Title:
ASEPTIC TECHNIQUE
Directorate:
Infection Control
Ref: 0994 Version 3
Classification: Protocol
Due for Review: 29/08/16
Document Control
Responsible
for review:
Sue Bradbury, Specialist Nurse Practitioner in Infection
Control
Ratified by:
Dr S Hoque, Director of Infection Prevention & Control (Acute Trust)
J Viner, Director of Infection Prevention and Control (Community Trust).
Jacquie Phare, Director of Nursing & Professional Practice (TSDHCT)
Applicability: All staff
CONTENTS
1. Introduction
2. Principles of Asepsis
3. Education
4. Audit
Appendix A- Recommended Technique for commonly Performed Procedures
Key References
Collated by Clinical Effectiveness
Aseptic Technique
Page 1 of 3
Summary
This policy aims to provide guidance on the ‘where’, ‘when’ and ‘how’ as well as a definition for the
practice of aseptic technique. It helps to identify principles for aseptic practice to help prevent
infection.
Key points include: hand hygiene, the use of personal protective equipment and thoughtful
preparation in order to facilitate the procedure and maintain patient comfort as much as possible.
Remember not to contaminate the sterile field and equipment during the procedure and that good
preparation is key to a satisfactory procedure.
1.
Introduction
Definition
Aseptic technique is the method used to prevent contamination of surgical wounds and other
susceptible sites from potentially pathogenic organisms. This can be achieved by ensuring
that clinical staff understand the principles, follow recommended protocols and use only
sterile equipment and fluids during invasive procedures.
The principles of asepsis remain the same whether you are dealing with a CVC line, postoperative wound, intravenous cannula or leg ulcer etc. However the level of precautions will
vary depending on procedure, e.g. (see appendix A).
Rationale
To minimise the risk of introducing potentially pathogenic micro organisms into a susceptible
site. Aseptic technique should be used in preparation and during any invasive procedure
which breaches the body’s natural defences e.g. the skin, mucous membranes, or when
handling equipment, such as urinary catheters, which will enter a normally sterile area.
2.
Principles of Asepsis

Hand hygiene
Hand washing is the single most important procedure for preventing healthcare acquired
infection as hands have been shown to be the common route of transmission of infection.
Transient bacteria can be removed by effective hand hygiene techniques. See SDHCT
Hand Decontamination policy. Ref 0239
Community Healthcare staff should refer to
Infection Control and hand hygiene policy available on ICARE.

Protective clothing
Protective clothing must be worn to:


prevent transfer of potentially pathogenic bacteria from patient to staff or staff to
patient
prevent user’s clothing from becoming soiled, wet or stained during patient care
activities.
Appropriate protective equipment must be worn, depending on procedure e.g.


aprons, gloves for a wound dressing
sterile gown, gloves, eye protection for a CVC line
Recommended Technique Applicable for Commonly Performed Procedure
Page 1 of 1
Collated by Clinical Effectiveness
(see SDHCT Standard Precautions Standard Infection Control Precautions Policy. Ref
0514)

Aseptic Non-Touch Technique
A Non-Touch Technique is used to maintain asepsis. Key principles include;
 effective hand washing
 avoiding contamination of key components or sterile equipment
 appropriate use of Personal Protective Equipment
It is essential to ensure that hands, even though they have been washed, do not
contaminate the patient or sterile equipment. This can be achieved by wearing sterile gloves
and using forceps as appropriate.
Catheterisation in community patients must be undertaken using an Aseptic non-touch
technique.

Inanimate objects
All instruments, fluids and materials which come into contact with a wound MUST be sterile
to avoid the risk of contamination. This includes not only products used during the
procedure but also the final dressing. Damage to packaging and the use by date must be
checked.

Dressing trolley
The trolley must be cleaned with detergent and water daily or if it becomes visibly
contaminated. Detergent wipes must be used between cases. These trolleys should not be
used for other purposes. Sticky tape residues must be removed from the trolley rails.
3
Education
All new clinical members of staff will receive training on the principles of asepsis during
clinical induction. Aseptic technique will be part of the competency assessment for other
invasive interventions such as, cannulation, insertion of chest drains and suturing.
4
Audit
Compliance with this policy will be monitored by the Department of Health, Saving Lives:
reducing infection, delivering clean and safe care, High Impact Interventions, No1Insertion of
Peripheral Cannula and No2 Central Venous Catheters.
Annual audit will also be undertaken.
ACKNOWLEDGEMENTS Leeds Mental Health Trust for allowing us to modify their policy
Appendix A- Recommended Technique for commonly Performed Procedures
Collated by Clinical Effectiveness
Aseptic Technique
Page 3 of 3
Appendix A
Recommended Technique Applicable for Commonly Performed Procedures
Procedure
Technique
Comments
Central venous catheter
Aseptic
Chest drain insertion
Aseptic
Surgical hand hygiene
Maximum barrier precautions
Surgical hand hygiene
Maximum barrier precautions
Cervical Smear
Clean
Use a sterilised speculum
Epidural
Aseptic
Surgical hand hygiene
Maximum barrier precautions
Gastrostomy or
jejunotomy tube insertion
(endoscopic/surgical or
radiological guidance)
Aseptic
Surgical hand hygiene
Maximum barrier precautions
Lumbar puncture
Aseptic
Surgical hand hygiene
Maximum barrier precautions
Indwelling urinary
catheter insertion
Aseptic
Routine hand hygiene
Sterile gloves and single use
disposable apron
Intermittent urethral
catheterisation
Clean in patients home
Aseptic in hospital
Routine hand hygiene
Sterile gloves and single use
disposable apron in hospital
IUD insertion
Aseptic
Surgical hand hygiene
required
IV medication preparation Aseptic non-touch
for immediate use and
technique
administration
Routine hand hygiene
Clean non sterile gloves
Suprapubic catheter
insertion
Surgical hand hygiene
Maximum barrier precautions
Aseptic
Manage as surgical wound
until healed
Suction-Laryngeal
Endotracheal
Tracheostomy
Clean
Dispose of catheter after each
insertion
Wound care for wounds
healing by primary
intention e.g. surgical
wound
Wound care for wounds
healing by secondary
intention e.g. venous
ulcers
Aseptic
Routine hand hygiene
Sterile gloves and single use
disposable apron
Clean
Routine hand hygiene
Clean gloves and single use
disposable apron
Recommended Technique Applicable for Commonly Performed Procedure
Page 1 of 1
Collated by Clinical Effectiveness
Protocols & Guidelines – Document Control
This is a controlled document. It should not be altered in any way without the express
permission of the author or their representative. On receipt of a new version, please destroy all
previous versions.
Ref: 0994
Title: Aseptic Technique
Date of Issue:
Version:
Author:
Index:
Classification:
Applicability:
29 August 2014 Next Review Date: 29 August 2016
3
E Childs, Director of Nursing and Governance
Infection Control
Protocol
All staff
The guidance contained in this document is intended to be inclusive for
all patients within the clinical group specified, regardless of age,
disability, gender, gender identity, sexual orientation, race and ethnicity
& religion or belief.
Yes
1. Infection Control Nurses Association. (ICNA) 2003. Asepsis:
Preventing Healthcare Associated Infection. www.ips.co.uk
2. epic2: National Evidence Based Guidelines for Preventing
Healthcare-Associated Infections in NHS Hospitals in England.
Journal of Hospital Infection Supplement 1 Volume 65 February 2007
3. Department of Health (2007) Saving Lives: reducing infection,
delivering clean and safe care. London: DH.
4. Department of Health (2009). The Health and Social Care Act 2008.
Code of Practice for the NHS on the prevention and control of
Healthcare associated infections and related guidance. DOH.
5. ANTT Theoretical Framework for Clinical Practice: Rationale
supporting evidence. Version 2.5, 2011. The Association of Safe
Aseptic Practice (ASAP)
Equality Impact:
Evidence based:
References:
Produced following
audit:
Audited:
Approval Route:
No
Yes
See ratification
Date Approved:
31 July 2012
Dr S Hoque Director of Infection Prevention & Control (Acute Trust).
Approved By:
J Viner Director of Infection Prevention and Control (Community Trust)
Ms E Childs, Director of Nursing and Governance
Links or overlaps with other policies 0239 – Hand Decontamination Policy; 0514 – Standard
Infection control Precautions; 0611 – Peripheral Venous Cannula Standards of Care
All SDHCF Trust strategies, policies and procedure documents.
PUBLICATION HISTORY:
Issue
1
2
3
Date
12 July 2007
28 January 2010
9 August 2012
Status
New
Revised
Revised
3
29 August 2014
Date change
Collated by Clinical Effectiveness
Authorised
Dr A Maggs, Director of Infection Prevention & Control
Dr A Maggs, Director of Infection Prevention & Control
Dr S Hoque, Director of Infection Prevention and
Control (Acute Trust)
J Viner, Director of Infection Prevention and Control
(Community Trust)
Sue Bradbury, Specialist Nurse Practitioner, Infection
Prevention and Control
Aseptic Technique
Page 5 of 5