It is well known that chronic and hard-to-heal wounds have created a global crisis. Delayed healing in these wounds is often associated with biofilm, and antimicrobial dressings can be effective in managing bioburden in chronic wounds. For the use of antimicrobial advanced wound care dressings...
By Margaret Heale, RN, MSc, CWOCN
Editor's note: This blog was originally published on December 24, 2014. It was updated and republished on December 11, 2020.
Reduce the Spread of Glitter
I had shopped before lockdown and had not needed to go to a supermarket for a while. Before my first big shopping event, I came across this online video: preventing your kitchen getting contaminated from your shopping.1 I smiled at the thought of people trying to use an aseptic technique in their kitchen while trying hard not to contaminate the kitchen, its contents, or themselves with imagined glitter (or coronavirus). As I ruminated, my thoughts wandered to dressing technique, so I did a search on YouTube. What I came across rather surprised me.
I watched three clips on dressing procedure2-4 and most notably observed that:
- Sterile packet contents were unnecessarily placed on a clean Chux
- Multiple Chux were used
- Gloves were not changed between cleaning the wound and placing the dressing
- The outside of the packets was handled with gloves used to clean the wound
- There was no clean, absorbent surface between the operator and the wound
- One dressing was picture framed instead of fully covered with tape
It is not easy to make such videos, and to be honest, every dressing is slightly different either because of the differences among primary dressings, basic policy differences among home health, hospital, and rehabilitation units, and the type and position of the wound. All of these make a one-size-fits-all video approach a daunting prospect.
The 2012 joint guideline of the Association for Professionals in Infection Control and Epidemiology (APIC) and the Wound, Ostomy and Continence Nurses Society (WOCN) on clean versus sterile technique5 has had no recent revision but stands up well currently. It starts with defining sterile and clean technique. Sterile dressings are applied using a sterile field and instruments, with contamination managed by ensuring sterile-to-sterile transfers. With clean technique, a clean field is set, but some sterile instruments and package contents may be handled with clean gloves, so the sterile-to-sterile transfers are not practiced. A sterile technique minimizes the possibility of contamination, and a clean technique attempts to do the same but using a clean field and clean gloves. Sterile instruments may be used, and some gauze and primary dressings may be kept for use at the next dressing change. A clean dressing procedure takes less time and is less costly. A single operator manages clean technique much more easily, but a sterile technique poses difficulty if there is no second person to assist, and this can lead to breaks in sterility and thus contamination.
Kent et al.6 conducted a literature review to produce an evidence-based report card for WOCN. The conclusion was that for acute wounds, clean technique does not increase the incidence of wound infection, but there is insufficient evidence to say the same for chronic wound care. The document goes on to state that to reduce the risk for infection when performing wound care, clinicians must critically analyze the technique to be used based on the patient’s overall status, wound type, and wound location. This is very sound advice because performing a dressing on a patient with exposed structures who is compromised calls for much more care and attention to detail than changing a bordered foam dressing on a skin tear. Critical thinking is the key.
A Few Helpful Rules (The Wound Is Full of Glitter—Don’t Let It Get Everywhere)
Utilizing the guidelines from WOCN and APIC, the following list was compiled to help ensure good clean technique.
- The aim is to ensure that contamination of the wound, any supplies, and the environment is minimized (or preventing the spread of glitter).
- Hands should be washed before starting and decontaminated before and after each glove change.
- Contamination of the wound is minimized by not directly touching it. Blotting excess fluid that pools in the wound and cleaning the periwound skin with moist gauze are acceptable. Removing debris with clean gloves and gauze is also widely practiced in wounds that are chronic or highly contaminated with stool or dirt. Sterile gloves may be worn if it is necessary to touch a deep wound directly, and these gloves should not contact anything other than the wound or the sterile products being used on it. This is particularly important if structures such as bone or tendon are present, if working in a hospital environment, or if the patient is immunocompromised. Sterile gloves are recommended for changing central line dressings and catheterization (including in the patient’s home).
- Contamination of the wound from supplies is avoided by opening and preparing all that is needed before removing the dressing and putting on fresh clean gloves.
- Contamination of the local environment and supplies is avoided by organizing the procedure to ensure that anything coming into contact with the wound does not contact jars, bottles, tubes, bedside table, or supplies to be kept for use later.
- A non-porous material should protect the surface under the wound.
- A clean field should replace the protective barrier before placing the dressing.
- The outer surface of the dressing should not be touched by gloves used to clean the wound (even if the gloves were sterile). This applies to tape and any wraps used for the dressing.
- If it is necessary to fully handle a dressing to tuck or pack it in the wound, use of sterile gloves should be considered for institutions, but they generally are not considered necessary in the patient’s home.
- Provided a primary dressing is dry and not contaminated, it may be kept for the next dressing change. This means it should be cut aseptically with sterile scissors (please consider in home health that the patient’s own scissors may cut meat, flowers, and hair). Cut dressings should be stored in the original package, sealed, labeled with the name of patient, dated, and put in a Ziplock bag. Finding cut Xeroform in a bag of supplies is concerning.
- Store all dressing materials off the floor and out of heat and light, preferably not in the bathroom.
Using these guidelines for decisions about dressing a wound requires access to materials, some idea of the type of wound being dressed, and the best procedure to be used. It is helpful to think of a dressing procedure in three main parts, after handwashing and with hand decontamination between each part.
- Organizing materials and positioning the patient: This ensures the patient is prepped (pain relief given, privacy ensured). An absorbent surface placed between the wound and the operator. Products are to hand and packets and bottles are open and ready.
- Cleaning the wound: Irrigating with a wound cleanser is easiest, by picking the spray bottle up with the non-dominant gloved hand and using the other hand first to clean debris off the wound and then, with fresh gauze, to clean and dry the periwound skin. To finish the process the periwound skin protectant should be applied and the absorbent field should be turned back or discarded. Gloves are removed, and the hands are decontaminated.
- Dressing the wound: Tape, wraps, or net may be prepared, and dressing packets may be opened (using the inside surface as a clean field can be useful). Hands are decontaminated, and the primary dressing is placed (with gloves if contamination may occur). The tape, wrap, or net should not be applied with gloves that have touched the wound (for example, a dressing ribbon may have been placed and tucked into the wound with the gloves on).
Having the wound care supplies listed and the order written out within the framework of set procedural details is immensely helpful if it is customized and kept brief. For example:
It is essential to ensure that staff members know what is expected of them. Clear, helpful policies are important, but competencies or checklists with peer review can help staff and managers to ensure that best practice is continued. Staff members need to know it is essential that they have a physician’s order and that they decontaminate their hands before and after every glove change, with care taken to change gloves at appropriate times. It is not acceptable to use scissors from their pocket or bag to cut a primary dressing. A clean field is necessary between them and the wound during cleaning the wound and a fresh one to place the dressing.
Critical thinking skills are not easily built into nursing, particularly because of our order-driven, tick-box, computer algorithm world. Self-assessment (reflective practice) and clinical supervision from a peer are helpful especially if they are structured within the employee evaluation process. Most importantly, “Apply every dressing as if you are a master of your art teaching a student,”
1. VanWingen J. Preventing your kitchen getting contaminated from your shopping. https://www.youtube.com/watch?reload=9&v=TKx-F4AKteE. Accessed November 30, 2020.
5. Association for Professionals in Infection Control and Epidemiology and the Wound, Ostomy and Continence Nurses Society. Guideline. 2012.
6. Kent DJ, Sardillo JN, Dale B, Pike C. Does the use of clean or sterile dressing technique affect the incidence of wound infection? J Wound Ostomy Continence Nurs. 2018;45(3):265-269.
Canadian Agency for Drugs and Technologies in Health. Use of single-use sterile dressings from a previously opened package in the community setting: safety, harms, and guidelines. 2012. cadth.ca/media/pdf/htis/june-2012/RB0507%20Single-Use%20Dressings%20Final.pdf. Accessed November 30, 2020.
Gray M. Doughty D. Clean vs. sterile dressing techniques for management of chronic wounds: a fact sheet 14. J Wound Ostomy Continence Nurs. 39(2 suppl):S30–S34.
Nazarko L. Good hygiene when dressing wounds. Nursing in Practice. 2016. https://www.nursinginpractice.com/clinical/good-hygiene-when-dressing-wo.... Accessed November 30, 2020
Rowley S, Clare S, Macqueen S, Molyneux R. An updated practice framework for aseptic technique. Br J Nurs. 2010;19:S5S11.
Snowdon DA, Leggat SG, Taylor NF. Does clinical supervision of healthcare professionals improve effectiveness of care and patient experience? A systematic review. BMC Health Serv Res. 2017;17:786.
Surgical Site Prevention and Treatment of Infection. NICE Guidelines 2008 London, United Kingdom: RCOG Press; 2008.
About the Author
Margaret Heale has a clinical consulting service, Heale Wound Care in Southeastern Vermont and draws on her extensive experience as a wound, ostomy and continence nurse in acute and long-term care settings to provide education and holistic care in her practice.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.