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J Wound Ostomy Continence Nurs. 2012;39(2S):S30-S34.

Published by Lippincott Williams & Wilkins

Clean vs. Sterile Dressing


Techniques for Management
of Chronic Wounds
A Fact Sheet

Definition of terms

exist. Terms have been used interchangeably and all are


subject to individual interpretation. The following definitions provide a point of reference for the terms used in
this document.
Sterile technique. Sterile is generally defined as
meaning free from microorganisms.3 Sterile technique involves strategies used in patient care to reduce exposure to
microorganisms and maintain objects and areas as free
from microorganisms as possible. Sterile technique involves meticulous hand washing, use of a sterile field, use
of sterile gloves for application of a sterile dressing, and
use of sterile instruments. Sterile to sterile rules involve
the use of only sterile instruments and materials in dressing change procedures; and avoiding contact between
sterile instruments or materials and any non-sterile surface or products. Sterile technique is considered most appropriate in acute care hospital settings, for patients at
high risk for infection, and for certain procedures such as
sharp instrumental wound debridement.3-5
Clean technique. Clean means free of dirt, marks, or
stains.3 Clean technique involves strategies used in patient
care to reduce the overall number of microorganisms or to
prevent or reduce the risk of transmission of microorganisms from one person to another or from one place to another. Clean technique involves meticulous handwashing,
maintaining a clean environment by preparing a clean
field, using clean gloves and sterile instruments, and preventing direct contamination of materials and supplies.
No sterile to sterile rules apply. This technique may also
be referred to as non-sterile. Clean technique is considered
most appropriate for long-term care, home care, and some
clinic settings; for patients who are not at high risk for
infection; and for patients receiving routine dressings for
chronic wounds such as venous ulcers, or wounds healing
by secondary intention with granulation tissue.1-7
Aseptic technique. Asepsis or aseptic means free
from pathogenic microorganisms.3 Aseptic technique is

Clean versus sterile technique. Various definitions


and descriptions of dressing technique for wound care

DOI: 10.1097/WON.0b013e3182478e06

Originated By:
Wound, Ostomy and Continence Nurses Society (WOCN)
Wound Committee and the Association for Professionals
in Infection Control and Epidemiology, Inc. (APIC) 2000
Guidelines Committee
Updated/Revised: WOCN Wound Committee, 2011
Date Completed:
Original Publication Date: 2001
Review/Update: 2005
Revised: 2011

Purpose
To present an update on the status of information about
clean versus sterile dressing technique to manage chronic
wounds.

Background/History
This document originated in 2001 as a joint position statement from a collaborative effort of the Wound, Ostomy and
Continence Nurses Society and the Association for
Professionals in Infection Control and Epidemiology, Inc.1,2
Its purpose was to review the evidence about clean vs. sterile technique and present approaches for chronic wound
care management. Then as now, areas of controversy exist
due to a lack of agreement on the definitions of clean and
sterile technique, lack of consensus as to when each is
indicated in the management of chronic wounds, and lack
of research to serve as a guide. Wound care practices are
extremely variable and are frequently based on rituals and
traditions as opposed to a scientific foundation.

Discussion of Problems/Issue/Needs

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the purposeful prevention of the transfer of organisms


from one person to another by keeping the microbe count
to an irreducible minimum. Some authors have made a
distinction between surgical asepsis or sterile technique
used in surgery and medical asepsis or clean technique
that involves procedures to reduce the number and transmission of pathogens.4
No touch technique. No touch is a method of changing surface dressings without directly touching the wound
or any surface that might come in contact with the wound.
Clean gloves are used along with sterile solution/supplies/
dressings that are maintained as clean.8
Definition of infection. Infection has been defined
as a continuum from contamination, colonization, critical
colonization, biofilm, and infection.9
Contamination. Contamination is the presence of
non-replicating microorganisms on the surface of the
wound. All open wounds have some level of bacterial burden that is ordinarily cleared by the host.9-11
Colonization. In colonization, microorganisms attach to the wound surface and replicate but do not impair
healing or cause signs and/or symptoms of infection. The
bacteria are not pathogenic and do not require treatment.
All chronic wounds are colonized to varying degrees.9
Critical colonization. With critical colonization,
the organisms attach to the wound surface, replicate and
multiply to a level that affects skin cell proliferation and
tissue repair without provoking systemic signs of infection. There is no invasion of the healthy tissue at this
point.9
Biofilm. Approximately 70% of chronic wounds have
biofilm.9 When organisms adhere to the wound surface,
they begin to develop biofilm, which is a complex system
of microorganisms embedded in an extracellular, polysaccharide matrix that protects from the invasion of other
organisms, phagocytosis, and many commonly used antibiotics and antiseptics. Biofilms are difficult to treat and
eradicate.9 Recently it has been proposed that biofilm
might be present in all chronic wounds.12,13
Infection. Infection occurs when organisms on the
wound surface invade the healthy tissue, reproduce, overwhelm the host resistance, and create cellular injury leading to local or systemic symptoms.9,14 Infection is often
described quantitatively as a bacterial count of greater
than 105 colony-forming units (CFU) per gram of tissue.9
However, some organisms such as beta-hemolytic streptococci impair wound healing at less than 105 CFU per gram
of tissue.15 According to Kravitz,16 infection should be defined as the presence of bacteria in any quantity that impairs wound healing.
Clinical signs of infection include lack of healing after
2 weeks of proper topical therapy, erythema, increase in
amount or change in character of exudate, odor, increased
local warmth, friable granulation tissue, edema or induration, pain or tenderness, fever, chills, elevated white blood
cell count, and elevated glucose in patients with diabetes.9

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In patients who are immunosuppressed or have ischemic


wounds, signs of infection can be subtle. Signs of inflammation such as a faint halo of erythema and moderate
amounts of drainage might be the only signs of an infected arterial wound.17 Studies have shown that in
chronic wounds, increasing pain, friable granulation tissue, wound breakdown, and foul odor have high validity
for infection.17,18

Definition of Wounds
Wound. A wound is any break in the skin that can
vary from a superficial to a full thickness wound. A partial
thickness wound is confined to loss of the epidermis and
partial loss of the dermis; whereas a full thickness wound
has a total loss of the epidermis and dermis and can involve the deeper subcutaneous and muscle tissues and/or
bone.19,20
Acute wound. Acute wounds occur suddenly and are
commonly due to trauma or surgery, which triggers blood
clotting and a wound repair process that leads to wound
closure within 2-4 weeks.14,19
Chronic wound. A chronic wound is a one that does
not does not proceed through an orderly and timely repair
process requiring more than 4 weeks to heal such as vascular wounds and pressure wounds.14,19
Surgical wound. A surgical wound that heals in an
orderly and expected fashion may be considered an acute
wound. Surgical wounds heal by primary closure or are left
open for delayed primary closure or healing by secondary
closure. Primary closure facilitates the fastest healing.
However, infected wounds should not be primarily closed.21

Gaps in Research Practice


There is no definitive evidence that sterile technique is
superior to clean technique, improves outcomes, or is warranted when changing dressings on chronic wounds.8
Insufficient evidence is available to determine if there are
significant differences in infection rates or healing when
wounds are treated using clean or sterile technique.14
There is a lack of agreement in published expert opinion
as to what constitutes sterile versus non-sterile technique
and when one or the other should be used.

Overview of Research/Published
Expert Opinion
Few national guidelines have addressed the topic of clean
vs. sterile technique. Sterile technique and dressings have
been recommended for post-operative management of
wounds for 24-48 hours by the Centers for Disease Control
and Prevention.22 No recommendations are provided beyond 48 hours for wounds with primary closure.22,23
In 1994, clinical practice guidelines for pressure ulcer
treatment, published by the Agency for Health Care Policy
and Research, recommended use of clean gloves and clean

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dressings for pressure ulcers as long as the dressing procedures complied with the institutions policies.24 Sterile
instruments were recommended for debridement. Recent
guidelines for pressure ulcers have not addressed specifics
of clean or sterile technique other than to state that
tap water or potable water can be used to clean pressure
ulcers and that sterile instruments are needed for sharp
debridement.25
There is a paucity of research about clean vs. sterile
technique for wound care and studies have varied greatly
in their design and findings. Angeras, Brandberg, Falk, and
Seeman26 compared the use of sterile saline or tap water
for cleaning acute traumatic soft tissue wounds and found
that the infection rate in the tap water group was 5.4%
compared to 10.3% in the group using sterile saline (p .05)
with a 50% decrease in costs for the tap water group.
Two studies examined the strike through contamination in saturated sterile dressings. Alexander, Gannage,
Nichols, and Gaskins27 reported that when gauze sponges
were saturated directly in their wrapper, that contamination occurred in 100% of sponges in uncoated wrappers.
In the coated wrapped sponges, 80% exposed to
Staphylococcus epidermidis and 20% exposed to
Escherichia coli had strike through. In another study, cultures were taken from gauze sponges that were saturated
directly on their wrappers on hospital over-bed tables of
postoperative surgical patients.28 The saturated gauze
showed significant growth of microorganisms. The authors reported there was no significant difference in strikethrough contamination in gauze saturated on coated or
uncoated wrappers. Investigators in both these studies
concluded that the practice of saturating gauze sponges on
their wrappers was unacceptable.
In 1993, Stotts and colleagues conducted a descriptive,
exploratory survey of members of WOCN to obtain information regarding wound care practices in the United
States.29 Two hundred and forty-two (242) members responded to the survey. Of the respondents, 51.4% reported
use of sterile technique and 43% reported use of non-sterile technique. Sterile technique was performed more frequently in acute care than in other settings. It was also
reported that 90% of patients with open wounds being
discharged from hospitals were taught to perform nonsterile technique at home regardless of whether clean or
sterile technique was used during hospitalization.
In 1997, Stotts and colleagues compared the healing
rates and costs of sterile vs. clean technique in post-operative patients (N 30) who had wounds healing by secondary intentions following gastrointestinal surgery.30
The authors reported there was no statistically significant
difference in the rate of wound healing between the two
groups (p 0.55). The cost however was significantly
higher with sterile technique (p .05) compared with
clean technique.
Also, in 1997, Wise, Hoffman, Grant, and Bostrom surveyed staff nurses (N 723) in five health care agencies

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about the use of sterile vs. non-sterile gloves for wound


care.31 The authors reported great variations in practice and
that acute care nurses used sterile gloves for wound care
more commonly than home care nurses. In acute care, sterile gloves were used more than non-sterile for packing
wounds, in cases of purulence or tunneling, or for open
orthopedic wounds. Clean gloves were used for dressing
changes of intact surgical wounds and pressure ulcers. In
home care, non-sterile gloves were commonly used except
for open orthopedic wounds (i.e., exposed bone/tendon).
Three factors that were identified as the most influential in
glove choice were type of wound, exposed bone, and immunosuppression. Some of the other factors affecting glove
choice included type of dressing, type of drainage, time
since surgery, licensure (i.e., registered nurse vs. licensed
vocational nurse), agency policy, physician preference, and
what they were taught in school.
Lawson, Juliano, and Ratliff32 in a non-experimental,
longitudinal study monitored infection rates and supply
costs of all patients with open surgical wounds healing by
secondary intention before and 3 months after implementing non-sterile wound care. There was no statistically
significant difference in infection rates. Dressing costs and
time to perform the wound care were reduced using nonsterile dressing techniques (i.e., staff did not use sterile
gloves, scissors, or bowls).
In 2006, Fellows and Crestodina reported that the optimal cleansing agent for wound cleaning should be sterile, noncytotoxic, and inexpensive.33 Because of the cost
of sterile saline and reluctance of patients to discard unused solutions, Fellows and Crestodina conducted a small,
quasi-experimental study in a home health setting to
compare the bacterial content of home prepared saline
made with distilled water and stored at room temperature
(2 gallons) to saline stored in a refrigerator (2 gallons).
Based on cultures of the solutions immediately following
preparation and at weekly intervals for 4 weeks, the authors concluded that saline solution prepared by patients
by adding table salt to distilled water (purchased from a
grocery store) remained bacteria free for a month if refrigerated. The saline kept at room temperature had undesirable levels of bacteria after 2 weeks. The authors
recommended further studies to confirm their findings.
An integrative literature review of seven published
studies of clean and sterile technique for dressings revealed that while there is a lack of consensus about the
benefit of clean versus sterile technique to improve healing or infection rates, clean technique results in lower
costs.5

Conclusions
There is not a consensus of expert opinion on the use of
clean or sterile dressing technique in the management of
chronic wounds. Research is limited and inconclusive
about value of clean or sterile in healing outcomes. Limited

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evidence indicates clean technique reduces costs and


might require less time to perform.
Wound care is provided in a variety of patient care settings including acute care, sub-acute care, long-term care,
outpatient clinics, and in the home. The question arises:
Should a different technique be utilized in the delivery of
wound care based on the health care setting? Decisions
made about the type of technique to be used may be more
reasonably based on what will be done to the wound,
rather than where or to whom the care is delivered.1,2
Other factors that may influence the technique are the
status/acuity of the patient, the health care setting, and
type of caregiver.31 For instance, a frail, elderly patient who
is receiving immunosuppressant drugs who has a large,
full thickness, sternal wound receiving daily dressing
changes might benefit from sterile technique. A middleaged patient who was in an automobile accident and subsequently developed a non-infected, Stage III pressure
ulcer treated with hydrocolloid dressings, changed every
3-4 days, might be adequately managed using clean
technique. There is no scientific evidence or consensus
that any one of these conditions is more or less important
in selecting the appropriate method of care for the wound.
It has been suggested that an assessment of patients risk
for infection is an important factor in choosing the type
of technique.3,34

Recommendations
Recommendations for Practice: Considerations for
Clean Versus Sterile Technique
1. The following factors should be considered when
planning and selecting dressing technique for
chronic wound care.2,34
a. Patient factors, immune status, acute vs. chronic
wound.
b. Type, location, and depth of the wound.

c. Invasiveness of wound care procedure.


How invasive is the procedure?
Is debridement to be performed?
Does the procedure involve changing a simple
transparent film or hydrocolloid dressing or
extensive packing of the wound?
d. Health care setting.
Who will be doing the wound care?
What is the environment in which the care
will be delivered?
e. Selection/use of supplies/instruments.
Use and maintenance may be based on likelihood of exposure to organisms in the care setting.
What is clean, what is sterile, and what is contaminated?
Keep items apart by using no touch technique.
f. Solutions for cleansing/treatment.
Initially, solutions such as commercially prepared
wound cleansers and normal saline are sterile.
The shelf life of solutions once they are opened
is based on manufacturers recommendations
and the policy of the health care institution
providing the care. No definitive scientific evidence exists to guide the policies of the health
care institution.
2. The Table addresses dressing technique for chronic
wounds.1,2,35

Recommendation for Education


Health care facilities should develop policies and educational programs for staff to enhance understanding and
principles of asepsis, choosing and criteria for performing
clean or sterile technique.

Recommendation for Research


Research is needed to provide an evidence-basis to support
either clean or sterile dressing technique to manage

TABLE.

Suggested Dressing Technique for the Management of Chronic Wounds


Supplies (Includes Solutions
and Dressing Supplies)

Instruments

Clean

Normal saline or commercially prepared


wound cleanser
Sterile, maintain as clean per policy*

Irrigate with sterile device;


maintain as clean per
policy*

Yes

Clean

Sterile, maintain as clean per policy*

Sterile; maintain as clean


per policy*

Dressing Change with Mechanical,


Chemical, or Enzymatic Debridement

Yes

Clean

Sterile, maintain as clean per policy*

Sterile; maintain as clean


per policy*

Dressing Change with Sharp


Conservative Bedside Debridement

Yes

Sterile

Sterile

Sterile

Intervention

Hand Washing

Gloves

Wound Cleansing

Yes

Routine Dressing Change without


Debridement

*Maintain clean per policy means that each health care setting must establish policies that address the parameters for use/maintenance of supplies/solutions,
taking into consideration such factors as expiration dates, costs, and manufacturers recommendations.

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chronic wounds. Continued research is needed that examines patient outcomes in terms of healing, infection rates,
and costs of clean vs. sterile techniques. Studies should
clearly describe methods and supplies used for clean or
sterile technique. Large multi-site, randomized studies
across health care settings are needed to insure appropriate patient outcomes are achieved in a cost effective manner that does not compromise patient safety.

References
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Date Approved by the WOCN Society Board of Directors:


September 27, 2011

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