By Margaret Heale, RN, MSc, CWOCN
Hi blog buddies,
Matron Marley is taking a vacation to allow her writer (me) to vent. The problem I see has evolved since the introduction of a 'clean dressing technique' over the last 15 years or so, and has little foundation in the distant past when Matron wandered the wards instilling dread into unsuspecting students as she put them 'on the spot'. This problem is most definitely a current problem and it needs attention.
The Prevalence of Unacceptable Clean Dressing Technique
I have traveled and worked in over 10 different environments in the US, from a 500 bed acute care hospital in New York to a small Vermont community critical access unit; a New Hampshire teaching hospital to community nursing agencies, nursing homes and busy city acute rehab facilities. The problem is widespread and needs to be addressed. "Why now?" you might ask. Well it started with a WOCN forum question from a colleague: "why are nursing schools still teaching wet-to-dry dressings?" She had quite a few responses and before I responded I decided to ask the three clinical teachers I know. One said they teach it because it is on "the boards", another added it ensures they can use a sterile technique and the other said, "It makes sure they know how dressings should be done." None of them taught clean technique.
I once asked an RN what the difference between a sterile technique and clean technique and (with tongue in cheek) he quickly responded, "Isn't that something to do with the five second rule?" I thought it funny then, but now I am not laughing at all because what I see scares me.
I have witnessed all of the situations below and been given no excuses, reasons or apologies for the blatant lack of basic cleanliness. Those items with the asterix, the nurses said when queried about the procedure, something similar to "Oh - we just use a clean technique here."
- Iodosorb tube covered in product, especially the grooved white top.
- Scissors used for removing a heavily soiled wrap then used to cut a dressing that was used to pack the wound. The portion of the primary dressing cut off was kept to be used for another dressing change a few days later.
- *A sterile field opened and packets opened and laid on it. Gloves were put on to remove the dressing, then worn to open up a bottle of saline and then clean the wound. The saline was kept for the next dressing change.
- *Clean gloves used to remove the dressing then open a debridement kit. The PA went on to run the same gloved finger along an exposed tendon and palpate exposed bone, as she pointed out the structures to a student.
- A soiled chux left in place while the wound was sprayed with skin cleanser (later noted to have stool on the handle.)
- Scissors used for cutting the ostomy wafer used to cut a primary dressing.
- Dressing field set up with a plant/urinal and hair brush within a foot.
- An experienced WOC nurse taking down a heavily soiled venous leg ulcer dressing without gloves on and then went on to clean the wounds, dress and wrap the wound without any hand hygiene at all (gloves were used for the cleaning and dressing).
- A bedside technique used for a NPWT dressing and the sponge dropped on the sheet more than once, picked up and placed in the wound.
- Dirty, blood soaked dressing removed and placed on the patient's bed-table.
I am infuriated that nurses think any of these are accepted as clean technique. I have watched materials management filling up shelves in a store room, and items fall on the floor. They are picked up and put with everything else, on the shelf (and that is fine). The nurse then opens one of these packets, removes gauze and with the same gloves, irrigates and cleans the wound. In many facilities, they would use just clean gloves to hold the moist gauze with the wound cleanser changing hands, back and forth.
Where do the gloves come from? One nursing home where I worked took gloves from the patient's bathroom to use for dressing changes. I was doing ostomy care recently and asked for another pair of gloves and the nurse brought over the box, no hand gel, just a box of gloves for me to dip my sweaty little digits in (but I didn't). How many times a day do you reach in and take gloves, then do your hands?
I have also watched aghast as a pharmacy tech unloads creams for the cupboard onto the floor before placing them on a shelf. I then went to watch a burn dressing done and the tubes were handled expertly to get every last drop of cream out, the gloves handling them were different from those that dressed the wounds, and I was impressed but wondered "is it always so?"
I have seen nurses put on sterile gloves then open cotton swab packets, place a clean chux over a soiled one, operate the bed to get it the correct height and answer their phone, then try to continue with the dressing. I have searched a cupboard for a dressing only to find a piece of Mepilex foam drifting about, a pair of scissors goopy from having cut Xeroform and a tube of Santyl under everything and with no lid on it. None of this is clean dressing technique, it is dirty and sloppy!
It is not all bad. Nurses do sometimes ask "should I change gloves," is this or that "okay," so many of them are thinking and taking care as they go, but many, many are not.
The Argument for Sterile Gloves in Chronic Wounds
The idea that once wounds are open (and become chronic) they become colonized, so it is acceptable to use 'clean' rather than sterile gloves in them, makes no sense at all to me. These wounds are colonized so let them stay colonized with their bacteria, let us not introduce more and please let us not spread what is in the wound around and about. As for a so called clean technique not making any difference to infection rates, experience elsewhere in the world seems to differ (Rowley 2010).
So why am I writing this, you ask? Well, I had to update our wound care policy and to my distress have to admit that a clean technique will become the norm at our facility. I read through some old policy documents and found a short list of the principles of asepsis. I then looked at the WOCN fact sheet and wrote my document but then, I just had to write this.
I hope you find it useful. It is basically an aseptic technique using clean gloves and no direct wound contact (except minimally to blot excess fluid away with dry gauze). It does allow for using spray wound cleansers and keeping a portion of a dressing for the next dressing change.
Do every dressing as though you are a master of your craft teaching a student.
Principles of a Truly Clean Dressing Technique
Aim: to ensure that contamination of the wound, any supplies and the environment is minimized.
- Hands should be washed before starting and decontaminated before/after glove changes.
- Contamination of the wound is minimized by not touching it. Blotting excess fluid that pools in the wound and cleaning the periwound skin with moist gauze is acceptable.
- Sterile gloves should be worn if it is necessary to directly touch the wound and these gloves should not contact anything other than the wound or the sterile products being used on it.
- 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 at a later date.
- 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 sterile gloves.
- 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, stored in the original package, sealed, labeled with the name of patient, dated and put in a Ziplock bag.
- Store all dressing materials out of heat and light.
- In a highly contaminated wound (stool or dirt), clean gloves may be used to handle moist gauze while cleaning debris from the wound.
Click on the image below for a printable PDF version of the cheat sheet
Rowley S, Clare S, Macqueen S, Molyneux R. (2010). ANTT v2: An updated practice framework for aseptic technique. British Journal of Nursing. 2010;19:S5-S11.
Surgical Site Prevention and Treatment of Infection. NICE guidelines 2008
Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, Regent’s Park, London NW1 4RG.
Wound, Ostomy and Continence Nurses Society Wound Committee. Clean vs. Sterile Dressing Techniques for Management of Chronic Wounds: A Fact Sheet. Journal of Wound, Ostomy & Continence Nursing. 2012;39(2S):S30-S34.
About The Author
Based on her extensive nursing experience Margaret Heale, Wound, Ostomy and Continence Nurse, takes us into the blog journal of a fictitious matron, "Perspective of Nursing Care from Past to Future by Matron Marley."
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.