1. Clean, Aseptic and Sterile Technique
Infection Control Basics

2. Sterile wound dressing

3. Definition: Clean Technique
Page 3
Definition: Clean Technique
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. Page 4
Clean Technique
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.

5. Examples of When Clean Technique is Used
Page 5
Examples of When Clean Technique is Used
Clean tech is appropriate for:
Taking blood pressures
Examining patients
Feeding patients

6. Definition: Invasive Procedures
Page 6
Definition: Invasive Procedures
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

7. Definition: Aseptic Technique
Page 7
Definition: Aseptic Technique
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.

8. Page 8
Aseptic Technique
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.

9. Definition: Sterile Technique
Page 9
Definition: 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
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.

10. Page 10
Sterile Technique
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.

11. Differences Between the Types of Techniques
Page 11
Differences Between the Types of Techniques
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

12. Iodophors, chlorheximide
Page 12
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
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.

13. To Prevent Contamination
Page 13
To Prevent Contamination
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
The sterile field is considered sterile except for the 2.5 cm border
Wet items are considered contaminated
Planning reduces errors
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.

14. Page 14
Trash
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 aren’t dropped or left behind.