetobacter, E.coli and MRSA. These organisms particularly favour Page 9

10 damp conditions, e.g. under rings and false nails, but they can be found on all parts of the hands, clothing and in the environment. Healthcare workers must ensure good hand hygiene. The wearing of protective clothing, e.g. gloves and an apron will provide a barrier between microbes present on hands and clothing and the susceptible site, e.g. a wound. Our duty of care in the NMC Code (2008) also extends to controlling the environment wherever possible. A dusty or dirty environment increases the risk of infection. An open packet of gauze or a dressing may soon become contaminated. Discard all opened packets of gauze or dressing products at the end of every procedure. Do not tape down and use for the next dressing change. Large amounts of microorganisms are shed into the air when a dressing is removed, therefore, this should be undertaken carefully. EQUALITY CONSIDERATIONS The author has considered the needs of the protected characteristics in relation to the operation of this policy and protocol to align with the outcomes with IP&C Assurance Framework. We have identified that ensuring that communication reaches all vulnerable groups. The service has been designed to ensure communication relevant to any outbreaks or other healthcare associated infections reaches all sections of the community. This includes taking into consideration communication barriers relating to language or specific needs to reach the whole population. IP&C work closely with multi agency groups and community partners where appropriate we will undertake engagement and outreach activity. We targeted action to relevant groups follow public health England s communication framework. Some groups are particularly vulnerable in relation to their protected characteristics, e.g. age, ethnic minority communities and disability and where we identify that, the expectation is that staff will meet the needs appropriately. Page 10

11 REFERENCES AND BIBLIOGRAPHY Department of Health (2003) Winning Ways: working together to reduce healthcare associated infection in England. Report from the Chief Medical Officer. DOH: London. Department of health (2007) Essential Steps to safe, clean care. London: DH Dougherty L, Lister S (eds) 2004) The Royal Marsden Hospital Manual of Clinical Nursing Procedures 6th edition. Oxford: Blackwell Publishing. Infection Control Nurses Association (2003) Asepsis: Full compliance with Aseptic technique is essential. ICNA, Bathgate. Mangnall J, Watterson L. (2006) Principles of aseptic technique in urinary catheterisation. Nursing Standard, 21:8 p Pratt RJ, Pellowe CM, Wilson JA et al (2007) epic2: National Evidence- Based. Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. The Journal of Hospital Infection 655,S1-S64. Xavier G (1999) Asepsis. Nursing Standard; 13:36, p National Institute for Clinical Excellence (NICE) (2003) Infection Control: Prevention of Healthcare Associated Infections in Primary and Community Care London: NICE. Department of Health (2006)The Health Act: Code of Practice for the Prevention and Control of Healthcare Associated Infections London DH Department of Health (2008) The Health and Social Care Act: Code of Practice for the Prevention and Control of Healthcare Associated Infections and related guidance London DH NHS Litigation Authority - Page 11

12 Appendix 1 - Competency for Aseptic Non Touch Technique (ANTT) in Wound Management Name:... Job Title:... Band:... Work Place:... Date Assessed:... Element 1 Read care plans/documentation available prior to procedure 2 Explained and discussed the procedure with the patient. 3 Washed hands with liquid soap and dried with paper towels (recommended) AND applied alcohol hand gel to all areas of physically clean hands. 4 Cleaned trolley (if available) with soap and water (dried with paper towels). Applied 70% alcohol solution and allowed to dry. 5 Placed all the equipment required for the procedure on the bottom shelf of the clean dressing trolley. 6 Positioned the patient comfortably. Ensured the area was easily accessible without exposing the patient unduly. 7 Cleaned hands with alcohol hand gel. 8 Checked the dressing pack was sterile i.e. the pack is undamaged, intact and dry. Opened the outer cover of the sterile pack and slid the contents onto the top shelf of the trolley (or alternative surface available). 9 Opened the sterile field using only the corners of the paper. 10 Checked other packs were sterile and opened by carefully tipping their contents onto the centre of the sterile field. 11 Put on the disposable plastic apron from the pack. 12 Cleaned hands with alcohol hand gel. 13 Placed hand inside sterile disposable bag and arranged contents of dressing pack. 14 Removed used dressing from patient, hand covered with the disposable bag, inverted bag and stuck to trolley/or used non-sterile gloves, without touching any open wounds. 15 If using saline sachets, swabbed along the tear area with 70% alcohol wipe. Poured saline into indented plastic tray. 16 Put on sterile gloves, touching only the inside of the wrist end. 17 If using saline pods or aerosol, creams or ointments, did not touch containers with contaminated gloves. Did not continue dressing the wound without new sterile gloves. 18 Redressed wound with appropriate dressings. Achieved? Y/N Page 12

13 Element 19 Ensured that the patient was comfortable. 20 Removed gloves. Disposed of waste as per Trust Policy - Waste Management Procedure Guidelines FIN 03a. 21 Cleaned trolley with soap and water (dried with paper towels). Checked the trolley was dry and physically clean. 22 Washed hands with liquid soap and dried with paper towels. 23 Documented procedure and updated care plans appropriately in patient records 24 Any equipment that became contaminated during the procedure was discarded. Achieved? Y/N The healthcare worker will only be assessed as competent at ANTT if ALL elements are completed. If any one element is failed the healthcare worker must be assessed again. Assessed by competent ANTT Assessor: Signature:... Print Name:... Job Title:... Band:... Work Place:... Click here to return to the table of contents Page 13