1. Principles and Practices of Asepsis
Module E
Principles and Practices of Asepsis
Role of hands and the environment in disease transmission
Welcome to Module E, Principles and Practices of Asepsis

2. Objectives Describe the principles and practice of asepsis.
Understand hand hygiene.
There are two main objectives for the this module.
Describe the principles and practices of asepsis; and
Understand hand hygiene

3. Defining Asepsis Medical Asepsis Surgical Asepsis Definition
Clean Technique
Sterile Technique
Emphasis
Freedom from most pathogenic organisms
Freedom from all pathogenic organisms
Purpose
Reduce transmission of pathogenic organisms from one patient-to -another
Prevent introduction of any organism into an open wound or sterile body cavity
Asepsis is the condition of being free from disease producing microorganisms. Aseptic technique refers to all those procedures that reduce or eliminate pathogens and their actions or minimize their areas of existence. There are two types of asepsis, Medical and Surgical.
Medical asepsis, also referred to as clean technique, is used during most routine patient care activities and non-surgical procedures. With medical asepsis, emphasis is placed on removing most of the pathogenic organisms to reduce transmission from one patient to another.
Conversely, surgical asepsis, also called sterile technique, is used only during surgical procedures. Unlike medical asepsis, the goal of surgical asepsis is to ideally remove all pathogenic organisms and prevent the introduction of any organism into a normal sterile body site.

4. Medical Asepsis
Measures aimed at controlling the number of microorganisms and/or preventing or reducing the transmission of microbes from one person-to-another:
Clean Technique
Know what is dirty.
Know what is clean.
Know what is sterile.
Keep the first three conditions separate.
Remedy contamination immediately.
Medical asepsis is based on several measures with the goal of controlling the number of microorganisms, not making things sterile. To achieve medical asepsis we must understand what is dirty, what is clean, what is sterile, how to keep these things separate, and how to remedy any contamination that might occur. When approaching each patient care activity, consider the following principles as a framework to guide your practice.

5. principles of Medical Asepsis
When the body is penetrated, natural barriers such as skin and mucous membranes are bypassed, making the patient susceptible to microbes that might enter.
Perform hand hygiene and put on gloves
When invading sterile areas of the body, maintain the sterility of the body system
When placing an item into a sterile area of the body, make sure the item is sterile
When performing invasive procedures, like placing an IV or giving an injection, one of the bodies’ first lines of defense against invading microorganisms is bypassed: the skin. When we bypass the skin, we increase the susceptibility of the patient to invading microorganisms.

6. principles of Medical Asepsis
Even though skin is an effective barrier against microbial invasion, a patient can become colonized with other microbes if precautions are not taken.
Perform hand hygiene between patient contacts
When handling items that only touch patient’s intact skin, or do not ordinarily touch the patient, make sure item is clean and disinfected (between patients).
The second principle of asepsis is focused on preventing the transfer of microorganisms from one patient to another via healthcare provider hands and shared equipment. All of us are colonized with many different types of bacteria, some helpful and some potentially pathogenic. When we fail to take the opportunity to perform hand hygiene between patients or clean and disinfect shared patient equipment between patients, we are creating opportunities for cross contamination that can introduce new, harmful microbes to patients.

7. principles of Medical Asepsis
All body fluids from any patient should be considered contaminated
Body fluids can be the source of infection for the patient and you
Utilize appropriate personal protective equipment (PPE)
The third principle of asepsis is recognizing that any body fluid is potentially contaminated. This means that if it is wet and not yours you should use the appropriate personal protective equipment (PPE) and perform hand hygiene after handling potentially contaminated fluids, and when performing patient care activities that require moving from dirty to clean patient care activities.

8. principles of Medical Asepsis
The healthcare team and the environment can be a source of contamination for the patient
Health care providers (HCP) should be free from disease
Single use items can be a source of contamination
Patients environment should be as clean as possible
The final principle of asepsis is that healthcare providers and the environment can also be a source of contamination. Healthcare providers can reduce their opportunities of transmitting disease by staying up to date on vaccinations, maintaining good personal hygiene, and performing hand hygiene appropriately.
Additionally, single use items can be a source of contamination if they are reused on another patient. For example, many sterile solutions used for irrigation do not have bacteriostatic or bacteriocidal compounds that prevent growth of microbes once they have been opened. Because of this, any excess fluid left in the bottle should be discarded - not stored for later use. It is important that you read the labels and follow manufacturers’ instructions for use.
The environment is also a potential source of contamination for the patient. If surfaces and shared patient equipment are not cleaned appropriately, they can be a source of cross-transmission. The role of the environment is discussed in more detail in Module G

9. Surgery increases the risk of infection!
Now that we have reviewed medical asepsis, let’s move on to surgical asepsis. More stringent requirements are used during surgery because the risk of infection increases during surgery.
Surgery increases
the risk of infection!

10. Surgical Asepsis
Practices designed to render and maintain objects and areas maximally free from microorganisms:
Sterile Technique
Know what is sterile
Know what is not sterile
Keep sterile and not sterile items apart
Remedy contamination immediately
Measures that keep and maintain objects and areas maximally free of microorganisms so that normally sterile body sites are not contaminated are the basis of surgical asepsis. Understanding which equipment and areas are sterile, and which are not, and keeping these two separate so as not to introduce contamination is critical to achieving surgical asepsis.

11. Principles of Surgical Asepsis
The patient should not be the source of contamination.
The operating personnel should not be the source of contamination.
The surgical scrub should be done meticulously.
The OR technique of the surgeon is very important.
Recognize potential environmental contamination.
While in the surgical environment, there are several principles which help maintain a sterile environment. First, the patient should not be a source of contamination. The skin around the surgical site is meticulously cleaned using a chemical antiseptic, like chlorhexadine alcohol solution, and all other areas of skin are covered by a sterile drape.
Similarly, operating room personnel should not be a source for contamination. Sterile operating room personnel (those working in the sterile field) should perform a surgical hand scrub, gown and glove, and only contact sterile items. Unsterile operating room personnel should only contact unsterile items and should not have direct contact with sterile operating room personnel.

12. Define Sterility
What is sterile in the operating room? Gowns are sterile in front from chest high level to the operative level. A sterile healthcare provider should keep hands in sight and at or above waist level at all times and should avoid direct contact with non-sterile personnel or equipment. Similarly, non-sterile personnel should avoid contact with sterile personnel and items, and stay at least one foot beyond the sterile field. Sterile areas should also be kept continuously in view, and sterile personnel should not turn their back to the sterile field. All items used within the sterile field must be sterile. Articles of doubtful sterility should be considered non-sterile. Tables are sterile only at the operative level.
Contamination occurs when sterile gowns and drapes are permeated, when non-sterile items are brought into the sterile field, and when sterile personnel drop their hands or body below the level of the table.

13. Remedy Contamination
Every case is a potential source of contamination and the same infection control precautions are taken for all patients.
When contamination occurs, address it immediately.
Breaks in technique are pointed out and action is taken to eliminate them.
Once there has been a breach in sterility, it is important that the contamination is recognized quickly and steps are taken to remedy the situation promptly.

14. Asepsis in Dental Laboratory and Radiology
Good aseptic practices should also extend to the dental laboratory and dental radiography settings.

15. Laboratory Asepsis
Clean and disinfect or sterilize all items coming from the oral cavity
Heat tolerant items (impression trays) should be sterilized
Heat labile items (prosthetics, impressions, bite registrations, and occlusal rims) should be disinfected by immersion or spray using an EPA-registered disinfectant
Wear appropriate PPE (gowns, gloves, safety eyewear, mask) until items have been decontaminated
Any instrument or piece of equipment used in the oral cavity or on an orally soiled prosthetic devices or impressions is a potential source of cross infection. If contaminated items were to enter the dental laboratory environment, infectious materials could be spread to prostheses and appliances of other patients and laboratory personnel could be placed at risk for exposure. As such, All personnel handling contaminated items should wear the appropriate PPE and all items coming from the oral cavity must be cleaned and either disinfected or sterilized before being worked on in the laboratory or before returning to a patient. All heat tolerant items, like impression trays, can be cleaned, packaged and heat sterilized for reuse. Most prostheses and prosthodontic materials cannot withstand heat sterilization. One should clean and disinfect all prostheses, impressions, bite registration and occlusal rims using an EPA-registered disinfectant with a tuberculocidal claim by immersion or spraying if the material cannot tolerate immersion. The device or material must remain exposed to the disinfectant for the contact time listed for tuberculosis. Disinfection should followed by thorough rinsing with tap water to remove any disinfectant. Once an item has been disinfected, PPE are no longer needed for handling of the items.

16. Radiology Asepsis Wear appropriate PPE to reduce personnel exposure
Use films held within FDA-cleared barrier pouches
Use heat-tolerant or disposable intraoral film-holding and positioning devices.
Digital radiographic sensors should be placed in FDA- cleared barriers.
All reusable items that contact mucous membranes must be heat sterilized or high-level disinfected
The radiographic process offers the possibility that body fluids will contaminate disposable and reusable items. As such, personnel must wear gloves when taking radiographs and consider gowns, mask and eyewear if risk of splatter exist. If using film based radiography, all films must be placed within an FDA-cleared barrier before use, and heat-tolerant or disposable intraoral film holding and positioning devices should be used. For digital radiography sensors, they must be covered using an FDA-cleared barrier over the sensors and wires (if present). Clean and heat-sterilize (or high-level disinfect) items that contact mucous membranes and non-intact skin between patients, even if they were barrier-protected during use. If the item cannot tolerate heat or chemical immersion (such as digital radiology sensors), at a minimum, use an FDA-cleared barrier during intraoral use, and clean and disinfect with an EPA-registered hospital disinfectant with tuberculocidal activity between patients. Consult with the manufacturer for methods of disinfection and sterilization of digital radiology sensors and for protection of associated computer hardware.

17. Radiology Asepsis Asepsis during darkroom activities
Exposed film paced in paper cup or paper towel
Gloves removed after all films exposed and hand hygiene performed
Re-glove for transport to dark room
Open film packs, drop on to clean surface, discard wrappers
Remove gloves and hand hygiene
Process films
Once radiographic film has been exposed, the films should be placed in a plastic cup or within a folded paper towel for transport. Gloves should be removed, hand hygiene performed, and new gloves should be donned prior to transporting the films to the darkroom. Once in the darkroom, film can be removed from wrappers and placed on a clean surface. Wrappers should be discarded in the trash. After all film has been removed from wrapping, gloves should be removed and hand hygiene should be performed before the films are processed.

18. Hand Hygiene The substance of asepsis
Hand hygiene is a general term that applies to routine hand washing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis.

19. What is Hand Hygiene Handwashing Antiseptic Handwash
Alcohol-based Hand Rub
Surgical Antisepsis
Hand hygiene substantially reduces potential pathogens on the hands and is considered a primary measure for reducing the risk of transmitting organisms to patients and health care personnel. Hospital-based studies have shown that noncompliance with performing hand hygiene is associated with health care-associated infections, the spread of multi-drug resistant organisms, and has been a major contributor to outbreaks. Studies have shown that the prevalence of health care-associated infections decreases as hand hygiene measures improve.

20. Why is hand hygiene so important?
Hands are the most common mode of pathogen transmission.
Reduces the spread of antimicrobial resistance.
Prevents healthcare-associated infections.
All of us have bacteria on our hands, even after performing hand hygiene. These bacteria are normal resident bacteria that generally reside in deeper layers of skin and are not likely to be removed during routine hand hygiene and are less likely to be associated with healthcare-acquired infections. When we provide patient care or have contact with the immediate patient environment, we pick up transient, potentially pathogenic microorganisms on our hands.

21. Hand-borne Microorganisms
Healthcare providers contaminate their hands with colony-forming units (CFU)of bacteria during “clean” activities (lifting patients, taking vital signs).
In the study sited above, the researchers found that healthcare providers contaminate their hands with an additional CFU of bacteria during clean activities like taking vital signs. By performing appropriate hand hygiene, we remove these transient microorganisms so they cannot be transmitted to other patients.
Pittet D et al. The Lancet Infect Dis 2006

22. Transmission of pathogens on Hands Five elements
Germs are present on patients and surfaces near patients
By direct and indirect contact, patient germs contaminate healthcare provider hands
Germs survive and multiply on healthcare provider hands
Defective hand hygiene results in hands remaining contaminated
Healthcare providers touch/contaminate another patient or surface that will have contact with the patient.
Transmission of health care-associated pathogens from one patient to another via healthcare provider hands requires five sequential steps:
1. Organisms are present on the patient’s skin, or have been shed onto inanimate objects immediately surrounding the patient;
2. Organisms must be transferred to the hands of the healthcare provider;
3. Organisms must be capable of surviving for at least several minutes on the healthcare provider’s hands;
4. Hand washing or hand antisepsis by the healthcare provider must be inadequate or entirely omitted, or the agent used for hand hygiene
inappropriate; and
5. The contaminated hand or hands of the caregiver must come into direct contact with another patient or with an inanimate object that will come into direct contact with the patient.

23. When to Perform Hand Hygiene
The CDC and WHO have guidance on the indications for hand hygiene, but they can be reduced down into 5 moments for hand hygiene.
1. Before touching the patient
2. Before clean/aseptic procedures
3. After body fluid exposure/risk
4. After touching the patient and removing gloves
After touching the patient surroundings.
Other indicators not included on the picture are before eating, after using the restroom and when moving from a contaminated body site to a clean body site during patient care.

24. HOW TO HAND RUB
To effectively reduce the growth of germs on hands, hand rubbing must be performed by following all of the illustrated steps. This takes only 20–30 seconds!
The use of an alcohol based hand rub is preferential to hand washing when hands are not visibly soiled. You should not use alcohol based hand rubs after providing care to patients with diarrhea. Review the steps for hand rubbing shown here.
credit: WHO

25. HOW TO HAND WASH
To effectively reduce the growth of germs on hands, handwashing must last at least 15 seconds and should be performed by following all of the illustrated steps.
Hand washing with antiseptic soap and water should be used when hands are visibly soiled and after providing care patients with diarrhea. Review the steps for hand washing shown here.
credit: WHO

26. Hand rubbing vs Handwashing
15sec
30sec
1 min
2 min
3 min
4 min 6 5 4 3 2 1
Bacterial contamination (mean log 10 reduction)
Handwashing
Handrubbing
Hand rubbing is:
more effective
faster
better tolerated
Why is hand rubbing with an alcohol-based sanitizer preferred over hand washing? When compared side by side using seconds of use, hand rubbing was significantly more efficient in reducing hand bacterial contamination. Because of its activity against a broad spectrum of epidemiologically important pathogens, use of alcohol-based hand rub as the primary mode of hand hygiene in healthcare settings is recommended by the CDC and the World Health Organization (WHO). The use of alcohol based hand rub in healthcare settings can increase compliance with recommended hand hygiene practices by requiring less time, irritating hands less, and facilitating hand hygiene at the patient bedside.
Pittet and Boyce. Lancet Infectious Diseases 2001

27. Hand hygiene compliance is low
Author
Year
Sector
Compliance
Preston
1981
General Wards
ICU
16%
30%
Albert
41%
28%
Larson
1983
Hospital-wide
45%
Donowitz
1987
Neonatal ICU 30
Graham
1990 32
Dubbert 81
Pettinger
1991
Surgical ICU 51
1992
Neonatal Unit 29
Doebbeling 40
Zimakoff
1993
Meengs
1994
Emergency Room
Pittet
1999 48
<40%
Adherence of healthcare providers to recommended hand hygiene procedures has been reported with great variation, and in some cases is unacceptably poor. A meta-analysis of 34 studies of hand hygiene practices of healthcare providers found, across all studies, there was average hand hygiene compliance rate of 40%.
Pittet and Boyce. Lancet Infectious Diseases 2001

28. Reasons for noncompliance
Inaccessible hand hygiene supplies
Skin irritation
Too busy
Glove use
Didn’t think about it
Lacked knowledge
Some of the most frequent reasons given for the lack of hand hygiene were:
products were inaccessible,
the products caused skin irritation,
healthcare providers were too busy and it interfered with patient care,
they were wearing gloves and felt hands were not contaminated,
they just didn’t think about it, and
they lacked the knowledge of when and how to perform hand hygiene.

29. Summary of Hand hygiene
Hand hygiene must be performed exactly where you are delivering healthcare to patients (at the point-of-care).
During healthcare delivery, there are 5 moments (indications) when it is essential that you perform hand hygiene.
To clean your hands, you should prefer hand rubbing with an alcohol-based formulation, if available. Why? Because it makes hand hygiene possible right at the point-of-care, it is faster, more effective, and better tolerated.
In summary, hand hygiene should occur where care is delivered. Healthcare providers should know the indications for when to perform hand hygiene. Caregivers should preferentially choose to use an alcohol based hand rub over and hand washing, unless their hands are visibly soiled or they provided care to a patient with diarrhea. Healthcare providers should use the correct technique and duration.
You should wash your hands with soap and water when visibly soiled.
You must perform hand hygiene using the appropriate technique and time duration.

30. Latex Hypersensitivity and Contact Dermatitis
Occupationally-related contact dermatitis can develop from frequent and repeated use of hand hygiene products, exposure to chemicals, and glove use.
Section C

31. Latex Allergy Type I hypersensitivity to natural rubber latex proteins
Reactions may include nose, eye, and skin reactions
More serious reactions may include respiratory distress–rarely shock or death
Latex allergy is a Type 1 or an immediate hypersensitivity reaction to the proteins found in natural rubber latex. These proteins can attach to the powder in gloves which, in turn, causes more latex protein to reach the skin.
•This reaction is generally a more severe and immediate systemic reaction than contact dermatitis. Common reactions include runny nose, itchy eyes, hives, and burning skin sensations.
•More severe reactions are characterized by breathing difficulty and, rarely, anaphylaxis (shock) or death.
Photo credit: Arto Lahti, MD, Department of Dermatology, University of Oulu, Finland.
Section C

32. Irritant contact dermatitis
Not an allergy
Dry, itchy, irritated areas
Allergic contact dermatitis
Type IV delayed hypersensitivity
May result from allergy to chemicals used in glove manufacturing
Not all skin reactions are due to an allergic reaction to latex rubber. Most skin reactions are attributed to an irritant or allergic contact dermatitis.
Irritant contact dermatitis develops as dry, itchy, irritated areas on the skin around the contact area. It is commonly associated with frequent handwashing and is not an allergic reaction.
The second type of contact dermatitis is a type IV or delayed hypersensitivity or allergic reaction due to contact with a chemical allergen (e.g., accelerators and other chemicals used in the manufacture of patient-care gloves). Reactions are generally localized to the contact area and occur slowly, over a period of 12–48 hours.
Section C

33. General Recommendations Contact Dermatitis and Latex Allergy
Educate DHCP about reactions associated with frequent hand hygiene and glove use
Get a medical diagnosis
Screen patients for latex allergy
Ensure a latex-safe environment
Have latex-free kits available (dental and emergency)
Other recommendations can minimize the risk of contact dermatitis and latex hypersensitivity:
•Educate dental healthcare personnel about reactions associated with frequent hand hygiene and glove use.
•Staff that have dermatologic problems should get a diagnosis from a qualified medical provider before making changes in gloves or hand hygiene agents.
•Screen patients and dental healthcare personnel for latex allergy in medical histories.
•Healthcare personnel and dental patients with latex allergy should not have direct contact with latex-containing materials and should be in a latex-safe environment with all latex-containing products removed from their vicinity.
•Have both dental and medical emergency latex-free products available at all times.
Section C

34. References
CDC Guidelines for Hand Hygiene in Healthcare Settings – Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC Hand Hygiene Task Force. MMWR October 25, 2002, 51(RR-16).
Guidelines for Infection Control in Dental Health- Care Settings, MMWR, December 19, :52(RR-17).
The following references were used in the preparation of this module.

35. Thank You