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CONTINUING PROFESSIONAL DEVELOPMENT
Page 58
Aseptic technique multiple
choice questionnaire
Page 59
Read Lucy Clayson’s practice
profile on sepsis
Page 60
Guidelines on how to write a
practice profile
Principles of aseptic technique in
urinary catheterisation
NS366 Mangnall J, Watterson L (2006) Principles of aseptic techniques in urinary catheterisation.
Nursing Standard. 21, 8, 49-56. Date of acceptance: October 3 2006.
Consider how a standardised approach to aseptic
technique can improve the quality of patient care.
Summary
Most nurses are aware of the importance of aseptic technique but
some may be unsure about applying the technique during urinary
catheterisation. This article explains the principles of aseptic
technique and their application to the procedure of urinary
catheterisation.
Authors
Joanne Mangnall is research and development fellow; Linda
Watterson is senior research and development fellow, Royal College
of Nursing Institute, Oxford. Email: [email protected]
Keywords
Aseptic techniques; Infection control; Urinary catheters
These keywords are based on the subject headings from the British
Nursing Index. This article has been subject to double-blind review.
For related articles and author guidelines visit our online archive at
www.nursing-standard.co.uk and search using the keywords.
Aims and intended learning outcomes
The aim of this article is to explain the principles
of aseptic technique and encourage nurses to
apply these principles to the procedure of urinary
catheterisation. After reading this article you
should be able to:
Understand how infection can occur during the
urinary catheterisation procedure.
Identify the key components of an aseptic
technique.
Relate the key components of aseptic technique
to the procedure of urinary catheterisation.
Adjust practice to incorporate the principles of
aseptic technique into urinary catheterisation
procedures in your workplace.
NURSING STANDARD
Introduction
The infection risks associated with catheter
insertion are not a modern phenomenon. More
than a century ago Stewart and Cuff (1899)
identified the key risks: ‘It is highly essential that
nurses should recognise the extreme importance
of absolute cleanliness when passing the catheter.
The careless use of an unclean instrument may
introduce germs into the bladder, which will grow
there and cause it to become inflamed – a most
serious and painful condition, the setting up of
which every nurse should do her utmost to avoid.’
This advice has changed little in more than 100
years, although current guidelines stipulate that
urinary catheters must be inserted using sterile
equipment and an aseptic technique (Pratt et al
2001, National Institute for Clinical Excellence
(NICE) 2003).
Most nurses are aware of the importance of
using an aseptic technique when inserting urinary
catheters (Bridger (1997), but some nurses may
feel uncertain about how to undertake such a
technique (Hallett 2000). This apparent
confusion is well documented. Bree-Williams and
Waterman (1996) found that not all nurses
followed the same actions while carrying out
aseptic techniques and that the rationale for the
practice of aseptic techniques was not always
evidence-based. They further argued that the
practice of aseptic technique had become
ritualistic and complex.
McLane et al (1983) revealed an unanticipated
high number of errors in nurses’ adherence to
aseptic techniques, while Kelso (1989) argued
that heavy workload was a contributory factor in
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poor compliance, particularly when the aseptic
technique was perceived to be complicated.
Schraag (2006) suggested that staff often do not
apply the principles of asepsis when working in a
number of healthcare settings, often believing
that aseptic technique is solely applied in the
operating theatre.
meet the standards set out in the Nursing and
Midwifery Council’s Code of Professional
Conduct (NMC 2004). Practitioners performing
urinary catheterisation should therefore have skills
and knowledge in regard to the technical aspects of
the catheterisation procedure and the ability to
accurately apply the principles of aseptic technique
to the procedure to minimise risk.
Catheter-associated urinary tract infection The
development of CAUTI is multifaceted, however,
infections will generally occur in one of three
ways (Ellis 2006):
Urinary catheterisation
At insertion because of poor aseptic technique.
Urinary catheterisation is one of the most
common healthcare interventions. Millions of
urinary catheters are inserted every year, with an
estimated 25 per cent of patients undergoing the
procedure during their hospital stay (Tenke et al
2004). The frequency with which urinary
catheterisation occurs should not be viewed as
confirmation of its safety. Patients undergoing
urinary catheterisation are placed in ‘significant
danger’ of acquiring a urinary tract infection
(UTI) (Pratt et al 2001).
The term healthcare-associated infection
(HCAI) encompasses any infection by any
infectious agent acquired as a consequence of
treatment for a medical condition, or acquired by
healthcare workers in the course of their duties
(Department of Health (DH) 2006a). Effective
prevention and control of HCAI should be
entrenched in everyday practice and applied by all
healthcare workers. However, effective action
relies on an accumulating body of evidence that
takes account of current clinical practices (DH
2006a) and an awareness of the risks posed by
clinical interventions.
Best available estimates suggest that 300,000
patients in the UK develop a HCAI each year and
at least 5,000 of these patients will die
unnecessarily (National Audit Office (NAO)
2005). UTIs account for 23 per cent of HCAIs,
80 per cent of which can be traced to use of
indwelling urinary catheters (DH 2003).
Many catheter-associated UTIs (CAUTIs) can
be serious and lead to significant morbidity,
particularly in patients whose health is already
compromised. The risk of acquiring bacteriuria is
approximately 5 per cent for each day of
catheterisation. Of those patients who acquire
CAUTIs, 1-4 per cent will develop bacteraemia
and, of these, 13-30 per cent die (Pratt et al 2001).
Urinary catheterisation is usually carried out by
nurses (Bissett 2005), who have a professional
responsibility to be aware of the risks of infection
related to the procedure. Failure to maintain
professional knowledge and competence or failure
to identify and minimise risk to patients in relation
to aseptic technique could be viewed as a failure to
Via intraluminal spread because of
colonisation of the drainage bag.
50 november 1 :: vol 21 no 8 :: 2006
Via extraluminal spread because of
colonisation on the outside of the catheter.
The risk of infection with indwelling devices
such as urinary catheters is therefore associated
with the method and duration of insertion, the
quality of device care and host susceptibility
(British Medical Association 2006). Some
patients are more vulnerable to infection than
others. An individual’s response to invading
organisms is influenced by a range of factors,
including (Hart 2004):
Age – neonates and older people have less
efficient immune systems.
Underlying disease – debilitating or malignant
disease.
Previous drug therapy – immunosuppressive
drugs and broad spectrum antimicrobials.
Surgery – instrumentation or the presence of
foreign bodies including urinary catheters.
Prevention of infection for immunocompromised
patients with multiple risk factors cannot always
be achieved but should always be strived for
(Taylor et al 2001).
National guidance The DH is committed to
reducing the incidence of HCAI (DH 2006a). It
has published guidance on reducing risks in key
documents such as Winning Ways (DH 2003) and
Essential Steps to Safe, Clean Care (DH 2006b).
These documents offer guidance on reducing
HCAIs based on guidelines such as those
developed by Pratt et al (2001) and NICE (2003).
These DH publications present clear information
on what should be done in specific clinical
situations to reduce risks, but give little detail
about how it can be done. Saving Lives: A
Delivery Programme to Reduce Healthcare
Associated Infection Including MRSA (DH 2005)
provides a framework to enable organisations to
understand the systems and processes required to
reduce HCAI. Local interpretation of national
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guidance is required to address the ‘how to do’
issues. Detailed operational protocols at local
level should incorporate the most important
principles for preventing HCAI based on national
guidance and guidelines (Pellowe 2004).
However, translating guidance into routine
clinical practice can prove difficult. The NAO
(2005) highlighted wide variations in compliance
with good infection control policies, particularly
those relating to catheter care. Despite the
significant dangers posed by CAUTIs, Tew et al
(2005) suggest that healthcare workers often
display ‘catheter apathy’, regarding UTI as an
acceptable, harmless consequence of urinary
catheterisation which is easy to treat. However,
which variations in technique are a result of
catheter apathy and which are caused by a lack of
understanding of the nature of the risks involved
is unclear.
Several simple catheter care practices are
recommended to prevent or delay the onset of
CAUTI. These include (DH 2003, 2005, 2006b):
sepsis’. Aseptic technique refers to practices that
help to reduce the risk of post-procedure
infections in patients by decreasing the likelihood
that micro-organisms will enter the body during
clinical procedures. The aim of an aseptic
technique is to prevent the transmission of
micro-organisms either directly or indirectly to
wounds or susceptible sites, thus reducing the risk
of infection (Hart 2004). It is essential when
aseptic techniques are used as a method of
preventing infection that these procedures are
sound in theory and carried out correctly
(Hart 2004).
Aseptic techniques are those that do some or
all of the following:
Limiting the risk by avoiding unnecessary
catheterisation and removing the catheter as
soon as possible.
Aseptic technique can, therefore, refer to any of
the practices performed immediately before and
during a clinical procedure, such as urinary
catheterisation, to reduce infection. These include:
Undertaking the procedure and after care as
safely as possible.
Hand washing and surgical scrub.
Ensuring that only healthcare workers who are
competent in aseptic technique should insert
urinary catheters.
Maintaining a closed drainage system.
Time out 1
Consider your professional
accountability with reference to the
NMC Code of Professional Conduct (NMC
2004) in relation to your practice in
performing aseptic technique. Are you
confident you understand the key principles
of aseptic technique? You may wish to make
a list of these and discuss them with a more
senior colleague.
Time out 2
Take a few minutes to reflect on the
last time you undertook urinary
catheterisation or observed this procedure
being performed. Think of ways in which you
could evaluate the effectiveness of the aseptic
technique used during the procedure.
Aseptic technique
Baillière’s nurses’ dictionary (Weller 1997)
defines asepsis as ‘freedom from pathogenic
micro-organisms’ and aseptic as ‘free from
NURSING STANDARD
Remove or kill micro-organisms from hands
and objects.
Use sterile instruments and other items.
Reduce the patient’s risk of exposure to
micro-organisms that cannot be removed.
Using personal protective equipment, for
example, gloves, aprons and surgical attire.
Patient preparation.
Maintaining a sterile field.
Using a safe technique.
Maintaining a safe environment in the
procedure area.
Each of these components should be included in
every procedure.
Time out 3
Soiled hands can be effectively
cleaned using an alcohol hand rub. Is this
statement true or false? Check your answer
with the information in the following section.
Hand washing Hand washing is the single most
important procedure for preventing HCAIs,
because hands are an important route of
infection transmission (Hart 2004). Rowley
(2001) suggests that many patients become
infected during simple procedures because of
poor hand washing technique by healthcare
personnel.
Hands should be cleaned before and after
every patient contact (Pratt et al 2001), and
before an aseptic technique is carried out, even
when sterile gloves are also used.
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It is important to remember that hands are
colonised by resident and transient bacteria. Skin
flora are comprised of mainly Gram-positive
organisms of low pathogenicity, for example,
diphtheroids, micrococci and coagulase negative
staphylococci (Staphylococcus epidermidis).
Their function is mainly protective and they are
difficult to remove without the use of a
disinfectant hand wash. However, these
organisms are opportunist and may cause
infection if introduced into an invasive device
such as a urinary catheter. The use of alcohol gel
hand rub will slow down bacterial growth.
Transient skin flora are comprised of a
mixture of Gram-negative and positive
organisms, many of which are harmful if
introduced into a susceptible site or to a
susceptible person, for example, coliforms such
as Klebsiella species, Proteus species,
Acinetobacter species, Escherichia coli and
meticillin-resistant Staphylococcus aureus
(MRSA). These organisms favour damp
conditions such as under rings and artificial
nails, but they can be found on all parts of the
hands, clothing and in the environment. Porteous
(2002) advises that artificial nails should not be
worn by those undertaking an aseptic technique
because they harbour microbes and cannot be
cleaned as effectively as short, natural nails.
Transient flora can be removed using either a
soap and water wash or an alcohol hand rub.
Both methods require an effective technique to
ensure coverage of the whole hand (Royal
College of Nursing 2005). Only physically
washing hands with soap and water will remove
soiling and spores (Infection Control Nurses
Association 2003). Appropriate use of an alcohol
hand rub avoids the need for nurses to leave the
patient during the procedure to wash their
hands, during which time contamination may
occur (Hart 2004).
Mapping the stages involved in the urinary
catheterisation procedure can be used to help
nurses assess at which points hands should be
washed with soap and water and when alcohol
gels can be used. In mapping the process, the
healthcare team can identify all points at which
hand contamination will occur and what the most
appropriate method of hand decontamination
will be. The team may find it useful to break down
hand washing into a series of steps and consider
the risks posed at each step of the process. Points
to consider include:
Access to a wash basin and running water –
difficulties posed in patients’ homes.
52 november 1 :: vol 21 no 8 :: 2006
Type of tap and risk of hand contamination.
Availability of soap – extrinsic contamination
of non-medicated liquid soap can lead to
hand-borne transmission of infection (Sartor
et al 2000).
Facilities available for drying hands following
washing – poorly dried hands can transfer
micro-organisms to other surfaces more easily
than dry hands (Patrick et al 1997).
Personal protective equipment During invasive
procedures such as urinary catheterisation, staff
are at risk of exposure to potentially infectious
body fluids. Aseptic techniques protect the nurse
as well as the patient by acting as a barrier against
micro-organisms.
A no-touch technique is essential to ensure that
hands, even though they have been washed, do
not contaminate sterile objects or the patient.
This can be achieved by the use of either forceps
or sterile gloves (Pratt et al 2001). However, it
should be remembered that gloves can become
damaged during use (Driever et al 2001).
Gloves should be removed carefully to prevent
hands becoming contaminated during removal
(Pratt et al 2001). Wearing gloves for prolonged
periods of time can result in occlusion conditions
that encourage rapid growth of flora on nurses’
hands (Pereira et al 1997), therefore careful hand
washing is also required following glove removal.
Girou et al (2004) highlight a need for a change
of behaviour in glove use. During an observational
study, Girou et al (2004) found that healthcare
personnel exposed patients to increased risks of
infection by failing to change or remove
contaminated gloves before performing activities
that required an aseptic technique.
Disposable plastic aprons should be worn to
protect nurses’ clothing from becoming
contaminated by body fluids containing
pathogenic micro-organisms which may then be
transferred to other patients in their care
(Callaghan 1998). Disposable plastic aprons are
single-use items worn for one procedure and then
discarded (Pratt et al 2001).
Time out 4
Reflect on the last time you inserted
a urinary catheter. How did you prepare
the patient in advance of the procedure?
Would you do anything differently next time?
Patient preparation Patient preparation should
start by providing him or her with adequate
information about the need for, insertion,
maintenance and removal of the urinary catheter
(Pellowe et al 2004). This includes information
regarding the risks of CAUTI (DH 2006a). It may
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be useful to explain the principles of aseptic
technique to patients, including what they can and
cannot touch during the procedure.
The usually harmless micro-organisms found
on the skin of a patient may cause infection when
introduced into an area of the body where they
are not usually found. These normal flora can
cause infection in an immunocompromised
patient, who is especially susceptible to infection.
Bissett (2005) suggests that if catheterisation is
inevitable, a thorough risk assessment should be
completed before inserting the catheter.
Maki and Tambyah (2001) emphasise that
infection can occur extraluminally (via the
outside of the catheter) when the catheter is
inserted, therefore careful cleaning of the urethral
meatus should be undertaken. Meatal cleansing
involves the mechanical removal of exudate and
smegma (Association for Continence Advice
2003). It is not necessary to use an antiseptic
preparation to clean the urethral meatus before
catheter insertion (Pratt et al 2001), however, to
avoid contamination of the sterile procedure field
it is advisable to use a sterile solution to cleanse
the urethral meatus. Sterile saline or water may be
considered. However, the team should agree what
solution will be used as part of the
standardisation procedure. If possible the patient
should be advised to wash with unperfumed soap
and water before the catheterisation procedure is
commenced. Standard principles for cleansing the
urethral meatus include retracting the foreskin
(where possible) and cleaning the glans for men
and adopting a front to back cleaning technique
for women. The labia minora should be separated
and the urethral opening washed using sterile
water and cotton wool balls or a sterile topical
swab in a downward direction. Each cotton wool
ball should be discarded after a single use (Dutch
Working Party Infection Prevention 2004).
Maintaining a sterile field Maintaining the
integrity of the sterile field is vital wherever
urinary catheterisation is being performed.
Differing approaches will apply depending on
the environment in which the catheterisation is
performed. Regardless of whether the procedure
will be performed in a hospital or the patient’s
home, the same principles apply.
Catheter packs should be used to provide a
sterile field. If no packs are available, a sterile field
should be created using sterile hand towels. The
surface to be used for the procedure should be
thoroughly cleaned with a neutral detergent and
warm water and then wiped using an alcoholimpregnated wipe:
Lay out all necessary equipment on a trolley
or appropriate work surface – assemble all
appropriate sterile items for the procedure.
The team should decide at which points hand
NURSING STANDARD
washing or alcohol hand rub should be used
and all staff should adhere to this protocol.
Staff should remember there are differing
degrees of clean and dirty. Sterile is a higher
level of cleanliness than disinfected. Work
surfaces are dirtier than equipment.
Movement should always be from clean to
dirty. Movement from dirty to clean requires
sterilisation, disinfection or sanitisation first:
Know what is clean.
Know what is contaminated.
Know what is sterile.
Keep clean, contaminated and sterile items
separate.
Keep sterile sites sterile.
Resolve contamination immediately.
Learn to recognise when you have broken
the aseptic technique.
Safe technique Urinary catheterisation is a
skilled procedure for which healthcare personnel
require training and an assessment of their
competence (Pellowe 2004). Only staff assessed
as competent should perform an aseptic
technique. Nurses with expertise in urinary
catheterisation should share their knowledge
with newly qualified staff, nursing students and
support workers, and ensure that their practice is
based on the best evidence available (Bissett
2005). New staff members should have their
catheterisation skills assessed by a senior member
of staff who has the necessary skills before being
permitted to carry out the procedure
independently (NICE 2003). Local policies and
procedures for the insertion of a catheter in male,
female and paediatric patients should be followed
(Bissett 2005).
Patients should be provided with adequate
information about the need for insertion,
maintenance and removal of the catheter by the
person planning their care and be given the
opportunity to discuss the implications of urinary
catheterisation.
The choice of catheter material and size will
vary depending on individual patient assessment
(NICE 2003), however, silver alloy catheters have
been found to significantly reduce the incidence
of asymptomatic bacteriuria in hospitalised
adults catheterised for less than one week,
compared with standard catheters. Silver alloy
catheters are also associated with a reduced risk
of symptomatic UTI (Pellowe et al 2004).
Catheter selection should be made before the
procedure starts, because breaking off during the
procedure increases the risk of contaminating
hands and sterile fields.
Antibiotic prophylaxis when changing
catheters should only be used for patients with a
history of CAUTI following catheter change, or
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BOX 1
Process mapping
for patients who have a heart valve lesion, septal
defect, patent ductus or prosthetic valve
(NICE 2003). There is evidence that changing the
indwelling catheter at start of antibiotic therapy
significantly improves the clinical and
microbiological outcome by removing the
bacteria contained within the biofilm (Raz et al
1998). However, an aseptic technique is still
required even if the patient is to receive a silver
alloy catheter, or is receiving antibiotic therapy.
All medical devices must carry the CE
(Conformité Européene) mark which allows
patients, clinicians and other users to be confident
that the medical device will perform as the
manufacturer intends and is safe when used as
instructed (Doherty 2006).
Urethral catheterisation can cause bruising
and trauma to the urethral mucosa, which then
acts as an entry point for micro-organisms into
the blood and lymphatic system (Bardsley 2005).
NICE (2003) recommend that an appropriate
lubricant from a single-use container should be
used during catheterisation to minimise trauma
and infection.
Time out 5
Consider the methods you can use to
maintain your competence in performing
urinary catheterisation.
Maintaining a safe environment Most clinical
areas are not designed to meet the same high
standards of asepsis as the operating theatre.
However, the goal of avoiding potential HCAIs
should be universal. The environment should not
affect other key aspects of the technique such as
hand washing and safe use of equipment.
Therefore, careful consideration of the processes
involved when performing urinary catheterisation
in a patient’s home may be indicated. Wherever
the procedure is performed, hazardous waste, wet
or soiled dressings and soiled incontinence pads
must be removed from the immediate area. In
some cases, general cleaning may be required to
ensure that there is an appropriate area in which to
establish the sterile field. Avoid performing an
aseptic procedure for at least 30 minutes after bed
making or domestic cleaning to reduce the risk of
contamination by airborne micro-organisms.
All equipment should be stored correctly to
ensure its sterility; patients should be given
appropriate advice if equipment is to be stored in
the home. Process mapping (Box 1) enables the
team to assess the equipment they are using and
lobby local supply departments if they feel the
54 november 1 :: vol 21 no 8 :: 2006
Process mapping is a method for depicting a process,
such as urinary catheterisation, in a diagrammatic
format. Flow charts are developed to enable the team
to gain a clearer understanding of the process
currently in use and to identify ways in which the
process could be improved.
equipment they are issued with is not conducive
to a good aseptic technique. For example, the
team may wish to only use catheters that are
packaged with an inner sterile sleeve which
allows for non-contamination of the catheter
during insertion.
There are many ways to accomplish an
effective aseptic technique. Different situations
may call for a slightly different approach: for
example, catheterisation as part of a surgical
operation versus a procedure carried out in a
patient’s home; yet the essential components
will still be required. However, it may be these
apparent variances that cause confusion for
nurses and lead to poor implementation of the
technique (Schraag 2006).
Time out 6
List the difficulties you might
encounter performing an aseptic
technique when carrying out urinary
catheterisation in different working
environments, for example, the patient’s home,
ward areas or operating theatres. Consider
how you might overcome these difficulties.
Standardised aseptic technique
It has been proposed that aseptic techniques
should be standardised across an organisation,
and that audits are used to monitor compliance
(DH 2006a). A standardised approach to aseptic
technique can achieve impressive results. In
October 2003 it was reported that a specialist
cancer unit had the lowest rates of MRSA and
other HCAIs in the then University College
London Hospitals (UCLH) NHS Trust. This was
unusual because the patients in this unit were
statistically more susceptible to infection than
other patients because of underlying malignant
disease. These results were achieved by the
introduction in the unit of a standardised aseptic
technique when administering procedures such as
intravenous injections. This standardised
approach ensured that hand washing was effective
and done at the right times and eliminated ad hoc,
variable aseptic techniques (UCLH 2003).
The standardised approach in this example
was developed by applying a number of key
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principles to the aseptic technique in question.
The principles are as follows (Rowley 2001):
The steps of the aseptic technique are broken
down and focus on the main elements of risk
to the patient.
This directs practice to the most important
aspects of asepsis and makes accurate and
detailed audit easier.
Known areas of ambiguity and variable
practice are rationalised with prescriptive and
clear direction.
The order by which the steps of the technique
are performed is fixed, which reduces the
variables and makes audit and evaluation easier.
The technique is designed to be time and
cost-efficient.
Effective hand washing is always central.
This step-by-step approach can be applied to
aseptic technique during urinary catheterisation.
Process mapping can be used by any healthcare
team to identify where it needs to start making
improvements that will have the greatest effect
for patients and staff. Control of unintended
variation in aseptic technique should be viewed
by healthcare workers as a quality control
initiative (Berwick 1991).
It is vital that all relevant team members are
involved in the process of practice improvement.
Not only will such involvement allow everyone to
contribute to the discussions, but it will also help
them to understand the aim and agree how to
evaluate success or lack of it. Three key questions
can help provide a focus (Berwick 1996):
Where do we want to go?
How are we going to get there?
What will success look like when we get there?
Time out 7
List the healthcare team members
who should be involved in developing a
standardised approach to aseptic technique
within an organisation.
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learning zone continence focus
Once the most appropriate method of performing
an aseptic technique is agreed, a map of the
improved way of working should be produced.
This becomes the protocol for practice. As new
clinical evidence becomes available the process
should be repeated and protocols amended
accordingly. It is essential that practitioners are
able to apply the principles of aseptic technique to
their working area. If unsure, advice should be
sought from local infection control teams,
specialist nurses for continence care and urology
or urogynaecology nurse specialists.
Conclusion
Urinary catheterisation is a procedure that has the
potential to cause significant harm to patients.
The procedure must be performed using an
aseptic technique. However, confusion about
effective aseptic techniques may increase
infection risks. Anyone who performs the
procedure has a responsibility to ensure they are
aware of the risks specific to the patient group
they are caring for and have the skills and
knowledge to apply the principles of a good
aseptic technique in their work area. Teamwork is
essential in developing a standardised approach.
Reviewing the process and agreeing how the
required components can be achieved can help to
ensure best practice NS
Time out 8
Now that you have completed the
article, you might like to write a practice
profile. Guidelines to help you are on page 60.
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