Applying Aseptic Technique in all Clinical Settings
By Jennifer Schraag
The practice of aseptic technique isnt solely isolated to the operating room. The practice has a place in every clinical setting.
As the mother of a neutropenic infant, many facets of aseptic technique and infection prevention encircle all aspects of my daily life. I recently had a lot of time to sit back and consider all the different ways in which the sterile field is repeatedly broken in the healthcare environment as I sat with my ill daughter for four days in the hospital as she fought against the highly resistant Streptococcus pneumoniae that had infiltrated her ear.
The printouts I received daily of her nonexistent neutrophils and nearly nonexistent total white blood cell count had me reeling as I looked around her room and watched the staff come and go. I found myself analyzing their every move. It became apparent to me during my observations that oftentimes when healthcare workers (HCWs) are out of an area requiring certain protocols, they do not always think to follow the same protocols in other areas they may infiltrate. For instance, my daughter was under contact and respiratory precautions during our stay. When staff entered our room, they donned the appropriate garb and adhered to the general principals. However, when we would go to the treatment room down the hall, on the same floor to change out her IV, it appeared those precautions were thrown to the wind and now anything goes simply because we now are in a different room. Nobody was wearing their protective gear, the masks were long forgotten, and other than the one-woman IV team, no one bothered to slip on any gloves either.
I had received this article assignment just prior to our admission and I was determining the best approach to take; ultimately, I realized that stressing the importance of applying aseptic technique in all clinical settings was an important topic to cover. I realized the importance, and the need, for infection control practitioners (ICPs) to help their staff to not only realize the importance of applying ordered protocols with each individualized patient no matter their location in the facility but also to aid in overshadowing any school of thought that aseptic technique be solely applied to areas encircling the operating room (OR).
I think that when you say aseptic technique, a lot of people automatically think operating room or surgical procedure, explains Kathleen Meehan Arias, MS, CIC, president of the Association for Professionals in Infection Control and Epidemiology (APIC) and director of Arias Infection Control Consulting LLC. Thats rightly so because that is where the bulk of it is. But whenever you are doing anything that bypasses the skin barrier, you should automatically think aseptic technique.
Arias says HCWs should focus on aseptic technique at any time a procedure can introduce microorganism into a persons body. IV lines, foley catheters, any kind of surgery, any kind of skin preparation, any time you are poking a hole in a persons body or bypassing the normal body defense. When you put a patient on mechanical ventilation, frequently, you may be putting a hole in their throat to put tubes down or put tubes down the nose all of that introduces organisms from the outside to the inside. So whenever you do that you have to take precautions, she asserts.
The general definition of aseptic is without microorganisms.¹ Aseptic technique is the application of preventative measures taken to reduce the likelihood of introducing microorganisms. However, there may be many variances to aseptic technique and the many definitions can oftentimes get confusing.
Bonnie G. Denholm, RN, MS, CNOR, a perioperative nursing specialist with the Association of Perioperative Registered Nurses (AORN)s Center for Nursing Practice, explains that aseptic technique may be confused with sterile technique (surgical asepsis) because they are closely related. Aseptic technique is applied in a variety of settings (e.g., starting IV lines, inserting urinary catheters, changing wound dressings), she points out. Surgical asepsis is most often considered OR-specific, but is used whenever the integrity of the skin or the mucosal barrier is interrupted."
Aseptic techniques are those that do some or all of the following:¹
- Remove or kill microorganisms from hands and objects
- Employ sterile instruments and other items
- Reduce a patients risk of exposure to microorganisms
Arias points out that all aspects of aseptic technique are part of infection prevention procedures. We use aseptic technique to prevent infections, she says. When I teach about aseptic technique, I always say that the basic premise is that aseptic means without microorganisms and aseptic technique means any kind of procedure or practice that we do that reduces the risk of introducing microorganisms into whatever we are doing. If we are cutting open a patient, introducing it into a wound; inserting a Foley catheter, introducing it into the urethra.
I always like to say there is a clinical aseptic technique and an OR aseptic technique. But the OR people get upset about that. Its basically all the same, its just that what were taking are the things that we do in the operating room we have to use the things that we use in the operating room to avoid contaminating the field or the wound with microorganisms we have to take them out of the OR and use them in any practice we do outside of the operating room that involves the likelihood of introducing microorganisms into a patients body.
Aseptic technique refers to the practices performed immediately before and during a clinical procedure. They include:¹
- Surgical scrub
- Using barriers (personal protective equipment)
- Patient prep
- Maintaining the sterile field
- Using safe operative technique (making small incisions, avoiding trauma to tissue and surrounding structures, and controlling bleeding)
- Maintaining a safer environment in the surgical/procedure area
Aseptic technique protects both the patient and the HCW. Using good aseptic technique minimizes, controls, and helps to contain the pathogenic microorganisms that cause infection, Denholm adds.
Invasive procedures are taking place in a variety of settings outside of the OR, she points out. While clinical areas outside of the OR generally do not allow for the same strict level of asepsis, avoiding potential infection remains the goal in every clinical setting.¹ In February, AORN released its 2006 guidelines and recommended practices. The AORN Recommended Practices for Maintaining a Sterile Field is intended to serve as a guideline that can be easily adapted to various practice settings. This recommended practice will help nurses develop a sterile conscience, Denholm says. They include:
- Surgical hand antisepsis
- Discussions of surgical attire and standard and transmission-based precautions
- Establishing a sterile field
- Ensuring that items on the sterile field are sterile and transferred to the sterile field appropriately
- Monitoring a sterile field
- Monitoring of environmental conditions that can influence the integrity of the sterile field
Nurses in all practice settings need to have a good understanding of the importance of hand asepsis and the proper technique for achieving skin preparation of the surgical or procedural site, Denholm adds. They also need to understand the basics of caring for and cleaning surgical instruments including the decontamination process and how to evaluate packaging systems to ensure conditions have been met for sterilization, storage, and handling of sterile instruments and supplies.
Hand hygiene compliance is the most important aspect in reducing cross-infection of microorganisms. If you really think about it, handwashing is the most basic of the aseptic techniques that we use, Arias asserts. A lot of people dont think of handwashing as being aseptic technique, but its the first step in any procedure involving aseptic technique wash your hands then put a pair of gloves on.
Glove use is important and gloves must be used appropriately. In a study measuring how the improper use of gloves limits compliance to hand hygiene and exposes patients to infection, researchers found that possible microbial transmission might have occurred in nearly 20 percent of all contacts observed during the study.² The researchers observed that used gloves were not removed before performing care activities that necessitated strict aseptic precautions. Failure to change or remove contaminated gloves was a major component in the poor compliance with hand hygiene and carried a high risk of microbial transmission, the researchers write.
Another study published last summer investigated the degree of hand hygiene compliance and the use of gloves by HCWs in hemodialysis units.³ The researchers observed a total of 977 opportunities to wear gloves for, and to wash hands following, a patient-oriented activity, and 1,902 opportunities to wash hands before such an activity. While gloves were actually used on 92.9 percent of these occasions, hands were washed only 35.6 percent of the time after patient contact, and only 13.8 percent of the time before patient contact. An interesting side note: the researchers found that personnels knowledge of patients infectious status did not modify their adherence to hand hygiene practices.
Another interesting incidence that highlights the importance of hand hygiene in aseptic technique involves a dialysis patient who contracted Vibrio vulnificus, a marine bacterium.4 The patient, receiving continuous ambulatory peritonitis dialysis (CAPD), developed peritonitis caused by V. vulnificus after handling seafood and not properly washing afterward. This case highlights the importance of strict aseptic technique during CAPD exchanges, the researchers point out.
People, especially healthcare providers, have to think about using aseptic technique outside of the operating room, Arias contends. Handwashing is the most important or the first thing that we think of when we talk of aseptic technique. So much of what we do bypasses that patient skin barrier.
Another aspect of aseptic technique that is of great importance is the proper usage of medications, especially multi-dose vials, according to Arias. Thats a big one for aseptic technique. People tend to forget about that, but when using multi-dose vials it is so important that people clean the diaphragm off before they put a needle in and that they do not contaminate or reuse a needle or syringe. There have been a lot of outbreaks in physician offices and in hospitals, she explains.
From May 3 to May 7, 1996, five infants contracted bloodstream infections (BSIs) caused by both Enterobacter cloacae and Pseudomonas aeruginosa, and one infant contracted a BSI caused by E. cloacae only.5 The investigators speculate that a dextrose multi-dose vial became contaminated during manipulation or needle puncture and that successive use of this contaminated vial for multiple patients may have been responsible for the BSIs. Aseptic techniques must be employed when multidose vial medications are used, the investigators write, adding, single-dose vials should be used whenever possible to reduce the risk of extrinsic contamination and subsequent transmission of nosocomial pathogens.
On February 19, 2003, four patients in a neurology unit underwent cranial magnetic resonance angiography (MRA) and developed fever within one hour following the procedure.6 The same molecular profi le of Klebsiella oxytoca was isolated from blood cultures of the first three patients. The researchers think that the normal saline solution used to check the functioning of the IV catheter became contaminated during manipulation and that successive uses might have been responsible for this cluster. Poor aseptic techniques employed during successive uses appear to be the most likely route of contamination, they conclude. Use of the solution for multiple patients was routine in this setting, but the access diaphragm of the bottle was not cleansed.
Further backing Arias suggestion is another case involving four patients who acquired severe sepsis when single-use vials were used for multiple doses in a surgical ward in Italy.7 Aseptic technique isnt solely the nurses duty either. Every person in healthcare must remain vigilant. In a multidisciplinary setting, all personnel must constantly monitor their own movements and practices, those of others, and the status of the overall field to prevent inadvertent breaks in sterile or clean technique, reads the Encyclopedia of Surgery.¹ It is expected that personnel will alert other staff when the field or objects are potentially contaminated.
HCWs can also promote asepsis by evaluating, creating, and periodically updating policies and procedures that relate to this principle.
One such area that should be recognized was highlighted in a New Zealand survey of anesthetists.8 Results of the survey found that the majority (86.3 percent) of respondents split one drug ampoule between more than one patient; 41.3 percent used multi-dose vials for more than one patient; and 2.2 percent used pre-fi lled syringes for more than one patient.
Furthermore, 2.2 percent admitted to occasionally using the same syringe to administer drugs to more than one patient.
The reuse of syringes is not an accepted practice, as Arias points out, and can pose a serious threat. Sometimes people think it is okay to reuse a syringe if they change the needle.
It doesnt happen too often, but just last year there was an outbreak of hepatitis C from doing that. They understand the not reusing the needle part, but the not reusing the syringes is very important too, she reminds us.
Arias offers one last tip. Try to let healthcare providers see that asepsis or introducing microorganisms to where they are not supposed to be occurs in a lot of what we do. So anything that you do that you think you can introduce organisms into the patients body, focus on what precautions you can take to avoid introducing those organisms.
As for myself, writing for ICT has provided me with much knowledge of the endless insidious organisms lurking in the healthcare environment.
And I think the above research gives a good idea of the many different types of bugs that are lurking as well. Armed with that knowledge, I have to admit I find myself nearing insanity as my panic level continually rises as I compare and contrast my gained knowledge with my daughters pathetically low counts.
Unfortunately, I cant go down the hall and throw all caution to the wind like the nurses on my daughters ward that night. I also cant skip a handwashing before administering her biweekly injections without thinking about how I would never forgive myself if in that one incidence an organism transfer were to occur.
Until my daughter outgrows this sinister autoimmune disorder, the thoughts, fears, worries, and aseptic and infection prevention practices will continue in my household indefinitely. It is my hope that you and your facility will continue throughout the continuum of care indefinitely as well.
1. Encyclopedia of Surgery: A Guide for Patients and Caregivers: A-Ce. Aseptic Technique forum. Aseptic Technique. www.surgeryencyclopedia.com/A-Ce/Aseptic-Technique.html.
2. Girou E, et. al. Misuse of gloves: the foundation for poor compliance with hand hygiene and potential for microbial transmission? J Hosp Infect. 2004 Jun;57(2):162-9.
3. Arenas MD, et. al. A multicentric survey of the practice of hand hygiene in haemodialysis units: factors affecting compliance. Nephrol Dial Transplant. 2005 Jun;20(6):1164-71. Epub 2005 Mar 15.
4. Wong PN, et al. Vibrio vulnificus peritonitis after handling of seafood in a patient receiving CAPD. Am J Kidney Dis. 2005 Nov;46(5):
5. Archibald LK, et. al. Enterobacter cloacae and Pseudomonas aeruginosa polymicrobial bloodstream infections traced to extrinsic contamination of a dextrose multidose vial. J Pediatr. 1998 Nov;133(5):640-4.
6. Sardan YC, et. al. A cluster of nosocomial Klebsiella oxytoca bloodstream infections in a university hospital. Infect Control Hosp Epidemiol. 2004 Oct;25(10):878-82.
7. Pan A, et. al. An outbreak of Serratia marcescens bloodstream infections associated with misuse of drug vials in a surgical ward. Infect Control Hosp Epidemiol. 2006 Jan;27(1):79-82. Epub 2006 Jan 6.
8. Ryan AJ, et. al. A national survey of infection control practice by New Zealand anaesthetists. Anaesth Intensive Care. 2006 Feb;34(1):68-74.
Whats New in AORNs 2006 Guidelines for Aseptic Technique?
Bonnie G. Denholm, RN, MS, CNOR, a perioperative nursing specialist with the Association of Perioperative Registered Nurses (AORN)s Center for Nursing Practice, says several AORN recommended practices that pertain to aseptic technique were updated for the 2006 Standards, Recommended Practices, and Guidelines.
The changes made to the Recommended Practices for Maintaining a Sterile Field include:
- specifications for gowns (e.g., liquid barrier performance, adequate size to close completely in the back, sleeve length adequate to prevent cuff exposure outside the glove)
- Clarifi cation that ear, nose, throat, and hemorrhoidectomy procedures should be performed using sterile instruments
- Sterile transfer devices should be used when delivering medications to the sterile field
The AORN Recommended Practices for Traffi c Patterns in the Perioperative Practice Setting has also been updated to include parameters for positive air pressure in the OR. There are also extensive updates to the Recommended Practice for Surgical Tissue Banking.
The AORN Guidance Statement: Reuse of Single-Use Devices was also revised for the 2006 Standards, Recommended Practices, and Guidelines. Although it is not new this year, the perioperative nurse consultants in the Center for Nursing Practice have been reinforcing the content in the AORN Guidance Statement: Fire Prevention in the Operating Room because more alcohol-based solutions are being used for skin preps.
Denholm says healthcare facilities should abide by the AORN Standards, Recommended Practices, and Guidelines as a basis for developing policies and procedures in aseptic technique. ICPs and nurse educators can also use the Perioperative Nursing Data Set, Perioperative Nursing Vocabulary (PNDS) as a resource for establishing education programs throughout the facility. She adds, One of the patient outcomes included in this nursing vocabulary states, The patient is free from signs and symptoms of infection. The potential nursing diagnoses, nursing interventions, and nursing activities that apply to this outcome are also presented to facilitate nursing care planning throughout a facility.
AORN works closely with the Centers for Disease Control and Prevention (CDC) and the Association for Professionals in Infection Control and Epidemiology (APIC) as well as other professional associations to review and develop the recommended practices and guidance statements.