ANTT Clinical Director (Europe). Lead cancer nurse, University College London Hospitals NHS Foundation Trust, London
Practice Development CNS, University College London Hospitals NHS Foundation Trust, London
Standardising aseptic technique is fundamental to providing safe healthcare. However, historically, it is an area of practice that has lacked evidence and guidance. As a result, aseptic practice within healthcare organisations is often highly variable, of poor quality and theoretically confused.
In contrast to these practical realities, patients expect hospital environments and healthcare professionals (HCP) to protect them from infection during clinical procedures. Though, considering the realities of processed, high-volume healthcare, the hospital environment should perhaps be considered 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 possibility of what was once thought impossible: namely, European, auditable standards of practice in key areas of aseptic practice.
Since 2003, the ANTT implementation initiative (www.antt.org.uk) has helped implement ANTT into approximately half of acute NHS hospitals and community organisations in England and in many internationally. This has been achieved through the origination and dissemination of clinical guidelines and a standard and robust implementation process. Hospitals that have implemented ANTT robustly have reported improvements in practice that have helped reduce rates of healthcare associated infection.1
An unhelpful paradigm
ANTT is a project that grew from dissatisfaction 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 rationalises a contemporary approach to aseptic practice, rather than the historically hierarchal paradigm of sterile, aseptic and clean techniques. This hierarchy of definitions has led to inaccurate and confusing terminology surrounding poorly defined techniques and practices that, in turn, has led to highly variable and poor standards of practice.
The use of accurate terminology is fundamentally important in defining practice and promoting clarity of purpose. Breaking down this unhelpful 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 atmosphere. 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 untypical circumstances. The widely used term ‘sterile technique’ – essentially the instruction to maintain sterility of equipment exposed to air – is obviously 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 equipment. Therefore, unlike sterile techniques, aseptic 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 does not necessarily meet the quality standard of asepsis.4 It is, therefore, not a useful quality standard for ‘technique’ for invasive clinical procures. However, the action of cleaning is an important component in helping render equipment and skin aseptic, especially when there are high levels of contamination that require removal or reduction.
ANTT has rationalised these confusing terms into an accurate, descriptive and achievable definition 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 required 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 environment in which a procedure is performed. This risk assessment is centred on the identification and protection of key-parts and key-sites and determines whether the clinical procedure represents ‘surgical’ or ‘standard’ 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).
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-sterile gloves. It relies heavily on a non-touch technique and the use of critical micro aseptic fields to protect key-parts.
The fundamental difference between surgical and standard ANTT is the requirement in surgical 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 understand 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 organisms. Therefore, in ANTT, aseptic field management is considered very important and is explicitly 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 catheter insertion – or when particularly open, invasive or technical procedures demand large aseptic working areas as in the operating theatre.
Most notably in such instances, the main critical 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 aseptic field, which consequently demands the use of sterile gloves. As a result, management of the aseptic 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 packaging etc. In practice, these protective methods constitute critical micro aseptic fields and traditionally have been understated and unappreciated. They provide an optimum environment for the protection of key-parts. It is also important that aseptic fields are fit for purpose. For example, 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 effectively (if required) and optimally protecting the key-parts and key-sites at all times during a procedure. 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
A case example: In 2006, Central Manchester and Manchester Children’s University Hospitals NHS Trust (CMMC) were experiencing high incidences of methicillin-resistant Staphylococcus 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 Staphylococcus 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 team from other hospitals such as Lancashire Hospitals 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 infection (HCAI) across a range of organisms and a continued downward trend in all major surveillance 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 basis, cascaded down through the physician group as well as nursing staff. This ‘top-down’ approach facilitated a credible and inclusive trust-wide implementation, helping to make CMMC one of the best examples of large-scale adoption of ANTT – or, in other words, of how ANTT, when implemented robustly and in mandatory manner by executive level leadership, could significantly help reduce HCAI using existing resources.
The ANTT practice framework and associated clinical guidelines provide healthcare organisations 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.
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- Rowley S & Clare S. British Journal of Infection Prevention 2009;10(1): Supplement
- Weller B, ed. Encyclopedic Dictionary of Nursing and Healthcare. Balliere Tindall, London; 1997: 81.
- McLeod W. The New Collins Dictionary and Thesaurus. Harper Collins, Glasgow; 1991.
- Ayliffe G, Fraise A, Geddes A, Mitchell K. Control of Hospital Infection: A practical Handbook, 4th edition. Butterworth Heinemannn, Oxford; 2000.
- Cotterill S et al. Journal of Hospital Infection 1996;32(3):207-216