Asepsis ASEPSIS

https://www.flickr.com/photos/kokopinto/1745524662

https://commons.wikimedia.org/wiki/File:Students_assisting_surgery.JPG Asepsis ASEPSIS

• Absence of pathogenic (disease- producing) microorganisms • Refers to “aseptic technique” • Often interchanged with “sterile technique” • Gold standard of infection control patient care practices

PHC 6517, Module 7: https://commons.wikimedia.org/wiki/File:USMC-080803-M-1855J-001.jpg “Asepsis and Hand Hygiene, Part I”

Aseptic & Clean Sterile (Aseptic) Technique Techniques • Goal: render & maintain objects & areas maximally free of microorganisms • Maintain area of sterile field with sterile gowns, gloves, & drapes • Wear appropriate attire as indicated by procedure risk & area where https://en.wikipedia.org/wiki/Adhesive_bandage https://en.wikipedia.org/wiki/Surgery procedure performed

Sterile Technique Examples Sterile Technique: Surgery

• Surgery

• Insertion of central lines

https://upload.wikimedia.org/wikipedia/commons/6/60/Blausen_0181_Cath eter_CentralVenousAccessDevice_NonTunneled.png • Insertion of urinary catheters

https://en.wikipedia.org/wiki/Urinary_catheterization https://en.wikipedia.org/wiki/Surgical_technologist https://commons.wikimedia.org/wiki/File:Ear_surgery_on_a_patient.jpg

1 Sterile Technique: Inserting Sterile Technique: Inserting a Central Line a Urinary Catheter

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http://cdn.c.photoshelter.com/img-get/I0000LFQAu86WXl8/t/170/I0000LFQAu86WXl8.jpg https://en.m.wikipedia.org/wiki/History_of_anesthesia

Sterile Technique: Setting up a Donning (putting on) Sterile Gloves Sterile Field Removing Gloves

https://commons.wikimedia.org/wiki/File:US_Navy_060426-N-5174T- 068_Hospital_Corpsman_1st_Class_Cynthia_Donaldson_prepares_surgical_tools_before_an_inguinal_ https://www.flickr.com/photos/madeincrediblyeasyuk/6053172236 hernia_repair_in_the_operating_room.jpg http://www.freestockphotos.biz/stockphoto/15279

Clean Technique Clean Technique Examples • Use barrier techniques to ↓ microbial transmission • Changing dressings from patient to HCW • Use meticulous hand hygiene • Use “no-touch” dressing technique to avoid • Wound care contamination of sterile supplies (or use sterile https://en.wikipedia.org/wiki/Negative-pressure_wound_therapy gloves for dressing application) • Wear gown or gloves to ↓ contamination of • Drawing blood clothing

• Wear clean gloves to avoid direct contact with https://commons.wikimedia.org/wiki/File:Blooddrawgenetics.jpg infectious materials

2 Clean Technique: Clean Technique: Changing Dressing or Wound Drawing Blood Care

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Placement or replacement of bandage using “no touch” technique

Sterile vs. Nonsterile Gloves http://whqlibdoc.who.int/publications/ 2009/9789241597906_eng.pdf Sterile The use of nonsterile gloves vs. sterile gloves for Putting on routine changing of & removing surgical site exam gloves: dressings remains Clean technique https://commons.wikimedia.org/wiki/File:Joint_Readin an unresolved issue ess_Training_Center_140117-F-XL333-797.jpg as wounds may be colonized &, Exam (non-sterile) gloves therefore not sterile Source: RR#4 https://c1.staticflickr.com/1/258/19115798089_d47f47aa9d_b.jpg

Why Do You Need Hand Hygiene to Know This? • One of the most important procedures • They are essential infectious disease for preventing transmission prevention strategies of disease-producing organisms or • They are important part of infection infections http://www.freestockphotos.biz/stockphoto/15286 prevention & control • Many hospital outbreaks of • Patient care practices involve both infections related to techniques in varying situations inadequate hand hygiene https://en.wikipedia.org/wiki/Hand_washing

3 Definition of Terms 1 Definition of Terms 2 • Hand hygiene: handwashing, antiseptic • Antiseptic hand rub: applying an antiseptic handwash, antiseptic hand rub, or surgical hand-rub product to all surfaces of hands to hand antisepsis  # microorganisms present (no water used) • Handwashing: washing hands with plain • Alcohol-based hand rub: alcohol-containing (non-antimicrobial) soap & water preparation designed for application to hands to  #’s viable microorganisms. In U.S., such • Hand antisepsis: refers to either antiseptic preparations usually contain 60%-95% ethanol or handwash or antiseptic hand rub isopropanol. • Antiseptic handwash: washing hands with water & soap or other detergents • Surgical hand antisepsis: Hand antisepsis containing an antiseptic agent performed preoperatively by surgical personnel to eliminate transient &  resident hand flora

Resident & Transient Transient Flora Skin Flora • Colonize superficial layers of skin • Often acquired by HCWs during contact with patients or environmental surfaces • More amenable to removal by routine handwashing with plain soap & water • Are organisms most frequently https://commons.wikimedia.org/wiki/File:Stethoscope_and_Laptop_Computer_-_Nci-vol-9713-300.jpg associated with HAI https://www.flickr.com/photos/82066314@N06/9223190460

Resident Flora Hand Hygiene Agents https://www.flickr.com/photos/usdagov/7008312299 • Plain (non-antimicrobial) soap • Attached to deeper skin layers • Alcohols • Chlorhexidine • Iodine & iodophors • More resistant to removal See RR#1: Appendix • PCMX (Chloroxylenol) “Antimicrobial Spectrum & • Less likely to be associated with HAI Characteristics • Hexachlorophene of Hand-Hygiene Antiseptic • Examples: coagulase (-) Staph & • Triclosan Agents” diptheroids • Quaternary ammonium compounds

4 Special Complicated Issue Situations • New terms RR#1 • None of the these agents are reliably • Old practices may no longer be sound sporicidal (Bacillus or Clostridium) • Need to change how people do things • Hands contaminated with B. anthracis or C. difficile-contaminated items should be • Need to substantiate claims with washed with a non-antimicrobial or studies antimicrobial soap & water • Involves patient, staff, & visitor safety https://en.wikipedia.org/wiki/Agar_plate

Excuses for Not Using Water Vs. Waterless Washing Hands

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images& • Not enough time cd=&cad=rja&uact=8&ved=0ahUKEwjc5f38- MLKAhULzGMKHVtQCg8QjRwIBw&url=https%3A%2F%2Fwww.flick r.com%2Fphotos%2Fcolalife%2F9362442935&psig=AFQjCNGpVWd • Emergency ki6Z6U3i2Er6YhFwAx28R9A&ust=1453741955454222 • No soap • No water • “I was wearing gloves” • “I’m not going to touch anything” http://www.ijccm.org/articles/2011/15/1/images/IJCCM_2 011_15_1_6_78215_f12.jpg

Hygienic Handrub Handwashing with Alcohol Base • Suboptimal compliance by HCWs • Used only in program with sustained improvement in hand hygiene compliance • Location of sink may be a barrier &  infection rates • Time factor • More convenient from excellent spreading & evaporation • Effects on skin- PH, lipid content, • No water necessary across skin water loss, • Optimal action: bacteria, fungi, viruses, yeasts https://commons.wikimedia.org/wiki/File:Wall- microbial shedding • Rapid acting mounted_hand_sanitizer_dispenser.JPG • Preferred method to decontaminate hands**** https://en.wikipedia.org/wiki/Hand_washing

5 How to Clean without Water How to Wash with Soap (hygienic hand rub) & Water – wet hands . Spread recommended amount into palm of one hand – soap up . Rub thoroughly over all surfaces until – wash for 15 seconds hands dry – vigorously rub all surfaces . Not recommended when hands soiled with – rinse organic material Category IB Recommendation – dry . Wash with soap & water after 5-10 times https://www.flickr.com/photos/arlingtonva/4314530838

Category Recommendations Category IA • IA = strongly recommended for • If hands NOT visibly soiled, use alcohol- implementation & strongly supported based hand rub for routinely decontaminating by well-designed studies hands in all clinical situations*** • Decontaminate hands after contact with body • IB = strongly recommended for fluids, excretions, mucous membranes, non- implementation & supported by some intact skin, & wound dressings studies & strong theoretical rationale • Exceptions: spore-contamination, visibly • 1C, II & No Recommendation: soiled Unresolved Issue ***= very important

Category 1A Category 1A

https://www.flickr.com/photos/colalife/9362442935 As part of multi-disciplinary program to improve hand hygiene adherence, provide • To improve hand hygiene adherence HCWs with a readily-accessible alcohol- among personnel, make alcohol- based hand-rub product based hand rub available at the entrance to the patient’s room or at the bedside, other convenient locations, & in individual pocket-sized Should NOT be containers to be carried by HCWs. placed near sink

6 Category 1A Category 1A

• If hands visibly dirty or contaminated with • Do NOT add soap to a partially empty proteinaceous material or visibly soiled soap dispenser with blood or other body fluid, wash hands with either a non-antimicrobial soap and • “topping off” can lead to bacterial water or an antimicrobial soap & water contamination of soap

DO NOT “top off”

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Lotions Category IA • Provide HCWs with hand lotions or https://www.flickr.com/photos/gezellig-girl/6261193918 creams to minimize the occurrence of • Lotions protect hands from cracking irritant contact dermatitis associated with • When hands are cracked, don’t get washed hand antisepsis or handwashing as often • Some protective qualities with lotions https://en.wikipedia.org/wiki/Lotion • Some petroleum-based ingredients in lotions can damage integrity of latex gloves

Artificial Nails Category IA https://commons.wikimedia.org/wiki/File:Tipsy.jpg Do NOT wear artificial fingernails or • More likely to harbor gram (-) organisms extenders when having direct contact with • Traced to outbreaks of infection in neonatal patients at high risk (e.g., intensive care intensive care units & others units, operating rooms) • Chipped nail polish may support growth of  #’s of organisms on fingernails https://www.flickr.com/photos/soaringbird/7341346614

7 Surgical Hand Antisepsis Category IB • Bacteria on hands can cause wound • Scrub hands & forearms for length of time infections recommended by manufacturer (2-6 • Bacteria multiply rapidly on gloved minutes) hands with plain soap • 5 minutes as effective as 10 • Long scrub times (10 minutes) are NOT necessary • 2-stage scrubs as effective as 5 minute antiseptic scrub • Brushes can damage skin & increase shedding of bacteria from hands

Why Wash After Removing Monitoring Compliance Gloves?

• Temperature warm on gloved hands • Moisture on gloved hands • Bacteria rapidly grow in such conditions • Gloves may tear

Category 1A Monitor HCWs’ adherence with recommended hand-hygiene practices & provide personnel with information regarding their performance

https://en.wikipedia.org/wiki/Doctor%E2%80%93patient_relationship