Action 3.9

The health service organisation has processes for aseptic technique that:

a. Identify the procedures where aseptic technique applies

b. Assess the competence of the workforce in performing aseptic technique

c. Provide training to address gaps in competency

d. Monitor compliance with the organisation’s policies on aseptic technique

Intent

A risk-based process is implemented that will prevent or minimise the risk of introducing infectious agents during clinical procedures and activities.

Reflective questions

What processes are used to ensure that the workforce is competent in aseptic technique?

How does the health service organisation ensure that clinicians routinely follow aseptic technique when required?

Key tasks

  • Use risk management tools to identify the procedures for which aseptic technique is required.

  • Identify gaps where aseptic technique is not applied appropriately.

  • Provide training to reduce gaps in competence.

  • Give priority to compliance assessment and auditing for aseptic technique in the areas of highest risk and most frequent use.

Strategies for improvement

Hospitals

Identify procedures and risks

Identify the clinical procedures and activities for which aseptic technique needs to be assessed, such as:

  • Surgical procedures, including invasive procedures performed in the operating room, procedure room or clinical areas
  • Venepuncture
  • Insertion of vascular access devices such as peripheral or central lines
  • Maintenance of vascular access devices, including line or dressing changes, or medicine administration through these devices
  • Urinary catheterisation
  • Simple dressings
  • Complex or large dressings
  • Gowning and gloving
  • Collecting of swabs and other specimens.

Conduct a risk assessment to identify the areas of the organisation with the highest risk when performing these procedures. Risks relate to the clinical environment, the patient and the frequency at which the procedure is performed.

Provide the workforce with current policies, procedures and protocols that provide guidance on aseptic technique and that have been developed or reviewed by members of the workforce who are competent in aseptic technique.

Assess training and competence

Identify the training needs of members of the workforce who perform procedures requiring aseptic technique. Consider the validity, currency and scope of previous training, and how often training should be repeated to maintain competence.

Assess the competence of members of the workforce who are required to perform aseptic technique and provide training to address gaps in competence. Set priorities for training based on risk assessment.

Identify opportunities to review practice to improve aseptic technique in specialised units such as emergency and anaesthetic departments, interventional radiology, dialysis, outpatient clinics (for example, wound care; ear, nose and throat; ophthalmic) and phlebotomy.

Use surveillance data, if available, for healthcare-associated infections, results of hand hygiene compliance audits and incident reports to help set priorities for assessment and training needs.

Support practice improvement

Consider technological advances to support improving aseptic technique in practice, such as:

  • Equipment bundles
  • Sterile ‘starter’ packs
  • Dedicated trolleys (for example, intravenous, dressing and urinary catheter trolleys).
Day Procedure Services

Identify procedures and risks

Identify the clinical procedures and activities for which aseptic technique needs to be assessed, such as:

  • Surgical procedures, including invasive procedures performed in the operating or procedure room
  • Venepuncture
  • Insertion of vascular access devices such as peripheral or central lines
  • Maintenance of vascular access devices, including line or dressing changes, or medicine administration through these devices
  • Urinary catheterisation
  • Simple dressings
  • Complex or large dressings
  • Gowning and gloving
  • Collecting of swabs and other specimens.

Conduct a risk assessment to identify the areas of the organisation that have the highest risk when performing these procedures. Risks relate to the clinical context, the patient and the frequency at which the procedure is performed.

Provide the relevant workforce with current policies, procedures and protocols that provide guidance on aseptic technique and that have been developed or reviewed by members of the workforce who are competent in aseptic technique.

Assess training and competence

Identify the training needs of members of the workforce who perform procedures requiring aseptic technique. Consider the validity, currency and scope of previous training, and how often training should be repeated to maintain competence.

Assess the competence of members of the workforce who are required to perform aseptic technique and provide training to reduce gaps in competence. Set priorities for training based on risk assessment.

Identify opportunities to review practice to improve aseptic technique.

Use surveillance data, if available, for healthcare-associated infections, results of hand hygiene compliance audits and incident reports to help set priorities for assessment and training needs.

Support practice improvement

Consider technological advances to improve aseptic technique in practice, such as:

  • Equipment bundles
  • Sterile ‘starter’ packs
  • Dedicated trolleys (for example, intravenous, dressing and urinary catheter trolleys).

Examples of evidence

Select only examples currently in use:

  • Policy documents that identify clinical procedures and activities for which aseptic technique is required
  • List of procedures undertaken in the health service organisation that require aseptic technique
  • Evidence of the assessment of workforce competence in performing aseptic technique
  • Skills appraisals and record of competencies of contractor, locum and agency workforce for aseptic technique
  • Training documents about aseptic technique, including training to reduce gaps in competence
  • Audit results of compliance with aseptic technique procedures
  • Actions taken to reduce identified risks associated with aseptic technique
  • List of invasive clinical procedures included in the aseptic technique assessment.
MPS & Small Hospitals

MPSs and small hospitals should identify the clinical procedures and activities in which aseptic technique is required to be assessed, such as:

  • Surgical procedures, including invasive procedures performed in the operating room, procedure room or clinical areas
  • Venepuncture
  • Insertion of vascular access devices such as peripheral or central lines
  • Maintenance of vascular access devices, including line or dressing changes, or medicine administration through these devices
  • Urinary catheterisation
  • Simple dressings
  • Complex or large dressings
  • Gowning and gloving
  • Collecting of swabs and other specimens.

Conduct a risk assessment to identify the areas of the organisation that have the highest risk when performing these procedures. Risks relate to the clinical environment, the patient and the frequency at which the procedure is performed.

Provide the relevant workforce with current policies, procedures and protocols that provide guidance on aseptic technique and that have been developed or reviewed by members of the workforce who are competent in aseptic technique.

Assess training and competence

Identify the training needs of members of the workforce who perform procedures that require aseptic technique. Consider the validity, currency and scope of previous training, and how often training should be repeated to maintain competence.

Assess the competence of members of the workforce who are required to perform aseptic technique and provide training to deal with gaps in competence. Set priorities for training based on risk assessment.

Identify opportunities to review practice to improve aseptic technique in specialised units such as emergency and anaesthetic departments, interventional radiology, dialysis, outpatient clinics (for example, wound care; ear, nose and throat; ophthalmic) and phlebotomy.

Use surveillance data, if available, for healthcare-associated infections, results of hand hygiene compliance audits and incident reports to help set priorities for assessment and training needs.

Support practice improvement

Consider technological advances to support improving aseptic technique in practice, such as:

  • Equipment bundles
  • Sterile ‘starter’ packs
  • Dedicated trolleys (for example, intravenous, dressing and urinary catheter trolleys).
Last updated 24th May, 2018 at 09:37pm
BACK TO TOP