St Mark's IF with AuSPEN 30 - 31 October 2015

1. Aseptic Technique: Sue Larsen, CNS- Auckland
• Acknowledgment - St Mark’s Intestinal Course

2. Introduction
 Discuss what is meant by an
aseptic technique and how it
should be performed
 Present the evidence base
surrounding key aspects of an
aseptic technique for the care of
central venous catheters

3. What is an aseptic
technique?

4. Asepsis
 “The absence of pathogenic
organisms or their toxins from
the blood or tissues” Wilson J (1995)
Infection Control in Clinical Practice. Bailliere Tindall, London
 Difficult to achieve
 Pathogenic organisms are present in
many different areas of the body

5. Techniques: definitions
Aseptic
• Necessary
infection control
measures to
prevent
pathogenic micro-
organisms on
hands, surfaces or
equipment from
being introduced
into susceptible
sites during clinical
practice
Clean
• A method involving
hand
decontamination,
maintaining a
clean environment,
clean non-sterile
gloves, sterile
instruments and
prevention of
direct
contamination of
materials and
supplies
No touch
• A method of
manipulation of
invasive devices or
wounds without
directly touching
the wound, device,
or any surfaces
that may come
into contact with
those sites
Dougherty et al (2010) Association for Professionals in Infection Control and Epidemiology (2001)

6. Aseptic Non Touch Technique
Peer reviewed & tested clinical guidelines
 Basic infection prevention & control principles
Aim to standardize & improve the efficacy of the aseptic technique
thereby reducing healthcare associated infections
 Standard or Surgical depending on length & complexity of procedure
Rowley (1994, 2004)

7. Aseptic technique: The evidence base
 No clinical or economic evidence
that any one approach is more
clinically or cost-effective than
another
 All recommendations are Class
D/GPP Loveday et al (2014)
Loveday et al (2014) UK Department of Health epic3: National Evidence-based guidelines for
preventing healthcare-associated infections. J Hosp Infect;86:S1–70

8. What technique would you
recommend for parenteral
nutrition?

9. Standard ANTT
 Technically uncomplicated
procedures
 < 20 minutes in length
 Involves small key sites
 Minimal key parts
Surgical ANTT
 Technically complicated
procedures
 > 20 minutes in length
 Involves large open key sites
 Large or numerous key sites
Principles are the same. The main difference is the
complexity of the aseptic field and how it is managed
Rowley & Clare (2011)

10. Key sites in CVC care

11. Should the technique be
standardised?

12. Current position  The technique should be
standardized across the
organisation Health and Social
Care Act, Department of Health
(2008)
 A standardised procedure for
parenteral nutrition is lacking
 Confusing for patients & staff
 Could impact upon efficacy
 Biggest impact on home care
nursing

14. Which elements of
central venous catheter
care are evidence-
based?

15. • Fendler et al (2002), Pittet et al (2000)Hand
decontamination*
• Kaler & Chin (2007), Simmons et al (2011)Disinfectant/method/
time for CVC hubs*
• Sweet et al (2012), Wright et al (2013)70% IPA port
protection*
• Calop et al (2000), Worthington et al (2010)Prefilled syringes
• Mitchell et al (2009), Schallom et al (2012)Flushing solution*
Evidence based elements of CVC care
Loveday et al (2014) UK Department of Health epic3: National Evidence-based guidelines for
preventing healthcare-associated infections. J Hosp Infect;86:S1–70

16. CVC hub disinfection
 Single use 2% CHG & 70% IPA
 Minimum of 15 seconds
 Mechanical friction
 Allow to dry for at least 30
seconds
Loveday et al (2014) UK Department of Health epic3: National Evidence-based
guidelines for preventing healthcare-associated infections. J Hosp Infect;86:S1–70

17. Aspects of catheter care
Aspect of catheter care Number of procedures (%)
Disinfection time/method/dry time*
No disinfection time/method/dry time
3 (8%)
6 (17%)
Flushing solution
0.9% sodium chloride for injection *
0.9% sodium chloride + heparinised saline
Heparinised saline only
Prefilled syringe*
21 (60%)
13 (38%)
1 (2%)
21(60%)
Glove type
Sterile
Non sterile
Not specified
None
29 (83%)
2 (6%)
3 (8%)
1 (3%)
Needle-free connector protection
Gauze & tape
70% IPA protector*
14 (40%)
13 (93%)
1 (7%)
* Evidence-based  Supported by national practice guidelines

18. 70% IPA port protection
 Single use protective cover with 70%
isopropyl alcohol foam disc
 Provides continuous passive
disinfection, plus a physical barrier to
cross contamination
 Initial studies promising in reducing
CRBSI Sweet et al (2012), Wright et
al (2013)
 ?if superior to active disinfection
 ?if equally effective on all brands of
needlefree connector
 ?if all brands equally effective
Added to Bionector ®
Curos® Port Protector with 70%
isopropyl alcohol disc
Alcohol disc passively disinfects
needlefree connector

19. Curos® evaluation in HPN patients
Phased introduction of Curos® to all HPN patients (n=285)
 Patients still to actively disinfect with 2% CHG & 70% IPA
 All patients using Vygon Bionector
Infection rates decreased at St Mark’s
Small (2014) Abstract
Infection pre Curos Infection post Curos P value
1.3/1000 CVC days 0.4/1000 CVC days <0.001

20. How can the efficacy of
an aseptic technique be
assessed?

21. Catheter related infection
 Monitoring catheter related infection is
an important outcome measure
 Differences in classifying infection
 Specifically catheter related bloodstream
infection (CRBSI) & central line associated
bloodstream infection (CLABSI)
 Availability of culturing methods, &
whether catheter tips are available for
analysis make direct comparison of
infection rates difficult

22. Assessing inter rater reliability
 Infection data for a calendar year were reviewed by 24 raters to
assess for variation and agreement with original classification of
CRBSI, CLABSI and non systemic infection
 12 raters classified the data on 2 occasions
 Large observed variation in practice
Small et al (2014) Abstract

23. The ideal procedure…
Focus on the principles of
asepsis rather than a step by
step list of instructions
Hospitals should incorporate
evidence based
recommendations into their
procedures