DOCUMENT CONTROL PAGE

Document Number: 576 Title: Aseptic Technique

Version Number: 1 Document Type: Guideline

Application: Trust Wide Content: Clinical

Author/Originator and Title: Infection Control Team

Date of Issue: December 2007 Replaces:

Description of Amendments:

Approved By: Approval Information:

Clinical Services Committee

Name: Dr TP Enevoldson

Signature: Original Held on File in Clinical

Governance

Date: 20th December 2007

Review Date: December 2008 Responsibility Of: Infection Control Team

Training Required: YES Name of Trainer/s: Infection Control Nurses,

Infection Control Link Personnel

CHECK LIST:

Completion of Distribution Information Page YES

Completion of Training Information Page (if required) YES

Aseptic Technique Guidelines

December 2007
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 Training Information

Document Title: Aseptic Technique

Trainer/s Name & Title:

Training Commencement Date (provisional):

Training Completion Date (provisional):

Trainee Name Department

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December 2007
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 Distribution Information

Document Name: Aseptic Technique

Format (electronic/
Name Department / Title Date
paper)
4 December
Claire Duckworth Cairns Paper
2008
4 December
Julia Cottrell Caton Paper
2008
4 December
Cathy Stoneley Dott Paper
2008
4 December
Lynn Davies Sherrington Paper
2008
4 December
Marie-Antoinette Payet Jefferson Paper
2008
4 December
Hilda Hammond Critical Care Paper
2008
4 December
Alison Sudlow Neurophysiology Electronic
2008
4 December
Anne Trafford Occupational Therapy Electronic
2008
4 December
Carol Whiteley OPD Paper
2008
4 December
Wallis Pinson Pathology Electronic
2008
4 December
Yvonne Shanks Radiology Electronic
2008
4 December
Jean Blevin Theatre Paper
2008
4 December
Dave Watling Clinical Trials Unit Electronic
2008
4 December
Gill McKetterick Finance Electronic
2008
4 December
Jackie Renshall Medical Records Electronic
2008
4 December
Michael Larkin Purchasing Electronic
2008
4 December
Sue Howard Secretariat Electronic
2008
4 December
Paula Furmedge Training and Development Electronic
2008
4 December
Peter Murphy Psychology and Pain Management Electronic
2008
4 December
Nicola Dean NRU Paper
2008
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December 2007
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 4 December
Mike Lynch IT Electronic
2008
4 December
SHO Accommodation Paper
2008
4 December
Registrar’s Room Paper
2008
4 December
Dr. TP Enevoldson Medical Director Electronic
2008
4 December
Mel Pickup Chief Executive Electronic
2008
4 December
Rosamund Harvey Head of Effectiveness and Audit Electronic
2008
4 December
Amanda Prendergast Head of Risk Electronic
2008
4 December
Andrew Maloney Head of Human Resources Electronic
2008
4 December
Chris Harrop Director of Finance Electronic
2008
Acting Director of Nursing and 4 December
David Melia Electronic
Governance 2008
Foundation Trust Programme 4 December
Jackie Holt Electronic
Director 2008
Director of Service Delivery and 4 December
Sheila Hill Electronic
Performance 2008
Divisional General Manager, 4 December
Julie Riley Electronic
Neurology 2008
Divisional General Manager, 4 December
Philippa Murphy Electronic
Diagnostics 2008
Divisional General Manager, 4 December
Tricia Anderton Electronic
Surgery 2008
4 December
Kelly Teague General Manager, Neurology Electronic
2008
4 December
Alison Hoole General Manager, Diagnostics Electronic
2008
4 December
David Jones General Manager, Surgery Electronic
2008

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December 2007
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 Equality and Diversity Checklist

Yes/No Comments
1. Does the policy/guidance affect one group less or more
favourably than another on the basis of:

• Race or ethnicity (including gypsies or travellers) No

• Age No

• Nationality No

• Gender (Male, Female, Transsexual) No

• Culture No

• Religion or belief No

• Sexual orientation including lesbian, gay and bisexual No

people

• Physical Disability No

• Cognitive Impairment No

• Learning Difficulties / Disability No

• Sensory Impairment No

• Mental Health Problems No

2. Is there any evidence that some groups are affected No
differently?
3. If you have identified potential discrimination, are any
exceptions valid, legal and/or justifiable?
4. Is the impact of the policy/guidance likely to be negative?
5. If so can the impact be avoided?

6. What alternatives are there to achieving the

policy/guidance without the impact?
7. Can we reduce the impact by taking different action?
If yes is answered to any of the above items the policy may be considered
discriminatory and requires review and further work to ensure compliance with
legislation
If you have identified a potential discriminatory impact of this procedural document,
please refer it to Mr. Andrew Maloney, Head of Human Resources, together with any
suggestions as to the action required to avoid/reduce this impact.
For advice in respect of answering the above questions, please contact:
Mr. Andrew Maloney,
Head of Human Resources,
2nd Floor,
The Walton Centre

Aseptic Technique Guidelines

December 2007
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 Contents Page

1 Introduction 7
2 Purpose 7
3 Scope 7
4 Duties
4.1 All employees 8
4.2 Line Managers/Heads of Department 8
5 Education and Training 8
6 Process of Monitoring the effectiveness of the policy 8
7 Principles of Asepsis 9
8 Aseptic Technique principles 10
9 Procedure for Aseptic Technique 11
10 References 12

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 1. Introduction

Aseptic technique is the effort taken to keep the patient as free from healthcare associated
infections as possible. It is a method used to prevent contamination of wounds and other
susceptible sites by organisms that cause infection.

An aseptic technique should be implemented during an invasive procedure that bypasses the
body’s natural defences e.g. the skin or mucous membranes. Asepsis must be maintained when
handling equipment prior to carrying out invasive procedures e.g. sterile equipment for surgical
procedures, wound care dressings, insertion and management of all invasive devices including
intravenous cannulae, urinary catheters, spinal and external drains and tracheostomy care.

Poor asepsis can lead to the risk of cross transmission of micro organisms from the healthcare
worker’s hands (HCW) and/or the equipment to susceptible patient sites which can result in serious
life threatening healthcare associated infections (HCAI).

Tackling HCAI is a priority for all National Health Service (NHS) organisations. The Health Act
2006: Code of Practice for the Prevention and Control of Healthcare Associated Infections
stipulates that all NHS organisations must in relation to preventing and controlling the risks of HCAI
have in place appropriate core policies, including Aseptic Technique.

This policy should be read in conjunction with the following policies /guidelines:

• Standard infection control precautions

• Hand hygiene
• Preventing surgical site infection
• Management of invasive devices
• Decontamination
• Safe use and disposal of sharps

2 Purpose

To provide Health care workers with clear evidence-based aseptic technique guidelines for the
prevention of cross infection when undertaking invasive procedures.

3 Scope

This policy applies to all employees of The Walton Centre for Neurology and Neurosurgery NHS
Trust including people holding honorary contracts, bank and agency staff, locums, trainees and
students. Each member of staff has a personal responsibility to ensure they comply with these
guidelines. All employees of the Walton Centre will be assessed as competent before performing
as aseptic technique.

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 4 Duties

4.1 All Employees

4.1.1 To ensure they are aware and adhere to the guidelines, and have read and understood
them which will enable them to carry out their work according to the Trust’s guidelines.
4.1.2 Attend all relevant training
4.1.3 Trained staff to undertake an aseptic technique competency on an annual basis. The
competency form should be completed by the assessor and filed in the member of staff
personal information file; held with the ward managers. This form will be part of the
personal development plan for all trained staff
4.1.4 Assess junior trained staff on aseptic technique and complete appropriate competency
form.

4.2 Line Managers/Head of Departments

4.2.1 Policies, procedures and guidelines are available in the purple folders in all wards and
departments and on the intranet. It is the responsibility of the manager to ensure that the
policy is fully implemented and that all staff comply with this guidance.
4.2.2 To clarify issues for the staff member who does not understand any part of the guideline.
4.2.3 To make staff aware of any changes or revisions to the guidelines
4.2.4 To ensure new versions of the guidelines are made available to staff and to ensure
superseded copies are removed from the ward/department
4.2.5 Ensure all trained staff complete aseptic technique competency on an annual basis.
4.2.5 To ensure staff attend all relevant training, including updates at the required frequency.
Attendance at training sessions will be built into the individual’s annual “performance and
development programme” and “personal development plan” linked to the realisation of the
Knowledge and Skills Framework.

5 Education and Training

5.1 All new staff attend the Walton Centre induction programme. Infection prevention and
control is a mandatory topic on this session.
5.2 All trained staff are assessed annually on aseptic technique. A competency form is
completed and filed in their person details folders.
5.3 All trust clinical staff undertake annual mandatory infection prevention and control update.
during both sessions the principles of asepsis are emphasised
5.4 The content of the mandatory and induction programmes will be reviewed at least annually

6 Monitoring effectiveness of the policy

6.1 Aseptic technique competencies

All trained staff receive appropriate training and undergo assessment of performing an
aseptic technique and only those staff assessed as competent will perform an aseptic
technique. This assessment is performed annually and forms part of their personal
development plan.
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 6.2 Observation and assessment will be carried out and documented as proof of competency
by using the Saving Lives: High Impact Intervention No 1: Preventing the risk of microbial
contamination.

7 Principles of asepsis

Infection is caused by organisms which invade the host’s immunological defence mechanisms
although susceptibility to infection may vary from patient to patient. The risk of infection is
increased if the patient is immunocompromised by:
• Age: neonates and the elderly are more at risk as their immune systems are less
efficient
• Underlying disease, e.g. patients with severe debilitating or malignant disease
• Drug therapy, such as the use of immunosuppressive drugs or the use of broad
spectrum antimicrobials.
The use of standard infection control precautions should be used as a minimum for all patients.
Those patients identified as having increased risk factors should be focused on more closely
as they are more susceptible to infection and appropriate interventions implemented. Standard
infection control precautions include:
• Hand hygiene
• Personal protective equipment
• Safe use and disposal of sharps
• Decontamination

7.1 Hand Hygiene

Hand decontamination/hygiene is crucial to the prevention of cross infection. Current
national and international guidelines identify that effective decontamination of the hands
results in significant reduction in carriage of harmful micro organisms on the hands
Application of the guidance will result in a reduction in the incidence of preventable
infections which leads to reduced patient morbidity and mortality

Prior to carrying out an invasive procedure, always remove jewellery. Cover cuts and
grazes and perform hand hygiene prior to aseptic procedure, (See Walton Centre “Hand
Hygiene” Policy).

7.2 Personal Protective Equipment

Gloves must be worn for invasive procedures, contact with sterile sites, non intact skin or
mucous membranes, and all activities where a risk assessment indicates that exposure to
blood, body fluid, secretions and excretions and contaminated instruments can occur.

Gloves are a single use item and must be removed and hands washed with liquid soap
and water on removal (See Walton Centre “Standard infection control precautions”
guidelines).

Disposable plastic aprons should be worn to protect the user’s clothing becoming
contaminated with pathogenic organisms which may subsequently be transferred to other
patients.
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 Disposable plastic aprons are single use items and must be removed after use.

7.3 Safe Use and Disposal of Sharps

Sharps or any other contaminated sharp device used during the procedure should be
disposed of by the user immediately after use, at the point of care into a sharps bin
(conforming to UN 3291 and BS 7320 standards (see Walton Centre “Safe use and
Disposal of sharps” Policy).

7.4 Decontamination
New evidence highlights that equipment can act as a vehicle to transfer micro organisms
between patients which may result in infection. Whenever possible, use single use
equipment. Re-usable devices must be decontaminated in line with Trust
Decontamination Policy.

8 Aseptic Technique Principles

8.1.1 Avoid exposing or dressing wounds or performing an aseptic procedure for at least 30
minutes after bed making or domestic cleaning.
8.1.2 Assemble all appropriate sterile items for the procedure.
8.1.3 Prepare the setting including decontamination of the working surface to be used with
detergent and water then dry. Alternatively, it can be disinfected with a 70% alcohol wipe.
8.1.4 A plastic disposable apron should be worn over clothing or uniform.
8.1.5 Remove hand jewellery, wash hands before commencing procedure with soap and water,
or if hands are not visibly soiled, an alcohol hand rub/gel can be applied to all areas of the
hands.
8.1.6 Carefully remove the dressing (a large amount of micro organisms are shed into the air).
8.1.7 Expose the wound for the minimum time to avoid contamination and maintain temperature.
8.1.8 Decontaminate hands again after removing dressing.
8.1.9 Put on sterile gloves.
8.1.10 Perform the procedure including skin preparation where applicable, avoiding accidental
contamination of sterile equipment/vulnerable site.
8.1.11 Always:
• Use Standard Infection Control Precautions.
• Dispose of single-use items after one use.
• Dispose of single patient use items after treatment.
• Decontaminate re-usable items according to local policy and manufacturer’s instructions.

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December 2007
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 9 Procedure for Aseptic Technique

Equipment

Sterile dressing pack

Fluid for cleaning or irrigation
Appropriate dressing
Any extra equipment that may be needed during the procedure e.g. canola, blood culture
bottles, urinary catheter, spinal needle, any surgical instruments
Appropriate hand hygiene preparation

Procedure
Explain and discuss the procedure with the
patient
Wash hands with soap and water
Ensure all equipment required is available and
that the trolley has been cleaned using soap
and water or Alco wipe. Place all equipment on
the bottom shelf of the trolley
Take the patient to the treatment room or
screen the bed area. Position the patient
comfortably so that the area to be dealt with is
accessibly without exposing the patient unduly
Decontaminate hands and put on disposable
plastic apron
Check dressing pack is sterile and in date.
Open the outer cover of the pack and slide the
contents onto the top shelf of trolley
Open the sterile pack using only the corners of
the paper
Clean hands with alcohol gel
Place hand in disposable bag found in the pack
and arrange contents of dressing pack
If applicable remove used dressing with hand
covered with plastic bag, invert bag and stick to
trolley
Check the sterility and dates of any other
equipment required for the procedure before
placing onto sterile field
Clean hands with alcohol gel
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Rational
To ensure the patient understands the
procedure and gives their consent
Hands must be cleaned before and after every
patient contact and before preparing the
equipment for aseptic technique to prevent
cross infection
To provide a clean working surface
To allow any airborne organisms to settle before
the sterile field (and in the case of a wound
dressing) the wound is exposed. Maintain the
patients dignity and comfort
To reduce the risk of transfer of transient
organisms from the healthcare workers hands
and to protect clothing becoming contaminated.
To ensure that only sterile products are used.
So that areas of potential contamination are
kept to a minimum
Hands may become contaminated from
handling outer packets
To maintain sterility
To minimise the risk of contamination by
containing dressing in bag.
To ensure that only sterile products are used
and date has not expired
Hands may become contaminated from
handling outer packages

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 Procedure Rational
Put on sterile gloves touching only the inside To reduce the risk of infection.
wrist end
Carry out procedure using aseptic principles To prevent the introduction of microrganisms
into a susceptible site
On completion of procedure make sure the
patient is comfortable
Dispose of waste and/or sharps into appropriate To prevent environmental contamination and/or
waste bag/container reduce the risk of sharps injury
If trolley is visibly stained with blood or body To reduce the risk of spreading infection
fluids wash with soap and water and dry
thoroughly with paper towels. If trolley is clean
use alco wipe or alcohol gel to decontaminate
Wash hands with soap and water To remove any transient organisms and prevent
the spread of infection
Place any bar codes from the outside of any Provides a record of the instruments used and
surgical instruments packs used during the enables the instrument to be tracked
procedure into the patients medical records
Record procedure in the appropriate patient To enable continuity of care
records and if applicable complete wound
assessment form

10 References

1 Ayliffe GAJ, Fraise AP; Geddes AM, Mitchell K (2000) Control of Hospital Infection, A
Practicle Handbook, 4th Ed Arnold
2 Centre for Disease Control and Prevention. Guidelines for hand hygiene in health-care
settings. Recommendations of the Healthcare Infection Control Practices Advisory
Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Morbidity and
Mortality Weekly Report 2002; 51 (no RR-16):1-45
3 Department of Health (2006) Code of Practice for the Prevention and Control of Healthcare
Associated Infection DoH London
4 Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SR, McDougall CM,
Wilcox MH (2007) Epic 2 National Evidence Based Guidelines for Preventing Healthcare-
associated Infections. Department of Health.
5 Royal Marsden Hospital Manual of Clinical Nursing Practice (2004) 6TH Ed Blackwell

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 This information can be translated on request or if preferred an interpreter can be
arranged. For additional information regarding these services please contact the
Walton centre on 0151 529 8511

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 Signature List
Document Name: Aseptic Technique

Date of Distribution: 4 December 2008

Department

Department Lead

Member of Staff Signature Date

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 Aseptic Technique Guidelines
December 2007
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 Aseptic Technique Guidelines
December 2007
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