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The key to improving aseptic technique

Article · June 2011

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Stephen Rowley Simon Clare

The Association for Safe Aseptic Practice (The -ASAP) University College London Hospitals NHS Foundation Trust
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 The key to improving
aseptic technique
Asepsis, like apple pie, is universally accepted as ‘a good thing’, but
no one has thought to write down the recipe. Now, however, the
Aseptic Non Touch Technique has done just that and its adoption
has cut infection rates
A
sepsis, like apple pie, is universally ac-
cepted as ‘a good thing’, but no one
has thought to write down the recipe.
Now, however, the Aseptic Non Touch
Technique has done just that and its adoption has
cut infection rates
Standardising aseptic technique is fundamen-
tal to providing safe healthcare. However, histori-
cally, it is an area of practice that has lacked evi-
dence and guidance. As a result, aseptic practice
within healthcare organisations is often highly var-
iable, of poor quality and theoretically confused.
In contrast to these practical realities, patients
expect hospital environments and healthcare pro-
fessionals (HCP) to protect them from infection
during clinical procedures. Though, considering
the realities of processed, high-volume healthcare,
the hospital environment should perhaps be con-
sidered more of a threat than a protector, but still
less of a threat than the HCP. In this light, aseptic
technique should be acknowledged as the last line
of defence between patients and clinical staff and
often the main difference between infection and
no infection.
The Aseptic Non Touch Technique (ANTT)
initiative recognises this and has demonstrated
that reducing the variables in aseptic practice by
standardising practice across large workforces
improves standards of practice and subsequently
reduces infection rates. With a unique theory and
practice framework, ANTT presents the possibil-
ity of what was once thought impossible: namely,
European, auditable standards of practice in key
areas of aseptic practice.
Since 2003, the ANTT implementation ini-
tiative (www.antt.org.uk) has helped implement
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Clinical Nursing and Patient Care
ANTT into approximately half of acute NHS Stephen Rowley
hospitals and community organisations in Eng- ANTT Clinical Director (Eu-
land and in many internationally. This has been rope). Lead cancer nurse,
achieved through the origination and dissemina- University College London
tion of clinical guidelines and a standard and ro- Hospitals NHS Foundation
bust implementation process. Hospitals that have Trust, London
implemented ANTT robustly have reported im-
provements in practice that have helped reduce Simon Clare
rates of healthcare associated infection.1 Practice Development CNS,
University College London
An unhelpful paradigm Hospitals NHS Foundation
ANTT is a project that grew from dissatisfaction Trust, London
with the vagaries and contradictions of historical
practice, and a desire to give HCPs credible, peer-
reviewed guidelines that interpret the best evidence
available for aseptic management. ANTT rational-
ises a contemporary approach to aseptic practice,
rather than the historically hierarchal paradigm of
sterile, aseptic and clean techniques. This hierar-
chy of definitions has led to inaccurate and confus-
ing terminology surrounding poorly defined tech-
niques and practices that, in turn, has led to highly
variable and poor standards of practice.
The use of accurate terminology is fundamen-
tally important in defining practice and promot-
ing clarity of purpose. Breaking down this unhelp-
ful paradigm is the first step to understanding just
what it is healthcare professionals are doing in
their daily clinical practice.
Sterile defined as ‘free from micro-organisms’2
is not achievable in typical healthcare settings due
to the natural multitude of organisms in the atmos-
phere. It may be possible to achieve ‘near sterile’
techniques by the use of controlled environments
such as a laminar air flow cabinet or a specially
equipped theatre; but these are costly and untypi-
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 cal circumstances. The widely used term ‘sterile
technique’ – essentially the instruction to main-
tain sterility of equipment exposed to air – is ob-
viously not possible. Despite this, the term is still
often applied inaccurately and inappropriately to
clinical interventions.
In contrast, asepsis defined as ‘freedom from
infection or infectious (pathogenic) material’2
aims to prevent pathogenic organisms, in sufficient
quantity to cause infection, from being introduced
to susceptible sites by hands, surfaces and equip-
ment. Therefore, unlike sterile techniques, asep-
tic techniques are possible and can be achieved in
typical hospital and community settings.
The term clean is defined as ‘free from dirt,
marks or stains’.3 Although cleaning followed by
drying of equipment and surfaces can be very
effective, it doesn’t necessarily meet the quality
standard of asepsis.4 It is therefore not a useful
quality standard for ‘technique’ for invasive clini-
cal procures. However, the action of cleaning is an
important component in helping render equip-
ment and skin aseptic, especially when there are
high levels of contamination that require removal
or reduction.
“Asepsis is defined as
freedom from infection
or infectious material”
ANTT has rationalised these confusing terms
into an accurate, descriptive and achievable defini-
tion of aseptic practice that creates an ‘umbrella’
term and practice framework that can be applied
to all aseptic procedures.
The ANTT theory and practice framework
ANTT is intended as a principle for all aseptic
practice no matter how simple or complicated
the clinical procedure may be. In other words,
the principles of ANTT are as applicable to the
surgeon as they are to the nurse or phlebotomist.
Because not all procedures and situations can be
covered by clinical guidelines, it is important that
staff, through risk assessment, are taught how to
determine the correct aseptic technique and re-
quired level and use of infective precautions.
Traditionally, risk assessment has been based
upon the age and clinical status of a patient. For
example, extra precautions are often used for sick
children or cancer patients, even if not warranted
by the technical difficulty of the procedure. In
contrast, a simple and standard risk assessment in
ANTT focuses on the technical challenge of the
clinical intervention, the skill of the HCP and the
002 | HHE 2011
23_Rowley&Clare_spellcheck.indd 2
environment in which a procedure is performed.
This risk assessment is centred on the identifica-
tion and protection of key-parts and key-sites and
determines whether the clinical procedure repre-
sents ‘surgical’ or ‘standard’ ANTT.
Surgical ANTT
Surgical ANTT is demanded when procedures are
technically complex, involve extended periods of
time, large open key-sites or large or numerous
key-parts. To counter these risks, a main critical
aseptic field and sterile gloves are required and
often full barrier precautions (Pratt et al, 2007).
Surgical-ANTT should still utilise critical micro-
fields and non-touch technique where practical to
do so (see below).
Standard ANTT
Procedures managed with Standard ANTT will
typically be technically simple, short in duration
(approximately <20 minutes), involve smaller key-
sites and key-parts (e.g. IV therapy or peripheral
cannulation). Standard aseptic technique typically
requires a main general aseptic field and non-ster-
ile gloves. It relies heavily on a non-touch tech-
nique and the use of critical micro aseptic fields
to protect key-parts.
The fundamental difference between surgical
and standard ANTT is the requirement in surgi-
cal ANTT to manage the aseptic field itself as a
key-part (i.e. intra procedure, key-parts must only
come into contact with other aseptic key-parts or
key-sites) in order to maintain asepsis of the key-
parts. In standard ANTT, it is not necessary to treat
the general aseptic field as a key-part. To under-
stand why, HCPs must understand the different
types of aseptic field management.
Aseptic field management
Aseptic fields promote or ensure the integrity of
asepsis during clinical procedures by providing
a controlled aseptic working space in what are
typically ‘dirty’, busy and dynamic environments
resident with unusual antibiotic resistant organ-
isms. Therefore, in ANTT, aseptic field manage-
ment is considered very important and is explic-
itly defined.
ANTT involves two grades of aseptic field
that require different management depending
on whether their primary purpose is to promote
or ensure asepsis. Firstly, critical aseptic fields are
used when key-parts, usually due to their size or
number, cannot easily be protected at all times
with covers and caps, or handled at all times by a
non-touch technique – such as in a peripherally
inserted central catheter (PICC) or urinary cath-
eter insertion – or when particularly open, inva-
4/11/10 12:55:51
 sive or technical procedures demand large aseptic
working areas as in the operating theatre.
Most notably in such instances, the main criti-
cal aseptic field demands to be managed as a key-
part. That is to say, only equipment that has been
sterilised can be introduced into the critical asep-
tic field, which consequently demands the use of
sterile gloves. As a result, management of the asep-
tic field is more complicated.
A sub-type of critical aseptic field is the critical
micro aseptic field. Traditional non-touch or so-
called clean techniques have protected key-parts
by syringe caps, sheathed needles, covers or pack-
aging etc. In practice, these protective methods
constitute critical micro aseptic fields and tradi-
tionally have been understated and unappreci-
ated. They provide an optimum environment for
the protection of key-parts. It is also important
that aseptic fields are fit for purpose. For exam-
ple, in IV therapy, ‘mobile’ aseptic fields such as
trays should provide an adequate working space
with high sides to contain equipment and sharps
and spillages.
General aseptic fields are used when key-parts
can easily and optimally be protected by critical
micro aseptic fields and a non-touch technique.
The main general aseptic field does not have to be
managed as a key-part and is essentially promoting
rather than ensuring asepsis. Subsequently, aseptic
technique is considerably simplified and typically
involves non-sterile gloves, as sterile gloves would
not provide added value (e.g. most IV therapy and
basic wound care).
The importance of key-parts
There are many causes of infection in healthcare,
but, during aseptic technique, there is ultimately
one cause or decisive failure – the contamination
of key-parts and/or key-sites. In ANTT, key-parts
are defined as the aseptic parts of the procedure
equipment that need to have direct contact with
aseptic key-parts connected to the patient, key-sites
or any liquid infusion, and key-sites are defined as
wounds, including insertion sites.
ANTT combats common failures in aseptic
practice by the practice of identifying, cleaning ef-
fectively (if required) and optimally protecting the
key-parts and key-sites at all times during a proce-
dure. The effective cleaning of key-parts is critical;
however, despite guidance, cleaning of key-parts
often carries a failure rate of up to 80%.1
Implementing ANTT
A case example: In 2006, Central Manchester
and Manchester Children’s University Hospitals
NHS Trust (CMMC) were experiencing high
incidences of methicillin-resistant Staphylococcus
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aureus (MRSA) bacteraemia. Following inspection
by the then Healthcare Commission, the trust
implemented ANTT and developed a trust-wide
compliance to the IV ANTT guideline.
At 12 months, methicillin-sensitive Staphylo-
coccus aureus (MSSA) was reduced by 27%, MRSA
by 63% and glycopeptide-resistant enterococci
(GRE) by 57%. Mapping exercises demonstrating
similar trends have been reported to the ANTT
Clinical Nursing and Patient Care
team from other hospitals such as Lancashire Hos-
pitals NHS Trust, Brighton and Sussex University
Hospitals NHS Trust, Salford Royal Hospitals NHS
Trust, South London Healthcare NHS Trust and
Addenbrooke’s Hospital, and the Children, Youth
and Women’s Health Service (Australia).
Eighteen months later, the CMMC reported
significantly reduced healthcare-acquired infec-
tion (HCAI) across a range of organisms and a
continued downward trend in all major surveil-
lance criteria. The first post-ANTT audit of staff
compliance in 2007 identified compliance to
policy at around 75% and at 90% a year later in
2008. Training was received on a one-to-one ba-
sis, cascaded down through the physician group
as well as nursing staff. This ‘top-down’ approach
facilitated a credible and inclusive trust-wide im-
plementation, helping to make CMMC one of the
best examples of large-scale adoption of ANTT
– or, in other words, of how ANTT, when imple-
mented robustly and in mandatory manner by ex-
ecutive level leadership, could significantly help
reduce HCAI using existing resources.
The ANTT practice framework and associated
clinical guidelines provide healthcare organisa-
tions with the tools to standardise and improve
aseptic technique across large workforces. Robust
implementation of ANTT has been shown to help
reduce practice variables and HCAI. ✦
Enquires about the ANTT Practice Framework and im-
plementing ANTT in healthcare organisations should be
sent to enquiries@antt.org.uk
References
1. Rowley S & Clare S. British Journal of Infection
Prevention 2009;10(1): Supplement
2. Weller B, ed. Encyclopedic Dictionary of Nurs-
ing and Healthcare. Balliere Tindall, London;
1997: 81.
3. McLeod W. The New Collins Dictionary and
Thesaurus. Harper Collins, Glasgow; 1991.
4. Ayliffe G, Fraise A, Geddes A, Mitchell K. Control
of Hospital Infection: A practical Handbook,
4th edition. Butterworth Heinemannn, Oxford;
2000.
5. Cotterill S et al. Journal of Hospital Infection
1996;32(3):207-216
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