Aseptic technique: evidence-based approach for patient safety

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.

ANTT® standardisation facilitates new efficiencies with a novel partially-sterile Standard-ANTT PIVC Pack

Introduction: The widespread adoption of the ANTT®Clinical Practice Framework as a single standard for aseptic technique, has highlighted that many clinical procedures do not require a sterile procedure pack to be performed safely and aseptically. This study explores the utilisation of a partially-sterile procedure pack that is specifically tailored to Standard-ANTT. Methods: A prospective project improvement evaluation, using a non-paired sample (pre: n=41; post: n =33) of emergency department staff in an NHS hospital. Staff were evaluated performing peripheral intravenous cannulations (PIVC) using Standard-ANTT and the B. Braun Standard-ANTT peripheral cannulation pack. Findings: Significant improvements were observed in practice following the implementation of the pack and training in Standard-ANTT, including: Key-Part protection significantly improved (pre: n=28, 68.2%; post: n=33, 100%), and reduction in the Key-Site being touched after disinfection (pre: n=17; 41.4%; post n=5; 15.1%). Conclusions: In conjunction with appropriate education and training, this study provides proof of concept that due to the widespread use of the ANTT Clinical Practice Framework as a single standard aseptic technique, procedure packs that are specifically tailored to Standard-ANTT, can help to promote best practice and improve efficiencies.

DEFINITIONS

Partially-sterile procedure pack - all items required to be sterile remain in their individual blister wrapper. The final assembled pack itself is not then subjected to a further round of sterilisation as it is not needed. Sterile procedure pack - often contains a mixture of non-sterile and sterile items that have been stripped from their individual blister wrapper requiring the sterilisation of the final assembled pack.

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.

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.

Survey to explore understanding of the principles of aseptic technique: Qualitative content analysis with descriptive analysis of confidence and training

BACKGROUND

In many countries, aseptic procedures are undertaken by nurses in the general ward setting, but variation in practice has been reported, and evidence indicates that the principles underpinning aseptic technique are not well understood.

METHODS

A survey was conducted, employing a brief, purpose-designed, self-reported questionnaire.

RESULTS

The response rate was 72%. Of those responding, 65% of nurses described aseptic technique in terms of the procedure used to undertake it, and 46% understood the principles of asepsis. The related concepts of cleanliness and sterilization were frequently confused with one another. Additionally, 72% reported that they not had received training for at least 5 years; 92% were confident of their ability to apply aseptic technique; and 90% reported that they had not been reassessed since their initial training. Qualitative analysis confirmed a lack of clarity about the meaning of aseptic technique.

CONCLUSION

Nurses' understanding of aseptic technique and the concepts of sterility and cleanliness is inadequate, a finding in line with results of previous studies. This knowledge gap potentially places patients at risk. Nurses' understanding of the principles of asepsis could be improved. Further studies should establish the generalizability of the study findings. Possible improvements include renewed emphasis during initial nurse education, greater opportunity for updating knowledge and skills post-qualification, and audit of practice.

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

BACKGROUND

Maintaining the principles of asepsis when performing wound care and other invasive procedures is one of the fundamental approaches of preventing healthcare-acquired infection. Such an approach has been advocated for community practitioners.

LITERATURE

The performance of an aseptic technique is an under-researched area. The few studies that have been conducted have identified how strict adherence to the technique is difficult and contamination of hands/gloves is common and that community nurses often have a fatalistic view about whether asepsis is possible in a community setting.

AIM

The overall aim of this research project was to examine how experienced practitioners have adapted the aseptic technique within a community setting and to what extent the changed procedure still adhered to the principles of asepsis.

METHODS

This study used a mixture of non-participant observation and individual semi-structured interviews to examine adherence to the principles of the aseptic technique among the district nurses. Data were collected from one Trust in England with a total of 10 district nurses taking part and 30 aseptic procedures been observed.

RESULTS

The results show that almost all of the staff understood the principles of asepsis and had adapted the standard procedure for use in a patient's home. Common challenges included wound cleaning using a single nurse procedure, the contents of the pack and the home environment. The research also identified misconceptions about clean versus aseptic procedures and a lack of training for staff.

CONCLUSIONS

This study highlights the challenges of maintaining the principles of asepsis in a home environment and the fact that district nurses are often relied upon to find creative solutions to such challenges. The study also highlights issues around the implementation of evidence-based practice and the need for clearer guidance about how evidence should be used alongside existing procedures.

District nurses' and aseptic technique: where did it all go wrong?

Concerns have been raised about whether it is possible to perform aseptic procedures within a community setting. Hallett (2000) has described how community nurses often have a fatalistic view about whether such procedures can really be performed at home. At the same time there has been an increase in the number of patients being cared for at home who need interventions which must adhere to the principles of asepsis. While it has been acknowledged for some time that community nurses must be resourceful and adapt the procedure, the view that community nurses cannot really perform aseptic procedures is a fairly new phenomenon. This article explores the reasons why concerns about the performance of aseptic procedures in the community may have arisen and what steps can be taken to address these concerns to ensure that care at home is both safe and effective.

Infection control and intravenous therapy in patients in the community

Recent efforts to reduce infections have been focused within the hospital setting. Early hospital discharge, shorter inpatient stays, day surgery and the movement of patients between acute and long-stay care facilities is likely to make community-acquired infection an increasing problem. There are, or course, universal precautions and general infection control issues to consider when undertaking any clinical procedure, both in hospital and the community, but when administering intravenous therapy (medicines and/or maintenance fluids) specific measures need to be considered. This is especially important if a patient is receiving intravenous therapy at home. There are many reasons why patients may need to receive intravenous therapy in the community and these will all present with specific problems. This paper will discuss some of the infection control procedures one must undertake when administering intravenous therapy to patients in the community.

Infection control and IV therapy in patients with Clostridium difficile

Clostridium difficile is a spore-forming anaerobe belonging to the family Clostridium, with the bacteria being found in low numbers in approximately 5% of the healthy adult population. Together with meticillin-resistant Staphylococcus aureus, it is a major healthcare-associated infection and is responsible for considerable morbidity and mortality. Antibiotics administered to patients can alter normal gut flora, allowing the proliferation of C. difficile and causing antibiotic-associated diarrhoea and colitis. Such diarrhoea, if severe, can lead to dangerous dehydration and even hypovolaemia, especially in the elderly. To limit the physiological impact of diarrhoea, it is sometimes necessary to administer intravenous therapy. Although good clinical practice demands that infection control should be considered in all clinical situations, specific infection control procedures need to be adhered to when administering intravenous therapy to patients with C. difficile.