Nursing Practice
Review
Infection control
Keywords: Aseptic Non Touch
Technique/Infection prevention
●This
article has been double-blind
peer reviewed
Increasing use of the Aseptic Non Touch Technique model for safe aseptic
practice is helping to significantly reduce healthcare-associated infections
ANTT: a standard
approach to
aseptic technique
In this article...
Definition of Aseptic Non Touch Technique (ANTT)
Why this approach is important
Principles of the ANTT framework for clinical practice
Author Stephen Rowley is clinical director;
Simon Clare is practice development lead,
both at The Association of Safe Aseptic
Practice.
Abstract Rowley S, Clare S (2011) ANTT: a
standard approach to aseptic technique.
Nursing Times; 107: 36, 12-14.
Aseptic technique is the most commonly
performed infection prevention procedure
in healthcare; it is also probably the most
critical. This article looks at the Aseptic
Non Touch Technique (ANTT) model for
reducing healthcare-associated infections
(HCAI). It outlines the principles of ANTT
and the approach to practice, and
discusses the challenges health
professionals still face in reducing HCAIs.
T
en years ago, Nursing Times featured an article on a new practice
framework for aseptic practice
called Aseptic Non Touch Technique (ANTT) (Rowley, 2001). The article
highlighted several problems in the practice of aseptic technique, including the lack
of standardised education and practice,
confused and variable technique, and the
touch contamination of critical procedure
components. The ineffective cleaning of IV
ports, ineffective hand hygiene, and confused and inaccurate application of the
terms “sterile”, “aseptic” and “clean” in clinical practice were also discussed. The piece
stressed the importance of standardising
aseptic technique and outlined the practice
framework for ANTT (Rowley, 2001).
At the core of the ANTT theoretical
framework for clinical practice (tinyurl.
com/ANTT-framework) was the singular
and clear infection prevention aim of
asepsis for all invasive clinical procedures,
no matter how simple or complex. The term
“asepsis” is an accurate and achievable
quality standard relating to the absence of
pathogenic microorganisms (Hauswirth
and Sherk, 2011). The framework’s focus was
based on the simple fact that, by definition,
sterile technique (requiring the complete
absence of microorganisms) is impossible
to achieve in typical healthcare settings due
to the prevalence of microorganisms in the
air. The term “clean” was discounted as
being too ambiguous as a quality standard
for invasive clinical procedures.
As a result of defining accurate and
achievable terminology, the ANTT practice
framework challenged the conventional
hierarchical paradigm of so-called sterile,
aseptic or clean techniques. The selection
of these techniques had historically been
commonly based on health professionals’
perceptions of patients’ risk of infection;
the framework took the opposite approach
and based risk assessment on how much
the patient was at risk from the healthcare
worker, the technical challenge of the
12 Nursing Times 13.09.11 / Vol 107 No 36 / www.nursingtimes.net
procedure and the practice environment.
This new approach was quickly
embraced nationally. ANTT better defined
the infection control methods and precautions necessary during invasive clinical
procedures to prevent the transfer of
microorganisms from health professionals, procedure equipment or the
immediate environment to the patient. It
is achieved by ensuring the asepsis of procedure key parts and key sites.
Now overseen by the Association for
Safe Aseptic Practice (ASAP), ANTT is the
de facto standard aseptic technique in the
UK. The framework has been endorsed by
Epic2 (Pratt et al, 2007), the RCN infusion
guidelines (RCN, 2010), the Australian
Commission on Safety and Quality in
Healthcare (National Health and Medical
Research Council, 2010), and is used to vary
-ing degrees in 15 other countries. The
importance of safe aseptic practice was recognised in the government’s white paper
Winning Ways (Department of Health,
2003) and in 2008 it became a requirement
of the Health and Social Care Act for
healthcare providers to have a standardised
aseptic technique in which education and
audit can be demonstrated (DH, 2008).
Why is aseptic technique so
important?
The interplay of microorganisms in the
clinical environment and their impact on
healthcare-associated infections (HCAIs) is
well accepted but not fully understood. It is
clear that significant numbers of infections
are caused by microorganism contamination of invasive clinical procedures due to
failed aseptic technique, especially via in
situ medical devices that breach patients’
natural defence mechanisms (Loftus et al,
Nursing
Times.net
5 key
points
For more articles on infection
control, go to nursingtimes.net/infection
Fig 1. The ANTT practice framework
1
The Health and
Social Care Act
2008 requires
healthcare
providers to have a
standardised
aseptic technique
in which education
and audit can be
demonstrated
Aseptic
technique
represents the last
line of defence for
patients from
microorganisms
during invasive
clinical procedures
Aseptic Non
Touch
Technique is the de
facto standard
aseptic technique
in the UK
Safe aseptic
technique
relies on effective
staff training, safe
environments and
equipment that is
fit-for-purpose
Basic infection
prevention
precautions, such
as effective hand
hygiene and glove
usage also help to
ensure asepsis
2
3
4
5
Fig 2. Key parts
2011). The invisible but ubiquitous presence of microorganisms in the clinical
environment means aseptic technique represents patients’ last line of defence from
microorganisms during invasive clinical
procedures, whether in hospital or the
community. In terms of preventable
HCAIs, aseptic technique can be seen as the
most common and critical infection prevention practice in healthcare.
Reducing HCAIs using ANTT
ANTT improves aseptic practice through
standardisation in two ways:
» The practice framework (Fig 1), which
provides a robust set of rules to teach
safe and efficient aseptic technique and
dispels the myths and rituals that have
confused and complicated practice;
» The widespread use of ANTT guidelines
for common clinical procedures in both
hospital and community settings.
Designed as visible practice prompts
displayed in clinical areas, the
rationalised equipment choices and
explicit sequencing act to “prescribe
out” variable practice. Hospitals and
community organisations use ANTT to
quality assure the aseptic technique
component of clinical bundles such as
Saving Lives guidance (DH, 2007).
The practice framework, clinical guidelines and competency-based education are
based on 10 foundation principles (Box 1).
The ANTT approach to practice
Key parts are the critical parts of equipment
that come into contact with liquid infusion
The influence and outcome of teaching the
ANTT practice framework can be illustrated by a simple example. At a hospital in
the planning stage of implementing ANTT,
an infection control nurse noticed a nurse
already practising exemplary ANTT – she
had been employed from a hospital that
used ANTT as standard. This shows how
best practice-based ANTT can be identified
by other ANTT users. This is an important
advantage as, rather than being dependent
on occasional and formal audit alone, the
defined and identifiable ANTT approach
enables a routine day-to-day level of peer
monitoring of practice standards. ANTTtrained staff also articulate a common
practice language and apply a consistent
approach to risk assessment and supporting aseptic processes in general.
Discussion
By deconstructing and rebuilding a problematic area of clinical practice, the ANTT
practice framework and its adoption has
done much to improve standards of aseptic
technique. However, many challenges
remain. Contrary to the requirement of the
Health and Social Care Act 2008, some hospitals and community organisations still
undervalue the critical procedure of aseptic
technique and do not have a single standard.
Audit by ASAP has shown such hospitals
practise what can only be termed “general”
aseptic technique. Typically, this is characterised by variable, subjective approaches
to practice, which means standards are also
variable. Ineffective practice is often protected by excessive autonomy in some specialties, while risk assessment is often
ambiguous and confused.
No other major industry would tolerate
an undefined and variable approach to
such a vital safety procedure; for example,
it is unthinkable that the aviation industry
would operate without a universal
standard for servicing jet engines. Indeed,
comparison with the aviation industry is
sobering; while some 800 people a year die
worldwide from air accidents, in 2007
around 9,000 patients died in the UK alone
from MRSA and Clostridium difficile infections (National Audit Office, 2009).
www.nursingtimes.net / Vol 107 No 36 / Nursing Times 13.09.11 13
Nursing Practice
Review
Conclusion
Over the last decade numerous NHS organisations have adopted ANTT to help significantly reduce HCAIs (Pike et al, 2009;
Rowley and Clare, 2009). The commitment
and hard work of participating hospitals
and community teams has no doubt contributed to saving many lives. In partnership with health professionals and
patients, the ASAP will continue its mission to significantly reduce HCAIs and
improve patients’ experience of healthcare
by further championing and standardising
aseptic technique. NT
The 4th Annual National ANTT Conference
will be held on 28 November in Manchester.
For more details, visit www.antt.org.uk
Box 1. The 10 principles
of ANTT
1. The main infection risk to the patient
is the health professional. It is essential
that healthcare organisations and
individual health professionals
understand and address the real risks
they pose to patients.
2. Health professionals must understand
what asepsis is and how to establish and
maintain it. Poor understanding and
application of the terms “sterile”,
“asepsis” and “clean” have contributed to
confused aseptic technique (Aziz, 2009).
The aim of ANTT “from the operating
theatre to the community”, is the
standard of asepsis.
3. Identifying and protecting key parts
and key sites is paramount. Key parts are
the critical parts of clinical equipment
that come into direct or indirect contact
with any liquid infusion, key sites and any
active key parts connected to the patient
(Fig 2). If contaminated they present a
significantly high risk of infection.
4. Asepsis is achieved with standard
ANTT or surgical ANTT. Standard ANTT
is the technique of choice if procedures
are technically uncomplicated, short in
duration (approximately <20 minutes),
involve small key sites and key parts, and
minimal numbers of key parts. Surgical
ANTT is needed when procedures are
technically complex, last approximately
>20 minutes, involve large open key sites,
and large or numerous key parts.
5. Clinical procedures should be risk
assessed to determine the need for
standard or surgical ANTT. ANTT risk
assessment is based on the technical
challenge of the procedure, practitioner
References
Aziz AM (2009) Variations in aseptic technique
and implications for infection control. British
Journal of Nursing; 18: 1, 26-31.
Department of Health (2008) Health and Social
Care Act. London: DH. tinyurl.com/health-andsocial-care
Department of Health (2007) Saving Lives:
Reducing Infection, Delivering Clean and Safe Care.
London: DH. tinyurl.com/saving-lives-reducing-infec
Department of Health (2003) Winning Ways:
Working Together to Reduce Healthcare Associated
Infection in England. London: DH. tinyurl.com/
winning-ways-together
Hauswirth K, Sherk SD (2011) Aseptic Technique.
Encyclopedia of Surgery. tinyurl.com/Aseptictechnique
Loftus R et al (2011) Hand contamination of
anesthesia providers is an important risk factor for
intraoperative bacterial transmission. Anesthesia
and Analgesia; 112: 1, 98-105.
National Audit Office (2009) Reducing Healthcare
Associated Infections in Hospitals in England. London:
competency and the environment in
which the procedure is performed. The
health professional asks: “Can I maintain
the asepsis of all key parts and key sites
by using a general aseptic field and
microcritical aseptic fields?” In other
words, can the procedure be performed
safely using the most simple and efficient
standard ANTT? If not, surgical ANTT is
used and the main aseptic field must be
managed critically (see principle 6).
6. Aseptic fields are important;
although the principles of ANTT remain
constant, standard and surgical ANTT
require different aseptic field
management. Healthcare environments
are typically resident with atypical, often
antibiotic-resistant and invisible,
microorganisms. As such, aseptic fields
are important to ensure a controlled safe
working space to help maintain the
asepsis of key parts and key sites. ANTT
uses two types of aseptic field that
require different management. Common
to standard and surgical ANTT is the use
of critical aseptic fields to maintain the
asepsis of procedure key parts.
In surgical ANTT, the critical aseptic
field will be a relatively large area on
which only equipment that has been
sterilised or is aseptic can be introduced.
In standard ANTT, the main aseptic field
is termed a “general aseptic field”
because it does not require critical
management. This is because procedure
key parts can easily and optimally be
protected using microcritical aseptic
fields, such as caps, covers and the inside
of equipment packaging.
7. Non-touch technique is the most
important component of standard and
surgical ANTT. Because the safest way of
14 Nursing Times 13.09.11 / Vol 107 No 36 / www.nursingtimes.net
The Stationery Office. tinyurl.com/NAO-infection
National Health and Medical Research Council
(2010) Australian Guidelines for the Prevention and
Control of Infection in Healthcare. Canberra: NHMRC.
tinyurl.com/prevention-control-infection
Pike D et al (2009) Reduction of HCAI by the
Adoption of Aseptic Non-Touch Technique (ANTT).
Poster Presentation at IHI International Quality and
Safety Conference. Berlin, March 2009.
Pratt RJ et al (2007) Epic2: national evidence
based guidelines for preventing healthcareassociated infections in NHS hospitals in England.
Journal of Hospital Infection; 65: S1-S64.
Royal College of Nursing (2010) Standards for
Infusion Therapy. London: RCN. tinyurl.com/
infusiontherapy
Rowley S (2001) Aseptic non-touch technique.
Nursing Times; 97: 7, 6-8.
Rowley S, Clare S (2009) Improving standards of
aseptic practice through an ANTT trust-wide
implementation process: a matter of prioritisation
and care. British Journal of Infection Prevention;
10: 1, S18-S23.
protecting a key part is not to touch it,
the principle and practice of non-touch
technique is a core element of standard
ANTT and surgical ANTT (when practical
to do so).
8. Appropriate infective precautions
help promote and ensure asepsis.
Although non-touch technique and
appropriate aseptic field management
are the core components of key-part and
key-site protection, basic infection
prevention precautions, such as effective
hand cleaning and glove usage are
important and help ensure asepsis.
9. Aseptic practice should be
standardised across and between
healthcare organisations. Typically, when
HCAI rates are high in specific areas,
hospitals react by standardising practice
with explicit guidance. ANTT has been
used to good effect reactively (Rowley
and Clare, 2009) but, in the best
interests of patients, it is best used
proactively to standardise aseptic
practice across large workforces.
Standardising practice naturally reduces
practice variability and the number of
variables in practice. It also enables peer
enforcement, monitoring of standards
and research enquiry.
10. Safe aseptic technique is reliant on
effective staff training in infection
control, safe environments and
equipment that is fit for purpose.
Effective aseptic technique is dependent
on healthcare organisations taking a
systematic approach to asepsis
management in general. The effective
education and training of healthcare
workers is paramount, as is ensuring
equipment is fit for purpose and clinical
environments promote asepsis.