Aseptic technique: evidence-based
approach for patient safety
Abstract
The fact that there is a relationship between the standards of aseptic technique
performance and the rise in hospital infection rates has heen suggested by the
Department of Heath's (DoH's, 2004) Winning Ways document. This literature review
considers how the aseptic technique is performed in the UK, and examines the nature
of ritualistic and evidence-based practice underpinning this skill-based procedure.
The findings have identified an emerging glove culture and continuing poor
hand-hygiene practices. The alternative 'clean technique' is also adopted widely in
clinical practice which confuses the aseptic theory-practice gap. While it is hard to
pinpoint an actual time or event that causes infection, it is unlikely nurses will ever
become involved in litigation as a result of a poorly performed aseptic technique.
However, the review concludes that nurses should not become too complacent. It briefly
considers how performance of the aseptic technique can be improved, through creative
educational strategy, applied risk assessment and clinical audits of nurses' practices.
Key words: • Infection control • Nursing: role • Patients: welfare
Most
frequently
missed
Cover piclure: Bacterial contamination of hands, showing areas of the skin that an often left contaminated after washing.
540
Rosemary M Preston
I
n recent months, questions concerning
hospital-acquired infections (HAIs) have
dominated boEh the professional and
national news media. The Witniings Ways
report, issued by the Department of Health
(DoH, 2004), describes how methicillin-resist-
ant Sfaphylococcus atireus {MRSA)-type infec-
tions have increased by 3.6% in England for
the year 2002-2003. One of the actions out-
lined in this report, pledged that clinical teams
will demonstrate consistently high standards of
'aseptic technique' in practice to help reduce
these rates of infections.
Unfortunately, 1 year after its publication, it
has been reported by Hartley (2()05a} that the
aseptic technique is still not being carried out
to a high standard across the country, This adds
to the growing concern about HAIs in the UK.
This concern is being addressed by the Chief
Nursing Officer, Christine Beasley, in her call
for improving aseptic techniques in managing
wounds and surgical sites (DoH, 2005).
Unfortunately, Hartley {2005a) reported that
practitioners themselves say 'the aseptic tech-
nique is not what it should be in some places'.
According to Michalopoulos and Sparos
(2003), this may be related to a theory-practice
gap. However, Hallett (2000) argues the prob-
I I Frequently I I Less
missed frequently lem may result from confusion and compla-
/ ^ missed cency in professional practice. Certainly, the
Government is concerned enough to
announce that an Essence of Care benchmark
on the aseptic technique is soon to be drawn
up and published (Hartley, 2005a). This will
encourage practitioners to use the same termi-
nology and working principles that will pro-
mote best practice and standardize the
technique across the whole of the UK.
In the current climate, health care requires
nurses to be able to apply the best evidence to
their practice. Gilmour (2000) argues that
infection control policies should be based on
evidence rather than ritual. Research shoiiki
Roseniary M Preston i^ Senior Lecturer. Prerej;! strati on
Programme, Postregistrarion Prtigramme, Postgraduate
Programme. Univtrsity of Liicon
Aat'ptfii for piihliiittion: April 2005
British Joum.ii of Nuning. 211(15.Vo! 14, No in

promote the practice of risk assessment to
minimize the incidence of cross-infection.
However, if general principles of asepsis are not
being practised to a high enough standard
(Hartley, 2nO5a), is there evidence to suggest
why this might be happening? This review of
the literature examines ritualistic and evi-
dence-based practice in relation to the educa-
tion and practice of the aseptic technique, as
well as its impHcations for patient safety.
Principles of the 'aseptic technique'
The aim of the aseptic technique is to prevent
the transmission of microorganisms to wounds,
or other susceptible sites, to reduce the risk of
infection (Bree-Williams and Waterman, 1996;
Xavier, 1999). However, pathogenic microhial
contamination continues to be identified as a
problem when practitioners carry out aseptic-
type procedures (Ward, 2(){H); Michalopoulos
and Sparos, 2UU3; Myatt and Langley, 2003). In
a survey conducted in two major hospitals \n
Greece, nurses demonstrated a sound knowl-
edge of the aseptic principle when questioned.
but 15.6% of nurses were found to have con-
taminated their hands during the procedure
(Michalopouios aiid Sparos, 2003).
Bree-Williams and Waterman (1996) and
Hailett (2000) have both observed that a failure
to use the aseptic technique correcdy could he
responsible for problematic and intractable infec-
tions such as MRSA. For example, Bree-
Williams and Waterman (1996), in their
observational study, found that 33% of nurses
contaminated their hands and equipment during
the aseptic tachnique procedure. This was found
to be a result of a number of factors, ranging
from making the procedure more complicated
than required, to poor skill in handwashing,
glove technique and use of non-touch principles
in handling sterile equipment and instruments.
In assessing attitudes towards the aseptic
technique, Hailett (2000) found that nurses dis-
cussed the concept of aseptic technique in
'fatalistic' terms. This was a small qualitative
study involving community nurses, who
expressed a belief that 'asepsis' was virtually
impossible to achieve in reality. While this
result may only have significance in a commu-
nity setting, Hatlet (2000) was concerned
about the degree of ambivalence and uncer-
tainty around infection control in wound care,
particularly as it could be related to how prac-
titioners are originally taught the aseptic tech-
nique, combined with a failure to adopt new
skills and techniques safely as they emerge in
professional practice. As Hailett (2000) con-
cluded, if there is no research evidence to sup-
port the aseptic procedure then it is not
British Journal ofNursmg,2IKJ5.Vol U. No Hi
INFECTION CONTROL NURSING
surprising if the practice is becoming obsolete political factors that may impinge on their
for some nurses. everyday working environments and expected
Therefore, is the aseptic technique always working practices.
necessary? According to Gilmour (2000) and
Weaver (2004), performing an aseptic tech- Teaching clean technique vs aseptic
nique requires sterile equipment, gloves and technique?
fluids, and 'non-touch' actions of the nurse. Over the past 10 years, a move tovrards a clean
This will help to minimize spread of potential technique has heen identified (Gilmour, 1999;
pathogens to other sites, wounds or selt. It is Williams, 1999; Michalopoulos and Sparas, 2(K)3).
also important for nurses to be able to account A clean technique adopts the same aims as the
for their actions at all times. This means being aseptic technique but uses clean rather than sterile
able to demonstrate a sound knowledge and gloves. It is also less ritualistic and relies on less
practice in maintaining a sterile field hand-washing intraprocedure, but continues to
(Gilmour. 1999; Xavier, 1999; Nursing and utilize sterile equipment and fluids as appropriate
Midwifery Council (NMC). 2002; Weaver, for individual patients' needs (Gilmour. 2000).
Table 1 . Exercising universal principles when performing an aseptic technique for
wound care
Assess risks of cross infection and sele^T^ja&^snd size of sterile gloves needed
Don a clean apron L
Wash hands at start of procedure and a ^ n y time contamination occurs
Open, dispense and transfer sterile equipment and fluids without contaminating them
Remove soiled dressing if present with hand gloved in sterile waste bag
Turn the bag inside out without contaminating your hands and continue to use for waste items
Apply sterile gloves as per Table 3 guidelines
Assess, cleanse if needed, and re-apply new dressing
Use non-touch actions when manipulating gauze swabs or irrigation, to avoid contaminating gloved hands.
the patients other susceptible sites, bed or general environment
Remove gloves from hands using guidelines from Table 3
Discard sterile field and waste bag into yellow plastic sack without contaminating your hands
Remove apron and discard into a yellow sack
Wash hands
Contominated
waste
Adapted from Baillie (2005}
2004). Gilmour (2000) goes on to argue that Parker (2000) observed that the clean tech-
despite its ritualistic nature (of being a formal nique was an alternative approach when dealing
procedure that is followed consistently), the with some chronic wounds using non-sterile
aseptic technique {Table 1), is an effective solutions such as tap water for irrigation {Riyat
infection control strategy. and Quinton, 1997; Hollinworth and Kingston,
However, in an observational study of 1998). Therefore, it must be asked whether the
healthcare practitioners in two accident and nurses in Hallett's study (2000) believed they
emergency departments, Al-Damouk et al were doing the 'best they could' when adopting
(2004) found that there was poor compliance this alternative approach. For example, one F-
with good-practice guidelines for the aseptic grade sister in the study commented she 'didn't
technique. This study was conducted in the really believe in this clean-aseptic procedure —
UK and New Zealand and it showed UK doc- she did the best she could'. This may be why
tors' rate of compliance to be as low as 27%. she and her colleagues felt the aseptic technique
Although it was accepted that a compromise in had become virtually obsolete in their commu-
standards of asepsis in very sick patients would nity practice. If so, it could be a reason why
be likely to occur, this low figure contrasted nurses in other practice areas are similarly con-
sharply with New Zealand's doctors who fused about when to apply the clean or aseptic
scored 58%. This result could imply that both approaches for a range of'aseptic-type' proce-
nurses and doctors in the UK may have dures (Table 2).
become confused and complacent about the
term aseptic in their everyday practice. It may Reinforcing aseptic technique
also be the result of the differences in how practices
professional practitioners are trained in the The complex issues surrounding the acceptable
UK, combined with other sociocultural and standard for performing the aseptic technique
541
L-ontinues to pose a challenge for all professional
healthcare practitioners. Evidence-based practice
(.'an be difficult to implement in infection con-
trol as most professionals tend to base their prac-
tice on experience or 'expert opinion' (Ward,
2002). It is usual to find nurses and doctors who
have both a lack of knowledge of the evidence
.ivaihble and an unwillingness to change their
behaviour based on new evidence {Davey, 1997;
Ward, 2()()(); Myatt and Langley, 2003).
The aseptic technique is one area of profes-
sional practice in which ritual can be recog-
nized from when to wash hands and don
gloves, to opening the sterile packages, and
performing procedures such as care of intra-
venous cannulae (Dougherty, 2000), or wound
Table 2. Clinical procedures requiring
risk assessment for an aseptic
technique approach
Redressing all acute wounds
Redressing some chronic wounds
Urinary cathetcrization '
Redressing dr.
Injection of meaicaiion^nncludmg intravenous,
intramuscular, subcutarjeous and intra-dermal
routes ^
Instillation of eye dropsr
Bladder washouts/irrigjtions
Blood-glucose ;••!"•" ' • v
Venepuncture
Cannulation
Care of central Imas (including Hickman lines)
Ad Im Baillie (2005)
care (Wilson, 2003). Successive studies on
wound care (Filetoth, 2003; Michalopoulos
and Sparos. 2003). hand hygiene (Patel, 2004:
Rickard. 2004) and glove use (Ross, 1999)
Iiave been well reported in the last 5 years.
For example, botb Filetoth (2003) and
Miclialopoulos ;tnd Sparos (2003) reported on
the need to improve aseptic technique practice
in wound care to reduce the rates of wound
infection. In handwashing practices, both Patel
(2004) and Rickard (2004) have reviewed the
various factors which inhibit good handwashing
techniques and have otfered suggestions on how
professionals can be helped to improve their
performance. In glove selection and technique,
Ross (1999) reported on an audit that identified
that practitioners were using gloves inappropri-
ately and that latex sensitivity was becoming a
problem for healthcare workers. This report also
highlighted the importance of risk assessment
for glove use in the healthcare setting.
542
The motivation to look at research and
explore new methods to improve skill-based
care is recognized to be a focus for ongoing
postregistration education (Ford and Koehler,
2001; NMC, 2002; Preston, 2004). In maintain-
ing good standards for the aseptic technique, this
should involve revisiting the skills of handwash-
ing, glove selection and technique, maintaining a
sterile field with use of non-touch principles
and developing risk-assessment protocols that
encompass safety issues for both the professional
practitioner and patient (Bree-Williams and
Waterman, 1996; Ford and Koehler et al, 2001;
Michalopoulos and Sparos, 2003).
Learning to visualize 'mkrobial
fallout*
As suggested by Rickard (2004), one of the
reasons for non-compliance in the aseptic
technique is because the individual cannot see
the microorganisms with the naked eye. The
relationship between contamination, coloniza-
tion and infection is not easy for the average
professional to perceive in practice, and it can
take many days for an infection to develop
(Wilson, 2003). This makes it harder to pin-
point the actual time, occasion or event that
caused the infection. To help overcome this
lack of awareness in practice. Ford and Koehler
(2001), for example, provided an educational
session for their staff that used colourful pom-
poms with parachutes to represent microbial
fallout. This helped staff to realize the location
of contamination on their equipment, the
patient and their hands while performing the
aseptic technique. Talcum powder or pillow
feathers have been used in a similar way.
Another visual aid useful for raising aware-
ness of'microbial fallout' is to follow a 'simple
hand-hygiene exercise' as reported by Aspock
and Roller (1999). This involves using a
creamy-coloured dye whicb is applied to
gloved hands and which are then washed with
soap and running water and dried using stan-
dard paper towels. The aim is to see the distri-
bution of dye on the gloves following this
bandwash procedure. Parts of the hands that
are frequently left contaminated with the soapy
dye (Griffiths, 2002) are the palms, between
the fingers and outer edge of the thumb. This
type of exercise can allow practitioners to
refine their handwashing technique to a higher
standard of performance.
Learning to wash hands effectively
The relationship between poor hand hygiene
and infection risks has been well documented
(Merchant, 2001; GrifFiths, 2002; Rickard,
2004). Hartley (2005b) reported intensive care
unit (ICU) nurses would need to wash their
hands every 3 minutes to ensure patient safety.
This was based on an observational study con-
ducted at the University College London
Hospital and the Royal Free Hospital, London.
This study identified 534 handwashing oppor-
tunities in a 26-hour observation period, i.e. one
every 3 minutes. It was interesting to note that
the nurses scored a low 29% for handwash com-
pliance for the total number of opportunities
observed.The findings also conveyed the impor-
tance of washing hands when moving between
different parts of the patient's body and ventila-
tor, e.g. so that colonization and spread of
MRSA was kept to a minimum. Although ICU
is a specialist area, the issue of handwashing
techniques, as well as timing and frequency, is
often viewed as the major causal link in HAIs
(Dunford, 1997; Rotter, 2001; Weaver, 2(K)4).
In relation to the aseptic technique, effective
handwashing practice is essential even if gloves
are worn at some stage in the procedure. Swales
(2003) identified that hands should be washed
before and after wound care, and also after
removal of gloves if worn. Pittet (2001) notes
that nurses often forget to do handwashing at
these times or devote too little time to wash
and dry their hands in an appropriate manner.
Bree-Williams and Waterman (1996) high-
lighted that contamination of gloves occurred
because hands were still wet when attempting to
apply the gloves. Further, good quality soap, towel
and wash-basin facilities continues to be a prob-
lem in ensuring compliance (Hampton, 2003).
When undertaking handwashing as part of
the aseptic procedure how many units still have
no "elbow* or foot-controlled taps? This means
nurses cannot safely mix hot and cold water
and turn the taps off without recontaminating
their washed hands. It would also be interesting
to investigate if practitioners use the foot ped-
als on waste bins or lift the bin hds with their
hands instead as this may pose a risk activity
leading to higher rates of HAIs. Clearly, there
is a need for all practitioners to conduct risk
assessments of the facihties they have available.
Any concerns raised by practitioners, such as
the risks posed by poor design, should be
heeded and action taken as a matter of high
priority in the healthcare setting.
Alcohol gels
The use of hand gels and alcohol rubs are an
additional aid to promoting hand hygiene
(Rickard, 2004).These have proved to be effec-
tive in reducing the time it takes to effect
decontamination of the hands compared with
using soap, water and paper towels (Jones et al,
2000; Bissett, 2002; Pittet, 2002; Patel, 2004).
British JoiirnjlofNiir5ing.2()0S,VDl 14, No
l^ickard (2004) discovered that in an average
8-hour shift, nurses could spend a total of
45mmLites, or 15% of their work activities,
devoted to hand-hygiene practices. The use of
alcohol, waterless-base ruhs reduces the time
spent on this activity.
However, inservice education emphasizes that
these rubs are only effective on hands that have
no visible signs of sailing (Bissett, 2002; Patel,
2004). Further, the efficacy of these rubs were
questioned by Kramer (2002), who found that
where the apphcation time was 8—16 seconds,
this would increase the likelihood of cross-con-
tamination. In this study, the researchers tested
the antimicrobial efficacy of If) gels and four
rinses on the contaminated hands of 15 volun-
teers. This showed that a rub time of at least
30 seconds is needed to meet acceptable stan-
dards for successful hand decontamination.
Rickard (2004) also reported other reasons
for poor hand decontamination. He high-
lighted issues involving hoth complacency and
avoidance factors related to skin problems,
workload and lack of time, poor facilities and
materials and disagreement with hospital pro-
tocol and training regulations.
Traditionally, it has been accepted that
increasing the amount of training and education
is the best strategy to take if compliance in hand
hygiene is to improve. Unfortunately, writers
like (lould (2000) have found that despite many
innovative strategies being forwarded in educa-
tional programmes, hand- hygiene behaviour
continues to be poorly applied. As Rickard
(2004) concludes, fliture strategies could involve
empowering patients to question practitioners'
hand-hygiene practice, improve hand-hygiene
facilities, and create local ownership of any
problems identified. These problems can be
assessed locally through regular risk assessment,
research, and feedback of infection rates.
Learning to select clean or sterile
gloves using a risk-assessment
protocol
Nurses are now expected to wear gloves for all
procedures to protect not only the patient, but
also themselves from infection (Hampton,
2002; Yip and Cacioli, 2002). Unfortunately,
this practice has promoted a distinct behav-
ioural culture, where nurses use gloves inap-
propriately for a number of tasks such as
conducting clinical observations and assisting
patients with feeding, where risks to either
patients or themselves are not identified
(Infection Control Nurses Association, 1999;
Raybould. 2001). In the Health and Safety
Commission (1999) report. Control of
Substances Hazardous to Health Regulations:
544
Table 3. Applying a safe glove technique
A. To don sterile gloves
Open outer glove wrapping without touching the gloves inside
Ensure gloves are positioned in front of you:
R -glove to your right and L- glove to your left with the fingers furthest away from your body
Pick up the edge of the cuff of the L-glove with your right thumb and index finger
Lift the glove and insert the fingers of your left hand
Puli the cuff to the wrist of your left hand and release the left cuff edge smoothly, leaving the cuff of the glo\
folded I
Point and insert fingers 2 5 of now gloved left hand into the folded cuff of the right giove
Lift right glove from surface and insert fingers of right hand into the glove, taking care not to touch either
gloves sterile surfaces
Puli the right glove over the right hand, and rotate folded cuff part over the right wrist as you so do
Insert fingers 2 5 of now gloved right hand back into fold of left glove and rotate fold over the left wrist as yo
so do
Assess whether gloves were contaminated during their application and then proceed with procedure
B. To remove soiled gloves
Move to waste bag or a foot pedal bin
Pick up the edge of the left glove sleeve on the wrist end with the thumb and index finger of your gloved righi
hand
Hook your third finger underneath and invert the glove as you gently pull off the left glove using your gloved
right hand to control its drop into the waste bag/bin
Insert the thumb of your now ungloved left hand into the glove cuff on the right wrist
Peel right glove carefully down right hand inverting glove as you so do
Drop glove into waste bag/bin
Both gloves should be fully inverted (turned inside out) when discarded, if correct procedure is carried out
Do not forget to wash your hands
Adapted from Aspock and Koller (1999)
Approifed Codes of Practice, it is suggested that In the case of acute wound care and urinary
risk assessment should follow specific guide- catheterization, for example, Hampton and
lines related to the barrier efficacy for the type Collins (2002) and Haberstich (2002) advocate
of gloves selected. Unfortunately, this is an area that sterile gloves should always be worn.
where the theory-practice gap is well docu- However, they also acknowledge that there are
mented (Gould and Chamberlain, 1997; some practice environments where the risk is
Curran, 2000; Rourke et al, 2001). assessed as low for some chronic wounds, such
For example, Curran (2000) reported on rea- as chronic leg ulcers when managed in the
sons for an outbreak of the hepatitis B infec- patients' home, as well as other sterile proce-
tion in a group of patients who were all dures. Both O'Toole (1997) and Gottrup et al
diabetic. Practitioners were found to be using (2001) support this view of adapting the asep-
gloves to protect themselves from blood-borne tic procedure to a clean technique for these sit-
infections when conducting blood glucose uations and of using clean non-sterile gloves
monitoring. However, it was discovered that and sterile equipment and fluids (but including
these practitioners had failed to understand the tap water when applicable).
risk posed to their patients by not changing Unfortunately, the technique for safely
their gloves between each procedure. This was applying sterile gloves has been shown to be of
how successive diabetic patients were found to a low standard. In relation to applying clean
have become infected. gloves, there appears to be no research on tech-
In addition, Hampton (2002) has highlighted niques for their application and it is left to the
the lack of understanding in relation to the practitioner to adapt the technique taken for
health risk of developing latex sensitivity, applying sterile gloves to minimize the risk of
assessing permeability (virus leaking) risks of contamination. Aspock and Koiler (1999) give
both polyvinyl and latex gloves material, and a clear explanation of how to apply and
recognizing the high costs and wastage remove sterile gloves correctly in their simple
involved when using gloves inappropriately in hand-hygiene exercise (Table 3). This is an
the healthcare setting. important skill, as Bree-Williams and
Uritish Journal orNiir5iiij(.2IK)5,Vol 14. No 10

Waterman (1996) found 33% of nurses put
gloves on incorrectly, which could have led to
glove contamination. Further, nurses often
selected the wrong glove size and some tried
to apply gloves while hands were still wet.
In a different study, Davey (1997) found there
was also some confusion relating to when
gloves should be applied in the aseptic proce-
dure. Some nurses did not know that the
wound dressing could be removed with the
sterile wastage bag to avoid contaminating their
hands, thus reducing the need for an extra pair
of gloves or forceps (see Table 1). Parker (2000)
supported the need for hands to be washed
after glove removal. This will remove any bacte-
rial growth from the hands that might have
occurred during glove use or on their removal.
Hampton (2002) also considers that it is pos-
sible for virus particles to leak through latex
and polyvinyl gloves. For example, while
nurses are performing wound care the amount
of exposure to exudates and blood can be
high, even in chronic wounds. It is, therefore,
important that even with gloves, non-touch
principles are used when assessing, cleansing
and redressing wounds (see Table 1). Gloves can
become perforated or the permeability altered
if they come into contact with chemical agents
like alcohol-hand gels.
As Jones et al (2000) argued, these gels have
not been tested on latex material, only human
skin. Therefore, the culture behaviour observed
in some nurses, who apply hand gels to disin-
fect gloves during the aseptic procedure, or
even between patients, as reported by Curran
(2000), is not recommended. If gloves become
soiled or contaminated, they should be
removed, hands washed or disinfected with an
alcohol rub, and dried well before fresh gloves
are applied. Only in this way can the nurse
ensure patient safety is maintained.
Aseptic technique: improving patient
safety?
It was reported in the DoH (2004) docu-
ment. Winning Ways, that the UK has one of
the highest HAl rates in Europe. Urinary-
tract infections are reported at 23%, with
wound infections 9% and blood infections at
6% (DoH, 2004). Certainly from the patient's
perspective, this equates to an alarming risk
to his/her safety, ranging from posing a threat
to his/her life, to a longer stay in hospital
with increased NHS costs, loss of personal
earnings and, for some, long-term disability
(Myatt and Langley, 2003).
According to Myatt and Langley (2003),
MRSA colonization and infection is consid-
ered to be endemic in NHS hospitals, with
Urinshjtjurnal of Nursing. 2(Ht5.Vol 14,NQ HI
INFECTION CONTROL NURSING
critical care units identified as the highest risk
areas. However, in all clinical environments,
this review has highlighted the need to ques-
tion basic aseptic principles when performing
a range of clinical procedures, whether these
are involving wound care, administration of
drugs, urinary catheterization or blood-glu-
cose monitoring.
In practice, both the clean and aseptic tech-
nique (Gilmour, 2000; Parker 2000) appear to
be used synonymously, but often without
recourse to risk assessment. Poor hand
hygiene, incorrect glove selection and tech-
nique and a failure to use non-touch actions
when manipulating sterile equipment are areas
which need most attention. Such failures indi-
cate a problematic theory—practice gap that
was identified by Michalopoulos and Sparos
(2003). However, this is further compounded
by an observed rise in glove culture (Hallett,
2000; Raybould 2001).
Risk assessment is not routinely carried out
before glove usage, and it has been observed by
Curran (2000) that some nurses wear the same
pair of gloves for multiple tasks. For example,
some nurses do not always change gloves
between patients when performing some clean
procedures such as blood-glucose monitoring
(Curran, 2000; Rourke et al, 2001). Regular
audits of practice behaviour and educational
support programmes are needed to resolve
some of these behavioural issues. Action plans
should be drawn up for nurses to follow if
standards of performance are found to be poor.
While the introduction of alcohol-based hand
disinfectants has significantly reduced hand-con-
tamination risks (Patel, 2004), poor practice in
its application can negate its efficacy. Nurses
should recognize that this practice only meets
liigh enough standards if they apply the disin-
fectants for at least 30 seconds (Kramer, 2002).
Applying hand disinfectants to gloved hands is
not recommended (Jones et al, 2000) as these
chemicals have not been tested on latex or syn-
thetic glove material, only human skin. Risk
assessments on type of gloves (latex or
polyvinyl), equipment, lotions and exposure risk
to blood and wound exudates, should be com-
pleted as a universal precaution for all aseptic
procedures (Weaver, 2004). This should guide
uurses to adopt safer principles when using
gloves and to enhance hand-hygiene practice.
It should be noted that aprons and uniforms
are easily contaminated and can be a reservoir
for cross-infection. Callaghan (1998) and
Pearson et al (2001) have both concluded that
plastic aprons should be changed between
patients and always before performing an asep-
tic or clean procedure. It is also recommended
(Callaghan, 1998) that uniforms are changed
daily and, if laundered at home, should be
washed at a high temperature of bO^C. From a
personal observation, the wearing of rings,
including wedding bands, should be considered
a source of pathogenic contamination if worn
during aseptic-type procedures.
Conciusion
Patient safety when performing the aseptic
technique is of the highest importance.
Considering the relationship between contami-
nation, colonization and infection is not easy
for the nurse to perceive in practice. This makes
it harder to pinpoint the actual time, occasion
or event that caused the infection. While drug
errors are more easily identified (Preston,
2004), errors in applying the aseptic technique
are more difficult to prove in law. Therefore, it is
unlikely that nurses will be involved in some
form of litigation as a result of a poor perform-
ance leading to HAI (Oxtoby, 2003).
However, nurses should not be complacent
about this area of their practice. It is recom-
mended that all nurses use risk-assessment pro-
tocols, attend educational updates, and conduct
regular audits in their practice areas. Such
strategies should promote ownership of the
problems identified in their practice and
improve the standard of aseptic technique per-
formance. This will not only have benefits in
promoting the safety and wellbeing of the
patients, but also provide a safe environment for
student uurses to learn and practice this skill in
a safe and competent manner. ISD
M-Daiiiouk M, Fudiiey E, Bleetnian A (2()(:)4) Hand hygiene
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KEY POINTS
• The practice of aseptic technique is causing
concern for patient safety.
• Giove culture is emerging as a threat
to controlling infection risks.
• Poor hand hygiene practices continue
to be observed.
• Hand disinfectants are oniy effective
if applied for longer than 30 seconds.
• Risk assessment should precede ali aseptic
technique procedures.
• Education strategies are needed
to visualize microbiai fallout.
545
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