(updated from previous article by Siobhan McCoulough, CNS Tissue Viability)
When it comes to wound care and reducing the risk of infection or cross contamination, the first stage is good practice in hand hygiene. National Institute for Clinical Excellence (NICE, 2012) states that all healthcare workers providing care should be educated in the principles of infection control, trained in hand decontamination and be proficient in the use of Personal Protective Equipment (PPE).
Hands are the most common carrier of pathogens in any healthcare setting. Hands should be washed with soap and water if they are visibly soiled, or have bodily fluids on them, or in clinical circumstances where there is potential for spread of infection which is resistant to alcohol (hand rubs) (NICE, 2012).
Occasionally, in the community, there may be poor access to soap and water, so hand cleansers and gels must be carried. Avoid contamination at work by keeping arms bare below the elbow when in direct contact with the patients, by removing all wrist and hand jewellery, keeping fingernails short and clean, no nail polish and covering cuts and broken skin with waterproof dressings (NICE 2012). If you suffer with contact dermatitis or skin irritation due to hand washing or use of PPE, you should be referred to Occupational Health for support, or dermatology for treatment to reduce the risk to both you and the patients.
Should I use Aseptic Non-Touch Technique (ANTT) when I am carrying out wound care?
It can be confusing to know how and when to cleanse wounds and whether you should use an ‘aseptic technique’ or a ‘clean technique’. The terms ‘sterility’, ‘clean’, ‘infection’ and ‘contamination’ are often used interchangeably and can cause confusion for clinicians.
The term ‘Aseptic Non-Touch Technique (ANTT)’ is used to describe a procedure, which is sterile-to-sterile contact, and is free from all pathogenic micro-organisms. It involves the deliberate prevention of the transfer of these micro-organisms from one individual to another (Rowley et al, 2010). To help, new vocabulary for existing terms has been introduced – key-parts (sterile equipment) and key-sites (open wounds, medical device access sites). Aseptic technique is used to support procedures, such as cannulation, blood cultures, wound dressings, insertion of urinary catheters and the administration of intravenous drugs (RCN, 2020). Local policies and guidelines should also be read if any clinician is unsure.
A ‘Clean Technique’, on the other hand, describes a less sterile procedure which is free from dirt, marks or stains and does not require sterile-to-sterile contact (Palmer, 2019).
When making the decision or if you are unsure whether to use either the ANTT or Clean Technique, please follow your local policies or consult the local Tissue Viability Service for advice.
The two most common used wound dressing techniques are:
Aseptic Non-Touch Technique (ANTT) with strict application of guidance on hand hygiene and correct use of PPE and sterile gloves: acute wounds, immune-suppressed patients, or those at high risk of infection. Consider if there is an increased risk of gloves coming in contact with non-intact skin or mucous membrane, potential exposure to blood, bodily fluids, secretions and excretions. Dressing packs are a good go-to as often contain all the equipment you need to undertake an aseptic technique.
- A clear, uncluttered, available workspace.
- A sterile dressing/procedure pack.
- Access to hand washing sink, hand wipes or alcohol hand wash.
- Non-sterile gloves to remove old dressing.
- Apron.
- Appropriate sterile dressings.
- Appropriate solution for cleaning the wound such as normal 0.9% saline.
Clean Technique: A clean rather than sterile procedure may be sufficient for chronic wounds such as leg ulcers. Clean Technique is defined as a modified aseptic technique used for certain procedures that acknowledges the use of some non-sterile items/ fluids but aims to reduce the risk of contamination by pathogenic (harmful) micro-organisms e.g. chronic leg ulcer care.
- A clear, uncluttered, available workspace.
- Non-sterile gloves
- Access to hand washing sink or alcohol hand wash.
- Non-sterile gloves to remove old dressing.
- Apron.
- Appropriate dressings.
- Types of cleansing fluid – cleansing can be achieved with either tap water or warm normal 0.9% saline
Wound Cleansing
REMEMBER: wound cleansing is NOT indicated for most wounds and should only be performed with a specific goal or aim.
It is a particularly valuable intervention for wounds that:
- Have remnants of old dressing material still in place.
- Cleaning the peri wound skin of debris, exudate or old dressings.
- Remove debris from traumatic wounds (lacerations) to prevent infection.
- Are showing clinical signs of infection.
- Contain slough or devitalised material.
- Are contaminated with faecal matter.
- Contain debris or foreign bodies.
- Visible or suspected biofilm (Kramer, 2019. Sibbald 2001).
For other wounds, cleansing should not occur and may traumatise fragile new tissue both within the wound bed and on the surrounding skin (Main, 2008). For example, granulating tissue is fragile and cleansing a clean granulating wound is unnecessary.
What wound cleansing fluid should you use?
A 2022 Cochrane Review reports that although various solutions have been recommended for cleansing wounds, normal saline is still a safe and effective solution and is not thought to interfere with the normal healing process. Although tap water, which is easily accessed, efficient and cost-effective is commonly used in community settings, there are still debates about its use. The review went on to say that cleaning wounds with tap water may make little or no difference to wound healing, compared with no cleansing, but highlighted there is no data relating to the impact on the use of tap water on wound infection.
It is important to note all wounds are unique and healthcare professionals should tailor their treatment recommendations based on a holistic wound assessment, patients’ individual needs, and circumstances.
References
Angeras, A and Bradband, A. (1992) Comparison between sterile saline and tap water for cleansing of acute traumatic soft tissue wounds. European Journal of Surgery 158 (33): 347 – 350
Beam J.W. (2006) Wound cleansing: water or saline? J Athl Train, 41: 196-197 Chintz, H, Vibits, H and Cortz, T. (1989) Need for surgical wound dressing. British Journal of Surgery, 76: 204-205 De Smet
Fernandez, R. et al (2022). Water for wound cleansing (review). Cochrane Database of Systematic Reviews. Issue 9, DOI: 10.1002/14651858.CD003861.pub4.
Kramer, A.,(2019). Care for wound cleansing. Journal of Wound Care, Vol 29 (10), Suppl 2.
Loveday HP, Wilson JA, Pratt RJ et al. (2014) epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection 86(S1): S1–S70. PMID: 24330862; DOI: 10.1016/S0195-6701(13)60012-2
https://pubmed.ncbi.nlm.nih.gov/24330862/
Main, R.C. Should chlorhexidine gluconate be used in wound cleansing? J Wound Care 2008; 17(3): 112-4
National Institute for Health and Care Excellence. Healthcare-associated infections: prevention and control in primary and community care. CG139. 2012. https://tinyurl-com.ezproxy.brighton.ac.uk/ycvqz9rs (accessed 27 November 2019)
Palmer, S. J., (2019). Practising asepsis during dressing changes in community settings. British Journal of Community Nursing. Vol 23 (12). Pg 569-614.
Prevention of health associated infections (NICE 2019) accessed on 10th May 2019. available at:
Royal College of Nursing (RCN (2020). Understanding Aseptic Technique. Clinical Professional Resource.
Sibbald, R.G. (2001) What is the bacterial burden of the wound bed and does it matter? In: Cherry. W. Harding, K.G and Ryan, T.J. (Eds) Wound Bed Preparation, London: Royal Society of Medicine Press Ltd, pp 41-50
Rowley S, Clare S, Macqueen S et al. ANTT v2: an updated practice framework for aseptic technique. Br J Nurs. 2010;19(1):S5–S11. Crossref PubMed.
