ASEPTIC TECHNIQUE AND ASEPTIC NON- TOUCH TECHNIQUE Clinical Guideline Register No: 08038 Status : Public Developed in response to: Best Practice Health and Social Act 2008 CQC Fundamental Standards: 12 Consulted with: Post/Committee/Group: Date: John Swanson Senior Infection Prevention Nurse October 2017 Infection Prevention Group October 2017 Ellie Makings Chief Medical Officer October 2017 Tom Gudde General Manager, Theatres October 2017 Susan Breitsameter Occupation Health Manager October 2017 Marcie Tunbridge Lead Nurse for Opthalmology October 2017 Margaret Smith Lead Nurse for Tissue Viabiltiy October 2017 Professionally Approved By: Dr. Louise Teare Director of Infection Prevention and Control 7 th December 2017 Version Number 3.0 Issuing Directorate Corporate Nursing Ratified by Document Ratification Group Ratified on 18 th January 2018 Trust Executive Sign Off Date February/March 2018 Next Review Date December 2020 Author/Contact for Information Nicola Gibson/ Lucy Ellis Infection Prevention Nurses Policy to be followed by (target staff) All staff Distribution Method Intranet and Website Related Trust Policies (to be read in conjunction with) 12021 Decontamination policy 04071 Standard infection prevention precautions policy 10078 Fogging Policy 04072 Hand Hygiene Policy Exposure Injuries to BBV 10004 Safe Handling and Disposal of Sharps Policy Prevention of IV Related Infections Document History Review: Version No: Reviewed by: Active Date: 1.0 Infection Control team 2008 2.0 Infection Prevention Team March 2014 3.0 Nicola Gibson/ Lucy Ellis Infection Prevention Nurses 12 th February 2018 1
INDEX 1. Purpose 2. Aims 3. Scope 4. Equality and Diversity 5. Roles and Responsibilities 6. Definitions 7. Principles of Aseptic Non-Touch technique (ANTT) 8. Applying ANTT 9. Audit and Monitoring 10. Training 11. Implementation and Communication 12. References 13. Appendices 1. Appendix 1: The ANTT Approach - a Diagrammatic Representation 2. Appendix 2: Skin Antisepsis 3. Appendix 3; The 6 Principles and 4 Safeguards of ANTT 4. Appendix 4: ANTT Clinical Guideline for the Preparation and Administration of Intravenous Drugs 2
1.0 Purpose 1.1 This policy details the practice framework and the theory for Aseptic Non-Touch Technique (ANTT) as the basis for standardising aseptic technique throughout the Trust. 1.2 The purpose of this document is to provide guidance and rationale to all staff undertaking aseptic technique so as to reduce the contamination of key parts and key sites, thereafter reducing the patient s risk of acquiring healthcare associated infections. 2.0 Aims of the Policy 2.1 The aim of this document is to ensure that all staff understand the principles and practice of ANTT when carrying out all clinical procedures that involve a risk of infection to the patient. 2.2 This document also aims to ensure all staff undertaking aseptic technique apply ANTT to practice effectively. 3.0 Scope 3.1 This policy applies to all staff employed by the Trust on a substantive or temporary basis. 3.2 An aseptic non-touch technique should be used for any procedure that breaches the body s natural defence mechanisms including; Insertion and maintenance of invasive devices Infusion of sterile fluids and medication Care of wounds and surgical incisions (epic3, 2013) 4.0 Equality and Diversity 4.1 Mid Essex Hospital Services NHS Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals. 5.0 Roles and Responsibilities 5.1 Managing Director The Managing Director has overall responsibility for ensuring that the Trust has the necessary management systems in place to enable the effective implementation of this policy and overall responsibility for the health and safety of staff, patients and visitors. 5.2 Chief Medical Officer The Chief Medical Officer has strategic responsibility to ensure that systems are in place to make medical staff aware of this policy and to give appropriate support to enable staff to adhere to practice as outlined in the document. 3
5.3 Director of Nursing The Director of Nursing has strategic responsibility for ensuring systems are in place to facilitate nursing staff awareness of this policy and appropriate support is given to enable staff in delivering practice as outlined in this policy. 5.4 Director of Infection Prevention and Control (DIPC) The DIPC will have operational responsibility for the effective implementation of this policy. 5.5 Infection Prevention and Control Team (IPT) The Infection Prevention and Control Team is responsible for ensuring all staff are made aware of this policy, to cascade ANTT training and undertake ANTT competency assessments for junior doctors on induction. 5.6 Occupational Health Manager The Occupational Health Manager provides the professional leadership for management of needle stick injuries and staff exposure to blood borne viruses. 5.7 All staff All staff must comply with this policy and act in a responsible manner, liaising with the IPT in a timely manner if they need advice or support. All staff who undertake aseptic procedures have the responsibility to ensure that ANTT is embedded into practice and applied consistently at all times. 6.0 Definitions 6.1 Aseptic technique Aseptic technique is defined as the infection prevention precautions taken during invasive clinical procedures to prevent the transfer of micro-organisms from the healthcare worker, the procedure equipment or the immediate environment to the patient. 6.2 Aseptic Non-Touch Technique (ANTT) ANTT is a specific technique which involves maintenance of sterility of key-parts and key-sites and may be applied as standard ANTT or surgical ANTT. (Refer to Appendix 1) 6.3 Standard ANTT Involves technically simple procedures, short in duration (in general less than 20 minutes), and involve smaller key-sites and key-parts e.g. peripheral cannulation and I.V. therapy. 4
6.4 Surgical ANTT Procedures are technically complex, involve extended periods of time, large open keysites or large or numerous key-parts e.g. surgery in operating theatre or central venous catheter insertion in ITU. 6.5 Key sites Key sites are those areas on the patient s body that are vulnerable to infection, such as wounds, entry / exit sites of invasive medical devices and intact skin where invasive devices are to be inserted. 6.6 Key parts Key-parts provide a direct route for the transmission of pathogens into a susceptible site on a patient Key parts are the critical parts of equipment used during the procedure that may come into contact directly or indirectly with a key site on a patient s body. This may be a needle, a hub of a syringe or infusion fluid for example Key parts will be sterile initially, but may become contaminated over time and require decontamination prior to manipulation, such as ports of IV devices 6.7 Aseptic field An aseptic field provides basic protection from the care environment. However, generally the key-parts will be easily protected by caps, covers, and a non-touch technique and so for standard ANTT procedures the aseptic field will often be a clean, disinfected tray. 6.8 Hand Hygiene Hand hygiene is an essential component of ANTT Hand hygiene in Standard ANTT is considered to be the promoter of asepsis and for Surgical ANTT is considered an ensurer of asepsis and demands surgical hand scrub The 5 moments for hand hygiene is reflected in ANTT to reduce the transfer of micro-organisms at all times 6.9 Decontamination and disinfection A single use application of 2% Chlorhexidine in 70% alcohol (e.g. Sanicloth CHG 2% wipes) is recommended to disinfect key-parts such as I.V. ports or blood culture bottles. This should be used for a minimum of 20 seconds and allowed to dry before being accessed (epic3, 2013) Where patients have a sensitivity to Chlorhexidine, povidone iodine in alcohol should be used to decontaminate access ports (epic3, 2013) 70% alcohol (Sanicloth 70) wipes should be used for disinfecting clean trays to be used as an aseptic field Key-sites such as the patient s skin must be disinfected prior to an invasive procedure. Generally single use sterile applications of 2% Chlorhexidine in 70% 5
alcohol (e.g. Chloraprep) is recommended. (Refer to Appendix 2) 7.0 The Principles and Safeguards of ANTT 7.1 The ANTT practice framework is based upon 6 principles and 4 safeguards. (Refer to Appendix 3) 7.2 The principles of ANTT are based on the premises that asepsis is achievable, and asepsis is the common aim of all clinical procedures that entail an infection risk. Asepsis means free from introducing pathogenic micro-organisms onto or into patient. 7.3 To re-enforce asepsis, the terms clean technique and sterile technique are not used in ANTT. 7.4 Principles and safeguards provide a logical and standard set of rules that all staff need to understand in order to apply a safe and effective aseptic technique in a wide range of clinical procedures. 7.5 Safeguards help to ensure asepsis is maintained at all times. 8.0 Applying ANTT 8.1 Clinical guidelines are available for certain procedures (e.g. IV drug administration see Appendix 4) and are a simple way of translating ANTT into practice. They provide a visual guide and prompt sequencing of the steps of a procedure, so standardising equipment and procedure order. 8.2 Risk assessment remains important, as staff will need to apply ANTT principles and safeguards to a range of clinical procedures that do not have guidelines. 8.3 When applying ANTT, staff should carry out a risk assessment based on the technical difficulty of maintaining key part or key site asepsis. This helps to determine the choice of Surgical-ANTT or Standard-ANTT. (Refer to Appendix 1) 8.4 Risk assessment should consider the following in the promotion of asepsis; Aseptic field management Non-touch technique Protection of the key parts and key sites Infection prevention precautions 8.5 The immediate environmental risks such as bed making, high dusting and any patient activity increases the risk of airborne contamination and also needs to be assessed. 8.6 Hand hygiene is an essential component of ANTT and should reflect the six steps technique as outlined in the Hand Hygiene policy (2017). Gloves do not replace the need for hand hygiene. 6
9.0 Audit and Monitoring 9.1 The Infection Prevention and Control Group reviews the Infection Control Policies. 9.2 Associate Directors of Nursing are required to monitor compliance with ANTT and ensure that any necessary remedial action is taken as a result of inappropriate practices and develop localised action plans which are monitored through the Directorate Governance Group for that clinical area. 9.3 Any training needs are identified and highlighted during monitoring within the directorate. 9.4 The results of any monitoring undertaken are appropriately documented, with a copy of the remedial actions sent to the Infection Control Lead Nurse. 10.0 Training 10.1 Any training needs are identified and highlighted during monitoring within the directorate. 10.2 ANTT training is included in the Professional Development programme and Mandatory Risk Management courses that all staff must attend. 10.3 Infection Prevention team will provide ANTT training to be cascaded throughout the organisation. 11.0 Implementation and Communication 11.1 The requirements detailed within this policy are already in place. 11.2 This policy will be issued to the following to disseminate to staff within their area(s) of responsibility; Ward Managers Bed Management Team Associate Directors of Nursing Matrons Clinical Directors Medical Consultants 11.3 The guideline will also be available on the Intranet. 12.0 References Aziz, AM (2008) Variation in aseptic technique and implications for infection control, British Journal of Nursing, Vol. 8, 1(26-31) The Health and Social Act: Code of Practice for the Prevention and Control of Health Care Associated Infections (2008). Department of Health, London Hospital Infection Society (2002) Behaviours and Rituals in the Operating Theatre Journal of Hospital Infection (2002) 51: 241-255 7
Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A, Bak A, Browne J, Prieto J and Wilcox M (2013) epic3; National Evidence Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection, Vol 86 (S1 S70) Rowley. S (2011) Aseptic Non-Touch technique (ANTT) a Practice Framework for Clinical Practice-Theory applied to practice, The Association for Safe Aseptic Practice (ASAP) www.antt.org Rowley. S., Clare. S., Macqueen, S & Molyneux, R (2010), ANTT V2: An update practice framework for aseptic technique, British Journal of Nursing, Rowley, S and Clare, S (2009) Improving standards of aseptic practice through an ANTT trust wide-wide implementation process: a matter of prioritisation and care, Journal of Infection Prevention, Vol. 10 (S18-S23) 8
Appendix 1 9
Skin Antisepsis Appendix 2 Procedure Product Use / Comment CHECK PATIENT S ALLEGY STATUS Pre-operative skin Chlorhexidine 2% in preparation 70% alcohol Single use sterile application (e.g. Chloraprep) preferred Disinfection of skin near eyes prior to ophthalmic theatre procedures Standard skin disinfection prior to all invasive procedures including; Peripheral line insertions Central line insertions Blood culture sampling Epidural lines Lumbar puncture Injection sites; Intramuscular Subcutaneous Venepuncture (but NOT for blood culture sampling) Povidone iodine 10% alcoholic solution 500ml (Videne Alcoholic Tincture) Povidone Iodine antiseptic solution half strength (Povidone Iodine 5% containing 0.5% available Iodine Chlorhexidine 2% in 70% alcohol (Chloraprep). 70% alcohol wipes or Chlorhexidine 2% in 70% alcohol impregnated swabs (Sanicloth CHG 2%) Where multiple-use solution is used the bottle must be labelled with the date of opening and used within 3 months. For invasive procedures in patients allergic or sensitive to Chlorhexidine. Bottle must be labelled with the date of opening and used within 3 months. Chloraprep should be applied to the skin for 30 seconds and then allowed to dry fully. Great Ormond St and Addenbrookes Hospitals recommend and use this product prior to lumbar puncture and there are no adverse effects as long as the prepared skin is fully dry prior to the procedure. Clean the site for 30 seconds and allow to dry. (Skin must be dry for antisepsis to be effective and to ensure that irritation is not caused by the preparation being injected into the tissue) Mucous membranes Povidine iodine 10% antiseptic aqueous solution 500ml (Videne Antiseptic Solution) Wound cleansing Urethral catheter care Traumatic wound cleansing (Theatres / A&E only Sodium chloride 0.9% irrigation fluid 25ml / 100ml sachets Chlorhexidine gluconate 0.015% (Unisept) Note for most invasive procedures, alcohol solutions are deemed more efficient than aqueous (Hospital Infection Society, 2002) NOT for skin decontamination
6 Principles and 4 Safeguards of ANTT Clinical Practice Appendix 3 Principle 1 The aim of ANTT for invasive clinical procedure and maintenance of invasive medical devices is always asepsis Principle 2 Asepsis is achieved by protecting Key-parts and Key-sites from microorganisms transferred from healthcare worker and immediate environment Principle 3 ANTT needs to be efficient as well as safe (Surgical-ANTT is used for complicated procedures and Standard-ANTT for uncomplicated procedures From Surgery to Community Care) Principle 4 Choice of Surgical-ANTT or Standard-ANTT is based on ANTT risk assessment according to the technical difficulty of protecting Key-part and Key-site Safeguard 1 Basic Infection Precautions Basic infection precautions such as hand cleaning and environmental controls significantly reduce the risk of contaminating Key-Parts and Key-sites Safeguard 2 Identification of Key-Parts and Key-Sites Key-Parts are the critical parts of the procedure equipment that if contaminated are most likely to cause infection. Key-Sites are open wounds and medical device access sites Safeguard 3 Non-Touch Technique Non-Touch Technique is a critical skill that protects Key-Parts & Key-Sites from healthcare worker and the procedure environment in both Surgical and Standard-ANTT Safeguard 4 Aseptic Field Management Aseptic Fields protect Key-Parts and Key-Sites from the immediate procedure environment. Surgical and Standard-ANTT require different aseptic field management Principle 5 Aseptic practice should be standardised Clinical and Organisation Management Principle 6 Safe aseptic technique is reliant upon effective healthcare worker training and environments and equipment that are fit for purpose
ANTT Clinical Guideline for the preparation and adminstration of I.V. drugs Appendix 4
Appendix 4