Asepsis Skills Station
1. What is the definition of “asepsis?”
Asepsis is the sum total of processes to prevent contamination of the environment and
colonization of the patient with disease producing organisms. It is used to protect the patient
by minimizing contamination to prevent infection. Rather than being a ritual, asepsis is the
purposeful prevention of the transfer of infection. If the transmission of microorganisms from
reservoir to susceptible host can be interrupted, infection will not occur.
2. What is the difference in medical asepsis and surgical asepsis?
Medical asepsis (also known as “clean technique”) are the measures taken to control the
number of organisms but does not aim for sterility. Surgical asepsis (also known as “aseptic or
sterile technique”) is a combination of measures taken to maintain the microbial count at an
irreducible minimum and prevent the transfer of organisms from one person to another or one
body site to another. Aseptic technique uses barriers such as sterile gloves, sterile gowns,
masks, and sterile drapes to prevent transmission of the organisms from the environment to
the patient on whom a procedure is being formed. “Sterile to sterile” involves using only sterile
instruments and supplies in changes of dressings; all contact with non sterile items or surfaces
must be avoided. It also involves antiseptic agents on the patient’s skin before the incision is
made in addition to cleaning and reprocessing of all patient care equipment and devices.
Handwashing is a necessary first step of the procedure in addition to use of an antiseptic hand
rub or antiseptic soap for surgical scrub before donning sterile gloves. In addition to surgery,
asepsis is also used when placement of invasive devices occurs.
However, “no touch” technique can be used to change surface dressings without directly
touching the wound or any surfaces that might contact the wound, depending on the type and
extent of the procedure.
Clean technique, though, involves strict hand hygiene, maintaining a clean environment by
preparing a clean field, using clean gloves (not necessarily sterile gloves), sterile instruments,
sterile supplies, and prevention of contamination of supplies. No “sterile to sterile” rules apply
with clean technique. Clean technique is non-sterile technique.
Asepsis and aseptic technique are basic principles to be used in all healthcare settings. As
more invasive procedures are formed, the level of asepsis should increase. For example,
stricter asepsis is needed for surgery than for decubitus wound care. In fact, many of the
practices used during some of these procedures all contribute to asepsis. For instance,
consider:
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Keeping the door closed during procedures
Diverting traffic to minimize the number of individuals in a given area
Cleaning /disinfection of environmental surfaces
3. How do we teach healthcare workers to practice asepsis?
Asepsis is not a new practice. Sue Crow, an Infection Preventionist & a mentor of this author,
notes from long ago in her book –Asepsis, The Right Touch – a simple process to put into
practice:
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Know what is dirty
Know what is clean
Know what is sterile
Keep the first three conditions separate
Remedy contamination immediately
Examples
“Dirty” (obviously soiled or
used on a patient)
-Healthcare workers’
unwashed hands which have
been in direct contact with a
patient
-Any patient’s body fluids
-Soiled dressings or linens
-Soiled toilets or bedside
commodes
-Used patient equipment such
as glucose meters
“Clean”
-An item that has been
thoroughly washed
-Clean linen or supplies such
as drinking cups, urinals, etc.
that have not been used on a
patient
“Sterile”
-Items that enter vascular
tissue or sterile areas which
have been sterilized such as
surgical instruments, IVs
catheters, urinary catheters,
etc.
-Items used in a sterile field
such as a sterile barrier or
container
Think “separate” when you think of the 3 categories above. Frequently in healthcare, one sees
items such as clean linen and dirty linen stored side by side. This results in an increased chance
of contamination of the clean supplies. Keep sterile items away from non-sterile items. For
example, do not store any sterile supplies under a sink or near a sink where wicking of fluid
could contaminate sterile packs. Also, when touching a sterile item, wear sterile gloves or
when in close contact with a sterile field such as in the OR, wear maximal sterile barriers such
as sterile gloves, gown, masks, hair covering, etc. Always allow for a margin of safety with any
possible contact with among sterile, clean, or dirty areas. If you do observe that any of the 3
areas have not been kept apart, whether in your practice or that of another healthcare worker,
act immediately. Every healthcare worker and provider should be patient advocates always
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looking to protect patients. It is EACH person’s responsibility to speak up and protect the
patient if a break in technique is observed.
4. What are the some of the main principles of “sterile” technique whether in the OR or at
the bedside on the unit?
Increasingly, surgical procedures are being performed in areas outside the traditional operative
environment. Procedures such as extensive wound debridement, tracheostomies, and port
placement, may be performed in the patient room. If so, it is critical that attention be paid to
the process in order to ensure a single standard of care and a safe patient experience. The
following are a few concepts to remember:
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All procedures begin with performance of an appropriate level of hand hygiene.
A sterile drape should be used to establish a sterile field. The part of the drape that
establishes the sterile field should not be moved once positioned as shifting the drape
may compromise the sterility of the field.
All item used within the field should be sterile, and opened and transferred to the field
by methods that maintain item sterility.
o Unscrubbed persons should open wrapped sterile supplies by opening outer
wrapper farthest away from them first to prevent their unsterile arm from
reaching across the sterile item. Then, they should open each of the side flaps with the nearest wrapper flap opened last.
o All wrapper edges should be secured when presenting items to the sterile field.
o No sterile item should ever be “tossed” onto the sterile field.
o Labeled solutions should be poured away from the label and entire contents
poured slowly to avoid splashing. A container’s edge is considered contaminated
after contents have been poured and content sterility cannot be ensured if the
cap is replaced.
A sterile field for one patient should be set up in the location in which it will be used.
The field should be prepared as close as possible to the time of use. The sterility of an
open field is event related (i.e., events determine when it becomes contaminated- such
as insects coming into contact with the field unobserved or water splashing on the
field), unless the field is monitored.
All sterile areas should be continuously monitored for possible contamination.
Sterile fields should not be routinely set up then covered, as uncovering the field may
contaminate it.
Unscrubbed persons should face a sterile field on approach and be aware of the need
for distance from the sterile field.
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5. There seems to be an ongoing discussion as to whether or not sterile gloves need to be
worn for dressing changes. How should that issue be addressed?
The concept behind glove use is really two-fold. First, gloves represent a protective barrier for
the healthcare worker so they do not come into contact with organisms that may contaminate
the skin of their hands or bypass the protective function of the skin if it is not intact. An equally
important concept is the use of gloves to protect the patient. Glove use may prevent
contamination of items that will be used during patient care. Typically we think of sterile glove
use, in that instance. It is true that sterile gloves, when used correctly, go a long way in
preventing transmission of organisms but also consider that patient wounds and incisions are
not sterile. Even after use of quality skin disinfectants, resident flora quickly begin
repopulation. The goal, therefore, is to prevent introduction of new organisms to the wound,
not maintenance of sterility.
In the July 2000 Bulletin of the American College of Surgeons, current recommendations
include use of sterile dressings and sterile technique for dressing changes for the first 24-48
hours. No recommendations were made after that. Some physicians will indicate that sterile
gloves are not needed after that time. From an infection prevention perspective, you must
consider the routine care practices of the facility healthcare personnel, the environmental
considerations and current microbiologic indicators. Again, preventing new organisms from
colonizing a wound is a priority. Because many of the activities that may contribute to external
wound colonization are not deemed as controllable, it is prudent to continue a policy that
clearly supports the use of sterile gloves and sterile supplies for dressing changes. In some
instances, that may not be necessary, but consistent application of policy allows for an
consistent approach to the monitoring of practice. Engage physician champions to discuss this
issue and help support the conceptual basis.
6. Can we help motivate staff and providers to use asepsis when needed?
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Each staff member must constantly monitor his/her movement, practice, and barrier
use to prevent inadvertent breaks in either clean or sterile technique.
Each staff member should be taught that they have “permission” to alert others when
the field or item becomes potentially contaminated for the safety of the patients they
care for—patients who are someone’s mother, father, husband, wife, daughter, son, or
friend.
Ensure policies and procedures are clear. When they address controversial approaches,
be sure they have been developed with a multidisciplinary approach and are firmly
rooted in evidence-based practice.
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Resources:
1. Crow, S. Asepsis, the Right Touch, Something Old is Now New. Bosssier City, LA:
The Everett Companies, 1989.
2. Association for Professionals in Infection Control and Epidemiology, (APIC) and the
Wound Ostomy Continence Nurses Society (WOCN) Position Statement: Clean vs
Sterile: Management of Chronic Wounds. See www.apic.org.
3. Association for Professionals in Infection Control and Epidemiology. APIC TEXT of
Infection Control and Epidemiology, 2009.
4. American College of Surgeons. July 2000 Bulleting.
http://www.facs.org/about/committees/cpc/ssiguide0700.pdf
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