Every year about 5,000 patients die unnecessarily in the UK from hospital-acquired infection (National Audit Office, 2000). Many become infected during simple procedures, such as administering intravenous drugs and managing wounds, owing to poor hand-washing and aseptic technique. Despite this, it has been shown that techniques and terminology vary greatly (Rowley, 1996).
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Stephen Rowley, BSc, RGN, RSCN, is senior nurse, haematology, University College Hospital, London
A review of the literature reveals an almost complete absence of research in this essential area of clinical practice. Aseptic techniques have evolved more from anecdotal evidence and ritualistic practice than from empirical research, and the principles of aseptic technique need to be re-established in nursing practice (Lund, 1983). It is essential that nurses can apply a standardised technique to aseptic procedures.
Surveys by Jones (1983) and Rowley (1996) highlighted significant variations in practice which can be confusing for staff and patients. The observational study of three teaching hospitals (Rowley, 1996) revealed four significant problem areas:
- Poor practice - areas with high intravenous therapy workloads, such as theatres and intensive care, often seemed to demonstrate the poorest aseptic practice. For instance, hand-washing was poor, IV ports were often not cleaned and syringes were often re-used after being placed on the patients’ bedlinen;
- False sense of security - constant use of sterile gloves often led to a false sense of security which resulted in contamination of key parts (Rowley, 1996);
- Labour-intensive practice - areas that practised a strict so-called ‘sterile technique’ resulted in this taking two nurses to do something as simple as inject a drug into a burette. This demonstrated a basic lack of understanding of what could and what could not be touched;
- Cost-effectiveness - staff would unnecessarily wear expensive sterile gloves for the most simple intravenous procedures and wound management.
Aseptic non-touch technique (ANTT)
To help address these types of problems the ANTT was developed. It is exactly what it says it is - a technique that maintains asepsis and is non-touch in nature. This is important, as other terms - such as sterile technique - are often used inaccurately and can subsequently confuse practitioners (Box 1). ANTT is supported by evidence and highlights the key components involved in maintaining asepsis and aims to standardise practice.
- The underlying principles of ANTT are:
- Always wash hands effectively;
- Never contaminate key parts;
- Touch non-key parts with confidence;
- Take appropriate infective precautions.
Approximately 10% of all endemic infections in hospital are airborne (Eickhoff, 1994; Schaal, 1991). It would therefore seem reasonable to assume that the potential for harmful contamination via this route is small in comparison to direct contact. Nurses can reduce the potential for airborne infection by taking sensible precautions, such as avoiding procedures that require ANTT immediately after bed-making or similar activities when airborne bacteria will be at its highest (Church, 1986a).
Maintaining asepsis of key parts is achieved by preventing them coming into contact with a significant amount of potentially harmful organisms. This is difficult, as the very tools we use to perform ANTT are covered in bacteria - our hands. It has been estimated there are as many as three million bacteria present per square centimetre of normal skin (Gould, 1991).
Pathogenic bacteria, such as pseudomonas and klebsiella, can be harboured on hands for months (Adams and Marrie, 1982). A worrying trend in hospitals is the emergence of antibiotic-resistant organisms which can survive on the hands of health care workers. Many, if not most, hospital-acquired infections continue to be spread by direct contact by the hands of health care workers (Bauer et al, 1990).
Hand-washing is the most significant procedure in preventing cross infection (Voss and Widmer, 1977). Organisms present on the hands are either resident or transient. Transient organisms are those that are not usually part of the skin flora. They are acquired by contact with infected patients or infected equipment. They can be easily removed by effective hand-washing techniques.
Our own normal resident skin flora consists of mainly Staphylococcus epidermis and Staphylococcus aureus bacteria. These are normally deeply ingrained into the epidermis and cannot be totally removed by hand-washing (Church, 1986b), although effective hand-washing can reduce the number significantly. However, research continues to highlight that many health care workers fail to wash their hands effectively (Pritchard,1994).
Although bacteria can be reduced by effective hand-washing, it can re-establish quickly over the entire hand surface in the warm and damp environment created beneath gloves (Gould, 1991). This is an important fact, as a study by Stringer et al (1991) highlighted that failure to wash hands after glove removal was the most frequent breakdown in universal barrier precautions.
Choosing between sterile, non-sterile or no gloves at all has become a contentious issue in IV therapy. The rationale for glove choice for the ANTT is based on the fact that there is no substantial evidence to prove that any particular type of glove reduces the incidence of IV-related infection. Also, COSHH regulations (1988) recommend protective clothing such as gloves for all procedures involving potentially hazardous substances, not just cytotoxics.
Ojajarvi (1980) highlighted the fact that colonisation of skin by transient bacteria is likely to result when skin is repeatedly moist or damaged. Shredded skin caused by such damage can transmit bacteria via the contact route (Gould, 1991). Nurses often have moist and damaged hands owing to frequent washing and drying. Gloves may therefore serve as a barrier to prevent descaling of bacteria on to key parts.
When the fundamental requirements of the ANTT are adhered to gloves become superfluous. However, as these two requirements cannot be guaranteed it would seem a sensible measure for gloves to be worn to protect the patient in case staff inadvertently touch key parts with poorly washed hands. The wearing of gloves for all procedures involving potential exposure to body fluids was recommended by the Center for Disease Control (1987) and were termed universal precautions.
Must the gloves be sterile?
The use of sterile gloves for particularly difficult procedures or those that take a significant amount of time seem both sensible and logical precautions, as the potential for accidental direct/indirect contamination is increased. However, it can be a waste of money to wear expensive sterile gloves for simple procedures or when using closed IV systems. After all, even sterile gloves cannot always be considered 100% sterile, due to a small but significant micropermeability and the potential for staff to contaminate them (DeGroot-Kosolcharoen and Jones, 1989).
It has been reported that excessive precautions for simple procedures can contribute to a false sense of security (Lund, 1993), and that many staff touched key parts unnecessarily when wearing sterile gloves.
A clean working environment is a sensible precaution. However, the need for sterile towels and dressing packs for all procedures is extravagant. For the majority of IV procedures the asepsis of only one or two small key parts is maintained. This can be achieved simply and effectively by the ANTT.
Is ANTT suitable for all IV therapy?
ANTT should be used for both central and peripheral line care as it can be counterproductive to promote two different concepts of technique. This can imply that peripheral techniques do not need to be as aseptic, resulting in terminology such as ‘clean technique’. Either a technique is aseptic or it is not. Nurses would be better advised to concentrate on developing an excellent and consistent technique rather than on the route of administration and the diagnosis of the patient.
To assess the degree of precautions required to maintain asepsis for any procedure nurses must be able to identify and consider the risk factors involved, such as the technical difficulty of the procedure, its duration, the environment and the number of key parts.
Fundamental to the effectiveness of the technique will be the nurse’s ability to identify the infection risks in every procedure. The nurse can then counter these risks by utilising appropriate aseptic precautions.
Preparing and administering an antibiotic to an immunocompromised patient via a central line
- Clean hands with alcohol solution on entry to the preparation room;
- Wipe a clean tray with an alcohol impregnated surface cleaner;
- Gather all equipment and drugs;
- While the tray dries wash hands with chlorhexidine solution and water;
- In accordance with COSHH regulations put on gloves (non-sterile);
- Prepare the equipment and arrange it in the tray tidily. Take care to maintain the asepsis of all exposed key parts, such as protecting syringe tips with capped needles;
- Prepare the drug aseptically;
- Enter the patient’s room and prepare the patient and expose his or her central line;
- Remove gloves and wash hands;
- Put on new non-sterile gloves. Only use sterile gloves if the key parts cannot be kept aseptic by a non-touch method;
- Make the central line port aseptic by cleaning with an alcohol and chlorhexidine wipe and ensure it is dry before use;
- Then administer.
Introducing and managing the ANTT
ANTT is time-saving and cost-effective as it involves a minimum of staff and resources. When introduced on a ward or unit it heightens awareness of the basic principle of achieving asepsis. Because it is logical in its approach it is relatively easy to teach.
Compliance is a vital ingredient of any standardised practice. It is therefore essential that staff are well prepared and educated in ANTT before it is introduced. Many staff may hold the opinion that their practice is already aseptic. However, observation and assessment will often demonstrate to even experienced staff that their practice could be improved. After implementation it is essential that compliance is monitored and audited on a regular basis.
The ANTT does not provide practitioners with a technique based on a randomised controlled study - the gold standard of research methodology. Until more of the main components of aseptic technique are proven, inconsistencies will remain. However, it does provide practitioners with the first concise and logical theoretical framework based on accepted best practice and supportive research. As more hospitals continue to adopt the ANTT as a foundation for good practice, audit and research should be better facilitated and standardised. This, it is hoped, will result in an ongoing refinement of evidence-based technique in many hospitals.