Leeds Teaching Hospitals NHS Trust Asepsis Leeds Teaching Hospitals NHS Trust Infection Prevention and Control, version 5, 19th August 2013

Addition Information Please refer to the last slide for additional information

Aims of this session Aim To provide the knowledge and skills for clinical staff to maintain asepsis during clinical procedures Objectives To be able to identify procedures that require an aseptic technique To provide the principles of asepsis, to enable staff to perform clinical procedures without contamination To understand that an aseptic non-touch technique is a method of delivering asepsis

Asepsis – definitions and purpose “Asepsis is defined as the absence of infectious organisms. Aseptic techniques are those aimed at the elimination of all infectious micro-organisms during procedures” (Humes and Lobo, 2009). “Evidence …demonstrates that the risk of infection declines following the standardisation of aseptic care and increases when …undertaken by inexperienced healthcare workers” (Pratt et al Epic 2007). “Aseptic technique is a critical last line of defence between patients and clinical staff “(Rowley and Clare, 2009).

Asepsis – Background “Asepsis is not a new concept and the principles have been around since Florence Nightingale’s time, where sanitation and handwashing were paramount in preventing the spread of infection. These principles were mainly used in wound care, but have been adapted over time to incorporate other aseptic procedures”. (Ingram and Murdoch, 2009).

Asepsis - Current Practice “A lack of understanding of aseptic practice can lead to confusion and poor performance of the technique” (Ingram and Murdoch, 2009). “Poor understanding of what aseptic technique means and which clinical procedures it should be applied to, can also cause confusion and non-compliance, as some healthcare staff believe aseptic technique is only used in the operating theatre” (Schraag 2006, cited in Ingram and Murdoch, 2009).

Asepsis – Legislation Health and Social Care Act The Health and Social Care Act 2008 (Code of Practice on the prevention and control of infections and related guidance, published 2010) states that where aseptic procedures are performed: • 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; and • an audit should be undertaken to monitor compliance with the technique. Department of Health (2010) The Health and Social Care Act 2008 (Code of Practice on the prevention and control of infections and related guidance)

Asepsis in practice - community settings “Despite the challenges which the performance of aseptic procedures in a home environment presents, increasing public and media attention around HCAI means that community nurses must ensure their practice adheres to the evidence-based care bundles which have been advocated for addressing infection risks” (Unsworth, 2011).

Asepsis in practice Asepsis ensures that microbes are not introduced to the site. NICE guidance 2012 states: Asepsis should be used during any clinical procedure that bypasses the body's natural defences Use of the principles of asepsis minimises the spread of organisms from one person to another Asepsis can be achieved through either: standard asepsis aseptic non-touch technique (ANTT®) Asepsis Videos

Effective Aseptic technique incorporates (1): Communicating with the patient to ensure risks are minimised and the environment is safe Performing effective hand hygiene using the 7 step technique Employing standard precautions at all times Storing sterile equipment in a clean dry area, free from dust and off the floor to protect the integrity of the packaging and equipment Using single-use items once 2

Effective Aseptic technique incorporates (2): Using single patient use items for only one patient Decontaminating re-usable items according to manufacturers instructions Using a sterile field (this may require the use of a dressing trolley) Using the correct pack as indicated by the procedure Utilising a competent health care worker with the relevant knowledge and skills

Effective Aseptic Non Touch Technique incorporates (1): (Reminder: This technique can be used if the procedure can be completed without touching key parts - If any of these parts are contaminated there is a risk of infection ) Washing hands effectively using the 7 step technique Choosing an appropriate field Cleaning key-parts for 30 seconds (a key-part is the part of the equipment that comes into direct contact with the liquid infusion e.g. needles, syringe tips, IV line connections, exposed lumens of catheters, tops of ampoules, etc).

Effective Aseptic Non Touch Technique incorporates (2): Drying is an essential part of the disinfection process (requires 30 seconds to dry fully) Protecting the key-part at all times by using a non-touch-technique Protecting yourself by wearing appropriate PPE including non sterile gloves and apron Minimising the amount of times manipulation is performed at intravenous sites (Rowley and Clare 2009)

When to use Asepsis and when to use ‘aseptic non-touch technique’ (ANTT): For complex procedures e.g. multiple infusions - to decide between the two applications of asepsis simply ask yourself: ‘Can I do this procedure without touching key-parts?’ If NO - use dressing pack and wear sterile gloves (Asepsis) If YES - wear non sterile gloves (ANTT)

When to use Asepsis / ANTT Clinical Procedure Equipment Technique to be used Dressing of wounds healing by primary intention Intravenous cannula insertion Urinary catheterisation Invasive vaginal examination Suturing Minor surgical procedures Medical invasive procedures e.g. central line insertion Cleaning and administration via tunnelled central venous devices e.g. portacath Pack appropriate to procedure Cannulation pack CVC insertion pack Dressing pack Urinary insertion pack Dressing trolley (this may not be necessary for intravenous cannula insertion in some clinical areas/situations or organisations) Sterile equipment e.g. dressings/syringes etc. Sterile gloves Aseptic technique

Clinical Procedure Equipment Technique to be used Cleaning of peripheral and central cannula with needle-free access device Administration of intravenous medicines via needle-free access device Administration of TPN Chronic wounds in patients who are not immunosuppressed and do not have compromise circulation Venepuncture Local sterile field Clinically clean receiver Sterile equipment e.g. syringes Non-sterile gloves Non-touch aseptic technique Preparation of intravenous medicines within clinical areas Visibly clean, uncluttered surface

Aseptic technique checklist (Dressing technique) Explain and discuss the procedure with the patient, and obtain verbal consent. Clean hands with soap and water. Clean a dedicated dressing trolley, from top to bottom, with a Sani-Cloth detergent wipe. Place all the equipment required for the procedure on the bottom shelf of the clean trolley, ensuring that all packs are intact and within the expiry date. Take the patient to the treatment room or screen the bed. Position the patient comfortably so that the area to be dealt with is easily accessible without exposing the patient unduly. Clean hands with alcohol hand rub and allow to dry. Put on a disposable plastic apron. Take the trolley to the treatment room or patient's bedside, disturbing the screens as little as possible. Loosen the dressing tape. Check the pack is sterile (i.e. the pack is undamaged, intact and dry), open the plastic outer cover of the sterile pack and slide the contents onto the top shelf of the trolley below the level of the sterile field. Open the sterile field using only the corners of the paper. Check any supplementary packs for sterility and open, tipping their contents gently onto the centre of the sterile field. Place hand in disposable bag, arrange contents of dressing pack. Remove used dressing with hand covered with the disposable bag, invert bag and stick to trolley. If a cleaning solution contained in a sachet is to be used, swab along the lotion sachet 'tear area' with a Sani-Cloth CHG 2% wipe. Tear open sachet and pour lotion into gallipots or on indented plastic tray. Clean hands with alcohol rub and allow to dry. Put on sterile gloves, using the appropriate technique. Arrange sterile sheet near the wound site, and then carry out procedure. Dispose of waste in yellow bag from pack and then dispose of this bag in yellow/orange clinical waste bags. Take off apron and gloves and wash hands using soap and water. If necessary, draw back curtains or, if appropriate, help the patient back to the bed area and ensure the patient is comfortable. Clean the trolley with a Sani-Cloth detergent wipes. Place small square bar code sterility label from the outside of any surgical instrument packs used during the procedure on the patient record form which is to be placed in the patient's notes. Document the procedure in the patient’s notes.

Resources: National policies and guidance ‘Clean Safe Care: Reducing infection and saving lives’ Department of Health, 2008 ‘Saving lives: High Impact Interventions’ Department of Health, 2007 LTHT Infection Prevention policies and Guidance Standard Infection Prevention and Control Precautions Policy Hand Hygiene Policy Central Venous Catheters in Adults and Children Blood Culture Sampling in Adults/ Children (SOP) Peripheral Venous Cannulae in Adults and Children Clinical Audit Policy

Resources: Hyperlinks http://lthweb/trust-news/sites/infection-control/infection-control http://Lthweb/content/marsden-manual/login.php http://www.antt.org.uk/ https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/151965/dh_123923.pdf.pdf

Resources: References Humes, D and Lobo, D (2009) Antisepsis, Asepsis and Skin Preparation. Surgery 27 (10) Ingram, P and Murdoch, M (2009) Aseptic non-touch technique in intravenous therapy. Nursing Standard, 24 (8) Marsden Manual (2011) Clinical Nursing Procedures, 8th Edition, Online at www.rmm.co.uk NICE (2012) Infection: Prevention and control of healthcare-associated infections in primary and community care. NICE Clinical Guideline 139. Pratt, R.J, Pellowe, C.M, Wilson, J.A, Loveday, H.P, Harper, P.J, Jones, S.R.L.J, McDougall, C, Wilcox, M.H (2007) epic2: National Evidence-Based Guidelines for Preventing healthcare Associated Infections in NHS Hospitals in England. Journal of Hospital Infection, 65S, S1-S64 Rowley, S, Clare, S (2009) Improving Standards of Aseptic Practice through an ANTT Trustwide implementation process: a matter of prioritisation of care. Journal of Infection Prevention, 10:s18 Sellors, J,E,I. Cyna, A.M.I. & Simmons, S.W.I (2002) Aseptic precautions for inserting an epidural catheter: a survey of obstetric anaesthetists. Anaesthesia, 104(2) 1450 – 1456. Unsworth, J (2011) District nurses’ and aseptic technique: where did it all go wrong? British Journal of Community Nursing Vol 16, No 01 29

Questions?

Asepsis Theory You have now completed your Asepsis Theory You will need to complete the Asepsis competency document. This can be found in the Asepsis course resources on the Training Interface or on the Infection Prevention Intranet site