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BASIC ASEPSIS:
A CRITICAL ELEMENT IN BREAKING THE CHAIN OF INFECTION
Standard Precautions and basic asepsis - Implementation of "Standard Precautions" is the primary strategy for successful prevention of healthcare associated infections of not only health care workers but also our patients. It contains the fundamental practices of infection control for the care of all individuals, regardless of their diagnosis or presumed infectious status. Effective use of personal protective equipment (PPE) can protect the health care worker from the patient’s infectious agents and vice versa. Since the development of Universal Precautions, there has been an emphasis on protecting the health care worker but we have forgotten message that these same practices can also protect the patient from infection if done correctly.
Surgical Conscience (Four Components): Optimal patient care during invasive procedures requires the sound practice of asepsis coupled with surgical conscience. Surgical conscience incorporates knowledge of aseptic principles, perpetual attention to detail and experience. Open and honest communication is crucial for acknowledgement of questionable breaks in technique or risks to patient safety. Surgical conscience recognizes the intimate contact between the patient and the surgical team and includes attention to personal hygiene health. Employees should feel comfortable to call-in if they are ill. (Editorial in Annals of Surgery, 1950 pp315-18. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1616565/pdf/annsurg01395-0161.pdf)
- Caring o Care enough to take care of yourself, know when to stay home. o Care enough to educate yourself and peers on the institution’s policies and procedures. o Care enough about your patients to develop a strong surgical conscience.
- Conscience o Ability to see and correct breaks in technique. o Inner guide to do what is right, not what it is the easiest, fastest, or fear of retaliation.
- Discipline o To follow policies and procedures that are in place. o To teach and mentor staff. o Always take the high road.
- Technique o Assimilation of all these values with the knowledge of aseptic principles that develop over time. o Techniques evolve through time, trial, and error / quality improvement studies. o Be open-minded. o Seek out evidence-based practice to challenge or implement changes.
Aseptic technique - Aseptic technique is the effort taken to keep patients as free from hospital micro-organisms as possible (Crow 1989).
- Sterile technique or surgical asepsis - A technique that restricts any microorganisms in the environment, on equipment and supplies from contaminating the wound or vascular system. It is the required technique for the use of critical items that enter sterile tissue or the central vascular system. At a minimum, sterile technique involves meticulous hand hygiene, use of a sterile field, sterile gloves for application of a sterile dressing and sterile instruments. Sterile technique may be expanded to include the use of clean attire, sterile surgeon gowns, surgical masks, hair covering and a controlled environment
- Clean technique or medical asepsis - A technique that places emphasis on the prevention of cross contamination or transfer of microorganisms to the involved body site, other body sites of the patient, between patients or the environment. It requires the use of Standard Precautions for the protection of the employee from the patient’s body fluids, secretions, and excretions. It is appropriate for the use of semi-critical items that have contact with intact mucous membranes. Clean technique includes meticulous hand hygiene, a clean environment including a clean field, use of clean gloves, sterile instruments, and prevention of direct contamination of materials and supplies.
Spaulding classification scheme
Body Contact Disinfection Requirements FDA Device Class sterile body cavity sterilization critical mucous membranes high level semi-critical intact skin low level non-critical
- Critical items - A category assigned to items that present a high risk of infection if the item is contaminated with any microorganisms, including bacterial spores. This category includes surgical instruments, cardiac catheters and indwelling urinary catheters, implants, and needles. Most of the items in this category should be purchased sterile or be sterilized.
- Semicritical items - A category assigned to items that come in contact with mucous membranes or with skin that is not intact. These items must be free of all microorganisms, with the exception of high numbers of bacterial spores. Intact mucous membranes are generally resistant to infection by common bacterial spores but are susceptible to other organisms, such as tubercle bacilli and viruses. Respiratory therapy and anesthesia equipment, endoscopes, and diaphragm fitting rings are included in this category. Semicritical items generally require high-level disinfection with the use of wet pasteurization or chemical germicides (i.e. gluteraldehydes, chlorine). Terminal sterilization of instruments
o Hands with intact skin - Healthy skin is less apt to harbor potentially dangerous organisms. o Free from upper respiratory illnesses - Sneezing, coughing and talking may contribute to the spread of organisms that may inhabit the upper respiratory tract. o All health care workers should be immunized against influenza to not only prevent the spread of influenza but also the spread of other common organisms from the upper respiratory tract, such as S taph aureus.
- Respiratory Hygiene/Cough Etiquette: Targets patients and visitors with undiagnosed transmissible respiratory infections, and apply to persons with signs of illness including cough, congestion, rhinorrhea, or increased production of respiratory secretions when entering a healthcare facility. Elements include: o Education of healthcare facility staff, patients and visitors. o Posted signs, in language(s) appropriate to the population served, with instructions to patients and visitors. o Source control measures (e.g., covering the mouth/nose with a tissue when coughing and prompt disposal of used tissues, using surgical masks on the coughing person when tolerated and appropriate). o Hand hygiene after contact with respiratory secretions. o Spatial separation, ideally >3 feet, of persons with respiratory infections in common waiting areas when possible. o Vaccination against respiratory illnesses as appropriate including influenza, pertussis, and pneumonia.
- Hand hygiene o Alcohol based gels Gel in and Gel out- Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in healthcare settings, unless hands are visibly soiled. The CDC recommends that healthcare workers be provided with a readily available alcohol-based hand rub product at the entrance to each patient care room, at the patient’s bedside, or at other convenient locations. Recommendations for increased use of waterless hand hygiene products do not negate the need for hand washing sinks. The efficacy of alcohol-based products or soap and water depends on the technique of the user. o Artificial fingernails or nail extenders are prohibited for those having direct contact with patients especially those at high risk (e.g. NICU. ICU, OR). o Soap - Hands should be washed with soap and water when visibly soiled with dirt or proteinaceous contaminates such as blood, other body fluids, secretions, and excretions, as soon as possible. Hands should also be washed with soap and water before eating and after using the restroom. Hands should be washed with soap and water (with or without gloves) if exposed (suspected or proven) to Bacillus anthracis,
Clostridum difficile, and some viral organisms such as Norovirus, Norwalk virus or Rotovirus. Antimicrobial Surgical scrub agents Bar soap o Lotions – should be provided. Personal hand lotions are discouraged in the patient care area. Outbreaks have been traced back to contaminated lotion. o 5 Moments for Hand Hygiene from the World Health Organization includes Human Factors Engineering principals. It focuses on principals –not tasks and offers what we should do and the rationale. (See Hand Hygiene presentation for more information.)
- Before patient contact- prevents organisms of the healthcare environment (including the worker) from contaminating the patient or their environment Example – shaking hands
- Before aseptic task- immediately before touching site to be protected will prevent any organisms (patient’s or healthcare environment’s) from contacting the aseptic area. Examples: medication administration, IV line care, food prep
- After exposure to body fluids - protects self and environment from contamination. Examples: oral care, emptying urinals.
- After patient contact
- After contact with patient surroundings Items 4 & 5 above protects healthcare environment from patient contaminants. Examples: adjusting blanket of patient in hallway, adjusting IV flow rate. o Hand hygiene is the corner stone of infection prevention and control and is identified as the first step of Standard Precautions. o Ayliffe (1978 ) developed the Seven step hand washing technique
- Palms
- Backsides
- Between fingers
- Back of fingers
- Thumbs
- Fingertips
- Wrists Ayliffe SA et al (1978) A Test for Hygienic Hand Disinfection. Journal of Clinical Pathology. Vol 31, p
o Alcohol-based rubs - follow the manufacturer’s recommendation for use; Dispense an appropriate amount of product (2.5 grams) into one hand Spread over both hands to wrists, interlace fingers and spread under fingernails, and rub into skin until dry (approximately 15-30 seconds) Wash hands with soap and water after 8-10 applications of alcohol gel to remove accumulated emollients. o Soap (plain lotion soap) and water instructions are as follows:
Recommended when doing dressing change on a fresh surgical wound that is not completely healed. Required if inserting a sterile catheter or needle in deep tissue or body fluids, usually to obtain fluid or instill therapeutic agent. Worn if handling instruments/supplies used for invasive procedures of sterile body cavities. Selected based on a number of factors, including size, the task has to be performed, anticipated contact with chemicals, and chemotherapeutic agents, and latex sensitivity.
Gowns
- Impervious gowns (isolation gown, lab coat or non-sterile surgeon gown) are: o Worn when it is likely that personal clothing will be soiled with any patient's body fluids. o Laundered by the institution.
- The need for and type of gown selected is based on the nature of the patient interaction including the anticipated degree of contact with infectious material and potential for blood and body fluid penetration of the barrier. Gowns may be worn not only to protect the clothing of the health care worker but may also provide clean/sterile attire.
- Impervious gowns used for personal protection should not be worn outside of the area where the exposure was anticipated (e.g. blue lab coats should not be seen in the hallways).
- AAMI Level 1 gown is typically used for isolation gowns or standard precautions. There is a consistent level of barrier protection throughout the gown – no reinforced areas.
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- Sterile items – check processing and package integrity o Peel packs - Package integrity - Not wet - Completely sealed - Not punctured - Check for outdates - Flip technique to place on field o Wrapped - Inspect package - Ensure integrity o Instrument pans: - Locks - Filter in place - Tracking tag in place o High level disinfection
- Monitor field once sterile items are opened
Clean Technique (Medical Asepsis)
- Supplies, Instruments and Utensils: o Have established protocols for handling all supplies and instruments o Manually remove debris from instruments with damp gauze or flush with water immediately after use to facilitate cleaning o Place grossly soiled instruments in a rigid leak resistant container with appropriate soaking solution and cover. o Hands are never used to retrieve objects from opaque solution since liquid may obscure reusable sharps. o Rinse grossly soiled utensils and place in designated soiled receiving area for future processing, which is to be ideally done by Central Services. o Use processing solutions which are approved by the Infection Control Committee and for their intended use only.
- Equipment: o Surfaces should be cleanable o Clean equipment with a disinfectant before use by another patient, i.e., cautery unit, etc. o Items are cleaned with a disinfectant before return to central storage area, and before repairs or preventative maintenance. o Large equipment returned to CS is wiped down before transport.
- Trash o Bag all trash and disposable items to prevent leakage.
o Consider decolonization of patient with known methicillin resistant Staphylococcal aureus (MRSA) colonization or infection.
- Patients requiring transmission based precautions o Established protocols for patients with a multiple drug resistant organism (MDRO) or any other infection requiring Contact or Droplet Precautions o Place patients with uncontrolled drainage from wounds in Contact Precautions. o Patients requiring Airborne Infection Isolation (AII) Precautions should be scheduled in surgical suite with a negative pressure anteroom and recovered in the same operating room or in another Airborne Infection Isolation (AII) room. Staff must wear the appropriate personal protective equipment during isolation. Respiratory protection should not have an exhalation valve or exhausted without a filtration system in place to protect the patient from pathogens from the health care workers upper respiratory tract. o Regardless of isolation status – all patients entering the surgical suite should have freshly laundered linens donned after their evening/morning shower or bag bath. Hair will be covered just prior to entering surgery. Trend to make a slight revision for Ophthalmology patients. They may wear their street clothes from the waist down and a clean patient gown if they are cocooned in freshly laundered linens. This only applies if the patient will remain on the eye cart throughout the surgical procedure. o All patient contact requires Personal Protective Equipment (PPE), typically gown and gloves. It is important that hands are washed after removing the gown, gloves, and other PPEs. Mask and goggles should be added with anticipated contact with blood or body fluids with possible splash, splatter or spray to the face or eyes.. o After the patient is draped in the OR, the circulator does not have to wear the isolation gown and gloves. Anesthesia should continue to wear gown and gloves when in direct contact with the patient. o Avoid contaminating items in surgery suite while wearing gown and gloves.
Surgery Scrub – Hand Antisepsis
- Wash hands at the beginning of the shift prior to and after performing the procedure, prior to entry into semi-restricted or restricted areas, and on exit of semi-restricted or restricted areas.
- No artificial fingernails or nail extenders
- Remove jewelry, don eye and face protection and do a final check to be sure all hair is secured.
- Clean nails under running water
- Apply antiseptic per posted manufacturer recommendations. Specific manufacturer instructions are to be posted by the scrub sink for easy reference.
- Dry with sterile towel completely before gloving
- When using an alcohol-based surgical hand rub product (with persistent activity), the hands and forearms should be pre-washed with plain lotion soap and dried completely.
Clean Attire
- Before donning surgical attire, all persons entering the perioperative suite should wash their hands with soap and water, antiseptic and water, or an antiseptic hand rub if visible soil is not present upon arrival.
- Facility-approved, clean, and freshly laundered surgical attire should be donned in a designated dressing area of the perioperative suite before entry or reentry into the semirestricted and restricted area.
- All individuals who enter the semirestricted and restricted areas of the perioperative setting should wear freshly laundered or disposable surgical attire intended for use within the perioperative setting.
- All non-scrubbed personnel should wear a long-sleeved jacket snapped closed with the cuffs pulled down to the wrists
- All attire is changed daily or more often whenever they become visibly soiled or wet. The two piece pant suit should be sized appropriately to prevent pant legs from dragging and provide adequate coverage. The top should fit snuggly at the hips or be tucked in to the pants.
- Wearing clean attire is limited to the inside of the institution. This does not include the grounds of the institution or residential housing. Clean attire should be completely covered with clean jumpsuit if worn outside during the course of job-related duties (e.g. walking from hospital to pack room, etc.).
- Duty shoes are kept clean and not worn outside. Shoe covers are only worn with reasonable anticipation of exposure to blood or potentially infective material. Shoe covers are removed following the procedure upon leaving the room. Shoe covers should not be worn as a substitute to having duty shoes. Hose or socks are worn.
- Long sleeved jackets or warm-up jackets should be worn by all non-scrubbed personnel in the central core or the operating room. Long sleeved jackets should be snapped close and changed daily or whenever possible contamination may have occurred. Clothing that cannot be covered by the clean surgery attire should not be worn.
- All jewelry is contained within scrub attire.
- All possible head and facial hair, including sideburns and neckline, should be covered. A hood is worn if scrub caps do not cover hair. Reusable hair coverings should be laundered after each use by an accredited laundry services. Single use hair covering is discarded at the end of the shift.
- Surgical attire helps contain bacterial shedding and promotes environmental control. An individual sheds millions of skin squames daily. Five percent to 10% of skin squames have bacteria.
- Surgical attire that has been worn during one shift has higher bacterial colony counts at the end of the work shift when scrub clothing is removed, or when stored in a locker and used again. Worn surgical attire should be placed in an appropriately designated container for laundering and should not be hung or placed in a locker for wearing at another time.
HIV infection should consult with an advisory panel for ongoing follow-up. (Reference: Infection Control and Hospital Epidemiology March 2010, Vol. 31, No. 3)
Skin Prep
- The operative site and surrounding areas should be cleaned before entry into procedure room (i.e., pre-op shower & shampoo).
- Hair should be removed prior to transport to operative/procedure area. Hair removal should be done only with a clipper or a chemical depilatory and only when absolutely necessary to facilitate wound closure and dressing. Hair removal should occur as close to incision time as possible.
- There should be a documented assessment of the operative site, which notes the presence of skin lesion.
- The operative site and the surrounding area should be prepped with an approved surgical scrub agent.
- Surgical scrub agents should be selected based on patient sensitivity, incision location, and skin condition.
- Surgical scrub agents should be used according to the manufacturer’s recommendations.
- Skin lesions or open areas should be prepped according to established protocols.
- Antimicrobial agents should be applied using sterile supplies and sterile gloves. Scrub jackets should be worn during the prep as long as this does not contaminate the prepped area. The antimicrobial agent should be applied proceeding from the incision site to the periphery with the exception of Chloraprep. Surgical scrub agents should not be allowed to pool under patient.
- Documentation of the skin prep should include assessment of the skin integrity, hair removal process, area prepped, solutions used, abnormal reaction to prep, and name of person(s) performing the task.
Sterile Gown
- Sterile gowns and gloves should be worn by scrubbed personnel.
- Sterile gowns should be available with various levels of protection. The standard surgeon gown is classified per ANSI/AAMI PB270:2003 standard as a Level 2 Barrier. Level 2 barrier gowns are appropriate for short procedures with little or no anticipated exposure to blood or body fluids. As the length and physical contact of the procedure increases there should be consideration to select a gown with greater barrier properties.
- Scrubbed personnel should don a sterile gown and sterile gloves from a sterile field other than the instrument table.
AAMI Classification Levels of Barrier Performance
Level Test Result Exposure Risk
1 Impact Penetration <4.5 g Minimal
2 Impact Penetration Hydrostatic Pressure
<1.0 g
20.0 cm
Low
3 Impact Penetration Hydrostatic Pressure
<1.0 g
50.0 cm
Moderate
4 ASTM F1670 (Drapes) ASTM F1671 (Gowns)
Pass Pass
High
- Strikethrough while wearing a sterile gown should be reported for possible exposure. Strikethrough indicates that a gown with better barrier protection should be worn. The ASTM F1670 determines the ability of a material to resist the penetration of synthetic blood under constant contact. The test sample is mounted on a cell separating the synthetic blood challenge liquid and a viewing port. The time and pressure protocol specifies atmospheric pressure for 5 minutes, 2.0 psi for 1 minute and atmospheric pressure for 54 minutes. The test is terminated if visible liquid penetration occurs before or at 60 minutes. The ASTM F determines the ability of a material to resist the penetration of a microorganism under constant contact using a method which has been specifically designed for modeling penetration of HBV, HCV, and HIV. The sterile gown with barrier protection has reinforced protection in the front and lower half of the sleeve.
- Sterile gowns are considered sterile in front from chest to the level of the sterile field, and the sleeves are considered sterile from two inches above the elbow to the cuff.
- The front of the surgical gown should be considered sterile from the chest to the level of the sterile field, and the sleeves should be considered sterile from two inches above the elbow to the top edge of the cuff.
- The area of sterility in the front of the gown extends to the level of the sterile field because most scrubbed personnel work adjacent to a sterile table. Surgical gown sleeves up to two inches above the elbow must remain sterile because the arms of scrubbed personnel must move across sterile fields. The neckline, shoulders, axilla, back, and cuffed portions of the gown sleeves are areas of friction; therefore, these areas should be considered ineffective microbial barriers (i.e., unsterile). The backs of surgical gowns cannot be under constant supervision by scrubbed personnel and, therefore, should be considered contaminated.
- After the sterile gloves are donned, the gown cuffs should be considered contaminated because as the scrubbed hand passes through the gown cuff, the cuff becomes contaminated.
o The receptacle is placed near the edge of the table or held be the scrubbed person, and the fluid is poured slowly to avoid splashing.
- The sterile filed should be constantly monitored, once unguarded it should be considered contaminated
- Opened instruments should not leave room of intended use.
- Do not cover sterile field to save until later because it is difficult to remove drape without contaminating the sterile filed.
- Once the patient enters surgical suite, all items should be considered contaminated to that case
- Scrubbed persons should keep their arms and hands within the sterile area at all times
- Movement around the sterile field should be done in a manner to maintain the integrity of the sterile field.
- Conversation should be kept to a minimum once the sterile items have been opened. There should be no gum chewing under the mask.
Sanitation
- Patients should be provided with a safe, clean environment free from dust and organic debris.
- Cleaning should be done on a scheduled basis to prevent cross-contamination.
- Furniture, lights, and equipment should be damp dusted with approved disinfectant before the first scheduled case.
- The area should be visually inspected before the instruments are brought into the room.
- External packing containers used during shipping should be removed before materials are transported into the procedure/operating room. The integrity of all packages should be maintained.
- Equipment from outside the procedure room should be damp dusted with an EPA approved germicidal agent prior to entry into the procedure/operating room. This includes but is not limited to items stored in outer corridor.
- Patients should be brought into the procedure/operating room with freshly laundered linens and gown.
- During the procedure, all activities should be directed at confining and containing contamination.
- There should be a prompt clean-up of contaminated surfaces with an approved disinfectant.
- Spray bottles should not be used during the procedure or set up.
- The patient's bed from the nursing unit should be cleaned with an approved disinfectant and freshly laundered linen should be applied.
- Items that come in contact with the patient and/or sterile field are considered contaminated.
- Disposable items with squeezable, dripable, pourable blood are placed in closeable, leak- proof containers or red bags that are labeled with the biohazard symbol. Used/unused or soiled disposable items are placed in the properly defined disposal receptacles.
- Gowns and gloves should be removed in a manner that contains contamination and gowns and gloves placed in the proper receptacle prior to leaving the procedure/operating room.
- Contaminated linen should be handled as little as possible. Linen from any open packs, whether soiled or not, should be placed in linen hampers for the laundry.
- Instruments should be placed by the gloved scrub person directly into instrument trays and placed in case cart.
- Disposable suction containers should be sealed and either sent to central processing area for disposal or emptied in designated soiled area by an individual wearing the appropriate PPE.
- All needles, sponges, instruments should be counted when there is a likelihood of items to be retained before disposal.
- Sponges should be discarded into or onto impervious surface for counting.
- Personnel should use gloves in handling sponges, organic material, and specimens.
Between Case Cleaning
- All surfaces should be disinfected between cases – know wet contact time claim
- Clean from the top to bottom (cleanest to dirtiest)
- Disinfect all surfaces that could be possibly contaminated o Includes area for circulator o Lead aprons/shields o Keyboards o Door panels o Phone
- Remove all debris from floor before mopping/wet vac (includes bone chips)
- The area mopped is dependent upon the likelihood of contamination. Some procedures are minimally invasive and there is no blood loss therefore floor disinfection is not necessary. Floors are cleaned with an approved disinfectant. A mop- head is used only once and not double dipped. It may require several mopheads to clean the floor.
- Scrub sinks should be cleaned after the scrub for each case
Term cleaning
- Terminal/daily cleaning of the procedure/operating room should be done at the conclusion of the day’s schedule.
- The areas to be cleaned include; lights, ceiling mounted equipment, all furniture including the wheels and casters, handles and pushes plates, face plates and vents, all horizontal surfaces, the entire floor, kick buckets, and scrub sinks.
- Thermostats should be set at 72 degrees Fahrenheit or warmer. Terminal/daily cleaning is also done in the related locker rooms, corridors, rest-rooms, workrooms and storage areas.
- Break rooms should be cleaned at least daily but typically need to be cleaned more often to keep trash to a minimum. Doors to break rooms should be kept closed at all times.
