ASEPTIC TECHNIQUE

Azharuddin

Department of Surgery, Zainoel Abidin Hospital/Faculty of Medicine
Syiah Kuala University, Banda Aceh
2011
Objectives
Define Infection Control and Aseptic Technique
Discuss the 3 elements of transmission of infections
List the 5 means of transmission of infectious microorganisms
Describe the five modes of transmission of infectious microorganisms
Define isolation and discuss isolation precautions
List and describe the five crucial areas, according to the C.D.C., for
maintaining isolation precautions and their implementations
Describe Standard precautions, including who is responsible for
implementation, when to implement, and methods of implementation
Demonstrate proper procedure for donning a sterile gown
Demonstrate proper procedure for removal of contaminated gloves
Recognize when the guidelines for a sterile field are violated and how to act
appropriately
Describe the purposes, types, materials, and methods of wound dressings
Definitions
Infection Control
Program of disease surveillance, designed to
investigate, prevent, and control the spread of infections
and their causative microorganisms

Aseptic Techniques
Are the methods and procedures used to create and
maintain a sterile field
Infection Control
Prevention of disease in hospitals is a major
concern

Transmission of infection requires three elements
A source of infecting microorganisms
A susceptible host
A means of transmission for the microorganism
Sources of Infection
Humans Sources
Include
patients
personnel
Visitors

Can be
Carrying an acute disease
In the incubation period of a disease
Colonized by an infectious agent
Chronic carriers of an infectious agent

Other Sources
Pts own Endogenous Flora (internal
microbes useful to the body)
Contaminated Objects
Equipment
Medications


Susceptible Host
Resistance among persons to pathogenic microorganisms varies greatly
Person may,
Be immune
Resistant to colonization
Become asymptomatic carriers
May develop clinical disease

Host factors may include, but not be limited to:
Age
Underlying diseases
Certain treatments with immunodepressive agents
Antimicrobials
Corticosteroids
Irradiation
Breaks in the first line of defense mechanisms caused by
Surgical operations
Anesthesia
Indwelling catheters

Means of transmission
Microorganisms are transmitted in hospitals by
several routes

The same microorganism may be transmitted by
more than one route

The five main routes of transmission are
Contact
Droplet
Airborne
Common vehicle
Vectorborne
Contact Transmission
The most important and frequent mode of infection
transmission

Divided into two subgroups
Direct contact transmission
Direct body to surface contact
Physical transfer of microorganisms between a susceptible host and
an infected or colonized person

Indirect contact transmission
Contact of a susceptible host with a contaminated intermediate
object, usually inanimate

Droplet Transmission
Droplets are generated from a source person by:
Coughing
Sneezing
Talking
Performance of certain procedures
Suctioning
Wound care

Transmission occurs when droplets containing microorganisms
generated from the infected person are propelled a short
distance through the air and deposited on a hosts conjunctivae,
nasal mucosa or mouth

Droplets do not stay suspended in air


Airborne Transmission
Occurs by two modes of dissemination
Airborne droplet nuclei
Are evaporated droplets containing the infectious agent
Remain suspended in air for long periods of time

Dust particles containing the infectious agent
Dispersed widely by air currents
Inhaled by a susceptible host


Common Vehicle Transmission
Applies to microorganisms transmitted by
contaminated items such as:
Food
Water
Medications
Devices
Equipments
Vectorborne Transmission
Occurs when vectors transmit
microorganisms
Vectors are vermin such as:
Mosquitos
Flies
Rats
This method is of less significance in hospitals
Isolation
One means of infection control is isolation
Isolation is the separation and placement of patients in
environments that reduce the potential for
transmission of infectious microorganisms

When a patient is placed in isolation:
Signage is posted outside the patients room indicating
specifically required isolation practices
A request is posted for visitors to see the patients nurse prior
to entering the patients room

Isolation Precautions
There are two levels of isolation precautions
Standard precautions
Designed for the care of all patients in hospitals regardless of diagnosis
or suspected infection status
Is the primary strategy for successful nosocomial infection control

Transmission precautions
Based on the concept of avoiding infection by limiting the potential for
transmission of microorganisms
Are designed only for the care of specified patients who are known or
suspected to be infected by epidemiologically important pathogens
Standard Precautions
Apply to
All patients receiving care in hospitals regardless of diagnosis or
presumed infection status
Blood
All body fluids, secretions, and excretions except sweat
Non-intact skin
Mucous membranes

Are designed to reduce the risk of transmission of
microorganisms from both recognized and unrecognized
sources of infection in hospitals


Transmission Based
Precautions
Designed for patients documented or suspected to be
infected with highly transmissible pathogens for which
additional precautions, beyond standard precautions, are
needed

There are three types of transmission based precautions
Airborne
Droplet
Contact

Are used in addition to standard precautions

can be used in any combination

C.D.C.
The C.D.C. stands for Center for Disease
Control
It is the hospital responsible for developing
and issuing guidelines for aseptic techniques
and isolation systems.
C.D.C.
The C.D.C.
Recommends isolation procedures based on 7 categories
Strict isolation
Respiratory isolation
Protective isolation
Enteric precautions
Wound and skin precautions
Discharge precautions
Blood precautions

Requires that guidelines
Have a basis that is epidemiologically sound
Emphasize the importance of all body fluids, secretions and excretions of nosocomial
pathogens
Contain precautions for infections transmitted by airborne, droplet, and contact routes
of transmission
Be simple to understand and use
Use terms to avoid confusion with existing systems


CDC Contd
The C.D.C. deemed five areas
crucial to maintaining isolation
precautions in hospitals
Administrative controls
Standard precautions
Airborne precautions
Droplet precautions
Contact precautions

Administrative Controls
Include
Education
Developing systems to ensure that patients, personnel and
visitors are educated about the use of precautions and their
responsibility to adhere to them
Adherence to precaution
Periodic evaluation of adherence to precautions
Use of findings to direct improvements
Standard Precautions
Include:
Handwashing
Gloves
Mask and eye protection
Gown
Patient care equipment
Environmental control
Linen
Occupational health and
bloodborne pathogens
Handwashing
Hands should be washed:
Immediately after touching,
Blood
Body fluids
Secretions
Excretions
Contaminated items
Immediately after gloves are removed
Between tasks and procedures on the same patient
Plain soap should be used
Procedures
Should last a minimum of 15 seconds
Involves vigorous rubbing together of all surfaces of lathered hands
Followed by rinsing under a stream of water
In the case of specific circumstances such as control of outbreak or
hyperendemic infections, an antimicrobial agent may be used

Gloves
Clean gloves should be worn when:
Touching
Blood
Body fluids
Secretion
Excretions
Contaminated items
Mucous membranes
Non-intact skin
Gloves should be changed in between tasks and
procedures on the same patient
Gloves should be removed promptly after use
Gloving Procedures
Glove pack is opened
Sterile wrapping containing gloves should be opened on a sterile surface with cuffs
toward person gloving
Sterile portion of a glove pack is opened by grasping the folds of the paper enclosing
the gloves
Grasp the left glove with your right hand by its cuff on the non-sterile portion and
work your left hand into it.
Once left is in place, place the first two or three fingers of the left hand inside the
sterile side of the cuff of the other glove
He lift the right glove using the fingers inside the cuff only
Then work the right hand into the glove pulling the sleeve over the gown
Now place the right fingers on the inside of the left glove cuff and pull that over the
gown
Once gloved both hands must remain above waist level
Removal of Gloves
One hand grasps the cuff of the other glove
The glove that is grasped is turned inside out as it is removed
The glove that is removed is compacted into the other glove
The thumb of the ungloved hand is hooked inside the remaining
glove
The remaining glove is pulled towards the fingers while being turned
inside out
Both gloves are removed with contaminated sides inward
Do not snap the gloves
Dispose the gloves in the appropriate container
Mask and Eye Protection
Are worn to protect mucous membranes of the
eyes, nose & mouth of health care providers

Should be worn when performing procedures
and patient care activities that are likely to
generate splashes or sprays of blood, body
fluids, secretions and excretions
Gown
A clean sterile gown can protect the skin and
prevent soiling of clothing of health care workers
Should be worn when performing procedures
and patient care activities that are likely to
generate splashes or sprays of blood, body
fluids, secretions and excretions
Should be removed promptly after procedure
Gowning Procedures
Open sterile pack
Grasp gown with hands above waist at all times
Shake open gown so it unfolds
Locate the neck and armholes of the gown
Without touching the outside, work both arms
into the sleeves
Have a nurse or other personnel tie the gown at
the back and neck
Patient Care & Equipment
Used patient care equipment that is soiled in blood, body
fluids, secretions or excretions should be handled in a
manner that prevents skin and mucous membrane
exposure, contamination of clothing, and transfer of
microorganisms
Ensure that equipment is not used for another patient
until it is cleaned appropriately
Ensure that single use items are discarded properly
Environmental Control &
Linen
Ensure that hospital protocols are in place regarding
routine care, cleaning, disinfection of environmental
surfaces, beds, bedrails, bedside equipment and other
frequently touched surfaces

Handle, transport, and process linen soiled with blood,
body fluids, secretions, and excretions in a manner that
prevents skin and mucous membrane exposures and
contamination of clothing
Occupational Health &
Bloodborne Pathogens
Disposable syringes and needles, scalpel blades and other
sharp items should be
Handled with care
Disposed of in proper puncture proof containers.
Never
Recap used needles
Manipulate them using both hands
Direct the point of a used needle toward any part of the
body
Remove needles from disposable syringes by hand
Bend, break, or manipulate used needles by hand
Mouthpieces, resuscitation bags & other devices should be
used as an alternative to mouth to mouth rescusitation
Airborne Precautions
Respiratory Protection
Such as an, N95 respirator, should be worn when
entering room

Patient Transport
Movement should be limited to essential purposes
Surgical Mask should be worn by the patient
Droplet Precautions
Mask
Should be worn when working within three feet of
the patient or upon entering room

Patient Transport
Should be limited to essential purposes only
Patient must wear a surgical mask
Contact Precautions
Gloves
Should be used as outlined under standard precautions
Must be changed constantly during the course of patient care
Must be removed before leaving patients room
Handwashing
Must use an antimicrobial agent
Gown
Must be removed before leaving room
Patient transport
Should be limited to essential purposes only
Patient Care Equipment
Use of this equipment should be limited to a single patient only

Sterile Field
Another aseptic technique is to provide and
maintain a sterile field.

A sterile field is most commonly required in an
operating room

There are 8 requirements for providing and
maintaining a sterile field.
Requirement 1
All items used within the boundary of a sterile field
must be sterile

Single use items are preferred

Packages are considered sterile only when
Initial packaging was performed properly
Package was stored in a proper manner
Package was not mishandled during distribution
Shelf life data has not been exceeded
Requirement 2
Once a package is opened, the edges are not
considered sterile
Care in opening sterile packages is required to
avoid having edges touch the contents of the
package, or having the edges touch the gloved
hands or sterile gown
Requirement 3
Once donned properly, sterile gowns are
considered sterile in the front from the shoulder
level to table top level, including the sleeves
Hands should be held above table top level, in
front of body during and after scrubbing,
gowning & gloving
Requirement 4
Only the top surface of a table is considered
sterile
Any surface above the level of the instrument
table, or above waist level, whichever is higher, is
a sterile surface as long as it is draped properly
Undraped or improperly draped surfaces, or
surfaces below the top level of the instrument
table or waist, are considered unsterile
Requirement 5
Only sterile items and personnel in sterile
attire may enter the field or touch items in a
sterile area.
Forceps can be used to transfer items into a
sterile area, but are considered contaminated
after one use.
Requirement 6
Activity in a sterile area cannot be allowed to
render the area unsterile.
Movement within the sterile area must be
measured and careful to avoid contact between
sterile and unsterile surfaces.
Any contamination of a sterile area must be
pointed out immediately by any personnel
present for the protection of the patient
Requirement 7
Penetration of a sterile barrier is considered
to cause contamination of a sterile field.
Penetration can be via
Liquid (most likely)
Airflow
Requirement 8
Sterile areas and fields should be prepared as
close to the time of use as feasible
They should not be left unattended
Where there is doubt about the sterile quality
of an area, a field, or an item, it should be
considered unsterile.
Wound Dressings
Two factors may dictate the type of dressing applied
or the method of application of a wound dressing
The location of the wound
The underlying pathologic conditions

No dressing should ever be applied that impedes
circulation

When non institutional care is appropriate, a patient
or patients family must be instructed carefully in
proper wound care

Purpose of Wound Dressings
The purposes of wound dressings are to
Protect physically the site of injury
Prevent contamination of a wound
Prevent transmission of infection from a wound
Promote healing
Evaluation of the Wound
Documentation of wound characteristics is necessary for:
Appropriate selection of dressing materials and protective agents
Monitoring progress in wound healing
Evaluation of the wound is necessary to determine:
Cause
Location
Area
Depth
Whether the wound is wet or dry
Whether wound is infected
Source of infection
Mechanism of infection
Microorganism of infections
Wounds can be measured with a ruler
Wounds can be documented by photograph.

Types of Dressings
Five methods of dressing applications for wound management are
Dry to dry
Application of a dry absorbent or non absorbent dressing to
cover the wound
Damp to damp
Application of a gauze pad moistened with saline solution
Damp to dry
Application of a moistened dressing that is allowed to dry
before removal
Occlusive dressing
Applied to provide a semipermeable barrier to air and moisture
penetration
Rigid dressing
Provides physical protection to a wound and the adjacent area
Materials/Application
Choice of materials for, and method of application
of dressing depends on:
Cause of the wound
Whether wound is clean or infected
If infected, what microorganism caused the infection
The type of dressing
The type, if any, of microbial agent to be applied
The site, area & depth of wound
Whether a trained professional, the patient, or the
patient's family will be responsible for monitoring and
changing the dressing
Types of Materials

The most basic dressing is a Band Aid
Telfa pads are best for small wounds
Gauze is the most common material used or dressings
Topical antimicrobial agents may be applied under the
gauze portion of the dressing
Compression wraps are applied to control edema in a
limb segment or to provide support to a join
Edges of lacerations can be approximated using Steri
Strips
Tape used to secure an adhesive can be cloth adhesive or
paper tape
Preparation of a
Dressing
Supplies must be easily accessible during procedure
Sterile fields, when required, must be prepared appropriately
Use appropriate application of aseptic techniques
Tape needs to be prepared before starting the application of a dressing
If tape is applied circumferentially on a limb segment, the ends should not
overlap
The size of the dressing should cover the wound site
In no case should adhesive portion of a dressing come in contact with a
wound
Packing a Wound
Wound may be packed with gauze depending on
the depth
Ensure that deeper layers of a wound heal before
surface layers
Once packed, cover the wound and packing with
additional dressing that is secured with a tape
Applying a Gauze Wrap
Lay portion of gauze roll against limb segment with the still rolled gauze
away from the limb

Wrap gauze in a spiral wrap which means in a continuous spiral manner
around the limb segment

Angle the roll of the gauze slightly to accommodate for sloping contour and
to avoid creating a tourniquet

Unroll the gauze around the limb segment with each successive wrap
overlapping the previous wrap by half

Secure the wrap with tape
When removing carefully use bandage scissors to cut gauze
Applying a Compression Wrap
Involves applying pressure when wrapping
The pressure should be more distal than
proximal
Compression wraps may be applied as:
Spiral wraps
Figure eight wraps
Same as spiral wrap except the direction of the wrap changes
each time the wrap completes one loop of a figure eight
Summary
Infection Control and Aseptic techniques are
programs and procedures put in place to limit
or prevent the spread of infectious
microorganisms

Transmission of infection requires three
elements, a source of infecting
microorganisms, a susceptible host and a
means of transmission for the microorganism

The five modes of transmission of infections
are contact, droplet, airborne, common vehicle
and vectorborne
Summary....
Isolation is the separation and placement
of patients in environments that reduce
the potential for transmission of infectious
microorganisms
There are two tiers of isolation
precautions: standard precautions and
transmission based precautions
The five crucial areas for maintaining
isolation precautions are administrative
controls, standard precautions, airborne
precautions, droplet precautions and
contact precautions

Summary....
Standard precautions include proper
handwashing, gloving, face & eye
protection, gowning, managing of patient
care equipment, environmental control,
linen care, observance of procedures
regarding occupational health &
bloodborne pathogens
Maintenance of a sterile field is usually
applied for surgical procedures
Summary.....
There are 8 requirements of maintaining a
sterile field they are proper handling of
opened packages, proper gowning, table
sterility, only sterile items can enter field,
activity cannot be allowed to render area
unsterile, penetration of sterile barriers are
considered contamination and sterile fields
should be prepared as close to procedure
time as possible
Wound care is designed to protect and
prevent infection of wound and involves
proper evaluation, type of, preparation and
application of dressing

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