1. Clean, Aseptic and Sterile Technique
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Clean, Aseptic and Sterile Technique
Session 4: Infection Control Basics

2. Learning Objectives
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Be able to state the requirements for clean, aseptic or sterile technique recommended for common procedures
Demonstrate use of the “SCRIPT” method to prepare for and carry out procedures
Be able to demonstrate aseptic and sterile technique for 4 procedures
4: Clean, Aseptic, Sterile

3. The Goal: Reduce Health Care Associated Infections
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The goal is to reduce health care-associated infections that occur when staff spread microbes to patients
Germs move to patients from hands, and from objects used for patient care
Use of clean, aseptic or sterile technique reduces the number of germs transferred and thus, reduces the risk of infection
The I-TECH video Separation of Clean and Dirty, discussed a key concept in infection control: the separation of clean and dirty. It discussed how to designate and prepare 4 work areas in a clean area, a dirty area for place, an area for used patient care items that are not reprocessed, and an area for personal items.
The goal is to keep microbes from traveling from dirty or contaminated areas to cleaner areas. And ultimately, of course the goal is to avoid spreading germs to patients either by direct hand contact or indirectly by germs on instruments, and supplies.
While some healthcare workers fear the diseases that patients can give them, the reality is that the vast majority of infections spread from health care workers to vulnerable patients.
Clean, aseptic and sterile techniques are strategies that reduce the chances of spreading infections to patients.
This modules talks about procedures that take place in clean areas, and discusses how to prevent the transfer germs to patients and to items that will be used on patients.
4: Clean, Aseptic, Sterile

4. Definition: Clean Technique
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For this training:
Clean technique refers to the use of routine hand washing, hand drying and use of non-sterile gloves
When staff are instructed to use clean technique, they are being asked to at least wash their hands with soap and water, to remove all visible dirt from their hands, and to dry their hands. If gloves are used, clean, non-sterile gloves are appropriate.
4: Clean, Aseptic, Sterile

5. Clean Technique
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Use clean technique if staff or objects will touch intact skin, intact mucous membranes or dirty (contaminated) items
The definitions of clean aseptic and sterile technique are often used in ways that overlap and cause confusion. When instructions say “use aseptic technique”, it is not always clear to a health care worker what they are being asked to do. Do they use a sterile field?: What type of glove or hand washing in needed. Is a ,sterile gown or skin antisepsis indicated?
To clarify what actions the worker should take, this lessons defines clean, aseptic and sterile technique to refer to three different broad categories associated with specific glove handwashing and barrier precautions such as gowns. (This distinction is similar to definitions used N. Fortunato’s Berry and Kohn’s Operation Room Technique, Ninth Edition. St. Louis Moby, 2000 p. 62. )
We define the techniques here because they are used in various overlapping ways in different reference books. Some references call aseptic technique “medical asepsis” and surgical technique “surgical asepsis
So the definitions used here are developed specially for this lesson. In real life, some procedures may have individual variations.
Clean technique used when patients, and the items in contact with patients touch only intact skin, intact mucous membranes or when workers are handling low risk items. The categories of risk are discussed in the module on reprocessing of instruments. Example of procedures where clean tech is appropriate are taking a blood pressure, removing a dirty dressing when the wound is not touched, or feeding a patient.
4: Clean, Aseptic, Sterile

6. Examples of When Clean Technique is Used
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Clean tech is appropriate for:
Taking blood pressures
Examining patients
Feeding patients
4: Clean, Aseptic, Sterile

7. Definition: Invasive Procedures
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Acts done to patients that come in contact with the wounds, blood stream, the inside of the body, or normally sterile parts of the body
Remember invasive procedures invade the inside of the body
4: Clean, Aseptic, Sterile

8. Definition: Aseptic Technique
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Aseptic technique is used for short invasive procedures. It involves:
Antiseptic hand hygiene (alcohol, betadine or chlorhexidine)
Usually sterile gloves
Antiseptic (e.g alcohol) on patient’s skin
Use of clean, dedicated area
When invasive procedures are done, there is a greater risk of infecting the patient, so greater care with handwashing and protective measures are needed.
Aseptic technique differs from clean technique in several ways. It tries to spread fewer germs. It generally uses an antiseptic hand product that kills germs. Alcohol hand rub is a good example.
Sterile gloves are generally used, particularly if sterile items are to be handled. Clean gloves may sometimes be used if no- touch technique is used, for example when starting IV’s where one does not touch the insertion site after applying asepsis.
The patient’s skin is cleaned and then swabbed with a antiseptic such as alcohol.
The procedure is done in a clean, dedicated area free from blood and body fluids. If it is done at the patient’s bedside, then a clean working area is provided by on a medication cart or by clearing, cleaning and wiping a bedside table with an antiseptic such as alcohol.
4: Clean, Aseptic, Sterile

9. Aseptic Technique
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Use aseptic technique for brief invasive procedures that may break skin or mucous membranes, or normally sterile parts of the body
Example: placing a urinary catheter, suctioning, placing an IV, emptying a ICD drain
Aseptic technique is used for brief invasive procedures that break or potentially break the skin or mucous membranes, or enter normally sterile parts of the body.
Can you give examples of brief invasive procedures? Clue: surgery is an example of a brief invasive procedure
Anytime a closed circuit is opened the patient is at high risk of infection, and aseptic technique should be used. Examples of closed circuits are an IV line, opening an intercostal chest drain, or opening a urinary catheter.
Other examples of procedures where aseptic technique is used are: suctioning, or placing an IV. Suctioning is often traumatic; it often breaks the skin and can introduce hospital pathogens into the lung, so aseptic technique with sterile gloves and use of sterile water, and a sterile suction catheter are recommended, even though the upper respiratory tract is not a sterile area.
4: Clean, Aseptic, Sterile

10. Definition: Sterile Technique
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Sterile technique is used for surgery or the preparation of sterile materials for multiple patients. It involves:
Surgical hand rub with long acting antiseptic
Hands dried with sterile towels
Sterile field
Sterile gown, mask
Sterile gloves
Sterile supplies
Skin prep
A dedicated room
When long invasive procedures are done, or ones that have a high risk of infection, we use sterile technique.
Sterile technique is used for surgery or the preparation of sterile materials for multiple patients. It involves:
-Surgical hand rub with long acting antiseptic like betadine or chlorheximine.
-Hands dried with sterile towels
-Sterile field
-Sterile gown, mask,
-Sterile gloves
-Sterile supplies
-Skin prep
-A dedicated room if possible.
Sterile technique, as we define it here, uses all the barriers and a surgical scrub hand. Only sterile items are placed on the sterile field, and the procedure is done in a dedicated room where no instruments are cleaned, and no contaminated items are present. These strict precautions aim to avoid staff transferring microbes or germs into the patient.
4: Clean, Aseptic, Sterile

11. Sterile Technique
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Use during surgery and for invasive procedures with high rates of infection
Examples:
Any long invasive procedure
Placement of central lines and thoracic lines
Bulk preparation of IV fluids or medications
Sterile technique is used during surgery and for procedures such as central lines that have high rates of nosocomial infection unless sterile technique is used.
Example of procedures: surgery, placement of central lines and thoracic lines, bulk preparation of IV fluids or medications.
Sterile technique is done when the introduction of germs can cause the most harm. For example during surgery, or when IV fluids are being prepared. This requires sterile technique because the germs can multiply in the fluid and reach dangerous levels before they are given to patients.
4: Clean, Aseptic, Sterile

12. Differences Between the Types of Techniques
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Space and work flow where procedures are done
Type of hand hygiene
Use of Personal Protective Equipment, including clean, or sterile gloves
Use of patient skin antisepsis
Use of a sterile drape or sterile field
Lets review how these three techniques, clean aseptic and sterile technique differ.
As we have defined them for this lesson, they differ in the following elements.
First, the type of space and work flow where procedures are done.
Sterile technique requires a separate room where contaminated procedures such as the reprocessing of instruments or the dumping of body secretions is not done. The work space must be large enough to allow a one way flow so that no contaminated procedures are done in the room and sterile, clean areas are completely separated.
Aseptic procedures can be done in a dedicated space after the area is cleaned and disinfected, and where no body fluids or contaminated items are placed.
Clean procedures can be done at the bedside or in areas on the patient ward except those areas designated to be dirty or contaminated areas.
The other elements include:
Type of hand hygiene
Use of Personal Protective Equipment, including clean versus sterile gloves
Use of patient skin antisepsis
Use of a sterile drape or sterile field
4: Clean, Aseptic, Sterile

13. Iodophors, chlorheximide
Clean
Aseptic
Sterile
Procedure space
On ward or at beside
Dedicated area
Dedicated room
Gloves
Clean or none
Sterile surgical
Hand hygiene before the procedures
Routine
Aseptic, e.g. alcohol
Surgical scrub
Iodophors, chlorheximide
Skin antisepsis No
Alcohol
Long acting agent
Sterile field
No*
Yes
Sterile gown, mask, head covering
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We can generalise to show the what is typically associated with clean, aseptic and sterile technique. Thse are general rules and there will be exceptions for some specific procedures.
READ SLIDE BY COLUMNS
The real world is not quite as neatly divided, and In fact, procedures are done on a spectrum from low risk to high risk and in your facility may fall somewhere in between these categories.
For example, giving IM injections is an invasive procedure. However if done with no touch technique, and the injection site is not touched by the health care worker after injection, this can be done without gloves.
Central venous access lines placed with sterile technique, e.g. sterile gowns, gloves, skin prep, and mask have lower rates of blood stream infection. So it is recommended to place them using sterile technique. In contrast peripheral IV’s have a lower risk of infection and can be placed using aseptic technique.
Note that the gown, mask and head covering and gloves are worn here to protect the patient; the HCW may wear other items such as boots in the operating room, or goggles to protect him or herself from splashes by blood or body fluids.

14. Facilities Differ in Their Ability to Prevent Nosocomial Infections
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Increase the level of technique from clean to aseptic, or aseptic to sterile if nosocomial infections persist
Facilities differ in many other factors that can influence the rates of nosocomial infection. These may include a different prevalence of disease in the patient populations, different cleaning procedures, ventilation, isolation precautions, procedures for patient care, antibiotic drug use, or reliance on families to give care.
If nosocomial infections continue after likely sources of infection have been ruled out, try to Increase the level of technique from clean to aseptic, or aseptic to sterile as part of efforts to control nosocomial outbreaks.
4: Clean, Aseptic, Sterile

15. Exercise: Matching Procedures and Techniques
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Matching procedures to the kind of technique required
Objective: to discuss measures currently done, and to discuss current recommendations
On the screen show the slide which describes the elements of the techniques.
Place the heading on another wall, distribute the cards to participants, and ask them to place the cards under the type of technique they are currently using for the procedures.
Ask the group to comment if they practice differently, or if they use a combination of techniques.
Then look for cards that have in placed in categories other than those suggested above.
Ask persons who placed those cards about what they do for those procedures, and review the evidence and rationale why the current placement is the recommended best practice.
Tape three heading on the wall “clean”, “aseptic” and “sterile”
4: Clean, Aseptic, Sterile

16. To Prevent Contamination
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Keep clean, dirty, and sterile items separate:
Only put sterile items in a sterile field
Change gloves and wash hands if going from a contaminated act to a aseptic or sterile act
Time skin antisepsis and surgical hand hand hygiene with a clock
The sterile field is considered sterile except for the 2.5 cm border
Wet items are considered contaminated
Note to facilitators: it is good to demonstrate these with props, as if a patient were to be prepped for a procedure.
Supplies: sterile drape with tape, sterile cup, iodophor antiseptic betadyne, cotton, sterile forceps, Sterile gloves, non-sterile cotton and alcohol to clean, table.
Demonstrate washing hands, cleaning surface with alcohol and cotton, letting dry. Washing hands with antiseptic hand rub
Place sterile field on table, open back back, side, side, front without contaminating.
Open cup and drop on field, open forceps and sterile cotton. Have second persons do alcohol hand rub and put on gloves. Pour betadyne in cup without touching. Bottle to cup.
Have a garbage container nearby and pass off all contaminated items without returning them to the sterile field.
Explain that you just demonstrated elements tell you what you need for clean aseptic and sterile technique.
Now let’s discuss how to use them.
First a couple of key concepts:
Keep clean, dirty, and sterile separate: place only sterile items in a sterile field
Change gloves and wash hands if going from a contaminated procedure to a clean, aseptic or sterile procedure. For example remove a dirty dressing with clean technique. Remove your gloves and wash your hands and then use aseptic technique to place a clean dressing on the open wound.
Time skin antisepsis and hygiene to allow for contact time to kill germs. Alcohol takes at least 15 seconds to kill, betadyne needs at least 2 minutes. This means a clock must be in the area, ask staff will not be able to look at watches.
The sterile field is considered sterile except for the 2.5 cm border. So never place items right on the edge of the sterile field.
Wet items are considered contaminated. If the sterile drape gets wet it is no longer a sterile barrier.
4: Clean, Aseptic, Sterile

17. Planning Reduces Errors in Technique
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Use the S.C.R.I.P.T. reminder to plan
Visualise every step in advance, to make sure supplies are available
4: Clean, Aseptic, Sterile

18. S.C.R.I.P.T Procedures Space and work flow?
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Space and work flow?
Clean, aseptic, or sterile technique?
Routine, aseptic or surgical hand hygiene?
Instruments and supplies?
Personal protective equipment?
Trash: sharps, infectious waste, radioactive waste, pathology or routine waste?
It is easy to gather the necessary supplies. What is more difficult, is to work within the rule of sterile or aseptic technique without contaminating supplies and patient.
Good organisation and teamwork help make this possible so it is not necessary to “break” sterile technique due to forgotten supplies or confusion about where the clean dirty and sterile fields are.
A way to improve organisation or teamwork for a procedure is to “script” the procedure ahead of time. Just like what film makers do in a Bollywood movie, the actions and items are planned for or “scripted” ahead of time. Imagine every step before you actually do it.
This is particularly important for teams that frequently work together, and for teams that are doing new procedures or introducing a change that may have been communicated only to part of the team.
The letters S, C, R, I, P, T stand for issues to be discussed and planned prior to the procedure, specifically:
S refers to Space and work flow
C refers to Clean, aseptic, or sterile technique
R refers to Routine, aseptic or surgical hand hygiene
I refers to Instrument reprocessing
P is for Personal protective equipment
T is for Trash: planning where to place sharps, infectious waste, radioactive waste or routine waste.
Use this memory device mentally do the procedure ahead of time and visualise all the supplies you need and where there will be placed.
4: Clean, Aseptic, Sterile

19. Space and Work Flow?
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Should the procedure be done in a dedicated room or space?
Who will ensure that all visible dirt is removed form the space ahead of time, and surfaces disinfected if necessary?
Decide if the procedure should be done in a dedicated room or space?
Who will ensure that all visible dirt is removed form the space ahead of time,and surfaces disinfected if necessary?
4: Clean, Aseptic, Sterile

20. Space and Work Flow?
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Work flow: can staff move from hand washing to hand drying to separate clean and sterile areas without passing or touching contaminated areas?
Where will used instruments and specimens be placed?
To avoid contamination contaminated, clean supplies, and sterile items should not be placed in the same areas. For example a hand washing sink can not be used to reprocess instruments because it will increase the risk that staff pick up microbes during hand hygiene.
Rooms used for sterile procedures should not be used to reprocess instruments.
Work flow: can staff move from hand washing to hand drying to separate clean and sterile areas without passing or touching contaminated areas?
To prevent sharps injuries it is important to separate waste at the point of origin. While passing instruments in the sterile field, a passing zone such as a kidney basin can be used to transfer the sharp when a team member calls out “sharps”. There should be a sharps container at the point of use, and a container for other waste or pathology items.
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21. Clean, Aseptic, or Sterile Technique?
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All team members should be clear on who should be using clean, aseptic or sterile technique and what elements are intended
Example: a physician places a thoracic drain with sterile technique,the nurse assisting uses clean technique, and the person who empties the drain in subsequent days uses aseptic technique
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22. Instruments and Supplies
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Plan what medical devices and supplies are needed
Plan where each item should be placed
Plan where and how each item should be discarded or sterilised
Plan what medical devices and supplies are needed and where each item should be placed.
Only sterile devices can be placed on the field, so a “back table” and or mayo stand may be needed to open and prepare instruments.
To get items onto the sterile field, it may be necessary to have a non-sterile, circulating staff member pour liquids such as betadyne from a primary contain into a sterile cup, or to open peel packs and offer them to a “sterile” team member.
Items wrapped in peal pouches will need a second staff to place them on the field; double wrapped items can often be placed by an uncurbed staff onto the field or handed to the ”sterile” team member.
Any wet item should not be placed onto nor allowed to drip onto the sterile field, even if the liquid is sterile. Sterile cottons used for skin prep should be handed off the field.
Where with tape be placed? If the tape is shared between patients it should not be placed at the patients bedside. Tape is a common source of infection. If a few pieces are to be torn where will they be placed and when? It is easies to tear tape without use of gloves. Hands should be clean though, as tape will pick up and transfer germs from fingers.
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23. Work Flow Chart: Decontamination Cycle
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24. Routine, Aseptic or Surgical Hand Hygiene?
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Prepare in advance for the type of hand hygiene that is necessary
Arrange the supplies including hand drying towels, as appropriate
The supplies and faculties needed for the appropriate hand hygiene for all team members should be reviewed:
Is there a sink with soap, water and hand drying materials? All team members with visible dirt on their hands will need to first do a routine hand wash.
Ideally, the sink should not be in the room where the surgical procedure is done. And should be located at a distance from where the aseptic technique will be done.
If an aseptic hand rub will be done is there a supply of 70% alcohol and or betadyne or at 2% chlorhexidine? If betadyne is used, a time will be needed to allow for the 3 minute contact time.
If a surgical hand rub is necessary before doing a procedure with sterile technique, a finger nail stick and a long acting antiseptic such as chlorhexidine, or betadine is desirable, not other activities other than hand washing should be done at the sink, and sterile drying towels will need to be provided on the surgical field. It is no longer recommended to use a brush during a surgical hand prep since this was shown to cause abrasions.
All staff should remove gloves directly into a waste container and then wash their hands.
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25. Personal Protective Equipment
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Discuss what other items are expected and needed
These may include aprons, shoe covers for bloody procedures, masks, hair coverings, face shields or goggles
Discuss what other items are expected and needed. These may include aprons, shoe covers for bloody procedures, masks, hair coverings, face shields or goggles.
Remember that the primary objective is to use barriers that will prevent the transfer of germs to the vulnerable patient, then add items that are needed to protect the health care workers from possible exposures to blood or body fluids.
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26. Trash
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Plan appropriate leak proof, puncture proof containers for the transfer and disposal of sharps, infectious waste, and specimens
Sharps containers should be moved to the point of use so sharps can be discarded by the original team and not left for later staff to find and discard
4: Clean, Aseptic, Sterile

27. Summary Clean, aseptic and sterile Examples of procedures
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Clean, aseptic and sterile
Examples of procedures
SCRIPT the procedure to clearly define what is expected and needed from all team members to reduce contamination
Who can describe for me the differences between clean aseptic and sterile technique?
Who can name three procedures that can be done with clean technique? Three with aseptic technique? Three with sterile technique?
Planning and communication with team members about a procedure help make good aseptic and sterile technique possible. What do the letters SCRIPT remind staff to do prior to starting a procedure?
4: Clean, Aseptic, Sterile

28. Exercise: Practising Procedures
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Team
Script
Processing sputum for NT culture
Emptying a urinary catheter bag
Inserting an intravenous line
Inserting a urinary catheter
Inserting a thoracic drain
Assign roles and demonstrate procedure
Assign observers who note contamination
See facilitator’s guide
4: Clean, Aseptic, Sterile

29. “Separating Clean and Dirty” & “Giving Injections Safely”
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“Separating Clean and Dirty” & “Giving Injections Safely”
Refer to facilitator’s manual for discussion guide
Nursing Demonstration Videos

30. Break