Practicing Medical Asepsis

What Areas Are Considered Sterile?

A sterile field is sterile only on the horizontal plane (e.g., the draped table top). Material that drapes over the horizontal plane may easily be contacted by nonsterile clothing or equipment. Consider a 1-inch margin along the borders of a sterile drape unsterile even if it remains on a horizontal surface. Because it is in contact with contaminated surfaces. If you are wearing sterile attire, consider only the front of your body from the chest to the level of the sterile field to be sterile, nothing else. Sleeve cuffs are considered unsterile when your hands pass beyond the cuff (cuffs are sterile if you don gloves using the closed method).

Standard Precautions

"Tier One" Precautions Use with all clients, in all settings, regardless of suspected or confirmed presence of infection. Principle: All blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain pathogens. Include: Hand hygiene; use of gloves, gown, mask, eye protection, or face shield (depending on expected exposure) and safe injection practices. Added for protection of patients more than of healthcare personnel: Safe injection practices, respiratory hygiene and cough etiquette, and wearing a mask when performing special lumbar puncture procedures. Standard precautions do not completely protect against microorganisms spread by contact, droplets, or through the air.

Transmission-Based Precautions

"Tier Two" Precautions Use for patients known or suspected to be infected or colonized with infectious agents. Principle: Routes of transmission for some microorganisms are not completely interrupted using standard precautions alone. Used in addition to standard precautions. *Three categories of precautions:* Contact Precautions—For organisms spread by direct contact with the patient or his environment. This is the most common form of transmission. Droplet Precautions—For pathogens spread through close respiratory or mucous membrane contact with respiratory secretions (e.g., sneezing, coughing, talking); pathogens that do not remain infectious over long distances. Airborne Precautions—For pathogens that are very small and remain infectious over long distances when suspended in the air and are easily transmitted through air currents (e.g., fanning linens, ventilating systems).

Medical Asepsis

("clean technique") refers to procedures that decrease the potential for the spread of infections. You probably already practice medical asepsis in other settings without realizing it. For example, at home you wash your hands before and after handling foods. In the healthcare setting, medical asepsis includes hand hygiene, environmental cleanliness, standard precautions, and protective isolation.

If You Are Exposed to Blood or Other Body Fluids

1. Immediately flood the exposed area with water and clean any wound with soap and water or a skin disinfectant if available. 2. Report the exposure immediately to the appropriate person in the agency. If you are a student, also report immediately to your instructor. 3. Seek immediate medical attention. Consent to testing and follow-up treatment as advised. 4. Complete an incident or injury report. 5. Attend counseling sessions provided by the agency.

Levels of Disinfection

High-level disinfection kills all organisms except high levels of bacterial spores. Intermediate-level disinfection kills bacteria, mycobacteria, and most viruses. Low-level disinfection kills some viruses and bacteria.

Transmission-Based Isolation

If the client is in transmission-based isolation, disinfect the equipment on REMOVAL from the room. When removing linen or nondisposable items from a room with contact, droplet, or airborne isolation, place them in special isolation bags.

CDC Guidelines for Preventing Transmission of Pathogens

In addition to hand washing and maintaining a clean environment, you should follow other precautions to protect yourself and your patients. CDC guidelines provide for two tiers of protection: *Standard precautions*, the first tier of protection, apply to care of all patients. You must assume that every patient is potentially colonized or infected with an organism that could be passed to others in the healthcare setting. *Transmission-based precautions*, the second tier of protection, are for patients with known or suspected infection or colonization with pathogens. Recall from the discussion on the chain of infection that pathogens may be transmitted by contact, droplet, or air. Each mode of transmission requires a different approach to prevent infection.

Levels of Asepsis

Recent guidelines suggest using modified sterile technique for many bedside procedures that have traditionally used sterile technique (e.g., tracheostomy care and wound care). Sterile, modified sterile, and clean techniques

Sterilization

Sterilization is the elimination of all microorganisms (except prions) in or on an object. The major sterilizing methods used in hospitals are (1) autoclaving with moist heat, also called immediate use steam sterilization, (2) gas or vapor (e.g., ethylene oxide or hydrogen peroxide), (3) dry heat, (4) ozone, and (5) liquid chemicals *Critical items* are those that pose a high risk for infection if they are contaminated with any microorganism—that is, those that enter the vascular system or sterile tissue or those items through which blood flows. Examples: Intravenous catheters, needles for injections, urinary catheters, surgical instruments, some wound dressings, and chest tubes

Disposing of Used Isolation Supplies

Place contaminated disposable equipment and materials containing body fluids in special isolation bags; use the bags only for contaminated materials. This process requires two healthcare workers. The worker inside the room wears protective clothing and handles only contaminated items. The second worker stands at the door and holds the isolation bag open. The first worker places items inside the bag without touching the outside of the bag. If the bag contains linens, the isolation bag is closed and placed in a laundry hamper. Securely close the isolation trash bag and place it in a special isolation trash container. Special disposal methods are used to prevent these objects from going into a landfill, where they could become a reservoir of infection.

Asepsis

is a term that means absence of contamination by disease-causing microorganisms

Cleaning

is the removal of visible soil (organic and inorganic) from objects and surfaces. In healthcare agencies, it is usually accomplished manually or mechanically using water with detergents or enzymatic products formulated to inhibit microbial growth. A goal of medical asepsis is to keep all public and patient care areas within the facility clean and free from dust, debris, and contamination. Any spilled liquids, dirty surfaces, or potentially contaminated areas should be cleaned immediately. *Items must be cleaned thoroughly before they can be disinfected or sterilized.

Sterile Technique

is the use of sterile gloves and sterile supplies (e.g., drapes, bandages, instruments, water).

Clean Technique

is use of clean hands or nonsterile gloves and clean, rather than sterile, supplies (e.g., tap water)

Modified Sterile Technique

is use of nonsterile procedure gloves with sterile supplies.

Surgical Asepsis (Sterile Technique)

or sterile technique, requires creation of a sterile environment and use of sterile equipment. It differs from medical asepsis in that it is more complex and it is not necessary to use it with all patients. Sterilization can be accomplished through the use of special gases or high heat. Surgical equipment and implanted devices are examples of materials that must be sterilized.

Disinfection

removes pathogens on inanimate objects by physical or chemical means, including steam, gas, chemicals, and ultraviolet light. Chemical germicides can achieve three levels of disinfection. Disinfection is used for semicritical and noncritical items: *Semicritical items* are those that contact mucous membranes or nonintact skin. They must be free of all microorganisms except bacterial spores, so they must at least be disinfected and sometimes sterilized. Examples: Reusable devices, such as flexible endoscopes, and respiratory therapy and anesthesia equipment *Noncritical items* are supplies and equipment that come in contact with intact skin but not mucous membranes. They do not carry a high risk of infection transmission, and they can be decontaminated where they are used. Disinfection is adequate for noncritical items. Examples: Bedpans, stethoscopes, and blood pressure cuffs Examples of noncritical environmental surfaces: Floors, food utensils, bed linens, and bed rails

Maintaining Clean Hands

KEY POINT: Hand hygiene is the single most important activity for preventing and controlling infection. Hand washing involves five key factors: time, water, soap, friction, and drying. 1. Time. In a nonsurgical setting, wash the hands vigorously for at least 15 seconds, longer if hands are visibly soiled. In a surgical setting wash for 2 to 6 minutes, depending on the soap or other product used. 2. Water. Use warm water and rinse off soap completely. 3. Soap. Use agency-approved soap; or The CDC recommends (2002) use a 60% alcohol-based solution (rubs, sprays, gels) for routine hand cleansing and plain or antimicrobial soap and water when hands are visibly dirty. Iodine compounds are also effective, but usually too irritating for regular hand hygiene. If there is a potential for contact with *bacterial spores* (e.g., when caring for a client with a C. difficile infection), you must wash your hands with soap and water; alcohol-based solutions are not effective against spores. 4. Friction. Rub all surfaces of the hands and wrists vigorously, including the backs of the hands and between the fingers. Remove jewelry and clean areas underneath. Clean underneath the fingernails using an orangewood stick. 5. Drying. Use single-use towels or hand dryers to remove all moisture after washing the hands. If using antimicrobial hand gels, apply and rub hands until dry.

Protecting the Equipment on the Sterile Field

KEY POINT: Sterile touches sterile. Unsterile touches unsterile. Only sterile items can be placed on a sterile field. Wash your hands before gathering materials from the sterile supply area and then gather the other required supplies and equipment. Handle sterile equipment only if you are wearing sterile gloves. Sterile liquids must be contained in sterile containers on the field or the sterile drape must be nonpermeable to avoid wicking. If the drape is permeable, liquid can seep through to the underlying surface and act as a wick for contaminants to travel upward to the sterile field. Make sure you are opening equipment packaged with labels indicating it has been sterilized properly, packaging intact and dry, and not expired. If packages are light and small, gently add them to the sterile field by separating the package flaps and allowing them to fall onto the field. If the object is large (e.g., an irrigation bowl), slowly unwrap the packaging and, grasping it through the outside wrapper, place the bowl on the field.

Protecting the Sterile Field

Move slowly and deliberately. Never reach across a sterile field. If you see someone else contaminate a sterile field or object, identify the break and cover the area with sterile drapes or replace with a new sterile setup, gown, or gloves. Remain at least 1 foot away from nonsterile areas if you are wearing sterile garb. Never turn your back to a sterile field. A sterile field and open sterile items must be kept above waist level and in constant view. You are responsible for monitoring and maintaining the sterility. If you cannot see the field, you do not know whether it has become contaminated. Make sure your clothing or lab coat never touches any part of the sterile field. Keep your fingernails short and clean. Avoid nail polish and artificial nails. Avoid wearing jewelry that dangles or can fall into the sterile field. Keep long hair pulled back or covered by a head covering designed for sterility. Change your gown or reinforce with additional sterile drapes if it is soaked through. Avoid splashing any kind of solution onto the sterile field. Keep doors closed so turbulent airflow does not contaminate a sterile area with airborne microbes. Clean wounds and prep sterile sites from clean to dirty.

Protective Isolation (Reverse Isolation)

Patients who are immunosuppressed (e.g., receiving chemotherapy) are sometimes placed in a special form of isolation Protective isolation usually includes following standard precautions; placing the patient in a private room; restricting visitors; wearing a mask, gown, and gloves for patient care; and special cleaning or disposal of the patient's equipment and supplies. If a client is in protective isolation, be sure that equipment has been disinfected BEFORE it is taken into the room. Take linen and dishes directly to the protective isolation room, and hand them to someone wearing the required protective clothing.