Learning Objectives

• Perform appropriate hand hygiene
• Use standard precautions
• Use category-specific, transmission-based precautions
• Maintain a sterile field and equipment
• Apply and safely remove sterile gloves and personal protective equipment
• Dispose of contaminated wastes appropriately

According to the Centers for Disease Control and Prevention (CDC), over 2 million patients in America contract a healthcare-associated infection, and 99,000 patients die from a healthcare-associated infection every year.^[1] Healthcare-associated infections (HAIs) are unintended and often preventable infections caused by care received in a health care setting. Healthcare-associated infections can be prevented by consistently following standard precautions and transmission-based precautions outlined by the CDC (2020). Standard precautions are used when caring for all patients and include performing appropriate hand hygiene; wearing personal protective equipment when indicated; implementing category-specific transmission precautions; encouraging respiratory hygiene; and following environmental infection control measures, including handling of sharps, laundry, and hazardous waste. Additional infection control measures include the appropriate use of aseptic technique and sterile technique when performing nursing procedures to protect the patient from transmission of microorganisms.^[2] Each of these strategies to keep patients and health care workers free of infection is discussed in further detail in this chapter.

References

1.

The Joint Commission. (n.d.). Hand hygiene. https://www​.centerfortransforminghealthcare​.org/improvement-topics​/hand-hygiene/?_ga=2​.185680553.1649963228​.1601313691-322773533.1571518854 ↵.

2.

Collins, A. S. (2008). Preventing health care-associated infections. In Hughes, R.G. (Ed.). Patient safety and quality: An evidence-based handbook for nurses. https://www​.ncbi.nlm​.nih.gov/books/NBK2683/ ↵. [PubMed: 21328752]

Standard Versus Transmission-Based Precautions

Appropriate Hand Hygiene

Hand hygiene is the single most important practice to reduce the transmission of infectious agents in health care settings and is an essential element of standard precautions.^[5] Routine handwashing during appropriate moments is a simple and effective way to prevent infection. However, it is estimated that health care professionals, on average, properly clean their hands less than 50% of the time it is indicated.^[6] The Joint Commission, the organization that sets evidence-based standards of care for hospitals, recently updated its hand hygiene standards in 2018 to promote enforcement. If a Joint Commission surveyor witnesses an individual failing to properly clean their hands when it is indicated, a deficiency will be cited requiring improvement by the agency. This deficiency could potentially jeopardize a hospital’s accreditation status and their ability to receive payment for patient services. Therefore, it is essential for all health care workers to ensure they are using proper hand hygiene at the appropriate times.^[7]

There are several evidence-based guidelines for performing appropriate hand hygiene. These guidelines include frequency of performing hand hygiene according to the care circumstances, solutions used, and technique performed. The Healthcare Infection Control Practices Advisory Committee (HICPAC) recommends health care personnel perform hand hygiene at specific times when providing care to patients. These moments are often referred to as the “Five Moments for Hand Hygiene.”^[8] See Figure 4.1^[9] and Figure 4.2^[10] for an illustration and application of the five moments of hand hygiene. The five moments of hand hygiene are as follows:

Figure 4.1

Five Moments of Hand Hygiene

Figure 4.2

Five Moments of Hand Hygiene Expanded

• Immediately before touching a patient
• Before performing an aseptic task or handling invasive devices
• Before moving from a soiled body site to a clean body site on a patient
• After touching a patient or their immediate environment
• After contact with blood, body fluids, or contaminated surfaces (with or without glove use)

When performing hand hygiene, washing with soap and water, or an approved alcohol-based hand rub solution that contains at least 60% alcohol, may be used. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of improved compliance. Hand rubs are also preferred because they are generally less irritating to health care worker’s hands. However, it is important to recognize that alcohol-based rubs do not eliminate some types of germs, such as Clostridium difficile (C-diff).

When using the alcohol-based handrub method, the CDC recommends the following steps. See Figure 4.3^[11] for a handrub poster created by the World Health Organization.

Figure 4.3

WHO Handrub Poster

• Apply product to the palm of one hand in an amount that will cover all surfaces.
• Rub hands together, covering all the surfaces of the hands, fingers, and wrists until the hands are dry. Surfaces include the palms and fingers, between the fingers, the backs of the hands and fingers, the fingertips, and the thumbs.
• The process should take about 20 seconds, and the solution should be dry.^[12]

When washing with soap and water, the CDC recommends using the following steps. See Figure 4.4^[13] for an image of a handwashing poster created by the World Health Organization.

Figure 4.4

WHO Handwashing Poster

• Wet hands with warm or cold running water and apply facility-approved soap.
• Lather hands by rubbing them together with the soap. Use the same technique as the handrub process to clean the palms and fingers, between the fingers, the backs of the hands and fingers, the fingertips, and the thumbs.
• Scrub thoroughly for at least 20 seconds.
• Rinse hands well under clean, running water.
• Dry the hands using a clean towel or disposable toweling.
• Use a clean paper towel to shut off the faucet.^[14]

By performing hand hygiene at the proper moments and using appropriate techniques, you will ensure your hands are safe and you are not transmitting infectious organisms to yourself or others.

Personal Protective Equipment (PPE)

Personal Protective Equipment (PPE) includes gloves, gowns, face shields, goggles, and masks used to prevent the spread of infection to and from patients and health care providers. Depending on the anticipated exposure, PPE may include the use of gloves, a fluid-resistant gown, goggles or a face shield, and a mask or respirator. When used for a patient with transmission-based precautions, PPE supplies are typically stored in an isolation cart next to the patient’s room, and a card is posted on the door alerting staff and visitors to precautions needed before entering the room.

Gloves

Gloves protect both patients and health care personnel from exposure to infectious material that may be carried on the hands. Gloves are used to prevent contamination of health care personnel hands during activities such as the following:

• anticipating direct contact with blood or body fluids, mucous membranes, nonintact skin, and other potentially infectious material
• having direct contact with patients who are colonized or infected with pathogens transmitted by the contact route, such as Vancomycin-resistant enterococci (VRE), Methicillin-resistant Staphylococcus aureus (MRSA), and Respiratory Syncytial Virus (RSV)
• handling or touching visibly or potentially contaminated patient care equipment and environmental surfaces^[17]

Nonsterile disposable medical gloves for routine patient care are made of a variety of materials, such as latex, vinyl, and nitrile. Many people are allergic to latex, so be sure to check for latex allergies for the patient and other health care professionals. See Figure 4.5^[18] for an image of nonsterile medical gloves in various sizes in a health care setting. At times, gloves may need to be changed when providing care to a single patient to prevent cross-contamination of body sites. It is also necessary to change gloves if the patient interaction requires touching portable computer keyboards or other mobile equipment that is transported from room to room. Discarding gloves between patients is necessary to prevent transmission of infectious material. Gloves must not be washed for subsequent reuse because microorganisms cannot be reliably removed from glove surfaces and continued glove integrity cannot be ensured.^[19]

Figure 4.5

Non-Sterile Medical Gloves

Figure 4.5 Nonsterile Medical GlovesWhen gloves are worn in combination with other PPE, they are put on last. Gloves that fit snugly around the wrist should be used in combination with isolation gowns because they will cover the gown cuff and provide a more reliable continuous barrier for the arms, wrists, and hands.

Gloves should be removed properly to prevent contamination. See Figure 4.6^[20] for an illustration of properly removing gloves. Hand hygiene should be performed following glove removal to ensure the hands will not carry potentially infectious material that might have penetrated through unrecognized tears or contaminated the hands during glove removal. One method for properly removing gloves includes the following steps:

Figure 4.6

Proper Removal of Gloves to Prevent Contamination

• Grasp the outside of one glove near the wrist. Do not touch your skin.
• Peel the glove away from your body, pulling it inside out.
• Hold the removed glove in your gloved hand.
• Put your fingers inside the glove at the top of your wrist and peel off the second glove.
• Turn the second glove inside out while pulling it away from your body, leaving the first glove inside the second.
• Dispose of the gloves safely. Do not reuse.
• Perform hand hygiene immediately after removing the gloves.^[21]

Isolation gowns are used to protect the health care worker’s arms and exposed body areas and to prevent contamination of their clothing with blood, body fluids, and other potentially infectious material. Isolation gowns may be disposable or washable/reusable. See Figure 4.7^[22] for an image of a nurse wearing an isolation gown along with goggles and a respirator. When using standard precautions, an isolation gown is worn only if contact with blood or body fluid is anticipated. However, when contact transmission-based precautions are in place, donning of both gown and gloves upon room entry is indicated to prevent unintentional contact of clothing with contaminated environmental surfaces.

Figure 4.7

Isolation Gown

Gowns are usually the first piece of PPE to be donned. Isolation gowns should be removed before leaving the patient room to prevent possible contamination of the environment outside the patient’s room. Isolation gowns should be removed in a manner that prevents contamination of clothing or skin. The outer, “contaminated,” side of the gown is turned inward and rolled into a bundle, and then it is discarded into a designated container to contain contamination. See more information about putting on and removing PPE in the subsection below.^[23]

Masks

The mucous membranes of the mouth, nose, and eyes are susceptible portals of entry for infectious agents. Masks are used to protect these sites from entry of large infectious droplets. See Figure 4.8^[24] for an image of nurse wearing a surgical mask. Masks have three primary purposes in health care settings:

Figure 4.8

Surgical Mask

• Used by health care personnel to protect them from contact with infectious material from patients (e.g., respiratory secretions and sprays of blood or body fluids), consistent with standard precautions and droplet transmission precautions
• Used by health care personnel when engaged in procedures requiring sterile technique to protect patients from exposure to infectious agents potentially carried in a health care worker’s mouth or nose
• Placed on coughing patients to limit potential dissemination of infectious respiratory secretions from the patient to others in public areas (i.e., respiratory hygiene)^[25]

Masks may be used in combination with goggles or a face shield to provide more complete protection for the face. Masks should not be confused with respirators used during airborne transmission-based precautions to prevent inhalation of small, aerosolized infectious droplets.^[26]

It is important to properly wear and remove masks to avoid contamination. See Figure 4.9^[27] for CDC face mask recommendations for health care personnel.

Figure 4.9

CDC Face Mask Recommendations

Goggles/Face Shields

Eye protection chosen for specific work situations (e.g., goggles or face shields) depends upon the circumstances of exposure, other PPE used, and personal vision needs. Personal eyeglasses are not considered adequate eye protection. See Figure 4.10^[28] for an image of a health care professional wearing a face shield along with a N95 respirator.

Figure 4.10

Face Shield and a N95 Respirator

Respirators and PAPRs

Respiratory protection used during airborne transmission precautions requires the use of special equipment. Traditionally, a fitted respirator mask with N95 or higher filtration has been worn by health care professionals to prevent inhalation of small airborne infectious particles. A user-seal check (formerly called a “fit check”) should be performed by the wearer of a respirator each time a respirator is donned to minimize air leakage around the facepiece.

A newer piece of equipment used for respiratory protection is the powered air-purifying respirator (PAPR). A PAPR is an air-purifying respirator that uses a blower to force air through filter cartridges or canisters into the breathing zone of the wearer. This process creates an air flow inside either a tight-fitting facepiece or loose-fitting hood or helmet, providing a higher level of protection against aerosolized pathogens, such as COVID-19, than a N95 respirator. See Figure 4.11^[29] for an example of PAPR in use.

Figure 4.11

PAPR In Use

The CDC currently recommends N95 or higher level respirators for personnel exposed to patients with suspected or confirmed tuberculosis and other airborne diseases, especially during aerosol-generating procedures such as respiratory-tract suctioning.^[30] It is important to apply, wear, and remove respirators appropriately to avoid contamination. See Figure 4.12^[31] for CDC recommendations when wearing disposable respirators.

Figure 4.12

CDC Recommendations for Wearing Disposable Respirators

Respiratory Hygiene

Respiratory hygiene is targeted at patients, accompanying family members and friends, and health care workers with undiagnosed transmissible respiratory infections. It applies to any person with signs of illness, including cough, congestion, rhinorrhea, or increased production of respiratory secretions when entering a health care facility. See Figure 4.13^[38] for an example of a “Cover Your Cough” poster used in public areas to promote respiratory hygiene. The elements of respiratory hygiene include the following:

Figure 4.13

Cover Your Cough Poster

• Education of health care facility staff, patients, and visitors
• Posted signs, in language(s) appropriate to the population served, with instructions to patients and accompanying family members or friends
• Source control measures for a coughing person (e.g., covering the mouth/nose with a tissue when coughing and prompt disposal of used tissues, or applying surgical masks on the coughing person to contain secretions)
• Hand hygiene after contact with one’s respiratory secretions
• Spatial separation, ideally greater than 3 feet, of persons with respiratory infections in common waiting areas when possible.^[39]

Health care personnel are advised to wear a mask and use frequent hand hygiene when examining and caring for patients with signs and symptoms of a respiratory infection. Health care personnel who have a respiratory infection are advised to avoid direct patient contact, especially with high-risk patients. If this is not possible, then a mask should be worn while providing patient care.^[40]

Environmental Measures

Routine cleaning and disinfecting surfaces in patient-care areas are part of standard precautions. The cleaning and disinfecting of all patient-care areas are important for frequently touched surfaces, especially those closest to the patient that are most likely to be contaminated (e.g., bedrails, bedside tables, commodes, doorknobs, sinks, surfaces, and equipment in close proximity to the patient).

Medical equipment and instruments/devices must also be cleaned to prevent patient-to-patient transmission of infectious agents. For example, stethoscopes should be cleaned before and after use for all patients. Patients who have transmission-based precautions should have dedicated medical equipment that remains in their room (e.g., stethoscope, blood pressure cuff, thermometer). When dedicated equipment is not possible, such as a unit-wide bedside blood glucose monitor, disinfection after each patient’s use should be performed according to agency policy.^[41]

Sharps Safety

Injuries due to needles and other sharps have been associated with transmission of blood-borne pathogens (BBP), including hepatitis B, hepatitis C, and HIV to health care personnel. The prevention of sharps injuries is an essential element of standard precautions and includes measures to handle needles and other sharp devices in a manner that will prevent injury to the user and to others who may encounter the device during or after a procedure. The Bloodborne Pathogens Standard is a regulation that prescribes safeguards to protect workers against health hazards related to blood-borne pathogens. It includes work practice controls, hepatitis B vaccinations, hazard communication and training, plans for when an employee is exposed to a BBP, and record keeping.

When performing procedures that include needles or other sharps, dispose of these items immediately in FDA-cleared sharps disposal containers. Additionally, to prevent needlestick injuries, needles and other contaminated sharps should not be recapped. See Figure 4.14^[43] for an image of a sharps disposal container. FDA-cleared sharps disposal containers are made from rigid plastic and come marked with a line that indicates when the container should be considered full, which means it’s time to dispose of the container. When a sharps disposal container is about three-quarters full, follow agency policy for proper disposal of the container.

Figure 4.14

Sharps Disposal Containers

If you are stuck by a needle or other sharps or are exposed to blood or other potentially infectious materials in your eyes, nose, mouth, or on broken skin, immediately flood the exposed area with water and clean any wound with soap and water. Report the incident immediately to your instructor or employer and seek immediate medical attention according to agency and school policy.

References

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Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care. https://www​.cdc.gov/infectioncontrol​/basics​/standard-precautions.html ↵.

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Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www​.cdc.gov/infectioncontrol​/guidelines​/isolation/index.html ↵. [PMC free article: PMC7119119] [PubMed: 18068815]

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Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www​.cdc.gov/infectioncontrol​/guidelines​/isolation/index.html ↵. [PMC free article: PMC7119119] [PubMed: 18068815]

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Centers for Disease Control and Prevention (2019, April 29). Hand hygiene in healthcare settings. https://www​.cdc.gov/handhygiene/ ↵.

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The Joint Commission. (n.d.). Update: Citing observations of hand hygiene noncompliance. https://www​.jointcommission​.org/-/media/tjc​/documents/standards​/jc-requirements/ambulatory-care​/2018​/update_citing_observations​_of_hand_hygiene​_noncompliancepdf​.pdf?db=web&hash​=F89BFFFAEDA700CC2E667049D8F542B2 ↵.

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World Health Organization. (n.d.). My 5 moments of hand hygiene. https://www​.who.int/infection-prevention​/campaigns/clean-hands/5moments/en/ ↵.

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This work is derived from “Hand​_Hygiene_When_and_How_Leaflet.pdf” by World Health Organization and is licensed under CC BY-NC-SA 3.0 IGO. Access for free at https://www​.who.int/infection-prevention​/tools/hand-hygiene/workplace_reminders​/en/ ↵.

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This work is derived from “Hand​_Hygiene_When_and_How_Leaflet.pdf” by World Health Organization and is licensed under CC BY-NC-SA 3.0 IGO. Access for free at https://www​.who.int/infection-prevention​/tools/hand-hygiene/workplace_reminders​/en/ ↵.

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“How​_To_HandWash_Poster.pdf” by World Health Organization is licensed under CC BY-NC-SA 3.0 IGO. Access for free at https://www​.who.int/infection-prevention​/campaigns/clean-hands/5moments/en/ ↵.

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Centers for Disease Control and Prevention (2019, April 29). Hand hygiene in healthcare settings. https://www​.cdc.gov/handhygiene/ ↵.

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RegisteredNurseRN. (2018, December 1). Hand hygiene for healthcare workers | Hand washing soap and water technique nursing skill. [Video]. YouTube. All rights reserved. Video used with permission. https://youtu​.be/G5-Rp-6FMCQ ↵.

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Centers for Disease Control and Prevention. (2016, October 17). YouTube live handwashing presentation. [Video]. YouTube. All rights reserved. https://youtu​.be/LWmok9avzr4 ↵.

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“Surgery Centre Accriditation.jpg” by Accredia is licensed under CC BY-SA 4.0 ↵.

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Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www​.cdc.gov/infectioncontrol​/guidelines​/isolation/index.html ↵. [PMC free article: PMC7119119] [PubMed: 18068815]

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“poster-how-to-remove-gloves.pdf” by Centers for Disease Control and Prevention is in the Public Domain. Access for free at https://www​.cdc.gov/vhf​/ebola/resources/posters.html ↵.

21.

Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www​.cdc.gov/infectioncontrol​/guidelines​/isolation/index.html ↵. [PMC free article: PMC7119119] [PubMed: 18068815]

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“U.S. Navy Doctors, Nurses and Corpsmen Treat COVID Patients in the ICU Aboard USNS Comfort (49825651378).jpg” by Navy Medicine is in the Public Domain ↵.

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Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www​.cdc.gov/infectioncontrol​/guidelines​/isolation/index.html ↵. [PMC free article: PMC7119119] [PubMed: 18068815]

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“USNS Comfort (T-AH 20) Performs Surgery (49803007781).jpg” by Navy Medicine is in the Public Domain ↵.

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Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www​.cdc.gov/infectioncontrol​/guidelines​/isolation/index.html ↵. [PMC free article: PMC7119119] [PubMed: 18068815]

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Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www​.cdc.gov/infectioncontrol​/guidelines​/isolation/index.html ↵. [PMC free article: PMC7119119] [PubMed: 18068815]

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“fs-facemask-dos-donts.pdf” by Centers for Disease Control and Prevention is in the Public Domain. Access for free at https://www​.cdc.gov/coronavirus​/2019-ncov/hcp/using-ppe.html ↵.

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“Checking Personal Protective Equipment (PPE) in the fight against Ebola” by DFID - UK Department for International Development is licensed under CC BY 2.0 ↵.

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"PAPRs_in_use_01​.jpg" by Ca​.garcia.s is licensed under CC BY-SA 4.0 ↵.

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Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www​.cdc.gov/infectioncontrol​/guidelines​/isolation/index.html ↵. [PMC free article: PMC7119119] [PubMed: 18068815]

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“fs-respirator-on-off.pdf” by Centers for Disease Control and Prevention is in the Public Domain. Access for free at https://www​.cdc.gov/coronavirus​/2019-ncov/hcp/using-ppe.html ↵.

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RegisteredNurseRN. (2020, May 11). N95 mask - How to wear | N95 respirator nursing skill tutorial. [Video]. YouTube. All rights reserved. Video used with permission. https://youtu​.be/i-uD8rUwG48 ↵.

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RegisteredNurseRN. (2020, May 29). PPE training video: Donning and doffing PPE nursing skill. [Video]. YouTube. All rights reserved. Video used with permission. https://youtu​.be/iwvnA_b9Q8Y ↵.

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Centers for Disease Control and Prevention. (2020, July 14). Demonstration of donning (putting on) personal protective equipment (PPE). [Video]. YouTube. All rights reserved. https://youtu​.be/H4jQUBAlBrI ^↵.

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Centers for Disease Control and Prevention. (2020, April 21). Demonstration of doffing (taking off) personal protective equipment (PPE). [Video]. YouTube. All rights reserved. https://youtu​.be/PQxOc13DxvQ ↵.

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“cycphceng​.pdf” by Error! Hyperlink reference not valid. is in the Public Domain ↵.

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Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www​.cdc.gov/infectioncontrol​/guidelines​/isolation/index.html ↵. [PMC free article: PMC7119119] [PubMed: 18068815]

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Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www​.cdc.gov/infectioncontrol​/guidelines​/isolation/index.html ↵. [PMC free article: PMC7119119] [PubMed: 18068815]

41.

Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www​.cdc.gov/infectioncontrol​/guidelines​/isolation/index.html ↵. [PMC free article: PMC7119119] [PubMed: 18068815]

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“Sharps-Containers.jpg” by Federal Drug Administration (FDA) is in the Public Domain. Access for free at https://www​.fda.gov/medical-devices​/safely-using-sharps-needles-and-syringes-home-work-and-travel​/sharps-disposal-containers ↵.

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Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www​.cdc.gov/infectioncontrol​/guidelines​/isolation/index.html ↵. [PMC free article: PMC7119119] [PubMed: 18068815]

Principles of Aseptic Non-Touch Technique

Aseptic non-touch technique (ANTT) is the most commonly used aseptic technique framework in the health care setting and is considered a global standard. There are two types of ANTT: surgical-ANTT (sterile technique) and standard-ANTT.

Aseptic non-touch technique starts with a few concepts that must be understood before it can be applied. For all invasive procedures, the “ANTT-approach” identifies key parts and key sites throughout the preparation and implementation of the procedure. A key part is any sterile part of equipment used during an aseptic procedure, such as needle hubs, syringe tips, needles, and dressings. A key site is any nonintact skin, potential insertion site, or access site used for medical devices connected to the patients. Examples of key sites include open wounds and insertion sites for intravenous (IV) devices and urinary catheters.

ANTT includes four underlying principles to keep in mind while performing invasive procedures:

• Always wash hands effectively.
• Never contaminate key parts.
• Touch non-key parts with confidence.
• Take appropriate infective precautions.

Preparing and Preventing Infections Using Aseptic Technique

When planning for any procedure, careful thought and preparation of many infection control factors must be considered beforehand. While keeping standard precautions in mind, identify anticipated key sites and key parts to the procedure. Consider the degree to which the environment must be managed to reduce the risk of infection, including the expected degree of contamination and hazardous exposure to the clinician. Finally, review the expected equipment needed to perform the procedure and the level of key part or key site handling. See Table 4.3 for an outline of infection control measures when performing a procedure.

Use of Gloves and Sterile Gloves

There are two different levels of medical-grade gloves available to health care providers: clean (exam) gloves and sterile (surgical) gloves. Generally speaking, clean gloves are used whenever there is a risk of contact with body fluids or contaminated surfaces or objects. Examples include starting an intravenous access device or emptying a urinary catheter collection bag. Alternatively, sterile gloves meet FDA requirements for sterilization and are used for invasive procedures or when contact with a sterile site, tissue, or body cavity is anticipated. Sterile gloves are used in these instances to prevent transient flora and reduce resident flora contamination during a procedure, thus preventing the introduction of pathogens. For example, sterile gloves are required when performing central line dressing changes, insertion of urinary catheters, and during invasive surgical procedures. See Figure 4.15^[1] for images of a nurse opening and removing sterile gloves from packaging.

Figure 4.15

Sterile Gloves

See the “Checklist for Applying and Removing Sterile Gloves” for details on how to apply sterile gloves.

References

1.

"Book-pictures-2015-199-001-300x241.jpg," "Book-pictures-2015-215.jpg," and "Book-pictures-2015-219.jpg" by British Columbia Institute of Technology are licensed under CC BY 4.0. Access for free at https://opentextbc​.ca​/clinicalskills/chapter​/sterile-gloving/ ↵.

2.

RegisteredNurseRN. (2017, April 28). Sterile gloving nursing technique | Don/donning sterile gloves tips. [Video]. YouTube. All rights reserved. Video used with permission. https://youtu​.be/lumZOF-METc ↵.

References

1.

“DSC_0319-1024x678.jpg” by British Columbia Institute of Technology is licensed under CC BY 4.0. Access for free at https://opentextbc​.ca​/clinicalskills/chapter​/sterile-gloving/ ↵.

2.

“Book-pictures-2015-700.jpg," "Book-pictures-2015-706.jpg," "Book-pictures-2015-708.jpg," and "Book-pictures-2015-709.jpg” by British Columbia Institute of Technology are licensed under CC BY 4.0. Access for free at https://opentextbc​.ca​/clinicalskills/chapter​/sterile-gloving/ ↵.

3.

“DSC_0313.jpg” by British Columbia Institute of Technology is licensed under CC BY 4.0. Access for free at https://opentextbc​.ca​/clinicalskills/chapter​/sterile-gloving/ ↵.

Steps

Disclaimer: Always review and follow agency policy regarding this specific skill.

1.

Remove jewelry according to agency policy; push your sleeves above your wrists.

2.

Turn on the water and adjust the flow so that the water is warm. Wet your hands thoroughly, keeping your hands and forearms lower than your elbows. Avoid splashing water on your uniform.

3.

Apply a palm-sized amount of hand soap.

4.

Perform hand hygiene using plenty of lather and friction for at least 15 seconds:

• Rub hands palm to palm
• Back of right and left hand (fingers interlaced)
• Palm to palm with fingers interlaced
• Rotational rubbing of left and right thumbs
• Rub your fingertips against the palm of your opposite hand
• Rub wrists
• Repeat sequence at least 2 times
• Keep fingertips pointing downward throughout

5.

Clean under your fingernails with disposable nail cleaner (if applicable).

6.

Wash for a minimum of 20 seconds.

7.

Keep your hands and forearms lower than your elbows during the entire washing.

8.

Rinse your hands with water, keeping your fingertips pointing down so water runs off your fingertips. Do not shake water from your hands.

9.

Do not lean against the sink or touch the inside of the sink during the hand-washing process.

10.

Dry your hands thoroughly from your fingers to wrists with a paper towel or air dryer.

11.

Dispose of the paper towel(s).

12.

Use a new paper towel to turn off the water.

13.

Dispose of the paper towel.

Steps

Disclaimer: Always review and follow agency policy regarding this specific skill.

1.

Gather supplies (antiseptic hand rub).

2.

Remove jewelry according to agency policy; push your sleeves above your wrists.

3.

Apply enough product into the palm of one hand and enough to cover your hands thoroughly, per product directions

4.

Rub your hands together, covering all surfaces of your hands and fingers with antiseptic until the alcohol is dry (a minimum of 20-30 seconds):

• Rub hands palm to palm
• Back of right and left hand (fingers interlaced)
• Palm to palm with fingers interlaced
• Rotational rubbing of left and right thumbs
• Rub your fingertips against the palm of your opposite hand
• Rub your wrists

5.

Repeat hand sanitizing sequence a minimum of two times.

6.

Repeat hand sanitizing sequence until the product is dry.

Steps

Disclaimer: Always review and follow agency policy regarding this specific skill.

1.

Check the provider’s order for the type of precautions.

2.

Ensure that all supplies are available before check-off begins: isolation cart, gowns, gloves, mask, goggles/face shields, etc.

3.

Perform hand hygiene.

4.

Apply PPE in the correct order:

• 1st (GOWN): Gown should cover outer garments. Pull the sleeves down to the wrists, and tie at neck & waist.
• 2nd (MASK/RESPIRATOR): Apply surgical mask or N95 respirator if indicated by transmission-based precaution. Fit the mask around the nose and chin, securing bands around ears or tie straps at top of head and base of neck.
• 3rd (EYE PROTECTION): Apply goggles/face shield if indicated for patient condition or transmission-based precautions.
• 4th (CLEAN GLOVES): Pull on gloves to cover the wrist of the gown.

5.

Remove PPE in the correct order:

• 1st REMOVE GLOVES: REMEMBER: GLOVE TO GLOVE; SKIN TO SKIN. Do not touch contaminated gloves to your skin. Take off the contaminated glove with your gloved hand, wrapping the contaminated glove in the palm of your gloved hand. Take off the glove with your bare hand to the skin of your wrist, moving inside of the glove to remove the contaminated glove inside out over the other glove. Note: If the gown is tied in front, untie it prior to removing your glove.
• 2nd REMOVE GOWN: Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in a gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull the gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose in trash receptacle.
• 3rd PERFORM HAND HYGIENE.
• 4th REMOVE FACE SHIELD or GOGGLES: Carefully remove face shield or goggles by grabbing the strap and pulling upwards and away from head. Do not touch the front of face shield or goggles.
• 5th REMOVE MASK or RESPIRATOR: Do not touch the front of the face shield or goggles.
• Respirator: Remove the bottom strap by touching only the strap and bringing it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator.
• Face mask: Carefully untie (or unhook from the ears) and pull it away from the face without touching the front.
• 6th PERFORM HAND HYGIENE after removing the mask.

References

1.

Centers for Disease Control and Prevention. (2020, August 19). Using personal protective equipment (PPE). https://www​.cdc.gov/coronavirus​/2019-ncov/hcp/using-ppe.html ↵.

Steps

Disclaimer: Always review and follow agency policy regarding this specific skill.

1.

Gather the supplies: hand sanitizer and sterile gloves.

2.

Perform hand hygiene.

3.

Open the sterile gloves on a dry, flat, clean work surface.

4.

Remove the outer package by separating and peeling apart the sides of the package.

5.

Grasp the inner package and lay it on a clean, dry, flat surface at waist level.

6.

Open the top flap away from your body; open the bottom flap toward your body.

7.

Open the side flaps without contaminating the inside of the wrapper or allowing it to close.

8.

With your nondominant hand, use your thumb and index finger to only grasp the inside surface of the cuff of the glove for your dominant hand.

9.

Lift out the glove, being careful to not touch any surfaces and holding the glove no more than 12-18″ above the table without contaminating the sterile glove; carefully pull the glove over your hand.

10.

Use your nondominant, nonsterile hand to grasp the flap of the package, and hold the package steady. With the sterile glove on your dominant hand, hold 4 fingers together of the gloved hand to reach in the outer surface of the cuff of the sterile glove, reaching under the folded cuff and with the thumb outstretched to not touch the second sterile glove. Lift the glove off the package without breaking sterility.

11.

While holding the fingers of the nondominant hand outstretched and close together, tuck your thumb into the palm, and use the sterile dominant hand to pull the second sterile glove over the fingers of the nondominant hand.

12.

After the second sterile glove is on, interlock the fingers of your sterile gloved hands, being careful to keep your hands above your waist.

13.

Do not touch the inside of the package or the sterile part of the gloves with your bare hands during the process.

14.

Maintain sterility throughout the procedure of donning sterile gloves.

Removing Sterile Gloves

1.

Grasp the outside of one cuff with the other gloved hand. Avoid touching your skin.

2.

Pull the glove off, turning it inside out and gather it in the palm of the gloved hand.

3.

Tuck the index finger of your bare hand inside the remaining glove cuff and peel the glove off inside out and over the previously removed glove.

4.

Dispose of contaminated wastes appropriately.

5.

Perform hand hygiene.

References

1.

Open RN Project. (2021, November 11). Applying Sterile Gloves. [Video]. YouTube. Video licensed under CC-BY-4.0. https://youtu​.be/xj8EAjJGn98 ↵.

Learning Activities

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

You are caring for an elderly male patient who is experiencing urinary retention. The provider has just ordered an intermittent catheterization for the patient based on the results of a recent bladder scan of 375 mL. You gather the equipment and enter the patient’s room. Based on the five moments of hand hygiene, describe the instances in which you will sanitize your hands when working with the patient and performing the intermittent catheterization.

Based upon the information provided, which clinical scenarios require the use of soap and water (versus alcohol-based hand scrubs) for proper hand sanitization?

a.

Entry into patient’s room with no contact precautions

b.

Patient on Clostridium Difficile (C-Diff) contact precautions

c.

Prior to Foley catheter insertion for a patient with no contact precautions

d.

Hands are visibly soiled