The term ‘aseptic technique’ means free from pathogenic microorganisms and is the deliberate prevention of the transfer of organisms from one individual to another by keeping the microbial count to an irreducible minimum (Rowley et al, 2010). On the other hand, clean technique is a slightly less sterile technique, but the term still indicates free of dirt, marks or stains. The technique involves care delivery using methods that prevent the transmission of microorganisms, such as by meticulous handwashing; maintaining a clean environment by preparing a clean field; using personal protective equipment, such as clean gloves and sterile instruments; and preventing direct contamination of materials and supplies. The main difference between the two is that, unlike aseptic technique, clean technique does not require ‘sterile-to-sterile’ (Rowley et al, 2010). This means that sterile technique requirements, such as wearing clean sterile gloves before touching any sterile surface, for example, a dressing field, do not apply. Clean technique would involve clean hands and clean—but not necessarily sterile—latex gloves. The sterile-to-sterile policy means that only sterile gloves that are clean and new out of their packet can be used before touching any sterile surface. Minimal transference is used in both cases, where gloves do not repeatedly go from the wound or patient, back to a sterile pack and then back again to the wound. Wound dressings would be opened onto the sterile field in a sterile-to-sterile technique. Clean technique is considered most appropriate for long-term and home care, and so is applicable most commonly as the most aseptic way of changing a dressing in community nursing practice. This is especially true in the case of large wounds that require many dressings, including packing of the wound for heavy exudate. Sterile packing should still be applied, as well as a sterile dressing, but clean technique would generally apply in this case, which is more appropriate for the cleansing of a heavily exuding wound Thus, it is appropriate, for example, for patients who are not at high risk for infection and for patients who require routine dressings for chronic wounds such as venous ulcers, or wounds healing by secondary intention with granulation tissue (Wooten and Hawkins, 2001; Kent et al, 2018).
Kent et al (2018) performed a literature search to examine the evidence and provide recommendations on whether the clean or aseptic technique is most effective in preventing wound infection when changing wound dressings. They looked into all wounds, chronic and acute. Some 473 articles were examined, and four research studies met the inclusion criteria as identified via a systemic approach. These four studies reported no significant difference in the rate of wound infection between the clean or aseptic technique with dressing application (Kent et al, 2018). However, the studies varied greatly in size, and the wounds were found not to be representative of those clinically encountered. Therefore, the findings were not generalisable or conclusive. The authors concluded that the use of clean technique for acute wound care is a clinically effective intervention and does not affect the incidence of infection, and that there is no recommendation regarding the ideal dressing technique for chronic wounds due to lack of evidence in the literature (Kent et al, 2018).
Aseptic technique aims to produce an environment that is free of microbial contamination to protect patients from developing infections (Marcovitch, 2005). The idea initially penned by Lister is that bacteria are the causative agents of infection. Thus, bacterial transmission can be kept to a minimum during wound treatment if a wound dressing is removed initially using a sterile bag and non-touch technique. The wound is cleaned with saline/another antiseptic solution while wearing gloves; and the hands are washed and dried and sterile gloves are applied to use a sterile dressing pack to then apply a sterile dressing (all products such as dressings and wound packs are sterile inside their packaging). This process is known as aseptic non-touch technique (ANTT), where no surface is touched in the aseptic process unless it is from sterile to sterile.
NICE guidance
National Institute for Health and Care Excellence (NICE) guidance covering healthcare-associated infection prevention and control in primary and community care was published in 2012. This guidance covered basic principles and stated that anyone providing care should be educated on the standard principles of infection control and trained in hand decontamination and the use of personal protective equipment.
The NICE guidance (2012) also stated that wherever care is given, the health worker must have appropriate supplies of materials for hand decontamination, sharps containers and personal protective equipment. Patients and carers should also be educated by the health worker visiting them on how to decontaminate their hands effectively, using the correct technique and timing and on the use of liquid soap and water or hand rub depending on what care has been given (NICE, 2012).
Hands must be decontaminated in various circumstances, as explained by the NICE (2012) guidance, including immediately prior to every episode of direct patient contact or care involving aseptic procedures; immediately following every episode of direct patient contact or care; immediately following any exposure to body fluids; immediately following any other circumstance whereby there has been contact with the patient's surroundings that could potentially cause hands to be contaminated, and always immediately after removing gloves (NICE, 2012). Additionally, hand rub must always be used, unless the circumstance requires liquid soap and water to be used to decontaminate hands.
When to decontaminate hands with soap and water?
Hands should be washed with soap and water if they are visibly soiled or may have body fluids on them, as well as in clinical circumstances where there is the potential for the spread of organisms that are resistant to alcohol (used in hand rub), for example, Clostridioides difficile or other diarrhoea-related organisms (NICE, 2012).
Avoiding contamination of the hands
Community nurses and health workers can ensure they avoid contamination while they are at work, by keeping their arms bare below the elbow when in direct contact with a patient; by removing all wrist and hand jewellery; by keeping fingernails short and clean; by not wearing nail polish, which can prevent visibility of contamination under the nails; and by covering cuts and abrasions with waterproof dressings (NICE, 2012).
Three stages of handwashing
Handwashing should involve the following three stages. The first is preparation, during which the hands should be wet under tepid water prior to applying liquid soap or an antimicrobial liquid. This is followed by washing, during which it should be ensured that the hand wash solution covers all areas of the skin surface of the hands and wrists. The hands should then be rubbed together vigorously for at least 10 to 15 seconds, with particular attention to the fingertips, thumbs and the areas between the fingers. The last stage is drying, for which NICE (2012) recommends using good-quality paper towels immediately after the hands are rinsed thoroughly.
The directions for the use of hand rubs are similar to the washing stage using soap and water, in that it should be ensured that all skin surfaces are covered. Before using a hand rub, the hands should be dirt-free and not have any organic material on the skin (NICE, 2012). The washing technique should continue until all of the hand rub has evaporated. NICE (2012) also recommends that an emollient hand cream be used regularly, to prevent any problems associated with the drying effects of regular hand decontamination, such as eczema. Further, the guidance recommends that the occupational health team be consulted if any particular soap or hand rub causes irritation.
Personal protective equipment
An assessment should be made as to the need for appropriate personal protective equipment. This includes the risk of transmission of microorganisms to the patient and contamination of the nurse's clothing or skin by the patient's blood, body fluids or excretions (NICE, 2012). Of course, gloves must be worn during all activities that involve exposure to blood, body fluids, secretions or excretions or sharp or contaminated instruments (NICE, 2012). Gloves should be single-use; they should be worn immediately before an episode of contact or treatment and removed immediately following completion of the task. They must always be changed between patients to avoid the spread of infection and should also be changed between different tasks of care for the same patient (NICE, 2012). Similarly, an apron should be worn where there is risk to exposure to blood, body fluids or secretions, and these should be single-use ones. A long-sleeved fluid-repellent gown should be worn if there is a risk of extensive splashing of blood, body fluids, secretions or excretions (NICE, 2012). NICE (2012) also states that face masks and eye protection must be worn where there is a risk of blood, body fluids, secretions or excretions splashing into the face and eyes, and that respiratory protective equipment, such as a particulate filter mask, must be worn when clinically indicated.
Conclusion
The principles of asepsis apply whenever there is high risk of bacterial contamination and, thus, a high risk of sepsis. These principles are followed in high-risk hospital environments following surgery and for other open or closed wounds related to burns, etc. In the community setting, it is not a sterile environment and, usually, the wound is chronic, for example, a long-term leg ulcer. It is advised that a clean technique, if not asepsis, be applied in this environment. At present, adequate literature is not available to prove whether the aseptic and clean techniques yield different or similar results when it comes to wound contamination and infection. In any case, one of the main factors in any bacterial contamination is the nurses' or health practitioners' own hands. Alcohol-based hand rub should be applied appropriately, or the hands should be washed with soap and water, as directed, according to whether there is soiling and what contact the hands have made. When washing the hands, the three stages should be followed and the 11 steps incorporated, as explained by the NHS website for handwashing (NHS, 2019). If the hands are kept as clean as possible, the chance for bacterial transmission is low. Alongside this, appropriate use of personal protective equipment should be followed. Community nurses provide an invaluable service in dressing many types of short- and long-term wounds. Appropriate use of asepsis or clean technique will help them ensure that chances of infection are kept to a minimum.
KEY POINTS
- Asepsis means free of pathogenic microorganisms, and aseptic technique involves the deliberate prevention of cross-contamination by keeping the microbial count to an irreducible minimum
- Clean technique differs to aseptic technique as it does not require sterile-to-sterile contact
- In community settings, wound care generally requires clean technique and not aseptic technique
- Use of alcohol gel is essential unless hand washing is required, for visibly soiled hands, those that have been in contact with bodily fluids, etc.
CPD REFLECTIVE QUESTIONS
- What are three scenarios where you have adopted an aseptic or clean technique approach?
- What is an incident or task you may have witnessed that did not adopt fully to aseptic policy? At what points could risk of contamination have been heightened, and how could the team learn from this incident?
- Reflect on the challenges you face in the community when trying to adhere to aseptic principles. How could these challenges be dealt with?