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Clean Vs Sterile Dressing Techniques For.7
Clean Vs Sterile Dressing Techniques For.7
Originated By: exist. Terms have been used interchangeably and all are
Wound, Ostomy and Continence Nurses Society (WOCN) subject to individual interpretation. The following defini-
Wound Committee and the Association for Professionals tions provide a point of reference for the terms used in
in Infection Control and Epidemiology, Inc. (APIC) 2000 this document.
Guidelines Committee Sterile technique. Sterile is generally defined as
Updated/Revised: WOCN Wound Committee, 2011 meaning free from microorganisms.3 Sterile technique in-
volves strategies used in patient care to reduce exposure to
Date Completed: microorganisms and maintain objects and areas as free
Original Publication Date: 2001 from microorganisms as possible. Sterile technique in-
Review/Update: 2005 volves meticulous hand washing, use of a sterile field, use
Revised: 2011 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 dress-
■ Purpose ing change procedures; and avoiding contact between
To present an update on the status of information about sterile instruments or materials and any non-sterile sur-
clean versus sterile dressing technique to manage chronic face or products. Sterile technique is considered most ap-
wounds. propriate in acute care hospital settings, for patients at
high risk for infection, and for certain procedures such as
sharp instrumental wound debridement.3-5
■ Background/History Clean technique. Clean means free of dirt, marks, or
This document originated in 2001 as a joint position state- stains.3 Clean technique involves strategies used in patient
ment from a collaborative effort of the Wound, Ostomy and care to reduce the overall number of microorganisms or to
Continence Nurses Society and the Association for prevent or reduce the risk of transmission of microorgan-
Professionals in Infection Control and Epidemiology, Inc.1,2 isms from one person to another or from one place to an-
Its purpose was to review the evidence about clean vs. ster- other. Clean technique involves meticulous handwashing,
ile technique and present approaches for chronic wound maintaining a clean environment by preparing a clean
care management. Then as now, areas of controversy exist field, using clean gloves and sterile instruments, and pre-
due to a lack of agreement on the definitions of “clean” and venting direct contamination of materials and supplies.
“sterile” technique, lack of consensus as to when each is No “sterile to sterile” rules apply. This technique may also
indicated in the management of chronic wounds, and lack be referred to as non-sterile. Clean technique is considered
of research to serve as a guide. Wound care practices are most appropriate for long-term care, home care, and some
extremely variable and are frequently based on rituals and clinic settings; for patients who are not at high risk for
traditions as opposed to a scientific foundation. 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
■ Discussion of Problems/Issue/Needs Aseptic technique. Asepsis or aseptic means free
Definition of terms 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
S30 J WOCN ■ March/April 2012 Copyright © 2012 by the Wound, Ostomy and Continence Nurses Society
the purposeful prevention of the transfer of organisms In patients who are immunosuppressed or have ischemic
from one person to another by keeping the microbe count wounds, signs of infection can be subtle. Signs of inflam-
to an irreducible minimum. Some authors have made a mation such as a faint halo of erythema and moderate
distinction between surgical asepsis or “sterile technique” amounts of drainage might be the only signs of an in-
used in surgery and medical asepsis or “clean technique” fected arterial wound.17 Studies have shown that in
that involves procedures to reduce the number and trans- chronic wounds, increasing pain, friable granulation tis-
mission of pathogens.4 sue, wound breakdown, and foul odor have high validity
No touch technique. No touch is a method of chang- for infection.17,18
ing surface dressings without directly touching the wound
or any surface that might come in contact with the wound. Definition of Wounds
Clean gloves are used along with sterile solution/supplies/ Wound. A wound is any break in the skin that can
dressings that are maintained as clean.8 vary from a superficial to a full thickness wound. A partial
Definition of infection. Infection has been defined thickness wound is confined to loss of the epidermis and
as a continuum from contamination, colonization, critical partial loss of the dermis; whereas a full thickness wound
colonization, biofilm, and infection.9 has a total loss of the epidermis and dermis and can in-
Contamination. Contamination is the presence of volve the deeper subcutaneous and muscle tissues and/or
non-replicating microorganisms on the surface of the bone.19,20
wound. All open wounds have some level of bacterial bur- Acute wound. Acute wounds occur suddenly and are
den that is ordinarily cleared by the host.9-11 commonly due to trauma or surgery, which triggers blood
Colonization. In colonization, microorganisms at- clotting and a wound repair process that leads to wound
tach to the wound surface and replicate but do not impair closure within 2-4 weeks.14,19
healing or cause signs and/or symptoms of infection. The Chronic wound. A chronic wound is a one that does
bacteria are not pathogenic and do not require treatment. not does not proceed through an orderly and timely repair
All chronic wounds are colonized to varying degrees.9 process requiring more than 4 weeks to heal such as vas-
Critical colonization. With critical colonization, cular wounds and pressure wounds.14,19
the organisms attach to the wound surface, replicate and Surgical wound. A surgical wound that heals in an
multiply to a level that affects skin cell proliferation and orderly and expected fashion may be considered an acute
tissue repair without provoking systemic signs of infec- wound. Surgical wounds heal by primary closure or are left
tion. There is no invasion of the healthy tissue at this open for delayed primary closure or healing by secondary
point.9 closure. Primary closure facilitates the fastest healing.
Biofilm. Approximately 70% of chronic wounds have However, infected wounds should not be primarily closed.21
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, polysac-
■ Gaps in Research Practice
charide matrix that protects from the invasion of other There is no definitive evidence that sterile technique is
organisms, phagocytosis, and many commonly used anti- superior to clean technique, improves outcomes, or is war-
biotics and antiseptics. Biofilms are difficult to treat and ranted when changing dressings on chronic wounds.8
eradicate.9 Recently it has been proposed that biofilm Insufficient evidence is available to determine if there are
might be present in all chronic wounds.12,13 significant differences in infection rates or healing when
Infection. Infection occurs when organisms on the wounds are treated using clean or sterile technique.14
wound surface invade the healthy tissue, reproduce, over- There is a lack of agreement in published expert opinion
whelm the host resistance, and create cellular injury lead- as to what constitutes sterile versus non-sterile technique
ing to local or systemic symptoms.9,14 Infection is often and when one or the other should be used.
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 strepto-
■ Overview of Research/Published
Expert Opinion
cocci impair wound healing at less than 105 CFU per gram
of tissue.15 According to Kravitz,16 infection should be de- Few national guidelines have addressed the topic of clean
fined as the presence of bacteria in any quantity that im- vs. sterile technique. Sterile technique and dressings have
pairs wound healing. been recommended for post-operative management of
Clinical signs of infection include lack of healing after wounds for 24-48 hours by the Centers for Disease Control
2 weeks of proper topical therapy, erythema, increase in and Prevention.22 No recommendations are provided be-
amount or change in character of exudate, odor, increased yond 48 hours for wounds with primary closure.22,23
local warmth, friable granulation tissue, edema or indura- In 1994, clinical practice guidelines for pressure ulcer
tion, pain or tenderness, fever, chills, elevated white blood treatment, published by the Agency for Health Care Policy
cell count, and elevated glucose in patients with diabetes.9 and Research, recommended use of clean gloves and clean
evidence indicates clean technique reduces costs and c. Invasiveness of wound care procedure.
might require less time to perform. • How invasive is the procedure?
Wound care is provided in a variety of patient care set- • Is debridement to be performed?
tings including acute care, sub-acute care, long-term care, • Does the procedure involve changing a simple
outpatient clinics, and in the home. The question arises: transparent film or hydrocolloid dressing or
Should a different technique be utilized in the delivery of extensive packing of the wound?
wound care based on the health care setting? Decisions d. Health care setting.
made about the type of technique to be used may be more • Who will be doing the wound care?
reasonably based on what will be done to the wound, • What is the environment in which the care
rather than where or to whom the care is delivered.1,2 will be delivered?
Other factors that may influence the technique are the e. Selection/use of supplies/instruments.
status/acuity of the patient, the health care setting, and • Use and maintenance may be based on likeli-
type of caregiver.31 For instance, a frail, elderly patient who hood of exposure to organisms in the care setting.
is receiving immunosuppressant drugs who has a large, • What is clean, what is sterile, and what is con-
full thickness, sternal wound receiving daily dressing taminated?
changes might benefit from “sterile” technique. A middle- • Keep items apart by using no touch technique.
aged patient who was in an automobile accident and sub- f. Solutions for cleansing/treatment.
sequently developed a non-infected, Stage III pressure • Initially, solutions such as commercially prepared
ulcer treated with hydrocolloid dressings, changed every wound cleansers and normal saline are sterile.
3-4 days, might be adequately managed using “clean” • The shelf life of solutions once they are opened
technique. There is no scientific evidence or consensus is based on manufacturers’ recommendations
that any one of these conditions is more or less important and the policy of the health care institution
in selecting the appropriate method of care for the wound. providing the care. No definitive scientific evi-
It has been suggested that an assessment of patients risk dence exists to guide the policies of the health
for infection is an important factor in choosing the type care institution.
of technique.3,34 2. The Table addresses dressing technique for chronic
wounds.1,2,35
■ Recommendations
Recommendation for Education
Recommendations for Practice: Considerations for Health care facilities should develop policies and educa-
Clean Versus Sterile Technique tional programs for staff to enhance understanding and
1. The following factors should be considered when principles of asepsis, choosing and criteria for performing
planning and selecting dressing technique for clean or sterile technique.
chronic wound care.2,34
a. Patient factors, immune status, acute vs. chronic Recommendation for Research
wound. Research is needed to provide an evidence-basis to support
b. Type, location, and depth of the wound. either “clean” or “sterile” dressing technique to manage
TABLE.
Suggested Dressing Technique for the Management of Chronic Wounds
Supplies (Includes Solutions
Intervention Hand Washing Gloves and Dressing Supplies) Instruments
Wound Cleansing Yes Clean Normal saline or commercially prepared Irrigate with sterile device;
wound cleanser maintain as clean per
Sterile, maintain as clean per policy* policy*
Routine Dressing Change without Yes Clean Sterile, maintain as clean per policy* Sterile; maintain as clean
Debridement per policy*
Dressing Change with Mechanical, Yes Clean Sterile, maintain as clean per policy* Sterile; maintain as clean
Chemical, or Enzymatic Debridement per policy*
Dressing Change with Sharp Yes Sterile Sterile Sterile
Conservative Bedside 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.