DOCUMENT CONTROL:

Version: 4

Ratified by: Quality and Safety Sub Committee

Date ratified: 4 July 2016

Name of originator/author: Karen Foltyn, Senior Clinical Nurse Specialist, Infection Prevention and Control

Name of responsible committee/individual:

Infection Prevention & Control Committee

Date issued: 11 August 2016

Review date: July 2019

Target Audience All Clinical Staff

Aseptic Non-Touch Technique Policy

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CONTENTS

Section Page No

1. INTRODUCTION 3

2. PURPOSE 3

3. SCOPE 4

4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4

4.1 Board of Directors 4

4.2 Chief Executive 4

4.3 Director of Infection Prevention and Control 4

4.4 Infection Prevention & Control Committee 5

4.5 Infection Control Doctors/Consultant Microbiologists 5

4.6 Infection Prevention & Control Clinical Nurse Specialists 5

4.7 Consultant Medical Staff/Medical Staff 6

4.8 Modern Matrons/Service Managers 6

4.9 Tissue Viability and Lymphoedema Service Nurse Specialist 6

4.10 Staff 7

5. PROCEDURE/IMPLEMENTATION 7

5.1 The Key Principles of ANTT 7

5.2 The Key Stages of ANTT 7

5.3 Preparation of the Patient 7

5.4 Preparation of Staff 8

5.5 Preparation of the Environment 8

5.5.1 Inpatient Areas 8

5.5.2 Community Areas 9

5.6 Preparation of Equipment 9

5.7 Performing the Procedure 10

6. TRAINING IMPLICATIONS 11

7 MONITORING ARRANGEMENTS 11

8. EQUALITY IMPACT ASSESSMENT SCREENING 11

8.1 Privacy, Dignity and Respect 11

8.2 Mental Capacity Act 11

9. LINKS TO ANY ASSOCIATED DOCUMENTS 11

10. REFERENCES 11

11. APPENDICES 12

Appendix 1 – The ANTT Approach Flowchart 13

Appendix 2 - Symbols commonly found on the packaging of consumables

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1. INTRODUCTION

Aseptic Non-Touch Technique (ANTT) is a theoretical framework which has been developed using research based evidence. The principles of ANTT are advocated as the acceptable standard for undertaking aseptic procedures and should only be undertaken by those staff trained and assessed as competent. Variability in practice, terms and definitions has led to significant ambiguity in practice and ANTT avoids confusion by eliminating the use of different terminology e.g. clean or sterile technique. Regardless of the healthcare setting the aim of ANTT is to prevent micro-organisms from hands, surfaces, equipment or the working environment being introduced into a susceptible (key) site by identification and protection of the key parts of any procedure. ANTT must be applied to all clinical procedures which bypass the body’s natural defences, such as inserting or accessing intravenous (IV) devices, phlebotomy, urinary catheterisation, wound dressings, minor surgical procedures and biopsies. Whilst it is recognised that adaptation is required when carrying out ANTT in the patient’s own home, the healthcare professional must adapt the procedure to ensure the environment is conducive to the procedure.

2. PURPOSE The purpose of this policy is to provide a standardised approach to ANTT which will ensure the principles of asepsis are observed during any invasive procedure that bypass the body’s natural defences. The policy content is based on sound infection prevention and control (IPC) principles and national guidance.

2.1 Explanations/Definitions of Terms Used Asepsis – is the absence of bacteria, fungi, viruses or other organisms that could cause disease Aseptic technique – the IPC precautions taken during invasive clinical procedures to prevent the transfer of micro-organisms from the healthcare worker, equipment or the immediate environment to the patient Key sites – are open wounds, including insertion and puncture sites Key parts – the parts of the equipment that come into direct or indirect contact with any liquid infusion, key-sites and any key-parts connected to the patient which if contaminated present a high risk of infection Aseptic field – a designated aseptic working space that contains and protects the procedural equipment from direct and indirect environmental and/or contact contamination by micro-organisms General aseptic field – the main aseptic field that promotes asepsis during procedures by providing basic protection from the procedural environment. Used when key-parts can easily and efficiently be protected e.g. by the use of caps and covers

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Critical aseptic field – the main aseptic field that ensures asepsis during procedures by the use of a sterile field which protects the procedure environment e.g. during urinary catheterisation, complex wound care Micro critical aseptic field - a small critical aseptic field used to protect a specific key-part, e.g. a syringe cap/needle cover

3. SCOPE This policy applies to all staff having contact with patients under the care of the Trust, whether in a direct or indirect patient care role regardless of the care environment. Adherence to this policy is the responsibility of all staff employed by the Trust, including agency, locum and bank staff contracted by the Trust. This policy should be read in conjunction with other IPC policies, particularly Hand Hygiene, Standard Infection Prevention and Control Precautions, Blood and Body fluid Spillages, Isolation, Waste Management, Decontamination, Cleaning Systems and Processes for the Environment, Patient Equipment and Medical Devices and the Collection/Handling and Transportation of Pathology Specimens policies. This policy should be considered and included in services that are contracted and commissioned by the Trust. Invasive sterile procedures are not covered under the ANTT policy. They will be covered by local policies/guidelines, however this policy may be adapted to cover these procedures where deemed appropriate.

4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES

4.1 Board of Directors The Board of Directors are responsible for having policies and procedures in place to support best practice, effective management, service delivery, management of associated risks and meet national and local legislation and/or requirements.

4.2 Chief Executive The Chief Executive (CE) is responsible for establishing and maintaining IPC arrangements across the organisation, but delegates the responsibilities to the Trust Board and the Director of Infection Prevention and Control (DIPC). The DIPC is the Director of Nursing and Quality.

4.3 Director of Infection Prevention and Control The DIPC acts on legislation, national policies and guidance ensuring effective policies are in place and audited and directly reports to the CE and the Board:

Any outbreaks of infection

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The organisations performance in relation to Healthcare Associated Infection’s (HCAI), providing regular reports including an annual report and an annual IPC programme

All incidents requiring a post infection review (PIR)

4.4 Infection Prevention & Control Committee

The main duties of the Infection Prevention & Control Committee (IPCC) are:

To oversee compliance with national standards/targets in relation to the IPC of HCAIs, including the Health and Social Care Act 2008, NHS Litigation Authority (NHSLA) and the Care Quality Commission (CQC) Fundamental Standards

To oversee key IPC issues in regards to:

o Policy development and review o Audit o Education & training o Communication with staff patients and the public o Monitoring of IPC incidents o Review of PIR reports, identify lessons learnt, develop and monitor action

plans o Agreeing the annual IPC report and work programme prior to its

submission to Clinical Governance Group

To inform the Clinical Governance Group of clinical risk issues relating to the Trust

To monitor compliance for IPC training

To oversee the Trust’s compliance with the Care Quality Commission (CQC) Fundamental Standards

4.5 Infection Control Doctors/Consultant Microbiologists

Medical microbiologists hosted within the provider acute Trusts are to:

Be available for 24 hour access, arrangements made through service agreements

Provide expert microbiology advice for the management and treatment of micro-organisms

Advise on antibiotic policy/prescribing and challenge inappropriate practices

Contribute to the PIR process

Support and provide education to all grades and all disciplines as appropriate

4.6 Infection Prevention & Control Clinical Nurse Specialists (IPCCNS)

The IPCCNS role is to:

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Provide expert professional advice and education on the prevention and control of infection to other professionals, multi-disciplinary groups, patients and carers

Report findings to the DIPC and the IPCC

Lead in the investigation of identified cases of infection/alert organisms and conditions

Advise on control measures, delegating responsibility to Trust staff as appropriate

Report any breaches in policy compliance through the IR1 system

4.7 Consultant Medical Staff/Medical Staff

Consultant medical staff are responsible for the supervision of junior medical staff and all medical staff must:

Ensure compliance with IPC policies

Liaise with the Consultant Microbiologist for advice when required

Contribute to and participate in PIR reports, including attendance at relevant meetings

Complete relevant actions required from reports

4.8 Modern Matrons/Service Managers

All Service Managers and Modern Matrons are responsible for:

Membership at the IPCC

On-going compliance with this policy within their clinical areas and reporting non-compliance to the DIPC

Reporting all matters relating to IPC to the DIPC

Facilitating feedback of information related to surveillance data and identified cases of infection/alert organisms and conditions

Reporting confirmed cases of HCAI through the Trust’s IR1 system

Ensuring that situation reports are completed to deadline as requested

4.9 Tissue Viability and Lymphoedema Service (TVALS) Nurse Specialist

The TVALS Nurse Specialists:

Provide expert professional advice and education on tissue viability issues to other professionals, multi-disciplinary groups, patients and carers

Deliver educational sessions relating the principles of asepsis and ANTT to the practical application of performing wound dressings

Lead in the investigation of identified breaches of Tissue Viability

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Advise on treatments and interventions, delegating responsibility to Trust staff as appropriate

Give advice on complex issues relating to Tissue Viability and report findings to the relevant Business Divisions

Report breaches in policy compliance through the Trusts electronic reporting system and to the Health and Safety Group.

4.10 Staff All staff must comply with this policy and related guidance.

5. PROCEDURE/IMPLEMENTATION

5.1 The Key Principles of ANTT A – Always ensure hands are decontaminated effectively prior to the procedure N – Never contaminate key parts of sterile materials/equipment of the patients susceptible key sites T – Touch non-key parts with confidence T – Take appropriate IPC precautions at all times

5.2 The Key Stages of ANTT Different clinical procedures present different levels of complexity. In ANTT, uncomplicated and complex approaches to technique are termed Standard ANTT and Surgical ANTT. The two approaches adhere to the same ANTT approach. The longer key parts and key sites are exposed to the environment, the greater the potential is for environmental or inadvertent touch contamination. Key parts must remain protected at all times using a micro critical aseptic field (MCAF) until the point of use. Key parts must remain protected at all times until the point of use by the use of a MCAF e.g. by leaving the sterile packet on a urethral catheter until the point of insertion. Standard ANTT is the technique of choice when procedures involve minimal/small key parts, are not significantly invasive, are technically uncomplicated to achieve asepsis and are short in duration. The use of a general aseptic field is required for standard ANTT, i.e. a clean surface or tray on which to place equipment with key parts protected, e.g. caps and covers. Surgical ANTT is the technique of choice when procedures involve large or numerous key parts, are significantly invasive, are technically complex to achieve asepsis or involve extended procedure time. The use of a critical aseptic field is required for surgical ANTT, i.e. a sterile procedure pack. It should be noted that while these two approaches differ to accommodate different levels of procedural complexity they both adhere to the same underlying principles of ANTT.

5.3 Preparation of the Patient

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Staff should inform the patient about the procedure and what is involved and gain consent. Written consent may be required for some procedures. Ensure privacy and dignity is maintained at all times. Patient key sites will need to be cleaned as appropriate for the clinical procedure being undertaken and unnecessary exposure of vulnerable sites should be avoided.

5.4 Preparation of Staff A risk assessment (RA) for each procedure should be undertaken to determine the personal protective equipment (PPE) required due to the level of exposure to blood and bodily fluid splashing. Disposable aprons must always be worn where there is a risk of contact with blood or body fluids or direct close contact. The disposable apron must be changed for each patient prior to commencing an ANTT procedure or between different procedures on the same patient. Staff must assess whether the procedure can be performed with or without touching the key parts of the equipment and the key sites of the patient. If it is possible to undertake the procedure without touching the key parts/sites (standard ANTT) then non-sterile gloves can be used. If a key part is to be handled or a key site touched (surgical ANTT) then sterile gloves must be worn (e.g. for urinary catheterisation). If gloves become contaminated during the procedure then they must be removed and hands decontaminated prior to donning a new pair. Eye and face protection may also be required if the procedure has a risk of splashing blood or body fluids to the face.

5.5 Preparation of the Environment

5.5.1 Inpatient Areas: The ideal environment for ANTT procedures is a designated clinic room. Where this is impractical, clinical procedures may be performed at the patient bedside but they must not be undertaken within 30 minutes after activities such as bed making, dusting, floor mopping and the use of commodes by other patients in a shared room, as these may contribute to airborne contamination. Windows must also be kept closed during the procedure. Portable fans must be turned off 30 minutes prior to the procedure. They must also not be used during the clinical procedure. The immediate environment should be clean and free from visible dirt and dust and the number of people entering the area should be restricted whilst the clinical procedure is being undertaken. The need for the use of standard or surgical ANTT must be assessed and the appropriate equipment sourced. The trolley/tray/surface on which equipment and

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consumables are placed on for procedures must be thoroughly cleaned with antimicrobial wipes (e.g. Clinell Universal wipes) and must be dry before use. If a dressing trolley is used it should be designated for this purpose only.

5.5.2 Community Areas: The environment within some community settings such as patient homes, schools, care homes etc. may not always be favourable for undertaking ANTT procedures. Staff may not have access to hand washing facilities, trolleys, or other equipment and satisfactory standards of environmental cleanliness cannot always be guaranteed. However, staff are responsible for ensuring that the environment allows the procedure to be carried out safely and for minimising any identified risks wherever practically possible. A clean surface i.e. a table or tray should be used to arrange the necessary equipment on. Where this is not possible dressing packs contain a sterile field which should be placed as near as possible to the patient. Best practice would be for staff to use wipeable plastic trays when carrying out ANTT procedures and to clean these with antimicrobial wipes (e.g. Clinell Universal wipes). In patient’s own homes, any pets present should be temporarily removed from the environment during the ANTT procedure. Also extraneous people should be requested to vacate the area to reduce the risk of contamination and to allow the privacy and dignity of the patient to be maintained. If clinical waste/sharps are to be carried in staff cars they should be placed in an appropriate transport container. Small amounts of clinical waste may be discarded with the patient’s permission into the domestic waste stream.

5.6 Preparation of Equipment Single use equipment should be used whenever possible. Equipment and products should be sourced prior to the procedure and cleaned as appropriate before the clinical procedure is performed. Products must not be used if they are out of date or damaged. There must not be any evidence of moisture penetration on sterile packs. If equipment has been sterilised by autoclaving the indicator tape must show visible consistent beige and brown lines. If compromised in any way it must not be used. The sterilisation label from re-usable items/packs must be placed in the patients care records or medical notes for traceability purposes. Sterile equipment/packs must be opened using an ANTT to avoid contamination of the contents and arranged in an organised manner in the aseptic field. If available, key parts must be protected at all times by a MCAF. Please refer to Appendix 2 for symbols commonly found on the packaging of consumables.

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5.7 Performing the Procedure ANTT clinical guidelines have been formulated to standardise common clinical invasive procedures by the Association of Safe Aseptic Practice. The steps for performing ANTT are as follows:

Ensure the environment is conducive for the procedure to be undertaken

Discuss with patient and obtain consent

ANTT RA to determine use of standard or surgical ANTT

Decontaminate hands

Clean trolley/tray with antimicrobial wipes (e.g. Clinell Universal wipes) and allow to dry

Decontaminate hands

Gather all equipment and consumables

Check suitable for use (e.g. expiry dates)

Don single use disposable apron

Decontaminate hands

If required, open dressing pack/sterile drape

Open and prepare equipment/consumables

Decontaminate hands

Don gloves (non-sterile or sterile as dictated by RA)

Perform procedure using ANTT

Dispose of waste into appropriate waste stream

Remove gloves and apron

Decontaminate hands

Clean trolley/tray

Decontaminate hands

Document procedure into appropriate care records

6. TRAINING IMPLICATIONS

Aseptic Non-Touch Technique Policy

Staff groups requiring training

How often should this be undertaken

Length of training

Delivery method

Training delivered by whom

Where are the records of attendance held?

Clinical staff undertaking procedures which involve ANTT:

Annually or as indicated in relevant policy e.g. Catheterisation Policy

1 hour approximately

Face to Face

Clinical Skills Co-ordinator and/or LCAT assessors/CPE/Clinical Nurse Specialists as appropriate

Electronic Staff Record system (ESR)

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7. MONITORING ARRANGEMENTS

Area for Monitoring

How

Who by

Reported to

Frequency

Non-adherence to policy

Via IR1 reports

Managers/Matrons and IPC Team

Infection Prevention and Control Committee (IPCC)

Bi-monthly

8. EQUALITY IMPACT ASSESSMENT SCREENING -

The completed Equality Impact Assessment for this Policy has been published on the Equality and Diversity webpage of the RDaSH website click here

8.1 Privacy, Dignity and Respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

Indicate how this will be met

No issues have been identified in relation to this policy.

8.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible.

Indicate How This Will Be Achieved.

All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1)

9. LINKS TO ANY ASSOCIATED DOCUMENTS

All related policies can be found in the Clinical Policies section of the RDaSH Intranet.

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10 REFERENCES ANTT® Clinical Practice Framework. Version 4.0 Copyright © 2015 The Association for Safe Aseptic Practice (The-ASAP) Available at www.antt.org Accessed 01.02.16 Aziz, AM (2008) Variation in aseptic technique and implications for infection control British Journal of Nursing, Vol.8, 1(26-31) Department of Health (2015), The Health & Social Care Act 2008: Code of Practice for Health and Adult Social Care on the Prevention and Control of Infections and related guidance. Griffiths R et al (2001) Is tap water a safe alternative to normal saline for wound irrigation in the community setting Journal of Wound Care 10 (10) p 407-411 Hart. S (2007) Using an aseptic technique to reduce the risk of infection. Nursing Standard 21, 47, p 43 – 48 National Institute for Health and Clinical Excellence (2012) Prevention and control of healthcare associated infections in primary and community care. NICE clinical guideline 139 Pratt R.J et al (2007) epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England Journal of Hospital Infection 86S1 (2014) S1–S70 Rowley,S and Clare S (2011) ANTT: a standard approach to aseptic technique. Nursing Times; 107(36) Rowley, J. S. (2001) Aseptic-Non-Touch-Technique. Nursing Times, 97(7), (Infection Control Supplement), VI-VIII. The Royal Marsden NHS Foundation Trust (2015) The Royal Marsden Manual of Clinical nursing procedures. 9th Ed.

11 APPENDICES

Appendix 1 – The ANTT Approach

Appendix 2 - Symbols commonly found on the packaging of consumables

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Appendix 1

The two types of ANTT can be simplified into ‘The ANTT-Approach’. The ANTT-Approach highlights and promotes the essential elements of safe aseptic technique.

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Appendix 2