Integrative review of the clean and sterile technique: agreement and disagreement in the execution of dressing

Revisión integrada de la tecnica limpia y esteril: consensos y controversias en la realización de curaciones

Abstracts

OBJETIVO: Analisar a literatura que descreve aspectos que envolvem a técnica limpa e estéril no cuidado de feridas. MÉTODOS: Trata-se de uma revisão integrativa da literatura, nas bases de dados Lilacs, Medline e Cinahl. RESULTADOS: Dentre as sete publicações identificadas, quatro compararam a técnica limpa e estéril do ponto de vista da ocorrência ou não de infecção; duas avaliaram a segurança microbiológica das luvas e uma analisou a solução de limpeza. CONCLUSÃO: É consenso que a técnica limpa reduz custos. Considerando a escassez de estudos, ressalta-se a necessidade de mais pesquisas de níveis I e II, segundo a hierarquia de evidências.

Assepsia; Bandagens; Infecção da ferida operatória; Esterilização

ARTICLE REVISION

Integrative review of the clean and sterile technique: agreement and disagreement in the execution of dressing

Revisión integrada de la tecnica limpia y esteril: consensos y controversias en la realización de curaciones

Adriano Menis Ferreira^I; Denise de Andrade^II

^IPhD. Professor of the Nursing Department - Universidade Federal do Mato Grosso do Sul- MS – Campus Três Lagoas

^IIAssociate Professor of the Department of General and Specialized Nursing – Universidade de São Paulo (USP) at Ribeirão Preto College of Nursing - Ribeirão Preto (SP), Brazil

^{Corresponding Author}

ABSTRACT

OBJECTIVE: This study aimed to describe, analyze, and categorize the evidence associated to the use of the clean and sterile technique in wounds.

METHODS: It is an integrative literature review using Lilacs, Medline and Cinahl databases.

RESULTS: Seven publications were found,, of which four compare the clean and sterile technique, regarding the occurrence of infection; two evaluate the microbiological safety of gloves, and one analyzed the cleansing solution.

CONCLUSION: There is consensus that the clean technique reduces costs. Considering the scarcity of studies, we stress the need to perform more level I and II research, according to the evidence hierarchy.

Keywords: Asepsis; Bandages/utilization; Surgical wound infection/nursing , Sterilization/methods

RESUMEN

OBJETIVO: Este estudio tiene como objetivo describir, analizar y categorizar las evidencias asociadas al uso de la técnica limpia y estéril en curaciones.

MÉTODOS: Se trata de una revisión integrada de la literatura en las bases de datos Lilacs, Medline y Cinahl.

RESULTADOS: Se tuvo un total de 7 publicaciones de las cuales 4 compararon la técnica limpia y estéril desde el punto de vista de la ocurrencia o no de infección; 2 evaluaron la seguridad microbiológica de los guantes y 1 analizó la solución de la limpieza.

CONCLUSIÓN: Es consenso que la técnica limpia reduce costos. Considerando la escasez de estudios se resalta la necesidad de más investigaciones de nivel I y II según la jerarquía de evidencias.

Descriptores: Asepsia; Vendajes/utilización; Infección de herida operatoria/enfermería; Esterilización/métodos

INTRODUCTION

Scientific and technological advancements demand specific knowledge and constant learning from health professionals in order to provide the highest quality of service.

The issue on a clean and sterile technique started in the 1970s, when Jack Lapides introduced the intermittent bladder catheterization concept with the clean technique. His work was considered audacious and groundbreaking by medicine and nursing professionals⁽¹⁾.

The use of a sterile technique has been frequently questioned in many fields, including medicine^(2-8). Particularly regarding wound care, there is little agreement on using tweezers or procedure or sterile gloves; and concerning the type of solution and bandage^*. The lack of research aiming to provide scientific evidence of these care practices certainly strengthens procedures based on myths and rituals.

Yet, basic nursing literature instruct to make a dressing from the cleaner to the most infected area, and, to reach this objective, sterilized tweezers should be used when removing the old dressing and making a new one^(9-10). Some nursing textbooks^(9-14) are unanimous in describing the dressing technique in sequential steps with their respective justifications emphasizing the wound infection control.

Within this context, advancements in microbiology, among other areas, have supported the recommendations of important and reputed organizations, such as the Agency for Healthcare Research and Quality, Association for Professionals in Infection Control and Epidemiology, Ostomy Continence Nurses Society, as well as many other studies^{(1,3,5,8,15-17)}. Despite the expressive involvement of international entities, the indication of the clean and sterile technique remains controversial when performing many procedures, for instance, making dressings.

There appears to be an agreement on the execution of some asepsis practices, with both the clean and sterile technique. Asepsis, therefore, is defined as the reduction of the microbial infection of live tissues, fluids, or materials by eliminating, removing, or killing the microorganisms. The aseptic technique is a general expression used for asepsis methods⁽¹⁸⁾.

In general, the sterile technique involves practices that promote maximum reduction in microbial load by means of microorganism-free objects, such as: washing hands, using sterile fields, gloves, tools, and bandages. In this technique, it is possible to touch what is sterile with another sterile object or tool. Breaking the "barrier" or touching any other non-sterile surface or product should be avoided⁽¹⁹⁾.

Regarding the clean technique, the use of procedure gloves and sterile tools is recommended, in addition to asepsis principles, which includes environment and hands. Such technique can be called "non sterile"^(18-19).

Considering the importance of an evidence-based practice, this study attempts to answer the following question: does the clean technique in dressings keep microbiologic safety, and, consequently, avoids predisposition to the risk of infection?

Therefore, the objective of this study was to analyze scientific articles that describe aspects regarding the clean and sterile technique on wound care.

METHODS

A literature review was performed using the database from Literatura Latino Americana em Ciências de Saúde (Lilacs), Medical Literature and Retrivial System on Line (Comprehensive Medline) and Cumulative Index to Nursing & Allied Health Literature (Cinahl). All the articles associated to the use of clean and sterile techniques in dressings were analyzed, apart from their publication date. The keywords for obtaining these articles were: acute wound, chronic wound, clean technique and sterile technique.

The theoretical framework adopted was evidence-based practice (EBP), which emphasizes the use of research to guide clinic decision and requires learning specific skills for the different processes used to assess articles in an analytical and reflexive fashion. Therefore, the EBP combines research and the professional's clinic competence and the patient's preferences to make a decision about a specific problem⁽²⁰⁾.

Evidence is defined as the presence of facts or signs that clearly show that something exists and is true, in other words, evidence is the proof or demonstration that this "thing" may legally be submitted to the assessment of the veracity of an issue^(21-22).

A six-level classification was proposed to assess the evidence from the studies⁽²¹⁾. This classification considers the methodological approach of the study, the outline used in the research and its strictness (Chart 1).

The systematic analysis of the articles involved: authorship, year, serial, objectives, outlining or design, and main results and recommendations.

RESULTS

In Lilacs and Cinahl databases, none of the articles met the purpose of this study. In Medline, seven articles were found (Chart 2).

The themes of the articles were: occurrence of infection with the clean and sterile technique (4), microbiological safety of gloves (2) and cleansing solution (1).

The Chart 2 presents a synthesis of the articles included in the present integrative review.

DISCUSSION

The data from the present study were very useful for the beginning of discussions on the clean and sterile technique in dressings.

One study⁽²⁵⁾ compared the clean and sterile technique in providing care to 30 patients with gastrointestinal surgeries that had their wounds healed secondarily. The subjects were divided into two groups of 15 patients each (clean and sterile technique) and studied from three to nine days. All of them had homogeneous variables. There were no statistical differences in the healing rate of the studied groups; there was only a reduction in the cost in the clean technique.

Regarding the solution used for cleaning wounds, a non-randomized clinic study⁽²³⁾ with 617 patients with traumatic soft tissue wounds compared the use of sterile saline solution and tap water. The wounds were cleaned by means of irrigation with saline solution, for seven weeks, or with tap water for the same period. The nurses who analyzed the wounds did not know which solution was being used for wound cleaning. Despite the methodological fragility and considering that there was no description about the clean technique, among other confusing variables of this study, the incidence of infection in wounds irrigated with tap water was 5.4% compared to 10.3% with sterile saline solution , for pd"0.05. Still, it presented a cost reduction of approximately 50% with tap water.

In the 1980s, there were some questions about the use of sterile and procedure gloves for routine care, such as changing dressings in burned patients. It is important to state that the literature is limited on the kind of gloves to wear and in non-invasive procedures⁽³⁾.

Therefore, there was an evaluation on whether the use of procedure gloves was safe enough in the burning unit, in non-invasive procedures, such as changing dressings. All the 26 boxes presented some kind of bacteria, inside or outside, and the highest incidence was the Staphylococcus aureus. This organism was found in seven (64%) of the boxes and in the patients' wounds. In order to prevent crossed infection⁽³⁾ it suggests that the use of the same box for two or more patients should be avoided.

A study with stomal therapy nurses (n=240) showed that over 80% used the clean technique for pressure and vascular ulcers, and 60% used it whatever the problem was (hypoxia, damaged perfusion, malnutrition, radiotherapy or immunosupression). The stomal therapy nurses used the clean technique the least in neonate patients (38%) compared to pediatric patients (60%). On the other hand, they used it in places of long term and home care (73%) when compared to hospitalized patients (55%). This explained the patients' instruction to perform the clean dressing technique when leaving the hospital. The global average of choosing the clean technique was 70%, ranging from 55% to 80% with a median of 60%⁽²⁴⁾.

Another study used a questionnaire to evaluate the use of sterile and procedure gloves for wound care. This study involved 723 nurses in five different health care units, and emphasized on the variability of indications of sterile and procedure gloves in clinical practice. Sterile gloves, in general, were indicated for deep wounds, with pus, tunnelized and exposed fractures. Procedure gloves were indicated for changing pressure ulcer and whole surgical wound dressings. Moreover, when comparing community and hospital nurses, less than a third of those in charge of home care use sterile gloves (33%) compared to hospital nurses (80%). These indicators were influenced by the place of care, professional education and clinical experience⁽²⁵⁾.

The aforementioned studies evaluated procedure gloves regarding their microbiota and compared the use of sterile and procedure gloves, in many clinical situations, with a view to find differences in the infection rate. Another research about microbial contamination was performed in 29 glove boxes. The first pairs, which were aseptically donned, presented an average contamination of 1.8 colony forming units, and the most frequent microorganism was the negative coagulasis Staphylococcus. The contamination rate and the microbiological density did not show significant changes with the position in the box. The routine use of gloves compared to the aseptic use increased the contamination rate in 11% and microbial density with an average of 3.4 colony forming units per pair. The period that the boxes remained open was not associated with the contamination of the last aseptically donned pair. Half the pairs of gloves were sterile despite the constant contact of the professionals with the boxes.

The infection rate and the cost were evaluated⁽²⁶⁾, in the clean and sterile technique in surgical wound dressings with healed secondary healing. The study was performed in two surgical units three months before and after implementation of the clean technique implementation. Before the implementation of the new technique, there were nine cases of surgical wounds. After three months using the clean technique, the infection rate was of eight wounds, which is not a statistically significant result. Another aspect shown in this study was the cost reduction.

Wound infection is one the major concerns of professionals who deal with this problem, not only due to the increase of trauma for the client but also because of the costs resulting from the infection process^(27). Thus, one may infer that what will determine wound healing is the interaction with the host rather than the presence of microorganisms⁽²⁸⁾.

CONCLUSION

The evidence found is not sufficient to elaborate recommendations for clinical practice.

Sendo assim, a elaboração de pesquisas com delineamentos do tipo experimental contribuirá na tomada de decisão dos profissionais quanto à uniformização de condutas relacionadas à técnica limpa e estéril.

Therefore, experimental studies will contribute with professionals when they have to decide about the standardization of sterile and clean technique practices.

Received article 15/03/2007 and accepted 28/05/2007

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Corresponding Author:

Denise de Andrade

Av. Bandeirantes, 3900

Monte Alegre - Ribeirão Preto - SP

CEP. 14040-902

E-mail: [e-mail]

*

The term dressing is used to refer to the several products manufactured to treat wounds, regardless of becoming in touch with the wound bed or not. Bandage, however, refers to the process of wound care.

Publication Dates

• Publication in this collection
  24 Apr 2008
• Date of issue
  Mar 2008

History

• Accepted
  28 May 2007
• Received
  15 Mar 2007