Aseptic Technique Policy and Procedure

Transcription

1 Aseptic Technique Policy and Procedure Authorising Officer Tom Cahill, Deputy Chief Executive Signature of Authorising Officer: Version: V2 Ratified By: Risk Management and Patient Safety Group Date Ratified: 28 th January 2009 Name of originator/author: Infection Control Team Name of responsible committee/lead Infection Control Committee individual: Date issued: March 2009 Review date: April 2011 Summary: This policy sets out the indications, principles and procedure for aseptic technique Target audience: These guidelines are applicable to all Hertfordshire Partnership NHS Foundation Trust direct care staff. Hertfordshire Partnership NHS Foundation Trust is committed to providing an environment where all staff, service users and carers enjoy equality of opportunity. The Trust works to eliminate all forms of discrimination and recognise that this requires, not only a commitment to remove discrimination, but also action through positive policies to redress inequalities. Providing equality of opportunity means understanding and appreciating the diversity of our staff, service users & carers and ensuring a supportive environment free from harassment. Because of this Hertfordshire Partnership NHS Foundation Trust actively encourages its staff to challenge discrimination and promote equality of opportunity for all. Page 1 of 9 Hertfordshire Partnership NHS Foundation Trust March 2009

2 Version Control Version Date Author Status Comment V1 Dec 07 D Pinkney Superseded V2 March 2009 D Pinkney Current V1 reviewed with minor changes. Agreed Lead Nurse Strategy group and ICC This policy links to the National Health Litigation Authority Risk Management Standard 4 Clinical Care April 2008 Level 1.4.9/2.4.9 The organisation has approved documentation which describes the process for managing the risks associated with infection prevention and control can demonstrate compliance with the objectives set out within the approved documentation. 2. The guidance meets the Health Act 2006 (revised January 2008) Code of Practice Section Clinical Care Protocols - Duty to adhere to policies and protocols applicable to infection prevention and control An NHS body must, in relation to preventing and controlling the risks of HCAIs, have in place the appropriate core policies concerning: Aseptic technique This document was circulated for comments to: Infection Control Committee and associated teams Members of the Lead Nurse Strategy Group Page 2 of 9 Hertfordshire Partnership NHS Foundation Trust March 2009

3 Contents 1. Introduction 4 2. Purpose 4 3. Indications of using Aseptic technique 4 4. Principles of Aseptic Technique 4 5. Procedure for Aseptic Technique 5 6. Clean Procedure 5 7. Indication of using a Clean procedure 5 8. Principles of a Clean Procedure 5 9 Training and Maintenance of Competencies Responsibilities Process for reviewing, approving and archiving this document Process for Monitoring Compliance with the Policy Dissemination, Implementation and Access to this document References Associated Documentation 8 Equality Impact Assessment 9 Page 3 of 9 Hertfordshire Partnership NHS Foundation Trust March 2009

4 1. Introduction This policy and procedure sets out the Trust requirements managing the risks associated with infection prevention and control through the use of aseptic technique procedures as required by the Health Act 2006 (revised January 2008) Code of Practice for the Prevention and Control of Healthcare Associated Infections. 2. Purpose The aseptic technique is often performed as a nursing ritual and is based more on tradition than on rational reason or research evidence. It is often performed without reference to the underlying principles of infection control or to the requirements of the situation to which it is being applied (Walsh and Ford, 1989). The aims of aseptic technique are To prevent the introduction of pathogens to the wound To prevent the transfer of bacteria from one service user to another To prevent staff from acquiring infection from the service user. The important principles are that the open wound should not come into contact with any item that is not sterile and that any items that have been in contact with the wound may be contaminated and should be discarded safely or decontaminated appropriately. 3. Indications of using aseptic technique The policy and procedure must be followed by all healthcare professionals involved in: Wounds healing by primary intention (before surface skin has sealed) Intravenous cannulation Urinary catheterization Suturing Vaginal examination during labour Medical invasive procedure. 4. Principles of Aseptic Technique Ensure that all equipment required is readily available and there is a clear field in which to carry out the procedure 1. Explain the procedure to the service user, obtain verbal consent and position the service user so that the procedure can be performed easily 2. Wash hands or disinfect clean hands with an alcohol handrub 3. Open the sterile pack, taking care not to contaminate the contents 4. Wear sterile gloves for the procedure to prevent introducing pathogenic bacteria to the sited, direct contact with body fluids and cross infection Page 4 of 9 Hertfordshire Partnership NHS Foundation Trust March 2009

5 5. Use aseptic principles to Ensure that only sterile items come into contact with the susceptible site Sterile items do not come into contact with non-sterile objects 6. After completion of the procedure, waste that has been contaminated with blood and other body fluids must be discarded into a yellow clinical waste bag. 7. Any sharps must be placed into an appropriate sharps container. 8. All protective clothing must be discarded into the clinical waste bag. 9. Wash hands effectively. (Adapted from Riverside Health Authority nursing procedures) 5. Procedure for Aseptic Technique The criteria to be followed is that set out in Chapter 4, Aseptic Technique of the Royal Marsden Hospital Manual of Clinical Nursing Procedures, available on the staff website. 6. Clean Procedure In many situations a modified aseptic or clean technique is more appropriate, for example, during the application of a dressing to a wound that is healing by secondary intention. Secondary intention is a description of healing in wounds when there is tissue loss and the gap must be gradually filled from the base by new tissue. These types of wounds are often referred to as chronic wounds and include ulcers, pressure sores and burns. These types of wounds are likely to contain large numbers of different bacterial species and will frequently be exposed to new bacteria from the environment. The aim of this procedure is to ensure that potential pathogens are not transferred to another service user or member of staff 7. Indications of using the clean procedure Dressing of wounds healing by secondary intention Removal of sutures Dressing intravenous lines Removal of drains Endotracheal suction Dressing tracheotomy site. 8. Principles of a Clean Procedure 1. Ensure that all equipment required is ready and that a clean area on which to place it is available. 2. Explain the procedure to the service user and obtain their verbal consent. 3. Position the service user so that the procedure can be performed easily Page 5 of 9 Hertfordshire Partnership NHS Foundation Trust March 2009

6 4. Wash hands and disinfect with alcohol handrub. 5. If direct contact with blood or body fluid is anticipated, gloves and a plastic apron must be worn 6. Use sterile swabs to clean the site and apply a sterile dressing 7. Avoid touching any clean area whilst performing the procedure. 8. On completion of the procedure, all clinical waste must be disposed of into a yellow clinical waste bag. This includes gloves and aprons 9. Effective hand hygiene must be implemented. 9. Training and Maintenance of Competencies The competencies required for effective infection control must be obtained and maintained by attending the relevant infection control training and following Trust infection control policy and procedure as set out in section 4 and 5. Ward Managers must ensure that new employed registered nurses are made aware of Trust infection control procedures during induction. Clinical training requirements and updates should be agreed during supervision. Infection Control Link nurses ensures that the nursing team is kept up-to-date with Trust infection control requirements. 10. Responsibilities The organizational responsibilities for infection control within the Trust are set out in the Management of Infection Prevention & Control Policy. Line Managers Line Managers are responsible for ensuring all staff undertake infection control induction training and updates as identified in the Trust Training Needs Analysis, local compliance with the Aseptic Technique Policy and Procedure, and attendance at audit and link personnel meetings when required. Healthcare Professionals All healthcare professionals are required to promote infection control and encourage colleagues and other Trust users to use good practice. To prevent and control the spread of infection all healthcare professionals who carry out aseptic technique are expected to: Read, understand and comply with the Trust s Aseptic Technique Policy and Procedure Assist in raising the awareness of other HCW s of the importance of effective aseptic technique and adherence to the Trust s Aseptic Technique Policy and Procedure. Page 6 of 9 Hertfordshire Partnership NHS Foundation Trust March 2009

7 Attend training in relation to aseptic technique. Comply with the requirements of their code of conduct. 11. Process for reviewing, approving and archiving this document This document will be reviewed annually or whenever national policy or guideline changes are required to be considered (whichever occurs first) by the author, following which it will be subject to re-ratification. 12. Process for Monitoring Compliance with the Policy The Aseptic Technique Policy and Procedure will be monitored for compliance through the Trust infection and control monitoring and reporting arrangements via the Infection Control Link Nurses, the Infection Control Team and the Infection Control Committee. 13. Dissemination, Implementation and Access to this document 13.1 This policy is disseminated throughout the Trust following ratification via the policy guardians and is published on the HPFT staff website. Access to this document is open to all via the Trust public website Infection control link persons are responsible in conjunction with the ward/team manager for the dissemination of infection control information and other duties with regard to the implementation of infection control policies and procedures. For medical staff this responsibility lies with the supervising clinician. 14. References Riverside Health Authority Nursing procedures Royal Marsden Hospital Manual of Clinical Nursing Procedures (7 th edition), 2008 Walsh M, Ford P (1989) Nursing Rituals, Research and Rational Actions. Butterworkth-Heinemann, Oxford Wilson J (1995) Infection Control in Clinical Practice, Bailliere Tindall, p Associated documentation This policy should be used in conjunction with the following Hertfordshire Partnership NHS Foundation Trust Infection Control policies all of which are available on the HPFT staff website: Hand hygiene Standard infection control precautions Decontamination Handling and Disposal of Waste Management of Infection Prevention & Control Policy Management Of Needlestick Injuries And Incidents Involving Exposure To Blood And Body Fluids Page 7 of 9 Hertfordshire Partnership NHS Foundation Trust March 2009

8 Stage One - Equality Impact Assessment Policy or service being assessed: Aseptic Technique Lead Person: Debbie Pinkney, Infection Control Team 1. Is this a new or existing policy or service? 2. What is the expected outcome of the service/policy (e.g. aims, objectives and purpose of the service/policy, standards for practice) 3. Does this policy/service link to others. If yes please state link below: Links to the following infection control policies Hand hygiene Standard infection control precautions Decontamination Sharps Waste 4. Who is intended to benefit from the policy/service: In what way. 5. How is the policy/service to be put into practice. Who is responsible. 6. How and where is information about the policy/service publicised? 7. What regular consultation do you carry out with different communities and groups re the policy/service? 8. Are there concerns that the policy/service could have an adverse impact* because of: Age Disability Gender Ethnicity Sexual Orientation Religion/Belief 9. If YES to one or more of the above please state evidence. 10. Do the differences amount to discrimination?* 11. If YES could it still be justifiable e.g. on grounds of promoting equality of opportunity for one group? New: Existing: Effective prevention and control of Healthcare Acquired Infection has to be embedded into everyday practice and applied consistently by everyone. Yes: No: Service users and staff of HPFT are protected by infection control procedures during wound management. Responsibility for and implementation by the nursing team. Via infection control training for staff and on the Trust website which also publicises the HPFT Infection Control Plan. No regular consultation. The plan follows the government strategy on the protection of the community from healthcare acquired infection. Yes: No: N/A Yes: Yes: No: N/A No: N/A Page 8 of 9 Hertfordshire Partnership NHS Foundation Trust March 2009

9 I.e. Indirect discrimination can be justifiable sometimes when a service is being provided for a particular target group E.g. Asian women s breast screening, Gay men s sexual health clinic, MHSOP etc. If Yes: Please give reasons below: N/A 12. Do you think this policy/service specifically contributes to promoting equality and diversity in Hertfordshire? If so, in what way? Please note any examples of good practice. 13. What approaches will you take to get feedback on your assessment? 14. How will the assessment link to other mainstream service planning or review processes? 15. Should there now be a Full Impact Assessment and if so what are the reasons? 16. What further data or information do you need to carry out a full assessment? 17. Do you need any additional assistance to help you carry out the full assessment? Yes/No The policy does not specifically promote equality and diversity. Feedback obtained from the HPFT EIA Scrutiny group. This policy is a requirement of The Health Act, Code of Practice for the Prevention and Control of Health Care Associated Infections. The Department of Health and links to the HPFT Infection control plan. No evidence that a full impact assessment is required. N/A N/A 18. Date of assessment: October 2007 Agreed by the HPT Equality Impact Assessment Scrutiny Group Page 9 of 9 Hertfordshire Partnership NHS Foundation Trust March 2009