Performing an aseptic technique in a community setting: fact or fiction?

Aseptic versus clean technique during wound management? Systematic review with meta-analysis

The management of wounds by health professionals usually involves aseptic technique. An alternative is the use of clean techniques where the risk of infection is minimised but use of non-sterile materials is considered permissible. This systematic review and meta-analysis compares these two approaches. Nine studies met the inclusion criteria. Overall risk of bias was judged to be low. The random-effects relative risk of infection for clean dressings rather than aseptic dressings was 0.86 (95% CI 0.67, 1.12). There was little evidence of statistical heterogeneity, although the small number of infections in either group resulted in wide confidence intervals. The 95% prediction interval for future studies was 0.63, 1.18. There was therefore no evidence showing inferiority of clean techniques compared to aseptic methods. Before clinical studies are undertaken with higher risk procedures, laboratory simulations should explore safety by investigating the potential for pathogen transmission at each stage in the dressing procedure.

What techniques are recommended to undertake procedures that require asepsis? Content and cluster analysis of information supplied in international guidance

BACKGROUND

Health professionals frequently conduct procedures requiring asepsis but there is no definitive evidence-based guidance on how aseptic technique should be undertaken.

OBJECTIVE

To undertake content and cluster analysis to compare and contrast information relating to the conduct of aseptic technique in national and international guidance.

METHODS

Content and hierarchical cluster analysis.

RESULTS

We identified 16 sources of information from: organizations that generate infection prevention guidelines, provide advice about infection prevention in addition to other topics, generate guidance for procedures (e.g., wound care); practice manuals; MeSH and Wikipedia. Content related to: theory underpinning aseptic technique; terminology used; how and when it should be undertaken; and equipment. The nature and amount of information varied widely. Most frequently stated information related to: environment or equipment (N = 13), followed by the absolute nature of asepsis and the importance of hand hygiene (N = 10); general personal protective equipment, the significance of pathogens, and no-touch techniques (N = 8); that it is risk-based (N = 7); the existence of key parts or sites, and that there are different types of aseptic technique (N = 6). The most comprehensive sources were a wound care organization in the USA, and a British internationally used textbook. Least information was provided in some general infection prevention guidelines.

CONCLUSION

Progress with research and practice in relation to aseptic technique suffers through lack of common goals and understanding. This study is one step towards establishing what constitutes aseptic technique, how and when it should be conducted, and the equipment necessary. This is required to support practice, policy and education, and may improve sustainability of healthcare resources.

Challenges undertaking procedures requiring asepsis: a qualitative interview study with nurses

BACKGROUND

Invasive devices and breaches to skin and mucous membranes increase susceptibility to infection. Nurses frequently undertake procedures requiring asepsis (PRAs), but report challenges and unwarranted variations in practice.

OBJECTIVE

To explore nurses' experiences, perceived gaps in information and support needed to conduct PRAs.

METHODS

Qualitative interviews were undertaken with 20 nurses in the UK National Health Service between September 2021 and January 2022 employing approaches to sampling and data collection adopted in grounded theory.

RESULTS

Informants were employed in diverse clinical settings. They thought that outside operating theatres, attempts to maintain asepsis would inevitably be compromised, but that much could still be done to contain the risk of contaminating susceptible sites irrespective of circumstances. Suboptimal practice was reported, and informants were unclear whether asepsis was needed to perform routine procedures (e.g. dressing chronic wounds, manipulating indwelling intravascular lines). Problems were attributed to inadequacies in nursing education, poor access to continuing professional development, and carelessness of junior nurses and medical staff. Informants wanted more detailed guidelines to conduct PRAs. Senior nurses wanted procedures to be conducted in the same way regardless of circumstance. Nurses who undertook PRAs regularly suggested that guidelines should be flexible.

CONCLUSION

There is a need for detailed guidelines to inform PRAs, better access to clinical updating, and improvements in pre-registration nursing education. To meet contemporary standards, guideline generation should adopt recognized methodology. Student nurses should be introduced to the knowledge and skills required to undertake and adjust PRAs according to circumstance during simulated practice before contact with real patients.

How aseptic technique is taught to undergraduate student nurses: A qualitative study

BACKGROUND

Aseptic technique is essential to prevent healthcare-associated infection and reduce the risk of antimicrobial resistance but little research has explored how it is taught in undergraduate nursing curricula.

OBJECTIVE

Explore how undergraduate student nurses learn about aseptic technique in classroom and clinical settings and the contribution of key stakeholders in the educational process: nurse educators, mentors and infection prevention nurses.

DESIGN

Qualitative interview study with observation of teaching.

SETTING

Two contrasting sites, one reporting greater innovation in relation to the teaching and practice of aseptic technique than the other. Each site comprised a university nursing department and the organisations providing student placements.

PARTICIPANTS

Student nurses, university-based nurse educators, clinical mentors and infection prevention nurses.

METHODS

Telephone interviews, fieldwork and unstructured observation of teaching in the universities.

FINDINGS

Student nurses reported feeling poorly prepared to undertake aseptic technique. There were misunderstandings and confusion about its purpose and how it should be conducted among nurse educators and mentors. Suboptimal facilities, poor curriculum design and arrangements for competency assessment in both sites contributed to students' experiences. Reports of better innovation in one of the participating sites compared to standard practice in the other were not reflected in the data.

CONCLUSIONS

The findings of this study corroborate earlier research: student nurses do not feel well-prepared to undertake aseptic technique. Healthcare providers and universities need to investigate and address deficiencies in understanding among those responsible for teaching and performing this key nursing skill. University curricula should be revised to ensure that teaching takes place optimally in relation to clinical placements, improve arrangements for students' competency assessment, focus more on teaching the principles underpinning aseptic technique and promote transferability from the classroom to different types of clinical settings. Communication between university and clinical staff should be strengthened.

Invasive Group A Streptococcus Outbreaks Associated with Home Healthcare, England, 2018-2019

emm typing and whole-genome sequencing can help identify case clusters.

Healthcare-associated invasive group A Streptococcus (iGAS) outbreaks are common worldwide, but only England has reported outbreaks associated with home healthcare (HHC). We describe 10 outbreaks during 2018–2019 in England. A total of 96 iGAS cases (range 2–39 per outbreak) and 28 deaths (case-fatality rate 29%) occurred. Outbreak duration ranged from 3–517 days; median time between sequential cases was 20.5 days (range 1–225 days). Outbreak identification was difficult, but emm typing and whole-genome sequencing improved detection. Network analyses indicated multiple potential transmission routes. Screening of 366 HHC workers from 9 outbreaks identified group A Streptococcus carriage in just 1 worker. Outbreak control required multiple interventions, including improved infection control, equipment decontamination, and antimicrobial prophylaxis for staff. Transmission routes and effective interventions are not yet clear, and iGAS outbreaks likely are underrecognized. To improve patient safety and reduce deaths, public health agencies should be aware of HHC-associated iGAS.

Undergraduate nursing students' education and training in aseptic technique: A mixed methods systematic review

AIM

To appraise and synthesize empirical studies exploring undergraduate nursing students' education and training in aseptic technique.

DESIGN

Mixed methods, systematic literature review adopting Joanna Briggs Institute methodology.

DATA SOURCES

Thirteen electronic databases were searched 1996-2020, followed by searches with a general browser, hand-searching key journals and reviewing reference lists of retrieved papers.

REVIEW METHODS

Potentially eligible papers were scrutinised by two reviewers. Those eligible were critically appraised and quality assessed using the Critical Appraisal Skills Programme and Specialist Unit for Review Evidence checklists.

RESULTS

Of 538 potentially eligible studies, 27 met the inclusion criteria. There was limited evidence of the effectiveness of different teaching methods. Students' knowledge, understanding and competency varied and were often poor, although they reported confidence in their ability to perform aseptic technique. Students and qualified nurses perceived that education and training in aseptic techniques might be improved.

CONCLUSION

Education and training in aseptic technique might be improved but the review findings should be viewed cautiously because the studies lacked methodological rigour.

IMPACT

This appears to be the first systematic review to explore undergraduate nursing students' education and training in relation to aseptic technique. There was limited evidence to support the effectiveness of different teaching methods and scope for improving nursing students' knowledge, understanding and competency in aseptic technique. Students and qualified nurses suggested that education and training might be enhanced. More robust studies are required to support education, practice and policy.

Survey with content analysis to explore nurses' satisfaction with opportunities to undertake continuing professional education in relation to aseptic technique

BACKGROUND

Aseptic technique is a key skill undertaken every day by large numbers of nurses. However, there is relatively little empirical evidence to underpin practice. Furthermore, it is not clear to what extent it should be considered a single task or a set of principles to be applied differentially depending upon the situation and how individual nurses make this decision.

OBJECTIVE

This study explored nurses' experiences of continuing professional education (CPE) in relation to aseptic technique.

DESIGN

A national survey was undertaken throughout the United Kingdom. Responses were subjected to inductive quantitative content analysis.

PARTICIPANTS

Participants were recruited via an electronic link placed on the website of a major nursing organisation.

RESULTS

941 nurses responded. 253 (26.9%) were satisfied with arrangements for continuing professional education. Satisfaction was associated with a perception of good support from employers, sound preparation before qualifying and practising aseptic technique regularly. 311 (33%) were dissatisfied. Reasons included witnessing unwarranted variations in practice (n = 55, 5.8%), witnessing suboptimal practice requiring correction (65, 6.9%), a perception that standards had fallen through a decline in pre-registration preparation (n = 109, 11.6%) and opportunities for updating (n = 124, 13.2%). Some employers had introduced training in conjunction with organisation-wide change in practice. In other cases participants reported receiving updates when required to perform a new procedure, when moving between clinical specialities or changing employer. Train-the-trainer (cascade) teaching was used in formal and informal arrangements for updating.

CONCLUSION

This study provides a springboard for exploring arrangements for updating and assessing nurses' competence to undertake aseptic technique. Health providers need to evaluate what is currently provided and address gaps in provision. There is clear evidence that the current system does not meet the needs of many nurses.

How widely has ANTT been adopted in NHS hospitals and community care organisations in England and Scotland?

Background:

To the detriment of patient safety, the important clinical competency of aseptic technique has been notoriously variable in practice, and described ambiguously in the literature, internationally. From a UK perspective, attempts have been made to improve patient safety by reducing variability and improving education and practice through standardisation. The Welsh Government mandated Aseptic Non Touch Technique (ANTT®) as a specific national standard in 2015. All healthcare organisations in England are required by the Health and Social Care Act 2008 to have a single standard aseptic technique, demonstrable by the clinical governance indicators of education, training, competency assessment and compliance audit. In Scotland, an education-based initiative was launched by NHS Education for Scotland in 2012. To review the impact of these and other initiatives on the current status of aseptic technique, all NHS trusts in England and NHS health boards in Scotland were assessed under the Freedom of Information procedure.

Findings:

93% of NHS trusts in England use a single standard for aseptic technique. In 88% of these trusts the single standard was stipulated as being ANTT. In Scotland, 62% of NHS acute and community care hospitals within health boards use a single standard. In 56% of these, the single standard was ANTT. When including those that use ANTT in combination with other techniques ANTT usage is 73%.

Conclusion:

These data demonstrate significant progress in standardising aseptic technique education, assessment and governance, and confirms ANTT as the de facto aseptic technique used in NHS trusts in England and health boards in Scotland.

National cross-sectional survey to explore preparation to undertake aseptic technique in pre-registration nursing curricula in the United Kingdom

BACKGROUND

Aseptic technique is a core nursing skill. Sound preparation is required during pre-registration nursing education to enable student nurses to acquire the knowledge and skills necessary to prevent and control healthcare-associated infection and promote patient safety. Few studies have explored nursing students' education and training in aseptic technique.

OBJECTIVES

To investigate what, when and how pre-registration nursing students are taught aseptic technique and how they are assessed in undergraduate, pre-registration nursing programmes in the United Kingdom.

DESIGN

National cross-sectional survey exploring preparation to undertake aseptic technique in pre-registration nursing curricula in the United Kingdom.

SETTING

Universities providing undergraduate, pre-registration adult nursing programmes in the United Kingdom.

PARTICIPANTS

Nurse educators.

METHODS

Structured telephone interviews were conducted with nurse educators. Descriptive and inferential statistical data analyses were undertaken.

RESULTS

Response rate was 70% (n = 49/70). A variety of different learning and teaching methods were reported to be in use. Teaching in relation to aseptic technique took place in conjunction with teaching in relation to different clinical procedures rather than placing emphasis on the principles of asepsis per se and how to transfer them to different procedures and situations. Wide variation in teaching time; use of multiple guidelines; inaccuracy in the principles identified by educators as taught to students; and limited opportunity for regular, criteria based competency assessment were apparent across programmes.

CONCLUSIONS

Pre-registration preparation in relation to aseptic technique requires improvement. There is a need to develop a working definition of aseptic technique. The generalisability of these findings in other healthcare students needs to be explored.

Challenges faced by nurses in complying with aseptic non-touch technique principles during wound care: a review

BACKGROUND

Surgical and wound site infections (SWSIs) are the second most frequent type of healthcare-associated Infection. One way of preventing SWSIs is by adhering to the principles of asepsis. However, many nurses struggle to apply the principles of aseptic non-touch technique (ANTT) during wound management.

AIM

To identify the barriers and enablers that influence nurses' adherence to the principles of ANTT during wound care.

METHOD

A literature search using a systematic approach was carried out. Four databases were searched to identify relevant studies published between January 1993 and December 2018. Titles and abstracts were reviewed. Studies that met the inclusion criteria were reviewed for quality. The extracted data were then synthesised.

FINDINGS

A total of seven studies fulfilled the requirements for inclusion. Three themes emerged and were found to be the most dominant factors influencing adherence to the principles of ANTT: material and resources, nurse education, and nurses' behaviour.

CONCLUSION

Nurses' compliance with aseptic practice is directly influenced by environmental and psychological factors. Ensuring compliance to ANTT may require an integrated approach involving local, national and worldwide organisations, in collaboration with higher education institutions that teach nurses and similar healthcare professionals.

Implementing the Aseptic Non Touch Technique (ANTT®) clinical practice framework for aseptic technique: a pragmatic evaluation using a mixed methods approach in two London hospitals

BACKGROUND

Aseptic technique is an important infection prevention competency for protecting patients from healthcare-associated infection (HAI). Healthcare providers using the Aseptic Non Touch Technique (ANTT®) aseptic technique have demonstrated reduced variability and improved compliance with aseptic technique.

OBJECTIVES

The primary aim of this study is to determine whether standardizing aseptic technique for invasive IV procedures, using the ANTT® - Clinical Practice Framework (CPF), increases staff compliance with the infection prevention actions designed to achieve a safe and effective aseptic technique, and whether this is sustainable over time.

METHODS

A pragmatic evaluation using a mixed-methods approach consisting of an observational audit of practice, a self-report survey and structured interviews with key stakeholders. Compliance with aseptic technique before and after the implementation of ANTT® was measured by observation of 49 registered healthcare professionals.

RESULTS

Mean compliance with competencies was 94%; each component of practice was improved over baseline: hand hygiene = 63% (P ≤ 0.001); glove use = 14% (P ≤ 0.037); Key-Part protection = 54% (P ≤ 0.001); a non-touch technique = 45% (P ≤ 0.001); Key-Part cleaning = 82% (P ≤ 0.001); and aseptic field management = 80% (P ≤ 0.001).

CONCLUSIONS

Results show implementation of ANTT® improved compliance with the prerequisite steps for safe and effective aseptic technique as defined by the ANTT®-CPF. Improvements in compliance were sustained over four years.