POSITION STATEMENT Clean vs Sterile ... - APIC | …

1 20 apic NewsPOSITION STATEMENTC lean vs Sterile : Management of Chronic WoundsThis document is a collaborative effort of the Association for Professionals in Infection Control andEpidemiology, Inc. ( apic ) and the Wound Ostomy Continence Nurses Society (WOCN). Its purpose isto review the evidence on which chronic wound care practice is based and to present approaches forchronic wound care management. Areas of controversy include a lack of agreement on the definitionsof Clean and Sterile technique and a lack of consensus as to when each is indicated in the manage-ment of chronic wounds. Current wound care practices are extremely variable and are frequentlybased on rituals and traditions as opposed to a scientific definitions associated withwound care have been proposed, pub-lished, and have beenused interchangeably, all subject to theindividual s interpretation.

2 The fol-lowing definitions are an attempt toprovide a point of reference for theterms used in this Techniqueinvolves strategiesused in patient care to reduce andmaintainobjectsandareasasfreefrommicr oorganisms as possible. Steriletechnique involves meticulous hand-washing, use of a Sterile field, sterileglovesforapplicationofasteriledre ss-ing and Sterile instruments. Sterile tosterile involves the use of only sterileinstruments and materials in dressingchange procedures; contact betweensterile instruments or materials andany nonsterile surface or product mustbe Techniqueinvolves strategiesusedinpatientcaretoreducetheov er-all number of microorganisms or toprevent or reduce the risk of transmis-sion of microorganisms from one per-son to another or from one place toanother. Clean technique involves me-ticulous handwashing, maintaining aclean environment by preparing aclean field, using Clean gloves, sterileinstruments, and prevention of directcontamination of materials and sup-plies.

3 No Sterile to Sterile rules technique may also betermed non- Sterile . Aseptic Techniqueis the purposefulpreventionofthetransferoforgan ismsfromonepersontoanotherbykeepingthe microbe count to an between surgical asepsis or steriletechnique andmedicalasepsisor Clean technique. 3No Touch Techniqueis a method ofchanging surface dressings without di-rectly touching the wound or any sur-face that might come in contact withthe the presence of micro-organisms without signs and/or symp-toms of infection. All chronic woundsare colonized to varying the presence of microor-ganisms with signs and symptoms ofdisease. Signs and symptoms whichmay be indicative of infection includeerythema, edema, changes in charac-ter/increaseindrainage,andincreas edodor, fever, altered mental status,and/or increased white blood disruptionofnormalanat-omic structure and function. 8 Acute Woundis a wound that eitherheals by regeneration or in a timelyand orderly Woundis a wound that has failed to proceed through an orderlyand timely process to produce anat-omic and functional integrity.

4 8 Surgical Woundis a wound in whichprimary healing occurs when thewound edges have been drawn to-gether to achieve surgicalwound may be considered an survey developed by the NursingConsortium for Research Practice con-cluded that a great variation exists with regard to Sterile technique 10 Inthesurvey,technique choices among staff nurseswere based on the education level ofthe caregiver, how I was taught inschool and perception of infectionrisk to the , the elementof a scientific foundation for woundcare practice was not 1993, Stotts et al. employed a de-scriptive,exploratoryresearchsurveyto obtain information regarding woundcare practices in the United (242) , Sterile technique and 43% reporteduse of non- Sterile technique. The per-centagesvariedwhenthetypeofwoundand care settings were taken into con-sideration. It was also shown that, inpreparationfordischargefromthehos-pita l,90%ofpatientswithopenwoundsweretaughtt operformnonsteriletech-nique at home regardless of whetherclean or Sterile technique was used dur-ing review of the literature revealednospecificscientificresearchstud iestosupport the use of either Clean or Sterile techniqueinanygivenpatientcare setting.

5 However, there is a studycomparing the use of Sterile saline ortap water for cleaning acute traumaticsoft tissue of strike-through contamination associatedwith saturated Sterile dressings havealso been ,14 Clinical Prac-tice Guidelines published by theAgency for Health Care Policy and Re-search, recommends the use of cleandressings, rather than Sterile ones beused in the treatment of pressure ul-cers as long as dressing procedurescomply with institutional infection-control guidelines. 6 However, theserecommendations are based on expertopinion and not on evidence-based :thereisnoconsensus of expert opinion on thecontroversy of Clean vs Sterile in themanagement of chronic wounds. Ex-pert opinions are based on currentpractice and anecdotal notes, not onevidence-based practice. Additionally,it should be noted that current prac-Continued on page 20 March/April 200121tices have not been shown to be of patient care settings includingacute care, subacute care, long-termcare, outpatient clinics, and in thehome.

6 The question arises: Should adifferent technique be utilized in thedelivery of wound care based on thehealthcaresetting?Decisionsmadeonthet ypeoftechniquetobeusedmaybemore reasonably based on what will bedonetothewound,ratherthanwhereortowhom it is to be delivered. Other fac-tors that may influence the techniqueare the status/acuity of the patient,healthcare setting itself, and/or en-counters with and type of ,elderlypatientwhois on immunosuppressant drugs with alarge, full thickness skin loss sternalwound and who is to receive dailydressing changes to the wound mightbenefit from Sterile technique. Amiddle-aged patient in an automobileaccident, subsequently developing anon-infected Stage III pressure ulcerand who is to receive hydrocolloiddressing changes to the wound every3 4 days, might be adequately man-aged using Clean technique. How-ever, there is no scientific evidence orconsensus that any one of these condi-tions is more or less important in se-lectingtheappropriatemethodofcarefor the considerations fortechnique selectionThefollowingfactorsshouldbecon- sidered when planning chronic see Table is Clean , what is Sterile , what iscontaminated Keep items apart byusing no touch technique.

7 Thehealthcare provider must have a thor-ough understanding of these entitiesto accomplish the goal of and extent of wound care pro-cedure How invasive is the proce-dure? Is debridement to beperformed? Does the procedure in-volve simply changing a transparentfilm dressing or hydrocolloid or exten-sive packing of the wound? Considera-tion should also be given to thelocation and depth of the of supplies/instruments to be usedSolutions for cleansing/treat-ment Use and maintenance may bebased on likelihood of exposure to ,so-lutions such as commercially preparedwound cleansers and normal saline aresterile. The life of these solutions isbased on manufacturer s recommen-dations and the policy of the health-care institution providing the , no scientific evidenceexists to guide the policies of thehealthcare Whowillbedoingthewound care? What is the environmentin which the care will be delivered?

8 ConclusionsThere is no agreement on the defi-nitions of Clean or Sterile Clean and ster-ile are not as important as choosingthe appropriate intervention for theprocedure when managing research is neededto support either Clean or Sterile management of chronic wounds. Thiswould best be accomplished by formalscientific studies in multi-site locationsthat would includeallhealthcare examination of evidence-based research could well lead to in-creased cost effectiveness and im-proved patient research could also impact re-imbursement regulations resulting inconsiderablesavingsinhealthcaredol-lar s without compromising Faller NA (1999). Clean vs Sterile : A Re-view of the Literature. Ostomy/WoundManagement, 45(5), 1. Suggested Technique for the Management of Chronic WoundsInterventionHandwashingGlovesSuppl ies(Includes solutions anddressing supplies)InstrumentsWound cleansingYesClean*Normal saline orcommercially preparedwound cleanser Sterile ;maintain as Clean percare setting policy**Irrigation with steriledevice; maintain asclean per care settingpolicyRoutine dressing changewithout debridementYesClean* Sterile ; maintain asclean per care settingpolicy** Sterile ; maintain asclean per care settingpolicyDressing change withmechanical, chemical,or enzymaticdebridementYesClean* Sterile ; maintain asclean per care settingpolicy** Sterile .

9 Maintain asclean per care settingpolicyDressing change withsharp, conservativebedside debridementYesSterile*SterileSterile*It must be remembered that reimbursement of wound care delivered in the outpatient and home care setting is governed by regulationsmandatedbytheHealthcareFinanc ingAdministration(HCFA).HCFA requiresuseofsterilesuppliesandequipment , from HCFA regulations in the delivery of wound care could result in the submission of fraudulent claims for reimbursement.** Maintaincleanaspercaresettingpolicy meanseachcaresettingmustaddresstheparame tersformaintenance,suchasexpirationdates for supplies, consideration of cost, and correct interpretation of the manufacturer s on page 2222 apic News2. Rhinehart E, MM Friedman. (1999). In-fection Control in Homecare. Gaithers-burg, MD: Aspen Sussman C, B Bates-Jensen. (1998).Wound Care: A Collaborative PracticeManual for Physical Therapists andNurses.

10 Gaithersburg, MD: Aspen Publish-ers, DeCastro MD, L Fauerbach, L Masters(1996). Aseptic Techniques. Infection Con-trol and Applied Epidemiology: Principlesand Practice; Association for Professionalsin Infection Control and Epidemiology,Inc. St. Louis: Mosby Crow S (1997). Infection Control Per-spectives. In Krasner, D, Kane, D. (Eds.),Chronic Wound Care: A Source Book forHealthcare Professionals, 2nded., pp. 990-96. Wayne, PA: Health Management Publi-cations, Bergstrom N, MA Bennett. C Carlson, etal. (1994) Treatment of Pressure Ulcers:Clinical Practice Guideline number 15:59-60. AHCPR Publication , MD: Agency for Health Care Pol-icy and Research, Public Health Service, Department of Health and Doughty DB. (1992). Principles ofWound Healing and Wound RA Bryant (Ed.), Acute and ChronicWounds: Nursing Management, p. 44. : Mosby Lazarus G, D Cooper, D Knighton, et al.