Equality and Diversity Lead Assessment

Aseptic Technique Policy - HH(1)/IC/674/13 Previous document(s) being replaced Location Policy Policy Name WEHCT CP060 Aseptic Technique Policy BNHFT IC/372/09 Principles of Asepsis and Aseptic Technique Document Summary Aseptic technique is often performed as a nursing ritual and has been based more on tradition than on rational reason or evidence based research. This policy outlines the principles of asepsis and aseptic technique based on recent evidence and best practice standards. It reflects both local and national guidelines on infection prevention and control and clarifies the role of every staff member in this aspect of clinical practice. This policy applies to all HHFT staff that carry out aseptic procedure as part of their clinical responsibilities. Ownership Author Karen Davis-Blues Job Title Infection Prevention and Control Nurse Document Type Level Level 1 Trust wide Related Documents Document Details See section 11 Relevant Standards CQC Outcome Outcome 8 NHSLA Standard N/A Equality Impact Completed by Equality and Diversity Lead Assessment Date Completed 1 October 2013 Final Document Approval Committee Policy Approval Group Date Approved 23 September 2013 Final Document Committee Executive Committee Ratification Date Ratified 26 September 2013 Authorisation Authoriser Mary Edwards Job Title Chief Executive Officer Signature Date Authorised 3 October 2013 Dissemination Target Audience All Trust Staff Dissemination and Implementation Plan Action Owner Due by Publicise detail of new document via Intranet and Midweek message Communication to all Senior Managers to advise publication of policy The policy will be available on the intranet and web site Review Expiry date July 2016 Review date March 2016 IPCT and Communication Team HHFT Healthcare Library HHFT Healthcare Library and Communication Team Within 1 week of publication On publication Within 1 week of authorisation Page 1 of 19

Document Control Document Amendments Version. Details Key amendments to note By whom Date 1 Review of BNHFT & WEHCT policies to produce harmonised HHFT policy Appendix B Karen Davis- Blues June 2013 Page 2 of 19

Contents 1. Introduction... 4 2. Purpose... 4 3. Scope... 5 4. Explanation of Terms... 5 5. Duties... 6 6. General Principles for Aseptic Technique... 7 7. Indications for Aseptic Technique... 8 8. Assessment... 8 9. Sterile Packaging Symbols... 9 10. Classification of Aseptic Technique Procedures... 9 11. Aseptic Technique Procedures... 9 12. Stakeholders Engaged During Consultation... 9 13. Dissemination and Implementation... 10 14. Training... 10 15. Monitoring Compliance with the Document... 10 16. References... 10 17. Associated Documentation... 11 18. Contributors... 11 Appendix A Equality Impact Assessment... 12 Appendix B Classification of Aseptic Technique Procedures... 14 Appendix C - Procedure for Aseptic Technique... 16 Page 3 of 19

1. Introduction Modern healthcare has brought unprecedented benefits but also risks and no risk is more fundamental than the risk of infection (DH, 2003). Hospital acquired infections (HAIs) or Healthcare Associated Infections (HCAIs) can have serious consequences for patients and may be costing the NHS as much as 1 billion a year (NAO, 2000). The Chief Medical Officer's December 2003 report, Winning Ways: Working together to reduce healthcare associated infection in England acknowledges that infection in hospitals cannot be completely eliminated but they can be substantially reduced. It is therefore important that all reasonable steps are taken to reduce the extent of avoidable hospital acquired infection within individual NHS Trusts. Research shows that one of the most effective ways of containing hospital acquired infections is through the application of a standardised aseptic technique for clinical procedures. The Health Act (2006) laid out a number of Clinical Care Protocols in relation to preventing and controlling the risks of HCAIs and states the following: Clinical procedures should be carried out in a manner that maintains and promotes the principles of asepsis. Education, training and assessment in the aseptic technique should be provided to all persons undertaking such procedures. The technique should be standardised across the organisation. Audit should be undertaken to monitor compliance with aseptic technique. This policy embraces the recommendations from national and local guidelines on infection control and reflects the Trust s commitment in reducing HAI. It is essential that infection control is seen as an organisational responsibility and priority, that adequate isolation facilities and resources are provided, and that appropriate infection control staff and support services are available. 2. Purpose The purpose of the policy is to reduce the risk of infection transmission both to and from patients and staff undertaking a procedure which requires an aseptic technique. Organisms can be transferred from one person to another if techniques to prevent such spread are not adopted. An aseptic technique is the method employed to help prevent contamination of wounds and other susceptible sites by organisms that could cause infection, by ensuring that only uncontaminated equipment and fluids come into contact with sterile or susceptible body sites during certain clinical procedures. It should be used during any procedure that bypasses the body s natural defences. Page 4 of 19

This policy aims to focus upon medical asepsis and the procedures that are currently carried out in ward and other treatment areas, using an aseptic non-touch technique. 3. Scope This policy and procedure will be applied fairly and consistently to all employees and service users regardless of their protected characteristics as defined by the Equality Act 2010 namely, age, disability, gender reassignment, race, religion or belief, gender, sexual orientation, marriage or civil partnership, pregnancy and maternity. For employees this policy also applies irrespective of length of service, whether full or part-time or employed under a permanent or a fixed-term contract, irrespective of job role or seniority within the organisation. Where an employee or service user has difficulty in communicating, whether verbally or in writing, arrangements will be put in place as necessary to ensure that the processes to be followed are understood and that the individual is not disadvantaged during the application of this policy. In line with the Equality Act 2010, the Trust will make reasonable adjustments to the processes to be followed where not doing so would disadvantage an individual with a disability during the application of this policy. This policy complements professional and ethical guidelines and the Nursing and Midwifery Council (NMC) Code of Professional Conduct (NMC 2008). 4. Explanation of Terms Aseptic technique - a practice or procedure undertaken for a patient which is designed to ensure the freedom from microbial contamination. Asepsis - the method by which microbial contamination during invasive procedures or care of breaches in the skin s integrity can be prevented (ICNA 2003). Two types of asepsis can be classified: medical and full asepsis (Ayliffe, et al. 2000). Medical asepsis - aims to reduce the number of organisms and prevent their spread and is mainly employed in ward areas and some other treatment areas, e.g. Outpatient clinics Full asepsis - is a strict process and includes procedures to eliminate microorganisms from an area and is practised by nurses and other health care workers in operating theatres and some other treatment areas. It is also appropriate in wards and other departments for invasive procedures such as the insertion of a central venous catheter. Page 5 of 19

Clean Technique a modified aseptic technique aimed to avoid introducing micro-organisms to a susceptible site and also to prevent cross-infection to patients and staff (Royal Marsden Manual 2011). It differs from an aseptic technique, as the use of sterile equipment and the environment are not as crucial as would be required for asepsis. The non-touch technique is incorporated as part of a clean procedure i.e. the ends of sterile connections should not be touched or other items that could contaminate a susceptible site. Clean, single-use gloves are worn rather than sterile gloves. Susceptible sites sites which are open to infection i.e. cannula sites, wounds etc Cleaning - the physical removal of micro-organisms and organic material on which they thrive. Disinfection - the removal or killing of potential pathogenic micro-organisms but not usually spores. Equipment - any item of equipment that has direct contact with the patient, be it diagnostic, therapeutic, or for direct patient care (e.g. bed, commode, mattresses). Invasive Procedure - any clinical procedures that by-passes the body s natural defence (e.g. skin or mucous membrane) which includes (but not limited to) insertion of intravascular devices, suturing and insertion of urinary catheters. Micro-organisms - living organisms that are too small to be seen without aid of a microscope. Single Use Only - should be used once and discarded. Single Patient Use Only - to be used for one patient only and discarded following that patient s use 5. Duties Post holders The Chief Executive Officer (CEO) The CEO has overall responsibility for the strategic and operational management of the Trust ensuring there are appropriate strategies and policies in place to ensure the Trust continues to work to best practice and complies with all relevant legislation in regard to aseptic technique. The Director of Infection Prevention and Control (DIPC) - The DIPC is the Trust Director responsible to the board for the delivery of IPC standards. Director of Nursing - The Director of Nursing will ensure that the medical Divisional Directors take clinical ownership of the policy. Divisional Operational Directors - The Divisional Operational Directors will ensure that all healthcare workers comply with this policy and that all healthcare workers Page 6 of 19

attend mandatory infection prevention and control training. They are responsible for ensuring adequate facilities and resources are available to adhere to this policy. Clinical Service Managers/Leads - The Clinical Service Managers/Leads will ensure that the current version of this policy is available in all of their areas. They will ensure that all healthcare workers comply with this policy and that all healthcare workers attend mandatory infection prevention and control training. All Trust employees - All Trust employees will comply with this policy and inform the Infection Prevention and Control Team about any issues or concerns relating to the policy. All staff will attend mandatory Infection Prevention and Control training annually. Infection control is the responsibility of ALL staff associated with patient care. A high standard of infection control is required on ALL wards and units, although the level of risk may vary. It is an important part of total patient care. Groups/Committees Infection Prevention and Control Team (IPCT) - The IPCT will act as a resource for information and support. They will provide education in relation to this policy which includes mandatory training. They will monitor the implementation of this policy via audit within clinical areas and be responsible for regularly reviewing and updating it. Health4Work department (H4W) - The Health4Work department (H4W) will act as a resource for information, and support and consult with managers, the Infection Prevention and Control Team and healthcare workers regarding the use of personal protective equipment. Health and Safety Team - The Health and Safety Team will act as a resource for information, and support and consult with managers, the Infection Prevention and Control Team and healthcare workers regarding the use of personal protective equipment. 6. General Principles for Aseptic Technique The timing of aseptic technique procedures such as re-dressing wounds in a ward area can be an important factor in helping to reduce the risk of infection. They should not be carried out when tasks such as bed-making are taking place, due to the risk of micro-organisms being dispersed into the air and potentially contaminating the sterile equipment or wound. Ideally, they should be carried out at a time when ward activities are less and cleaning activities suspended i.e. windows and fans should be closed and turned off and cleaning suspended for a minimum of 30 minutes. Clean, non-infected wounds should be dressed first; colostomies and infected wounds should be dressed last to minimise environmental contamination and crossinfection. Page 7 of 19

7. Indications for Aseptic Technique Care of wounds healing by primary intention, e.g. surgical incisions and fresh breaks Suturing of wounds Insertion of urinary catheters Insertion, re-siting or dressing intravenous cannulae or other intravascular devices, such as Central Venous Cannulae (CVC) lines, Hickman lines and Arterial lines Insertion of gastrostomy and jejunostomy tubes Insertion of tracheostomy tubes or chest drains Vaginal examination when taking samples (e.g. smear taking, high vaginal swabbing, colposcopy) Assisted delivery (e.g. forceps and ventouse) Biopsies This list is not exhaustive of all procedures that may require an aseptic technique. 8. Assessment Assess the individual patient s infection risk, and plan appropriate care: Is the patient at increased risk of acquiring an infection from others or the environment Does the patient pose an infection risk to those around them? Are they currently colonised or infected with bacteria or a multi-resistant organism? Does the patient have any invasive devices? Consider the patient s age: elderly and neonates are more at risk as their immune systems are less efficient. Does the patient suffer from an underlying disease, i.e. a severe debilitating or malignant disease? Consider the patient s prior drug therapy the use of immunosuppressive drugs or broad-spectrum antimicrobials can increase the risk of infection. Is the patient undergoing surgery or has the patient undergone surgery? (HCAIs are known to present in surgical incision wounds, accounting for 10 30% of all HCAIs). What is the patient s general health status? What is the patient s nutritional state? Has the patient previously been exposed to infection, or does the patient suffer from an existing infection? Page 8 of 19

9. Sterile Packaging Symbols Symbol Used for Symbol Used for Single Use Do not reuse Used by YYYY-MM-DD or YYYY - MM Batch code Serial number Date of Manufacture Sterile 10. Classification of Aseptic Technique Procedures See Appendix B for Classification of Aseptic and Clean Technique procedures. 11. Aseptic Technique Procedures See Appendix C for Aseptic and Clean Technique procedures. 12. Stakeholders Engaged During Consultation Stakeholder Date of Consultation Infection Prevention and Control (Lead Infection Prevention & 24 June 2013 Control Nurse) Health and Safety (Health and Safety Advisor) 12 August 2013 Safeguarding (Trust Safeguarding Lead) 12 August 2013 Information Governance (Information Governance Manager) 12 August 2013 Assistant Risk and Compliance Manager (Risk and Compliance) 12 August 2013 Divisional Directors and Divisional Directors (Operational) 12 August 2013 Equality and Diversity Lead (Equality & Diversity) 12 August 2013 Health4Work 12 August 2013 Infection Prevention and Control Committee 12 August 2013 Consultant Microbiologists 12 August 2013 Clinical Service Managers/Leads 12 August 2013 Operational Service Managers 12 August 2013 Page 9 of 19

13. Dissemination and Implementation The policy will be disseminated in the following ways: Action(s) Publicise detail of new document via Intranet and Midweek message= Communication to all Senior Managers to advise publication of policy The policy will be available on the intranet Owner IPCT and Communication Team HHFT Healthcare Library HHFT Healthcare Library 14. Training Individuals in the Trust should receive annual infection prevention and control training to ensure they are aware of their responsibilities. Education and Training will be provided in accordance with the Trust Training Needs Analysis (Learning and Development Policy). Aseptic technique is taught as part of medical and nurse education. National Vocational Qualification (NVQ) students are also taught aseptic technique as part of their course. Competency self assessment forms for extended roles include aspects of aseptic technique should be reviewed annually by the nurse and their manager during their appraisal. Training on aseptic technique will be provided by the IPCT as part of clinical skills programmes and local assessors will be appointed. 15. Monitoring Compliance with the Document Minimum requirements Effectiveness of policy Requirement Reviewed by Infection Prevention and Control Team Method of Monitoring Audit of peripheral cannula, urinary catheters and central venous catheters Frequency of Review Monthly Monitoring Committee Infection Prevention and Control Committee 16. References References The Royal Marsden Hospital Manual of Clinical Nursing Procedures, Professional Edition 8 th edition April 2011 available on the trust intranet Page 10 of 19

Harris, R., Hyman, R.B. (1984) Clean versus sterile tracheotomy care and level of pulmonary infection. Nursing Research 33: 2, 80-85. Symbols and their meaning: http://www.mhra.gov.uk/publications/postersandleaflets/con076416 Wilson, J (2006), Infection Control in Clinical Practice, 3rd Edition, London: Baillière Tindall Legislation The Health and Social Care Act 2008: Code of Practice on the Prevention and Control of infections and related guidance. December 2010 London DH Guidance from other organisations 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) Department of health (2007) Essential Steps to safe, clean care. London: DH NHS Litigation Authority. http://www.nhsla.com/home.htm 17. Associated Documentation Hand Hygiene Policy Standard Precautions (incorporating Personal Protective Equipment) Policy Cleaning, Disinfection and Sterilisation Policy Prevention and Management of Needlestick-Sharps Injuries and Exposures to Body Fluids Policy Waste Management Policy Care and Management of Central Venous Catheters Policy Peripheral Venous Cannula Insertion and Management (Adults) policy 18. Contributors Contributor Job Title Lead Infection Prevention and Control Nurse Contributor Name Hazel Gray Page 11 of 19

Appendix A Equality Impact Assessment PART 1 To be completed by the document owner Document Title: Aseptic Technique Policy Yes/ Comments 1. Could the application of this document have a detrimental equality impact on individuals with any of the following protected characteristics? (See te 1) Age Disability Gender reassignment Race Religion or belief Sex Sexual orientation Marriage & civil partnership Pregnancy and maternity 2. If you have identified any potential detrimental impact, do you consider this to be valid, justifiable and lawful? If so, please explain your reasoning. 3. If you have answered no to question 2, has the policy been amended to remove or reduce any potential detriment? If you answer yes, please summarise the changes made If you answer no. please explain why not 4. Based on the answers to questions 1 3 do you consider that a detailed equality analysis is needed? N/A N/A NAME: Karen Davis-Blues JOB TITLE: Infection Prevention and Control Nurse DATE: 24 June 2013 Page 12 of 19

PART 2 To be completed by the Trust s Equality and Diversity Lead Brief Summary of potential impact of this document and whether sufficient consideration has been given to the Equality Duty The application of this policy to reduce the risk of infection transmission both to and from patients and staff undertaking a procedure which requires an aseptic technique is completely clinically based, and ensures the appropriate approach would be the priority. However the Trust would endeavour to continue to meet patients and employees individual needs as far as is practicable. 1. Is this document recommended for publication without amendment? 2. Is this document recommended for publication but with recommended amendments? Please specify. Yes/ YES NA Comments 3. Is this document not recommended for publication without amendments being made? Please specify? NA 4. Is it recommended that this document requires a more detailed equality analysis to be undertaken prior to publication? 5. Specify with which, if any, individuals and groups you have consulted in reaching your decision. NA NA NAME: Diane Pittard JOB TITLE: Head of Wellbeing, Inclusivity and Engagement DATE: 1 st October 2013 te 1 Under the terms of the Equality Act 2010 s public sector Equality Duty, the Trust has a legal responsibility to think about the following three aims of the Equality Duty as part of our decision making and policy development. Eliminate unlawful discrimination, harassment and victimisation; Advance equality of opportunity between people who share a protected characteristic and people who do not share it; and Foster good relations between people who share a protected characteristic and people who do not share it. Page 13 of 19

Appendix B Classification of Aseptic Technique Procedures - not an exhaustive list Procedure Technique Environment CVC Insertion Full Asepsis Theatre or Similar Environment Chest Drain Insertion Full Asepsis Theatre or Similar Environment Epidural Insertion Full Asepsis Theatre or Similar Environment Epidural Dressing Change Full Asepsis Theatre or Similar Environment PICC Insertion Full Asepsis Ward/Treatment Room/Clinic Gastrostomy & jejunostomy Full Asepsis Theatre or Similar Environment insertion Suture/Clip Removal Aseptic Technique Ward/Treatment Room/Clinic Re-dressing New Wound/Surgical Wound Aseptic Technique Ward/Treatment Accessing Central/PICC/Hickman Lines Aseptic Technique Ward/Treatment Urinary Catheter Insertion Aseptic Technique Ward/Treatment Sampling from Urinary Catheter Aseptic Technique Ward/Treatment Supra-Pubic Catheter Insertion Aseptic Technique Ward/Treatment Room/Clinic Sampling from Supra-Pubic Catheter Aseptic Technique Ward/Treatment Changing Supra-Pubic Catheter Aseptic Technique Ward/Treatment Treatment Vaginal examination taking Aseptic Technique samples Peripheral Cannula Insertion Aseptic Technique Ward/Treatment Accessing Peripheral Cannula Clean Technique Ward/Treatment Room/Clinic IV Medication Preparation Clean Technique Ward/Treatment IV Medication Administration Clean Technique Ward/Treatment Wound Dressing Removal Clean Technique Ward/Treatment Re-dressing Chronic Wound (e.g. leg ulcers) Clean Technique Ward/Treatment Vaginal examination (e.g. TV US & HSG) Clean Technique Treatment See Peripheral Venous Cannula Insertion and Management (Adults) Policy: Appendix B - Abbreviated guide to Peripheral Venous Cannulation (Adult) Full Asepsis Aseptic Technique Clean Technique Sterile Drapes Sterile Gowns Sterile Gloves Classification of Aseptic Technique Procedures V.1 Page 14 of 19 Authorised by: Policy Approval Group Date: 23/09/13

Sterile aprons Clean Gloves Clean Gown/Apron Hat Mask * * Facial/eye protection * * * * Facial/eye protection should always be worn where there is a risk of contamination of the eyes/mucous membranes during any activity performed. Please read in line with Standard Precautions (incorporating Personal Protective Equipment) Policy. Classification of Aseptic Technique Procedures V.1 Page 15 of 19 Authorised by: Policy Approval Group Date: 23/09/13

Appendix C - Procedure for Aseptic Technique Full Asepsis For PICC Insertion see Care and Management of Central Venous Catheters Policy. For all other procedures refer to Theatre local guidelines. Aseptic Technique 1. Explain the procedure to the patient, obtain consent and position them so the procedure can be performed easily 2. Ensure that your environment is clean and clear before performing an aseptic procedure 3. Ensure that open windows are closed and fans switched off, that your environment is allowed to settle for at least 30 minutes following cleaning/dusting of any kind 4. Wash hands with soap and water in accordance with the Hand Hygiene Policy. Don clean apron and gloves to protect hands and uniform whilst cleaning your procedure trolley 5. Clean trolley with detergent and water/detergent impregnated wipes. Use a systematic backwards and forwards method followed by a front to back method to ensure that the entire surface area of the trolley is cleaned. Clean paper towels may be used to dry the surface of the trolley only when using detergent and water. Flip the top shelf of your trolley over and repeat the same cleaning method on the uppermost surface. Then clean the lower surface using the same method, the four legs and finally the wheels. Disinfect the top shelf of your trolley with a 2% chlorhexidine wipe i.e. PDI Wipe using the same systematic method as demonstrated previously, this time allow to air-dry 6. Remove aprons and gloves, dispose of into orange or tiger stripe waste stream and decontaminate hands. See Waste Management Policy 7. Be prepared - ensure that all required equipment including your Softdrape* sterile dressing pack and a sharps container if necessary, is available and is placed on the lower shelf of your trolley. Check that all packaging is intact and that the products are within their use by date. Take your trolley to the patient s bed-side. te: Catherisation packs do not contain a disposable bag or a sterile apron at present. Procedure for Aseptic Technique V.1 Page 16 of 19 Authorised by: Policy Approval Group Date: 23/09/13

8. Re-wash hands with soap and water in accordance with the Hand Hygiene Policy 9. Open your Softdrape* sterile dressing pack carefully touching only the external corners of the internal pack to prevent contamination of the contents. 10. Decontaminate hands with alcohol gel 11. Remove previous dressing wearing non-sterile gloves or using the disposal bag from Softdrape* sterile dressing pack 12. Wash hands with soap and water 13. Apply the apron and sterile gloves from Softdrape* sterile dressing pack 14. Use aseptic principles to ensure that only sterile items come into contact with the susceptible site. Sterile items should not come into contact with non-sterile objects 15. After completion discard any used sharps straight away directly into sharps box 16. Single use items are to be used once only and must be disposed of after use into the orange/tiger stripe waste stream 17. Waste contaminated with blood/body fluids must be disposed of into the white disposal bag provided with the Softdrape* sterile dressing pack 18. Remove protective clothing apron first followed by gloves and discard into white disposal bag provided. Dispose of your white bag and its contents into the orange/tiger stripe waste stream 19. Wash your hands thoroughly with soap and water to prevent cross infection 20. Clean your trolley with detergent and water/detergent impregnated wipes using the same systematic method as previously used. Return your trolley to the clean utility area 21. Document the procedure carried out, the technique used and the care given. Ensure that the Trust standard for documentation is used e.g. Vascular Access Device (VAD) form, urinary catheter form if required. *Softdrape is a universal latex free dressing pack presented in easy to carry bags of 20 individually wrapped sterile packs and contains all the components required: 1 Large apron 1 Large disposal bag 1 Dressing Towel 1 Pair sterile Vitrex latex-free gloves available to order in three glove sizes 2 Sterile fields 5 Large swabs Procedure for Aseptic Technique V.1 Page 17 of 19 Authorised by: Policy Approval Group Date: 23/09/13

1 Tray 1 Wound Measuring Device Product Code NHS Code Size 908810 EJA045 Small Gloves 908820 EJA046 Medium Gloves 908830 EJA047 Large Gloves Clean Technique 1. Explain the procedure to the patient, obtain consent and position them so the procedure can be performed easily 2. Ensure that you environment is clean and clear before performing a clean procedure. 3. Ensure that open windows are closed and fans switched off and that your environment is allowed to settle for at least 30 minutes following cleaning/dusting of any kind. 4. Wash hands with soap and water in accordance with the Hand Hygiene Policy. Don a clean apron and gloves to protect your uniform whilst cleaning either your procedure trolley or your plastic tray. 5. Clean trolley with detergent and water/detergent impregnated wipes. Use a systematic backwards and forwards method followed by a front to back method to ensure that the entire surface area of the trolley is cleaned. Flip the top shelf of your trolley over and repeat the same cleaning method on the uppermost surface. Then clean the lower surface using the same method, the four legs and finally the wheels. 6. When using a plastic tray for IVs please clean all surfaces inside and out with detergent and water/detergent impregnated wipes as you would the trolley. 7. Disinfect the top shelf of the trolley or the inside of your plastic tray with a 2% chlorhexidine wipe i.e. PDI wipe using the same systematic method as demonstrated previously, allowing to air dry. 8. Remove aprons and gloves, dispose of into orange or tiger stripe waste stream and decontaminate hands. See Waste Management Policy 9. Be prepared - ensure that all required equipment including your Softdrape* sterile dressing pack and a sharps container if necessary, is available and is placed on the lower shelf of your trolley. Check that all packaging is intact and that the products are within their use by date. Take your trolley to the patient s bed-side. If accessing IVs please take the tray to the bed space having disposed of any unnecessary sharps prior to going to the patient s bed space. 10. Re-decontaminate hands either by washing with soap and water or alcohol gel in accordance with the Hand Hygiene Policy. Procedure for Aseptic Technique V.1 Page 18 of 19 Authorised by: Policy Approval Group Date: 23/09/13

11. Removal of dressing wearing non-sterile gloves or using the disposal bag from the Softdrape* sterile dressing pack if doing a wound dressing. 12. Decontaminate hands in accordance with the Hand Hygiene policy. 13. Access IVs in accordance with the Peripheral Venous Cannula Insertion and Management (Adults) policy 14. If redressing a wound please follow aseptic technique from point 14 in Aseptic Technique section above. Procedure for Aseptic Technique V.1 Page 19 of 19 Authorised by: Policy Approval Group Date: 23/09/13