Tissue Viability Policy - Practice Guidance Note Aseptic Non Touch Technique V01 Date issued Issue 1 Jan 16 Planned review January 2019 TV-PGN-03 Part of NTW(C)18 Tissue Viability Policy Author/Designation Responsible Officer / Designation Kevin Chapman Tissue Viability - Modern Matron Damian Robinson - Director of Infection Prevention and Control [DIPC] Contents Section Description Page No 1 Introduction 1 2 Principle of Asepsis 3 3 Key References and Bibliography 9 Document No Appendix listed separate to practice guidance note Description Issue Issue Date Review Date Appendix 1 Wound Care using ANTT 1 Dec 15 Dec 18 Practice Guidance Notes form part of the NTW(C)18 Tissue Viability Policy. It is expected that staff will follow the guidance contained within them unless there is a compelling reason to deviate from it. Such reasons should be documented whenever the circumstance occurs and notified to the Tissue Viability Modern Matron where appropriate 1. INTRODUCTION 1.1 Definition 1.1.1 Aseptic non touch technique is the method used to prevent contamination of wounds and other susceptible sites by potentially pathogenic (harmful) organisms. This can be achieved by ensuring that clinical staff understand the principles, follow recommended protocols and use only sterile equipment and fluids during invasive procedures. 1.1.2 Asepsis should be maintained when carrying out a variety of procedures inclusive of handling equipment prior to carrying out invasive procedures e.g. wound dressings, accessing enteral/peg feeding preparation and administration, and urinary catheter insertion and continuing care. (Pratt et al 2007) 1
1.1.3 A theoretical framework has been developed using research based evidence. This framework is known as Aseptic Non Touch Technique (ANTT). ANTT is a standard for safe and effective aseptic practice which can be applied to all clinical procedures. It standardises practice and rationalises the many different techniques currently in use. 1.1.4 The principles of ANTT are advocated by Northumberland, Tyne and Wear NHS Foundation Trust (the Trust/NTW) as the acceptable standard for undertaking aseptic procedures. 1.1.5 Poor aseptic technique and asepsis may lead to cross contamination of pathogenic microorganisms (Preston 2005). The estimated incidence of healthcare associated infections in England is 8.2 % (National Audit Office 2009). 1.1.6 Whilst it is recognised that adaptation is required when carrying out aseptic technique procedures in secondary care settings and within the patient s own home, the healthcare professional must adapt the procedure to ensure the environment is conducive to the procedure and that the equipment remains sterile or clean. 1.2 Rationale 1.2.1 Aseptic non touch technique must be used during any invasive procedure which breaches the body s natural defences e.g. the skin, mucous membranes. It is also to prevent introducing harmful bacteria into a susceptible site or wounds from hands, surfaces or equipment e.g. when handling equipment, such as performing urinary catheterisation, which will enter a normally sterile area. 1.2.2 Aseptic non touch technique also prevents the transfer of harmful bacteria from the susceptible site or wound to staff and other patients, equipment or environments. 1.3 Scope 1.3.1 The contents of this practice guidance note (PGN) apply to all clinical staff employed by or working on behalf of the Trust who are required to carry out these procedures as part of their role and job description. 1.4 Purpose 1.4.1 The purpose of this PGN is to provide staff with evidence based aseptic non touch technique guidelines which, Minimise the risk of introducing potentially pathogenic organisms into a wound or other susceptible site during aseptic or aseptic non-touch techniques Prevent the transfer of organisms capable of causing infection to other susceptible sites, patients or staff 2
Prevent the contamination of specimens obtained for diagnosis 1.4.2 The key principles of ANTT are: Always decontaminate hands effectively Never contaminate key parts of the equipment or the patients susceptible site Touch non key parts of the equipment with confidence Take appropriate infection prevention and control precautions 1.4.3 When should an aseptic non touch technique be used? When dressing wounds healing by primary intention, e.g. surgical wounds, burns, self-harm injuries When dressing wounds healing by secondary intention, e.g. pressure sores, leg ulcers, simple grazes, removing drains or sutures When inserting, re-siting or dressing an invasive device, e.g. urinary catheter When the patient is immunocompromised 1.4.4 Who should undertake an aseptic technique Only perform the procedure if you are correctly trained and competent in doing so or adequately supervised if in a learning capacity. Note: wound dressing should not be taken down for a ward round unless there is a clinical need to see the wound 2 PRINCIPLES OF ASEPSIS 2.1 Hand decontamination Hand washing is the single most important procedure for preventing healthcare acquired infection as hands have been shown to be the common route of transmission of infection Hands should be washed and thoroughly dried and alcohol hand rub/foaming sanitizer applied. This will reduce or remove and destroy transient micro-organisms (Refer to Trust s NTW(C)23 Infection, Prevention and Control Policy, practice guidance note - IPC-PGN-04.1 - Hand Hygiene and use of alcohol rub) 3
2.2 Barriers Using protective equipment Protective clothing must be worn to: prevent transfer of potentially pathogenic bacteria from patient to staff or staff to patient Sterile gloves must be worn Wearing gloves prevents direct contact from the hands and the susceptible site or wound Disposable aprons are water repellent and impermeable to bacteria. Wearing an apron will prevent contamination of user s clothing from becoming soiled, wet or stained during patient care activities Aprons and gloves must be changed or removed after each episode of care. (Refer to Trust s NTW(C)23 - Infection, Prevention and Control Policy, practice guidance note, IPC-PGN-02.1 - Standard Precautions) Maintaining a safe environment The purpose of maintaining a safe environment is to reduce possible contamination of the susceptible site and the environment If the ward has a clinical room this should be where all procedures which require an aseptic non touch technique are performed Expose the wound for the minimum time to avoid contamination and maintain temperature Limit the number of people in the room during the procedure The environment including any dressing trolley musts be cleaned and disinfected in preparation before and after use (Refer to Trust PGN IPC-PGN-10 - Disinfection and decontamination practice). Dispose of clinical / offensive waste correctly (Refer to Trust s policy NTW(O)24 - Waste Management) 4
Patient preparation Explain the procedure to the patient Position the patient comfortably so that the procedure can be easily performed Ensuring the patient is fully aware of the procedure will improve concordance and reduce the likelihood of them inadvertently compromising the sterile field Preparing and maintaining a sterile field Where appropriate, perform the aseptic non touch technique in a clean environment, such as a treatment/clinical room or service users own single room Where used the dressing trolley must be cleaned with detergent and water and thoroughly dried. The trolley must then be disinfected using an alcohol wipe specifically for surfaces. A dressing trolley should not be used for any other purpose. Any sticky tape residues must be removed from the trolley rails. (Refer to the Trust s NTW(C)23 - Infection, Prevention and Control Policy, practice guidance note, IPC-PGN-10 Disinfection and decontamination practice) Place all of the equipment required for the procedure on the bottom shelf of the trolley. Making sure that the dressing pack and any equipment is undamaged, dry and intact Open the dressing pack and using only the corners place the sterile field onto the trolley Sterile items do not come into contact with non-sterile objects this includes not only products used during the procedure but also the final dressing. This will prevent the susceptible site or wound from being contaminated during the procedure Only sterile items come into contact with the susceptible site or wound 5
If staff have no access to an appropriate trolley then the procedure should be performed in the most sterile area possible, treatment room, clients own room etc. The Trust recommended sterile wound packs should be used which contain the majority of items required for an average wound. Where staff anticipate the need for additional items such as Sterile tweezers, additional dressing etc these should be gathered before the procedure and opened and decanted onto the sterile field without contaminating them Always Use: o Use Standard (Universal) Precautions. Refer to the Trust s NTW(C)23- Infection, Prevention and Control Policy, practice guidance note - IPC-PGN-02.1 - Standard Precautions o Dispose of single-use items after one use o Dispose of single patient use items after treatment o Store sterile equipment in clean, dry conditions, off the floor and away from potential damage o Dispose of waste as per local policy o Minimise interventions e.g. Peeking at wounds Equipment o Appropriately sized (S,M,L) Sterile dressing pack, containing an indented plastic tray or gallipots, low-linting swabs and gloves, sterile field, dressing towel and disposable bag o Fluids for cleaning and /or irrigation o If required a syringe for irrigation or a sterile saline pod o Clean dressing trolley (where available) o Appropriate dressings (NTW(C)18 - Tissue Viability Policy, practice guidance note TV-PGN-04 - Wound Management to be issued early 2016) o Wound assessment form o Any other material will be determined by the nature of the dressing: special features of a dressing should be referred to in the service users care plan and wound assessment form o Do not carry out this procedure if you have not been assessed and deemed competent 6
2.3 Procedure 2.3.1 Key Stages of ANTT Before every clinical procedure staff must review the whole procedure to ensure the principles of ANTT will be applied and followed throughout. Prior to the procedure perform a robust risk assessment for the procedure, the environment and specific client risk factors Make sure service user is aware of the procedure, is comfortable and where appropriate has received any prescribed pain medication Staff must be bare below the elbow Staff must always decontaminate hands before and after a procedure using ANTT and when putting on and removing gloves. Refer to the Trust s NTW(C)23 - Infection, Prevention and Control Policy, practice guidance note IPC-PGN-04.1 - Hand Hygiene and use of alcohol rub available on the Trust Intranet site. If hands are contaminated during a procedure then gloves must be removed and hands decontaminated prior to donning new gloves Staff must ensure the patient area is visibly clean, free of dust and soilage before commencing clinical procedures using ANTT The ideal environment for ANTT procedures at ward level is a designated clinic room. Where this is impractical, clinical procedures performed at the patients bedside must not occur directly after activities such as bed making which may contribute to airborne contamination. Windows must also be kept closed and fans turned off during the clinical procedure Staff must consider whether the procedure can be performed with or without touching the key parts of the equipment or the key sites of the patient. If it is possible to undertake the procedure without touching the key parts/sites then non sterile gloves can be used. If it is not possible to perform the procedure without touching the key parts/sites then sterile gloves must be used 2.3.2 Keysites - Are open wounds, including insertion and puncture sites 2.3.3 Keyparts Are the parts of the procedure equipment that come into direct or indirect contact with any liquid infusion or keysites and with any active keyparts connected to the patient. If contaminated they present a very high risk of infection to the patient 7
Examples of procedures that usually require non sterile gloves include leg ulcer management, venepuncture. Examples of procedures that require sterile gloves include urinary catheterisation and the majority of wound dressings.(specialist advice is available from the TVN or specific dressing documentation) Ensure procedure trays or trolleys are cleaned thoroughly with neutral detergent and hot water or a sanitising wipe and allowed to thoroughly dry before use All the packaging of the necessary equipment must be checked for damage, expiry dates and sterility. If the pack has been sterilised by autoclaving ensure the autoclave indicator tape has consistent beige and brown lines If using a sterile pack the contents must be slid out onto the procedure tray/ trolley and opened using only the corners of the sterile paper/cloth Equipment and the patients susceptible site will need to be cleaned as appropriate for the clinical procedure being performed A non-touch technique must be used. Only non-key parts of the equipment must be handled. For example when touching a syringe with a needle you would handle the syringe but not the needle which is a key part. If a key part is to be handled then sterile gloves must be worn i.e. inserting fingers into a wound cavity Appropriate infection prevention and control precautions must be taken. Personal protective equipment must be worn following an individual risk assessment of the clinical procedure, the patient, the level of exposure and risk of splashing of bodily fluids Following the clinical procedure gloves and other personal protective equipment must be removed and disposed of appropriately in line with Trust Waste management policy All sharps must be disposed of safely and immediately at the point of use. Refer to the Trust s NTW(C)23 - Infection, Prevention and Control Policy, practice guidance note IPC-PGN-03.1 - Safe use and disposal of sharps The clinical procedure which has been undertaken must be documented in the patient s health care records. (RiO) (An example of using ANTT for wound dressing in Appendix 1) Complete any formal wound assessment form enter planned date for reassessment and ensure care plans are updated 8
Symbols and their meanings 1998-06 30 Use by date, i.e. use by 30th June 1998 1996 06 Date of manufacture, i.e. manufactured during June 1996 Do not re-use, Single use, Use only once Batch code 3 KEY REFERENCES Prevention and control of healthcare-associated infections in primary and community care (NICE, 2012) Available at: http://www.nice.org.uk/guidance/cg139/resources/guidance-infection-pdf Infection Control Nurses Association. (ICNA) 2003. Asepsis: Preventing Healthcare Associated Infection. www.icna.co.uk epic2: National Evidence Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection Supplement 1 Volume 65 February 2007 National Institute for Clinical Excellence Infection Control Prevention of Healthcare Associated Infection in Primary and Community Care. June 2003 Essential steps to safe, clean care. Department of Health July 2006 Bibliography Ayliffe G. A. J., Fraise A.P., Geddes A. M., Mitchell K., (2000) Control of Hospital Infection: A Practical Handbook 4 th edition, Arnold Publishers, London. Department of Health (2007) Saving lives: a delivery programme to reduce healthcare associated infection including MRSA revised edition, HMSO, London. Department of Health (2008) The Health and Social Care Act, Department of Health, London, December 2010. Dougherty L and Lister S (eds) (2008) The Royal Marsden Hospital manual of clinical nursing procedures 8 th edition, WileyBlackwell, Chichester. epic2: National EvidenceBased Guidelines for Preventing healthcare Associated infections in NHS Hospitals in England (2007) Journal of Hospital Infection, 65S, pp S1S64. 9
Infection Control Nurses Association (2003) Asepsis: Preventing Healthcare Associated Infection, Fitwise in association with shermond, Bathgate. Preston R.M (2005) Aseptic technique: evidence based approach for patients safety British Journal of Nursing 14 (10) pp 540542, 544546 Rowley S (2001) Aseptic non touch technique Nursing Times 97 (7) pp 68. 10