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Clinical Practice Keywords Aseptic technique/Aseptic
Review non-touch technique/ANTT
Infection prevention This article has been
double-blind peer reviewed
In this article...
● The importance of asepsis to prevent healthcare-associated infections
● Difference between medical and surgical asepsis
● The underpinning principles of asepsis
Principles of asepsis 1: the rationale
for using aseptic technique
Key points
Authors Andrea Denton and Carole Hallam are independent nurse consultants, AC
The term asepsis Independent Nursing Consultants.
means the absence
of potentially Abstract Aseptic technique is a core competency for many nurses. This article, the
pathogenic
first in a two-part series, describes the principles of asepsis and part 2 will describe
micro-organisms the procedure for changing a simple wound dressing.
Aseptic technique itation Denton A, Hallam C (2020) Principles of asepsis 1: the rationale for using
is used to achieve aseptic technique. Nursing Times [online]; 116: 38-41.
asepsis in order to
prevent the transfer
of potentially t is estimated that 300,000 patients each What is asepsis?
pathogenic micro- year in England will develop a health- Aseptic technique is a process or proce-
organisms to a care-associated infection (HCAI) dure used to achieve asepsis to prevent the
susceptible site I tional Institute for Health and Care transfer of potentially pathogenic micro-
(Na
Excellence, 2012). These infections are more organisms to a susceptible site that may
Medical asepsis
likely to occur in patients with invasive result in the development of infection
aims to reduce devices, such as peripheral canulas, vascular (Wilson, 2019). An aseptic technique is
the number of access devices or urinary catheters in situ, or required for many clinical interventions
or
ganisms and after invasive procedures (NICE, 2012). including wound dressing and insertion of
prevent their spread To reduce patients’ risk of developing a invasive devices, as well as the mainte-
by use of standard HCAI, it is vital to prevent the transmission nance of these devices (Loveday et al, 2014).
principles of of micro-organisms between staff and Healthcare workers who perform an
infection prevention patients when undertaking any invasive aseptic technique should receive training
procedure (Loveday et al, 2014); this can be in how to correctly perform the procedure;
An aseptic achieved by asepsis. The term asepsis this should include a competency assess-
technique is - ment (Loveday et al, 2014).
means “the absence of potentially patho
required for many genic micro-organisms” (Loveday et al, A variety of terms are used to refer to
clinical interventions 2014). It could be suggested tha
t under- aseptic technique; this can be confusing
including wound standing the principles of asepsis goes back for frontline healthcare staff (Loveday et
dressing, peripheral far as Florence Nightingale, who made
as al, 2014). Medical asepsis – sometimes
cannula or other the links between good hand hygiene and referred to as standard aseptic technique
vascular access reduction in wound infections in 1855 (Association of Safe Aseptic Practice, 2015)
device insertion (Rowley et al, 2010). Indeed, as far back as – aims to reduce the number of organisms
the mid-1800s, the association between and prevents their spread by use of
revention of good hand hygiene and reduced infection standard principles of infection preven-
infection can help
rates was identified by Ignaz Semmelweis tion (Loveday et al, 2014). Surgical asepsis
to reduce the (Wilson, 2019). With the increased focus on includes procedures to eliminate, rather
r
equirement for antimicrobial resistance (AMR) there is than reduce, micro-organisms from an
antimicrobial also a need to carefully consider antibiotic area and is practised by surgical teams and
prescribing -
usage, and prevention of infection can help nurses in operating theatres and proce
to reduce the need for antimicrobials in the dure areas, including interventional radi-
first place (HM Government, 2019). ology (NICE, 2012). The term ‘clean
Nursing Times [online] May 2020 / Vol 116 Issue 5 www.nursingtimes.net
38
Clinical Practice
Review
technique’ is often used to describe the Box 1. amples of when to allowed to become wet or damaged as this
procedure for dressing chronic wounds; it use a medical aseptic affects the sterility of the equipment
includes hand hygiene, preparation of a technique inside. Ideally the equipment should be
clean area with use of clean gloves and kept out of direct sunlight as this could
sterile instruments, such as scissors and ● Dressing a leg ulcer also affect the packaging, as well as the
forceps (Wound, Ostomy and Continence ● Dressing a surgical wound quality of the sterile products of the equip-
Nursing Society, 2012). A ‘clean technique’ ● Inserting a peripheral cannula ment. It is also sensible to store the equip-
can be classed as medical asepsis or ● Redressing of vascular access devices ment in a manner that enables staff to
● Venepuncture te it easily, preventing wasted time.
standard aseptic technique, as it uses the loca
same principles. ● Inserting a urinary catheter
Rowley et al (2010) recognised the need for ● Administrating intravenous drugs Preparing equipment
● Administrating of enteral feeds -
a systematic and robust approach to aseptic Preparation of aseptic technique equip
- ment before performing a procedure
technique that aims to prevent the contami
nation of wounds or other susceptible sites ● Are short in dura tion (usually less than should be done in a clean area. A suitable
tion in practice (Rowley et 20 minutes); surface should be prepared, such as a
by removing varia
al, 2010). The ANTT® (aseptic non-touch ● Involv e small sites such as puncture sites; dressing trolley or a procedure tray, by
- ● Hav e a minimal numbers of key parts
technique) framework was developed to pro cleaning it with a detergent wipe or
vide consistent step-by-step guidance for an (usually considered to be less than five according to local policy (Loveday et al,
aseptic non-touch technique tha
t can be although there is no evidence to -
2014). Ideally, preparation should be under
applied to several invasive procedures, support this). taken far enough away from hand washba-
including insertion of urinary catheters and Surgical aseptic technique should be sins to prevent droplets from the sink
ting the prepared equip-
peripheral cannulas, phlebotomy and used when procedures are technically outlet contamina
administration of intravenous drugs (Box 1) complex and invasive, involve extended ment (Centers for Disease Control and Pre-
(Rowley et al, 2010). It provides a comprehen- procedure time (more than 20 minutes) or vention, 2019). Each sterile package should
sive set of principles including ANTT, which a large, open key site and large or numerous be inspected to ensure the packaging is still
e surgical asepsis; the ANTT intact with no visible damage; the expiry
aims to achiev key parts. The main aseptic field needs to
approach is widely used in hospitals and be managed as a critical aseptic field (a date must be checked to ensure the equip-
community settings (NICE, 2012). controlled working space that ensures ment is still in date (Lloyd Jones, 2014). All
equipment required should be ga
asepsis by providing protection from the thered at
rinciples of asepsis procedure environment – typically by this point and laid out in a manner to pro-
The fundamental principle of an aseptic using a sterilised drape), using sterile tect key parts using sterile packets, covers
technique/ANTT incorporates protecting - owley et al, 2010). Alternatively,
gloves and often with full barrier precau and caps (R
key elements of the equipment that should tions to include sterile gown, mask and cap a sterile field can be created using a sterile
remain free from micro-organisms, for (ASAP, 2015). For the purpose of this article dressing pack (Lloyd Jones, 2014).
example, the inside of a sterile dressing or all references to aseptic technique refer to
the barrel of a sterile needle (NICE, 2012). medical/standard aseptic technique. Consent
These ‘key parts’ or ‘key sites’ are crucial It is important to inform the patient before
components of any invasive procedure. If tages of medical aseptic undertaking any procedure and to obtain
technique -
they become contaminated, this can result consent, allowing time to explain the spe
- Hand hygiene cific procedure and to help reduce any anx-
in the patient acquiring a preventable infec
tion. Key parts are defined as the parts of the There are a number of stages and principles ieties the patient may have (Royal College
equipment used in the procedure that come for aseptic technique (Table 1); the funda- of Nursing, 2017). Where the patient has
into direct or indirect contact with another mental initial stage is hand hygiene, which capacity, this can usually be done verbally
key part or site. Key sites are defined as open must be performed before any aseptic tech- and then documented in the patient’s
wounds, including insertion sites and punc- nique (World Health Organization, 2019; record (RCN, 2017). A best-interest deci-
ture sites. Both key parts and key sites always eday et al, 2014). Hands can be decon- sion may need to be made for a patient who
Lov
need to be protected (Rowley et al, 2010), taminated by washing with soap and water is unable to give consent and this decision
which can be achieved by not touching the or by use of alcohol-based handrub needs to be clearly documented in the
key part and by using caps and covers, such (Loveday et al, 2014). Hand hygiene must be patient’s record (NHS, 2018).
as the sterile wrapper of a syringe to protect performed before preparation of the sterile
the key part of the syringe before use. equipment to avoid contamination of the Environment
Risk assessment before the procedure equipment, and may need to be repeated The procedure should be carried out in a
immediately before the procedure if the -
will direct the practitioner as to whether location that maintains the patient’s pri
vacy and dignity, such as a treatment room,
the key parts and key sites can be protected hands have become contaminated
- t the bedside with the curtains drawn or in
by non-touch or whether the procedure (Loveday et al, 2014). It must also be per a
will require the use of sterile gloves, such formed after the procedure (WHO, 2019). the patient’s own home (Lloyd Jones, 2014).
as for the insertion of a urinary catheter or To reduce the risk from airborne dispersal
for taking blood when the re-palpation of Storage of equipment of micro-organisms, the procedure area
All sterile equipment should be stored
the puncture site is required (ASAP, 2015). in a should be prepared by closing windows,
- clean and dry environment (National turning off any fans that are in use and
Medical asepsis can be used in proce
dures that: Health and Medical Research Council, avoiding any bed making being undertaken
● Are considered technically simple; 2019). The sterile packages should not be in close proximity (Lloyd Jones, 2014).
Nursing Times [online] May 2020 / Vol 116 Issue 5 www.nursingtimes.net
39
Clinical Practice For more articles
Review on infection prevention, go to
nursingtimesnet
infection
Table 1. rinciples of aseptic technique onclusion
Asepsis is an essential component of infec-
Action ationale tion prevention and control practice to pro-
tect patients from potential HCAIs (Loveday
Hand hygiene Remove transient micro-organisms from the hands et al, 2014). All steps in a non-touch aseptic
Safe storage of Prevent damage to the sterile equipment, preserve technique should be seen as an opportunity
-
equipment sterility of the equipment and prevent microbial to reduce the transfer of pathogenic organ
contamination isms. Healthcare workers should be edu-
Cleaning of the Reduce microbial contamination cated and trained in an aseptic technique
procedure trolley or tray that should include competency assess-
ment (Loveday et al, 2014) and should be
Preparation of equipment Prevent microbial contamination of sterile equipment considered a core competency for many
Personal protective Aprons provide protection from potential contamination nurses. NICE guidance (2012) suggests that
equipment (PPE) from the healthcare worker’s (HCW) uniform and the the ANTT framework provides a possible
procedure and also protects the HCW from potential approach to standardised aseptic technique
contamination from the procedure removing ambiguity and variance that
allows a process for audit and assurance. It
Non-sterile gloves provide protection for the HCW from is vitally important that nurses understand
contamination from blood and body fluids that may the principles of asepsis, and the ANTT
-
contaminated the hands framework may provide a way of imple
menting the principles. NT
Sterile gloves protect key sites from potential microbial eferences
contamination from the HCW’s hands Association of Safe Aseptic Practice (2015) The
Preparation of the Reduce microbial contamination during the procedure ANTT Clinical Practice Framework, Version 4.0.
environment ASAP.
Centers for Disease Control and Prevention (2019)
Preparation of the patient Gain informed consent and reduce anxiety Injection Safety. CDCP.
HM Government (2019) Tackling antimicrobial
Waste disposal Prevent contamination of the environment resistance 2019–2024: The UK’s five-year national
action plan. HM Government.
Documentation Provide essential communication and meet the standards lod ones M (2014) Fundamental care in
in the NMC Code (2015) practice: 2. Infection prevention and control. 2.5
Aseptic technique and aseptic non-touch
technique. British Journal of Healthcare Assistants;
Use of gloves and aprons achieved by careful opening of the sterile 8: 3, 113-115.
oveda HP et al (2014) epic3: National evidence-
A clean disposable apron provides an ideal packets to avoid contamination of the based guidelines for preventing healthcare
barrier between potentially contaminated sterile equipment and the sterile surfaces associated infections in NHS hospitals. Journal of
uniforms and the procedure, reducing any of the inside packaging. If a sterile dressing Hospital Infection; 8651: S1-S70.
ational Health and Medical esearch Council
contamination that may arise from the pack is being used, care should be taken to (2019) Australian Guidelines for the Prevention and
procedure. The decision as to whether ensure that only the corners are used when Control of Infection in Healthcare. NHMRC.
opening out the sterile field. Carefully open ational nstitute for Health and Care cellence
single-use sterile or single-use non-sterile (2012) Infection Control: Prevention of healthcare-
examination gloves should be worn, or any other sterile equipment and gently associated infection in primary and community
whether gloves are required at all, should place it onto the sterile field, avoiding any care (Updated 2017).
HS (2018) Mental Capacity Act. NHS.
be based on a risk assessment (NHMRC, contamination of the sterile surfaces of the ursing and Midwifer Council (2018) The Code:
2019; Loveday et al, 2014). Single-use non- equipment (Lloyd Jones, 2014). Professional Standards of Practice and Behaviour
sterile gloves should be worn to protect the for Nurses, Midwives and Nursing Associates. NMC.
owle S et al (2010) ANTT v2: An updated
healthcare worker when there is a risk of Equipment disposal practice framework for aseptic technique. British
contact with blood or body fluids during At the end of the procedure, all waste must Journal of Nursing (Intravenous Supplement); 19: 5,
any procedure (Loveday et al, 2014). Where be disposed of in the appropriate waste S5-S11.
oal College of ursing (2017) Principles for
there is a risk that key parts or key sites stream bin, such as a healthcare waste bin. Consent. Guidance for Nursing Staff. RCN.
cannot be protected, for example, during Sharps, including needles, suture cutters, ilson (2019) Infection Control in Clinical
urinary catheter insertion, sterile gloves scissors and blades must be disposed of at Practice. Elsevier.
Wound, Ostomy and Continence Nurses Society
- (2012) Clean vs sterile dressing techniques for
should be worn (NHMRC, 2019; Rowley et the point of use in an approved sharps con management of chronic wounds: a fact sheet.
al, 2010). It is important to remember that tainer (Loveday et al, 2014). The remaining Journal of Wound, Ostomy and Continence
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non-sterile, should be applied immediately should be disposed of according to local orld Health rganiation (2019) Clean Care is
before beginning the procedure; applying policy (Loveday et al, 2014). When all the Safer Care. 5 moments of hand hygiene. WHO.
- waste has been disposed of safely and
them before this point is likely to contami A rinciples of asepsis
nate sterile gloves and/or prevent an oppor- apron and gloves, if worn, have been
tunity for hand hygiene (NICE, 2012). removed hands should be decontaminated art Understanding the rationale May
(Loveday et al, 2014). Once you have clean for aseptic technique
Maintaining a sterile field hands, the procedure should be clearly art Aseptic technique for a
During the procedure, the sterile field documented in the patient’s records simple wound dressing June
needs to be maintained; this can be (Nursing and Midwifery Council, 2018).
Nursing Times [online] May 2020 / Vol 116 Issue 5 www.nursingtimes.net
40
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