Haesler E et al. A systematic review of the literature ... · addressing asepsis in wound management ... of aseptic technique in wound management over the ... A systematic review

Wound Practice and Research 208

A systematic review of the literature addressing asepsis in wound management

ABSTRACTThere has been extensive ongoing debate on the application of aseptic technique in wound management over the previous decades and changes to the way in which theory is applied to clinical practice have occurred regularly. Clinicians often express confusion over the way various techniques should be applied, particularly when practising in clinical settings in which maintenance of strict asepsis is inherently difficult (for example, community-based wound management). Wound cleansing, use of open but unused

wound dressings and storage of wound management equipment are frequent issues on which clinicians request guidance. A systematic review using Joanna Briggs Institute methods was undertaken in order to establish the current state of the scientific literature on this topic and inform the development of recommendations for practice in this field. All levels of evidence were included in the review, including opinion papers. Findings from the 20 quantitative studies were reported in narrative summary and findings from 37 qualitative research papers were aggregated in a thematic synthesis. Although high-level evidence on wound cleansing solutions was identified, the review concluded that there is a paucity of scientific literature on most topics related to asepsis in wound care.

Keywords: Asepsis, wound cleansing, aseptic non-touch technique, handwashing, infection control.

INTRODUCTIONWound infection has a large impact on individuals and the health care system. Precise incidence rates are difficult to determine due to the many types of wounds and various methods of diagnosing and tracking wound infection. As many as 60% of chronic wounds have infection in the form of demonstrated presence of surface bacteria or invasive biofilm1,2. Rates of surgical site infection vary substantially based on surgical site3; however, recent estimates suggest 10–12% of all surgical wounds become clinically infected4. Infection rate in lacerations is cited at 5%5, and rate of biofilm in all acute wounds is approximately 6%2.

Facility-acquired wound infection is of particular concern given the increasing significance of antibiotic-resistant bacteria. Infection control procedures are first-line strategy to prevent infection spread6. Given the impact of wound infection and significance of infection control practices in reducing its incidence, it is important that clinicians understand the implementation of infection control procedures when managing wounds. Historically, there have been major changes to aseptic theory in wound management7-9. Surveys indicate clinicians experience confusion about how to implement aseptic technique and other infection control principles10,11.

Within Australia, the introduction of a standard on health care-associated infection12 and publication of a national

Haesler E, Thomas L, Morey P & Barker J

Haesler E et al. A systematic review of the literature addressing asepsis in wound management

Emily Haesler*PhD, BN, PostGradDipAdvNurs(Gerontics)Adjunct Associate ProfessorCurtin University, School of Nursing, Midwifery and Paramedicine, WA, AustraliaHonorary AssociateLa Trobe University, Australian Centre for Evidence Based Aged Care, Vic, AustraliaEmail: [email protected] +61 2 6244 2946

Lyn ThomasRN, NP, BHlthSci(Nurs), MNP Community and Aged Care Services,Greater Newcastle Sector, Hunter New England Local Health District, NSW, Australia

Pam MoreyMN, NP, STN, PhD(C)Nurse Practitioner, Advanced Wound Assessment Service, Silver ChainNurse Practitioner Course CoordinatorCurtin University, WA, Australia

Judith BarkerRN, NP, BHlthSc(Nurs), MNPNurse Practitioner — Wound ManagementAdjunct Associate Professor, University of Canberra, Synergy: Research Centre for Nursing and Midwifery Practice, CanberraCanberra Hospital, ACT Health, ACT, Australia

* Corresponding author

Volume 24 Number 4 – December 2016209

infection control policy13 led to a demand for updated wound management procedures. Wounds Australia established a working party to develop clinical guidance on procedures associated with prevention and control of wound infection. To inform the development of this document, a systematic review (SR) was undertaken.

AIMSThe objective of this review was to identify the contemporary evidence addressing topics associated with aseptic technique and infection control in wound management. Specific aims were to identify evidence related to cleaning considerations when performing a wound procedure, techniques for wound cleansing, environmental considerations in performing wound management and ways in which wound dressings can be handled and stored aseptically.

REVIEW METHODSThe review was undertaken using methods published by the Joanna Briggs Institute (JBI)14,15. An initial search was conducted in MEDLINE, CINAHL, EMBASE, Current Contents and the Cochrane library. All papers published in English up to October 2015 that related to topics outlined in the aims were eligible for inclusion. All research designs, qualitative research and opinion papers were eligible for inclusion; however, news items, letters and conference abstracts were excluded. Papers related to aseptic technique in the operating room, intravenous therapy or catheterisation were excluded. Search terms and MESH headings included: asepsis, non-touch technique, aseptic technique, steriliz/sation, disinfection, microbial and bacterial contamination, hospital, healthcare and community-acquired infection. These terms were used in combination with terms associated with wound care, wound dressings, equipment storage, cleansing, and equipment recycling. The working party reviewed the search strategy to ensure it captured the intended literature. On review of the evidence it was noted by the working party that significant changes in theory and practice have occurred in the field of aseptic technique. It was determined that inclusion would be limited to papers published between January 2000 to October 2015 in order that the review findings reflect contemporary knowledge. References cited in included manuscripts were also considered for inclusion.

All papers meeting inclusion criteria were critically appraised by two independent reviewers using the JBI suite of appraisal tools. For randomised controlled trials (RCTs) and pseudo-RCTs, critical appraisal evaluated randomisation, blinding, allocation concealment, withdrawals, comparability and equivalent treatment of participants, outcome measurement and statistical analysis14. Consistent with JBI appraisal, RCTs and pseudo-RCTs were ranked as high quality or lower15. For descriptive studies and case series, process for randomisation, sample inclusion, outcome measurement, management of confounders, participant withdrawal and data analysis were evaluated14. These studies received a

ranking of low or very low quality15. For interpretive and critical research, congruity of philosophies, methodology, research methods and analysis was evaluated, as well as reflexivity14. Qualitative research was ranked as high quality or lower15. Textual and opinion papers were evaluated based on source and logic of opinion and arguments, focus, referencing and support from peers14 and ranked as low or very low quality15.

Data extraction used standardised JBI tools. Quantitative results were not appropriate for meta-analysis as they generally addressed different topics, had heterogeneous methods, or were meta-analyses. These results are reported in a narrative format. Qualitative studies and opinion papers were analysed to identify themes, concepts and meanings within the research14, with identification of primary findings that were grouped in categories based on similarity in meaning. The categories were meta-aggregated in syntheses.

IDENTIFIED RESEARCHThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram16 is presented in Figure 1. The searches initially identified over 2,000 potential studies that was reduced to 57 papers that met inclusion criteria and were critically appraised. As indicated in Figure 1, most studies were excluded in the first review of the flagged references due to having insufficient focus on the topic of this review.

Of the 57 included papers, 14 were quantitative research papers17-30, six were SRs31-36, three were qualitative research papers10,11,37 and 34 papers were non-research articles7-9,38-68. The quantitative research consisted of six RCTs18,21,23,25,26,29 (level 1.c evidence) that were of low or moderate quality15. There was one very low quality before/after study22 (level 2.d evidence), five observational studies17,19,20,28,30 (level 2 and 3 evidence), one very low quality cohort study24 (level 3.c evidence) and a very low quality cross-sectional study27 (level 4.b evidence). The SRs31-36 (level 1 evidence) ranged in quality from low to very high and the qualitative research10,11,37 (level 3 evidence) was of moderate to high quality. The majority of findings in this review arose from textual papers providing low and very low quality evidence. Table 1 presents summaries of the research papers.

Quantitative results from the literature

Cleansing solutions and technique

SRs and studies exploring irrigation fluids received the most attention in quantitative research. As the individual studies18,19,21,23,26,29 (Table 1) were included in identified SRs, only SR results are reported below; however, none of the individual RCTs established significant differences in infection rates between wounds cleansed with sterile solutions versus tap water18,19,21,23,26,29.

A high quality SR36 compared sterile saline (n=326) to tap water (n=257) for cleansing lacerations, acute and chronic wounds. Pooled results from two RCTs showed no significant



difference in wound infection rates, with tap water slightly less likely to result in infection (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.36 to 1.72, p=0.55)36.

A moderate quality Cochrane SR33 compared cleansing methods for lacerations, open fractures, chronic and surgical wounds. Infection rate in all wound types (3 RCTs) was not significantly different between tap water cleansing and no cleansing (relative risk [RR] 1.06, 95% CI 0.07 to 16.50, p=not significant [ns]). There was no difference in infection rates in all acute sutured wounds (3 RCTs) between tap water versus sterile saline irrigation (RR 0.66, 95% CI 0.42 to 1.04, p=ns). Cost-effective analyses favoured tap water33. This Cochrane review reached the same conclusions as earlier systematic reviews by the same research team34,35.

A low quality SR compared tap water to sterile saline. Significantly more wounds cleansed with sterile saline became clinically infected (saline 7.1% versus tap water 4.3%, RR 0.62, 95% CI 0.39 to 1.01, p=0.05). There was no significant difference in wounds with positive cultures (saline 3.1% versus tap water 4.4%, RR 1.53, 95% CI 0.79 to 2.99, p=0.21)31.

A low quality SR compared bathing to no bathing for post-surgical foot wounds. Normal hygiene groups showered at 1–5 days postoperative (n=1,639). Patients abstaining from foot hygiene waited until sutures/staples removal (n=511). There were no significant differences in surgical site infection rates in any study32.

Although confounding factors are noted (for example, administration of saline at cooler temperatures than water) when controlled for these factors the outcomes did not change. Findings from the high-level evidence31,33-36 indicated no increase in wound infection rates associated with cleansing wounds in tap water.

Reuse of wound dressing products

A moderate quality observational study investigated rate of contamination of opened hydrogel products. The products were opened after handwashing, using clean gloves and away from direct patient care. After 28 days, one package from 60 random samples returned a positive bacterial culture. The sample collection technique may not reflect clinical practice17. A very low quality observational study reported contamination rates for opened dressings and reusable equipment stored in different containers in patients’ homes. After 14 days, 75% of samples (n=21) were contaminated30. Another low quality observational study investigated contamination rates for randomly selected multi-use saline flasks stored in hospital settings. Approximately half of the samples were found to be contaminated20.

Wound dressing practice

In a low quality RCT, leaving surgical wounds uncovered after surgery (n=235) was compared to wound dressings applied in the operating theatre (n=216). Patients were reviewed after seven days for clinical signs of infection and no significant difference in infection rates was found (exposed wounds 1.7% versus covered wounds 1.4%, p=ns)25.

Figure 1: PRISMA review flowFigure 1: PRISMA review flow

Original references flagged in searches as potentially meeting inclusion criteria (n> 2,000)

Excluded: (n=86) Published prior to 2000 (n=33) No unique information, summarises studies already included (n=19) Not focused on aseptic technique (n=12) Letters, abstracts, duplicate reports (n=12)Low quality, including no methods or no results reported (n=5) Libraries unable to obtain (n=3) Not wound care related (n=3)

Excluded as not sufficiently related to topic, letters to editor, duplicate reports and conference abstracts (n=37)

Full review against inclusion criteria and critically appraised (n=143)

Review of title/abstracts against inclusion criteria (n=180)

Included studies (n=57): Systematic reviews (n=6) Quantitative research (n=14) Qualitative studies (n=3) Non-research papers (n=34)

Excluded: duplicate references (majority of studies), not sufficiently related to topic (n>1,820)



A very low quality cohort study compared sterile (n=1,070 admissions) and clean (n=963 admissions) dressing procedures for surgical wounds. The outcome measure was positive wound culture established by wound swab. There was no significant difference in surgical site infection rates (0.84% versus 0.83%, p=ns) and the clean procedure was faster (10 minutes versus 13 minutes)24.

Aseptic technique education and behaviours

A very low quality before/after study investigated an education program delivered to medical students. The course was based on principles associated with handwashing and dressing procedures. After 10 weeks, there was a significant decline (p<0.001) in the ratio of students who were able to achieve a pass mark in the assessment, indicating the education had no prolonged influence on practice. Poor role modelling and lack of resources were identified as contributing to poor outcomes22. A very low quality observational study reported clinical practice amongst nurses in community settings. Practice was established through direct observation and validated in interviews with participants. As many as 40% of nurses did not engage in handwashing before a procedure28.

Qualitative results from the literature

Three hundred and eighty-six findings were extracted from qualitative studies and non-research articles. Using the JBI ratings15, 60 of the findings were rated as unequivocal, 218 were rated as credible and 20 findings were rated as unsupported, generally where an assertion was made without any supporting reference. These findings were grouped in 65 categories and aggregated into 23 syntheses (Figure 2).

Current evidence base

Synthesis 1: Research on wound cleansing and aseptic technique is insufficient and that which is available is poorly translated into practice.

There is a lack of research on aseptic techniques9,65. Inconsistencies in terminology and practice guidance, and ongoing change to theory interpretation has a negative impact on compliance7-9. The need for more research on aseptic technique, including translation to different clinical settings was highlighted38,44,48.

Handwashing practices

Six categories aggregated into two syntheses represented textual findings on handwashing.

Synthesis 2: Liquid alcohol rub, antimicrobial hand wash or soap and water can be used for washing hands. When hands are visibly soiled, use soap and water.

Articles referred to three handwashing solutions: alcohol-based rubs, antiseptic/antimicrobial hand washes and soaps/detergents. Alcohol rub has broad spectrum activity51 and is quick to apply without the need for water8,40,45,50,51,55,57,59. A small risk of fire from alcohol exposed to a heat source before complete evaporation45 and potential for dry hands are

reported. Some texts suggest alcohol-based hand rubs are not appropriate when hands are visibly soiled40,55. Antiseptic or antimicrobial hand wash with water is suggested for cleaning visibly dirty hands40,45,51,55 although it may be more expensive or cause irritation51. Antimicrobial-impregnated towels are an alternative for visibly clean hands, but not a replacement for soap and water40,45,55. Opinion articles agreed that soap and water is appropriate for visibly soiled hands40,49,51,55,64.

Synthesis 3: Handwashing should occur before and after patient contact, regardless of the use of gloves, and consist of vigorous rubbing for at least 15 to 30 seconds.

Hands should be washed before/after patient contact, or after contact with body fluids, to prevent cross-contamination7,40,55,56,64. Use of gloves does not preclude the need to wash hands40,55-57,59 because hands may become contaminated when removing gloves56. Handwashing should be a vigorous process covering all hand surfaces using soap and water or an alcohol rub40,55,59. Most papers suggested that handwashing should take at least 15 seconds40,55; however, one suggested at least 30 seconds59.

Gloves and personal protective equipment

Three syntheses related to the use and selection of gloves, and one related to other personal protective equipment.

Synthesis 4: Gloves are required to prevent contamination and cross-infection; however, they do not replace routine handwashing.

Textual findings highlighted that the primary purpose of gloves is to prevent contamination, between the patient and the nurse, or cross-infection between different anatomical sites on the same patient40,44,51,55,59. It was suggested that gloves are worn when there is a risk of coming into contact with bodily fluids or non-intact skin40,55; when removing old wound dressings45; and for invasive activities51. Use of gloves does not preclude handwashing45,57, regardless of the implementation of double-gloving45. Findings suggested gloves be removed immediately following care40,55.

Synthesis 5: Selection of gloves is guided by the procedure to be performed, risk of contamination, latex allergies and cost.

Synthesis 6: Sterile gloves are required for surgical aseptic non-touch technique, surgery and invasive aseptic procedures and clean gloves are for non-sterile procedures/standard aseptic non-touch technique.

Level of expected direct contact with susceptible sites44,53,57 should guide glove selection. Latex allergy influences glove choice44,50,59, and some texts identified the increased cost of sterile gloves as a factor in selection59,62. There was agreement that sterile gloves are required for sterile procedures44,48,51,57,61. Within the literature ‘sterile procedures’ referred to invasive activities44,51 surgical procedures44, aseptic technique44,



aseptic non-touch technique (ANTT) requiring direct contact with key parts61, and delivering sterile pharmaceuticals44. Clean, non-sterile gloves were suggested for removing old wound dressings48, performing clean procedures48 and performing procedures that do not require direct contact with the key parts61.

Synthesis 7: Wearing appropriately selected personal protective equipment helps to reduce the risk of cross-infection from exposure to body fluids or airborne contamination.

Personal protective equipment is designed to reduce the risk of contamination for both the patient and clinician57,64. When protective equipment is used, the clinician is protected from body fluid exposure (for example, blood splashes)51,57 and the patient is protected from the clinician as a source of infection risk59. Textual findings focused on using plastic aprons51,59 with selection of equipment based on the level of risk of body fluid exposure64.

Wound management environment

Two syntheses addressed the general and specific environment in which wound management is conducted.

Synthesis 8: Actions should be taken to reduce airborne and other infection risks in the home and hospital to ensure wound care is conducted in a clean environment.

The requirement for a clean environment, free from airborne and other infection risks was described51,61,64. The risk posed by carpets, soft furnishings and pets was reported64. Strategies to reduce environmental risk included reporting infection risk in the home to authorities64, ensuring there are cleaning routines that incorporate the ventilation and water supplies64; reducing airborne infection by closing windows, reducing foot traffic and turning off fans64; leaving the wound exposed for the shortest time64; and disposing of waste promptly and appropriately64.

Synthesis 9: A wound management field can be established on a clean surface in a space at low risk of environmental contaminants. Once established, introduction of contaminated external objects should be avoided.

The importance of establishing a sterile local field on a clean surface8,57,64 was discussed. Strategies for establishing a sterile field in a clean environment included using a visually clean dressing trolley57 or cleaning a hard surface with a broad spectrum disinfectant64. In the community, a plastic apron or lid could be used8,64. Considering the wound, an extension of the wound management field was suggested7, as was ensuring the wound management field remains sterile57. Findings were consistent that objects external to the wound and field should not contaminate the wound management field7,57,61. Clinicians could use either a critical aseptic field into which only sterile equipment is introduced (for example, for an invasive or extensive procedure) or a general aseptic field in which key parts are individually protected within the field (for example, for a simple wound procedure)61.

Cleansing solutions and technique

Eighteen categories were aggregated into six syntheses related to wound cleansing.

Synthesis 10: An ideal wound cleanser should adequately clean the wound, not cause cell damage or sensitivity and have a long shelf life.

The principle of doing no harm and preventing infection were highlighted as guiding the choice of wound cleanser9. Consideration to the toxicity of a cleanser and its potential to cause sensitivity was highlighted42,63. Using an expired product should be avoided57 by selecting a wound cleanser with a long shelf life42,63. The ability to effectively remove organic material and reduce bioburden are other considerations42,63.

Synthesis 11: An assessment should be conducted by the interdisciplinary team to determine if a wound bed should be cleansed, and if so, the cleansing process to use.

Not all wound beds require cleansing as a wound may heal without disruption if there are no visual contaminants or signs of infection39,58. The wound management team could work together to determine the best approach for individual patients9,39,58.

Synthesis 12: Normal saline, potable tap water, sterile water and low concentration antimicrobial solutions are safe and effective wound cleansers. Antiseptics are not a good choice for wound cleansing.

Sterile saline is an isotonic solution that has no impact on tissue repair processes42,46; therefore it is a safe and traditional option62, particularly in hospital environments46 or for vulnerable wounds9. Tap water, sterile water and normal saline were all reported as safe; however, none of these solutions reduces bioburden in the wound42,46,56,57,67. Antimicrobial solutions reduce bioburden63,67, although concentrations should be selected carefully in light of potential cell toxicity63,67. Use of skin cleaners and antiseptics in wound cleansing is warned against39,42,58,63. Cell toxicity42,58,63, potential carcinogenicity41, insufficient contact time with the wound to effectively reduce bacteria levels39 and association with antibiotic-resistant bacteria39 were concerns.

Synthesis 13: Apply a wound cleanser at a lukewarm temperature with consideration to the potential for cross-infection and using low pressure to irrigate the wound bed.

Irrigation at a low pressure (4 to 15 pounds per square inch) using a syringe or faucet tubing is suggested for promoting debris removal without disrupting granulating tissue42,56,62,65. Applying fluid at lukewarm temperature avoids vasoconstriction that lowers tissue healing capacity9,45,46,54,62,66. The potential for cross-infection between patients, or contaminated water from dirty body areas flowing over a wound are considerations when washing in a shower9,54,58. Directing fluid flow appropriately when irrigating54 was noted as another strategy to prevent cross-infection.



Synthesis 14: Good quality tap water is a cost-effective option for cleansing dirty wounds, chronic wounds and wounds with closed or sutured edges, although it may cause pain.

Benefits and disadvantages of tap water were discussed39,42,46,54,56,58,62,66. Water was noted as acceptable for sutured39, sacral/perineal56, open traumatic56, and chronic56 wounds, and wounds with sealed edges39. Ensuring high quality water is important54,56,62,66, although commentators noted that in cities with monitored and drinkable tap water it is sufficiently safe for wounds54,56,62,66. Texts suggested using running tap water for at least 30 seconds62 or soaking wounds in a bucket58. Higher, constant pressure62, large fluid volumes62, patient satisfaction66 and reduced time66 are advantages of water. Lack of additional equipment (for example, syringes) contributes to the cost-effectiveness of water46,54,62,66. However, there is potential that water may cause pain due to increasing osmotic pressure46.

Synthesis 15: Precautions can be taken to reduce the risk of potential contamination of water sources.

Another disadvantage is the potential for contaminated tap water9,41. One commentator suggested a risk of acquiring virulent pathogens or biofilm from hospital water41. This risk may be higher for immunocompromised patients41. However, precautions can be taken41,42,56. Water filters41, running taps for a few minutes before using the water42 and evaluating the water storage and delivery before use9 were suggested.

Selecting wound care technique and equipment

Four syntheses addressed selection of wound care techniques and equipment.

Synthesis 16: Selection of sterile/surgical ANTT or clean/standard ANTT is determined by the level of risk posed to the patient by his or her health status, the environment, factors associated with the wound and the type of wound management procedure being performed.

The infection risk from the surrounding environment is one consideration in selecting a wound management technique7,37,44,57,60,61,68. Findings illustrated that both the health care setting7,37,44,68 and the storage of equipment68 influences the ability to maintain a sterile or aseptic environment. The complexity of the procedure is a contributing factor, for example extensive debridement, wound packing and necessity to touch key parts were considered more invasive and requiring greater precautions44,51,57,60,61,68. Patient-related factors (for example, immune status) may also contribute to the risk of infection from a dressing procedure7,44,57,60,68. The chronicity, depth and location of the wound also contribute to selection of a technique7,44,50,56,57,68. Rigorous asepsis was considered to be inappropriate for chronic wounds50,56,57,68.

Synthesis 17: Simple wound management procedures on low-risk patients can be performed with non-sterile but clean equipment, solutions and gloves. More complex procedures or procedures in higher risk patients require surgical aseptic

non-touch technique, using sterile gloves, solutions and equipment.

Textual findings referred to clean technique/standard ANTT and aseptic technique/surgical technique/surgical ANTT. The first technique is appropriate for routine dressing changes without surgical conservative debridement and simple procedures lasting less than 20 minutes37,61,68. This technique was reported to involve a clean surface, non-sterile gloves and clean equipment and irrigation fluids (for example, tap water)37,61,68. The surgical ANTT requires sterile gloves and equipment and a sterile irrigation fluid, with a strict aseptic field37,56,57,61,68. The findings suggested this procedure was appropriate for patients at high infection risk, wounds requiring surgical conservative debridement, complex/invasive procedures with many key parts or procedures lasting longer than 20 minutes56,57,61,68. One commentator suggested that this should be standard practice56.

Synthesis 18: Wound management equipment should be single use or cleaned with alcohol preparations. Using cleansers and wound dressings in smaller packages reduces waste and contamination risk.

Ensuring products are cleaned appropriately via sterilisation, disinfection or decontamination is important57,61,64. Using alcohol preparations or wipes and vigorously rubbing equipment to remove visual soiling cleans reusable products61,64, although single-use products may be easier, especially in community settings64. Wastage of excess products was noted as a concern, especially from dressing packs with pre-selected materials that are not always appropriate for the procedure8,11. Selecting smaller packages to reduce waste or risk of contamination from reusing products was suggested45,65.

Synthesis 19: When performing surgical ANTT the wound management field must remain free of non-sterile items, including equipment, cleansing fluids and gloved hands that have touched a non-sterile object.

Commentary highlighted the importance of all sterile equipment being free from potentially contaminated objects, including water that had touched surrounding skin during washing or forceps that had touched the wound bed7,8,43,51,68. One text referred to a dirty hand or forceps/a clean hand or forceps7. The difficulty clinicians have in manoeuvring forceps was raised7,56, and using a gloved hand for parts of a procedure was proposed as an optional wound management method7,8,56, if the potentially contaminated hand could be maintained away from the wound management field7,68.

Managing patients with known infection

Synthesis 20: Extra infection control precautions should be taken for people with known infection.

One opinion article addressed infection control for patients with known methicillin-resistant Staphylococcus aureus (MRSA)49. Findings indicated that clinicians should take



additional precautions by thoroughly disinfecting surfaces, putting down plastic sheeting and using disposable equipment when possible49. Reusable equipment could be cleaned immediately49. Double-bagging waste products before disposal may reduce cross-infection49. Diligence is required in handwashing and the use of personal protective equipment49.

Product storage

Synthesis 21: Wound management products should be stored in dry, clean environments to reduce risk of contamination and cleansers should be dated on opening and discarded if visually contaminated or according to organisation policy.

Storing dressing products in a clean, dry space was suggested56,64. Wound cleansers should be dated and refrigerated on opening, although there is no set time frame after which they should be disposed45. One commentator mentioned discarding fluids if there is visual contamination, or to follow the organisation policy45. Risks posed by storing gloves in a manner that attracts mould or contamination were noted50,62.

Structural support

Two syntheses summarised eight categories related to structural support for aseptic technique and infection control.

Synthesis 22: Staff education that incorporates skills practice, simulation learning, theoretical knowledge update and procedures for different clinical settings is essential in promoting best practice in aseptic technique and infection control.

Importance of education was highlighted8,11,38,39,44,49-51,57,59,64. Some references suggested that clinicians develop ritualistic practice and may not fully understand theoretical concepts8,11,39. Qualitative studies indicated that community nurses experience frustration and have fatalistic attitudes11 that may influence the way in which they perform wound care10. Ongoing reinforcement of knowledge and skills through regular education using simulation learning53,57, visual feedback (for example, dye in handwashing exercises)59, hands-on practice with feedback64 and didactic lectures53 is suggested.

Synthesis 23: Best practice in aseptic technique and infection control procedures is promoted through development of facility policies, regular risk surveillance, annual auditing of staff practice, engaging with staff and patients and provision of acceptable hand hygiene products.

Regular risk surveillance7,50,59,64 promoting a culture of clinicians identifying risks50, and root cause analysis64 were highlighted as promoting quality improvement. Engaging with staff and patients by working with a wound champion to promote best practice38,64, empowering patients to ask clinicians about hand hygiene59 and ensuring adequate staffing levels may promote best practice51. Commentators

proposed incorporating annual handwashing audits into quality improvement programs8,38,40,55,59. The importance of local policies and procedures was raised8,48,61, especially for topics for which there is insufficient evidence to make recommendations48. Finally, provision of products that are acceptable to clinicians (for example, low allergen) may promote handwashing40,55.

DISCUSSIONThere was general agreement between the quantitative and qualitative/textual findings in this review. Use of potable tap water for irrigation received the most attention, and findings from SRs, RCTs and non-research articles were in agreement that for many wound types, cleansing with good-quality, lukewarm tap water does not increase risk of wound infection18,20,21,23-26,29,32-36,39,42,46,54,56,58,62,66. This evidence should be considered when selecting appropriate and cost-effective wound management techniques.

Limited evidence was available on other topics of interest. No significant evidence was identified regarding strategies for managing opened wound dressing packages and minimal commentary on the advantages and risks of this practice was identified. One moderate quality study17 suggested reusing hydrogel products may be safe if the product was dispensed in controlled conditions. A very low quality study suggested contamination of opened wound dressings is an issue in community settings30 and commentators suggested using smaller packages to reduce waste45,65. There was also limited evidence on methods of performing aseptic technique, with technique details often derived from unreferenced opinion sources61. There is a strong need for well-designed studies exploring these issues.

There was a paucity of evidence on environmental factors in conducting wound care identified in the available literature. There was agreement that the environment in which wound care is conducted should be clean51,61,64, with guidance generally focused on strategies to address the potential risk from airborne contamination51,61,64. Practical solutions for maintaining asepsis in home care settings were provided8,51,61,64; however, the evidence supporting these practices was at best minimal.

This review is not without limitations. Foremost, the literature search was limited to journal articles. Reports12 and guidelines13,69 also inform this topic; however, these resources are developed from the existing body of evidence and are not specific to wound management. The search terms used for this review focused specifically on asepsis in wound management. It is probable that evidence on some included topics is available in the broader literature. Except for evidence related to irrigation, the evidence was primarily from non-research texts of low and very low quality and this should be considered when evaluating the adoption of the suggestions into practice. It should be noted that theory and translation in this field has changed substantially over time. The reviewers attempted to identify a cut-off date in order



to exclude outdated concepts; however, given that much of the findings were opinion, some ideas may be anachronous.

CONCLUSIONSThe findings of this systematic review highlighted the lack of high-level evidence in many clinical areas associated with aseptic wound management practice. There is a need for further research in this field to establish with certainty the procedures that are necessary to prevent and control wound infection. Until such research exists, guidance based on the

current evidence base, evidence derived from other clinical procedures (for example, intravenous therapy), broader guidelines12,13,69 and expert opinion is required to assist facilities in developing local policies and procedures.

ACKNOWLEDGEMENTSSue Atkins and Liz Howse undertook second review of some papers included in this systematic review.

Wounds Australia contributed to the funding of the systematic review.

1

Figure 2: Thematic analysis of qualitative research and textual findings

Findings Category Synthesis

(Level 1 findings) (Level 2 findings) (Level 3 findings)

Synthesis 1

Research on wound cleansing and aseptic technique is insufficient and that which is available is poorly translated into practice

Finding 1 Inadequate advice on translating evidence into practice has led to variety in ways clinicians incorporate wound cleansing into aseptic technique.8 [C] Finding 2 There is inconsistency in irrigation technique between trials, particularly with respect to volume and pressure.9 [UE] Finding 3 Research conducting on irrigating acute wounds may cannot be extrapolated to diabetic foot ulcers, especially those with exposed tendon and bone.9 [C] Finding 4 Changes in wound care theory and practice can cause confusion for students and practising health professionals.7 [UE] Finding 5 Debate over use of clean versus aseptic technique have a negative impact on compliance with standardised technique.8 [C]

Category 1 Inconsistencies and changes in interpretation of evidence and theory related to wound cleansing into clinical practice has a negative impact on compliance.

Finding 6 Previous evidence on optimal pressure for removing bacteria while preventing contamination and disruption to wound healing is based on small studies and may not be reliable.65 [C] Finding 7 Studies investigating cleansing have inadequate sample sizes and have methodological limitation (e.g. do not ensure cleansers are equivalent temperature). 9 [C]

Finding 8 There is insufficient evidence to provide comprehensive recommendations for appropriate cleansing methods for traumatic wounds.65 [C]

Finding 9 More research is needed on how nurses currently perform wound care and the effectiveness of different wound care strategies.48 [UE] Finding 10 More research on the effectiveness and implications of different dressing technique is required.38 [C] Finding 11 Further research and evidence is required on influence of clean vs sterile gloves in aseptic techniques.48 [C]

Category 3 More research is required on aspects of performing aseptic technique.

Category 2 There is insufficient good quality existing evidence on wound cleansing.

[UE] unequivocal [C] credible [US] unsupported

1




Synthesis 1

Research on wound cleansing and aseptic technique is insufficient and that which is available is poorly translated into practice

Finding 1 Inadequate advice on translating evidence into practice has led to variety in ways clinicians incorporate wound cleansing into aseptic technique.8 [C] Finding 2 There is inconsistency in irrigation technique between trials, particularly with respect to volume and pressure.9 [UE] Finding 3 Research conducting on irrigating acute wounds may cannot be extrapolated to diabetic foot ulcers, especially those with exposed tendon and bone.9 [C] Finding 4 Changes in wound care theory and practice can cause confusion for students and practising health professionals.7 [UE] Finding 5 Debate over use of clean versus aseptic technique have a negative impact on compliance with standardised technique.8 [C]

Category 1 Inconsistencies and changes in interpretation of evidence and theory related to wound cleansing into clinical practice has a negative impact on compliance.

Finding 6 Previous evidence on optimal pressure for removing bacteria while preventing contamination and disruption to wound healing is based on small studies and may not be reliable.65 [C] Finding 7 Studies investigating cleansing have inadequate sample sizes and have methodological limitation (e.g. do not ensure cleansers are equivalent temperature). 9 [C]

Finding 8 There is insufficient evidence to provide comprehensive recommendations for appropriate cleansing methods for traumatic wounds.65 [C]

Finding 9 More research is needed on how nurses currently perform wound care and the effectiveness of different wound care strategies.48 [UE] Finding 10 More research on the effectiveness and implications of different dressing technique is required.38 [C] Finding 11 Further research and evidence is required on influence of clean vs sterile gloves in aseptic techniques.48 [C]

Category 3 More research is required on aspects of performing aseptic technique.

Category 2 There is insufficient good quality existing evidence on wound cleansing.

[UE] unequivocal [C] credible [US] unsupported



Wound Practice and Research 216 2



Category 5 Antimicrobial hand wash can be used to wash hands that are visibly soiled.

Synthesis 2

Liquid alcohol rub, antimicrobial hand wash or soap and water can be used for washing hands. When hands are visibly soiled, use soap and water.

Finding 12 Alcohol rub cannot remove spores, does not have persistent antibacterial activity, is flammable, does not remove soiling and can cause dry hands if used frequently.51 [C] Finding 13 When hands are not visibly soiled they can be cleaned with an alcohol-based hand rub.40,55 [C] Finding 14 Alcohol rub has broad spectrum activity that is simple, has fast action, is cost effective and contains emollient.51 [C] Finding 15 When using alcohol-based hand rubs, rub hands together after application until all alcohol has evaporated to reduce the small risk of fire.45 [C] Finding 16 Alcohol rub is faster to use than soap and water.59 [C] Finding 17 Alcohol based hand gels can be used as often as required without the need for soap and water washes in between applications.45 [C] Finding 18 Use an alcohol based hand rub.57 [C] Finding 19 Liquid aqueous alcohol rub can be used for hand washing instead of soap and water.50 [C] Finding 20 In the community setting, alcohol gels can be used for effective hand hygiene.8 [C]

Finding 26 Visibly dirty hands or those contaminated with protein material should be washed with soap and water.40,55 [UE] Finding 27 Wash visibly soiled hands with soap and water rather than alcohol rub.49 [UE] Finding 28 Hand hygiene can be achieved through washing with either soap and water or using alcohol decontaminant.64 [UE] Finding 29 Plain detergent, warm water and paper towels remove visible soiling and reduce skin irritation.51 [UE]

Category 4 Liquid alcohol rub can be used for washing hands, ensuring the all alcohol evaporates after application.

Category 6 Regular soap and water can be used to wash visibly soiled hands.

Finding 21Antiseptic hand wash, warm water and paper towel remove visible soiling, and have residual activity against microbes for approximately 6 hours.51 [C] Finding 22Antiseptic hand wash, warm water and paper towel is expensive, require nearby sink and waste bin, is time consuming and may irritate the skin.51 [C] Finding 23When hands are visibly soiled they can be cleaned with antimicrobial soap and water.40,55 [C] Finding 24Antimicrobial impregnated towels are not an acceptable replacement for alcohol based hand rubs or antibacterial soap. 45 [C] Finding 25Antimicrobial impregnated wipes are an alternative to non-antimicrobial soap and water but are not a replacement for alcohol hand rub or antimicrobial soap and water.40,55 [C]


Volume 24 Number 4 – December 2016217 3



Category 8 Hands should be washed before and after wearing gloves.

Finding 30 Preventing contamination of the wound from dirty hands by implementing rigorous handwashing is the most effective way to prevent wound infection.7 [UE] Finding 31 Hands should be washed before direct contact with patients, after contact with patients and after contact with body fluids, including wound dressings.40,55 [C] Finding 32 Hands should be washed when moving from a contaminated part of the patient to a non-contaminated part of the patient during care.40,55 [C] Finding 33 Handwashing frequency should be determined based on patient and clinician factors.56 [C] Finding 34 Hands should be washed before and after touching the patient, before and after aseptic procedures, after body fluid exposure and after touching patient surroundings.64 [UE]

Finding 39 When using soap and water, hands should be rubbed together vigorously covering all surfaces for at least 15 seconds.40,55 [C] Finding 40 When using alcohol-based hand rub hands should be rubbed together, covering all surfaces until the hands are dry.40,55 [C] Finding 41 Hand disinfectants should be used for at least 30 seconds.59 [UE]

Category 7 Hands should be washed before and after patient care to prevent contamination.

Category 9 Hands should be rubbed vigorously for 15 to 30 seconds, covering all hand surfaces.

Finding 35 Wash hands before and after using sterile gloves.57 [C] Finding 36 Handwashing should be conducted before and after procedures, even if gloves are worn.59 [UE] Finding 37 Hands should be washed after wearing gloves because hands could become contaminated under the gloves or when the gloves are removed.56 [C] Finding 38 Hands should be washed after removing gloves.40,55 [UE]

Synthesis 3

Hand washing should occur before and after patient contact, regardless of the use of gloves, and consist of vigorous rubbing for at least 15 to 30 seconds.





Category 11 Gloves do not replace hand washing.

Synthesis 4

Gloves are required to prevent contamination and cross infection; however, they do not replace routine handwashing.

Finding 42 Gloves should be worn when contact with blood or non-intact skin could occur.40,55 [UE] Finding 43 Gloves should be changed when moving from a contaminated patient site to a non-contaminated patient site.40,55 [C] Finding 44 Gloves should be removed when patient care is completed.40,55 [UE] Finding 45 Gloves are required for all procedures to protect nurses and patients from infection.59 [C] Finding 46 Aim of wearing gloves is to reduce cross infection, reduce contamination of hands or to protect the hands from chemicals.48 [UE] Finding 47 Gloves must be worn when removing an old dressing to prevent risk of cross-contamination.45 [C] Finding 48 Sterile gloves are required for invasive activities to protect the patient and health professional.51 [C]

Category 10 Gloves prevent contamination and cross infection.

Finding 49 After removing gloves, wash hands with either antiseptic hand wash or antiseptic rub.45 [C] Finding 50 Double gloving is not an acceptable replacement for washing hands (with either soap and water or an antiseptic rub) and donning new gloves.45 [C] Finding 51 Gloves are not a substitute for hand hygiene.57 [C]

Category 14 Cost is a consideration in selecting gloves.

Finding 56 Selection of gloves should be based on any allergies of nurse and patient.48 [C] Finding 57 Selection of gloves should be considered carefully due to latex allergy risks.59 [C] Finding 58 Before using latex gloves, assess the risk of latex allergy of the nurse and the patient.50 [UE]

Synthesis 5

Selection of gloves is guided by the procedure to be performed, risk of contamination, latex allergies and cost.

Finding 52 If forceps are used sterile gloves are not required for aseptic non touch technique.53 [C]

Finding 53 Selection of gloves should be based on their purpose. 48 [C] Finding 54 Selection of clean versus sterile gloves should be determined by level of expected contact with the wound.57 [C]

Finding 55 Selection of gloves should be guided by a risk assessment that includes assessment of contact with susceptible sites or devices, type of potential contamination and whether it is a sterile or a non-sterile task.48 [C]

Category 12 The type of procedure, level of contact and risk of contamination influence the choice of glove types.

Finding 59 Selection of gloves should be considered carefully due cost factors.59 [C] Finding 60 Sterile gloves are costly and may lead to requiring an assistant.62 [C]

Category 13 Latex allergy is a consideration in selecting gloves.





Finding 70 When performing sterile procedure, clean gloves are used for removing the old dressing.48 [C] Finding 71 Clean gloves may be contaminated from other staff taking gloves from the box; however, evidence shows this risk does not influence wound infection rates.62 [C] Finding 72 When performing clean procedure, two pairs of clean gloves are required, one for removing the old dressing and one for applying a new dressing.48 [C] Finding 73 Clean, non-sterile gloves may be an acceptable alternative to sterile gloves.56 [C] Finding 74 Use clean non-sterile gloves if there is no requirement to touch key parts in an aseptic non-touch technique.61 [US]

Finding 61 Sterile gloves should be worn for surgical wound dressings and surgical procedures. 48 [C] Finding 62 Sterile gloves should be worn for procedures requiring aseptic technique.48 [C] Finding 63 Sterile gloves should be worn for invasive procedures and insertion of invasive devices, especially in immune compromised patients.48 [C] Finding 64 Sterile gloves should be worn for administering sterile pharmaceutical preparations.48 [C] Finding 65 Sterile gloves are required for invasive activities to protect the patient and health professional.51 [C] Finding 66 Sterile gloves are required for invasive activities to protect the patient and health professional.51 [UE] Finding 67 When performing sterile procedure, sterile gloves are used to apply the new dressing.48 [C] Finding 68 Do not touch non-sterile items after donning sterile gloves.57 [UE] Finding 69 Use sterile gloves for aseptic non-touch techniques if there is a need to touch key parts.61 [US]

Category 15 Sterile gloves are required for surgery, aseptic procedures, invasive procedures, procedures in which the wound will be touched and for inserting invasive devices or sterile pharmaceuticals.

Synthesis 6

Sterile gloves are required for surgical aseptic non-touch technique, surgery and invasive aseptic procedures and clean gloves are for non-sterile procedures/ standard aseptic non-touch technique.

Category 16 Clean gloves are worn as an alternative to sterile gloves for removing old dressings and for aseptic non-touch technique (ANTT) where there will be no requirement to touch the wound or key parts.





Category 18 Selection of personal protective equipment should be guided by the level of risk of exposure to body fluids and airborne infection.

Synthesis 7

Wearing appropriately selected personal protective equipment helps to reduce the risk of cross infection from exposure to body fluids or airborne

Finding 75 Personal protective equipment is designed to prevent transmission from patient to healthcare professional.64 [UE] Finding 76 Use personal protective equipment when there is a risk of contamination to the caregiver, including contact with body fluids.51 [UE] Finding 77 Personal protective equipment should be used to prevent cross contamination and/or exposure to body fluids.57 [UE] Finding 78 Uniforms and jewellery are source of potential contamination.59 [C]

Category 17 Personal protective equipment is used to reduce the risk of cross infection.

Finding 79 Disposable plastic apron should be worn when undertaking tasks that risk contaminating the wearer’s clothing (e.g. splash back from irrigation).51 [C] Finding 80 Plastic aprons should be used to reduce cross infection and changed between patients.59 [C] Finding 81 Selection of personal protective equipment is determined by the level of risk, including exposure to body fluids and airborne infections.64 [UE]

Category 20 The home can be a source of contamination.

Synthesis 8

Actions should be taken to reduce airborne and other infection risks in the home and hospital to ensure wound care is conducted in a clean environment.

Finding 82 Cleanliness of the care environment influences actual and perceived risk of infection and should be maintained in all care environments.64 [C] Finding 83 Do not undertake aseptic procedures at times when environmental risk is higher, such as during housekeeping.51 [C] Finding 84 The environment in which aseptic non-touch technique is performed should be clean and dust free.51 [C] Finding 85 Infection sources include the health professional and the immediate environment.61 [US]

Category 19 Environment in which wound care is attended must be clean.

Finding 86 Carpets and soft furnishings may be a source of infection. 64 [UE] Finding 87 Consider the implications for cleanliness of pets in the home. 64 [UE]

Category 21 Effort should be made to reduce infection sources (including airborne infection sources) in the area in which wound care is performed.

Finding 88 If a home environment poses significant infection risk, assistance should be provided to reduce the risk and when high the risk should be reported to local and environmental agencies.64 [C] Finding 89 Cleaning schedules and standards and the ventilation and water supplies should be monitored regularly.64 [C] Finding 90 Reduce airborne infection risk by closing windows, turning off fans, completing housework before undertaking wound care, restricting foot traffic around wound care, exposing wound for the shortest time possible, dress clean wounds before infected wounds, dispose of old dressings in sealed waste bags.64 [C] Finding 91 The environment can be cleaned through disinfection or decontamination.64 [UE]



7



Finding 92 Chlorine is recommended for surface cleaning due to its broad spectrum action.64 [C] Finding 93 If using a dressing trolley, ensure it is clean before use.57 [C] Finding 94 In the community setting, the nurse should place the sterile field at a height that prevents contamination with skin scales and fibres.64 [C] Finding 95 In the community setting, the nurse should establish the sterile filed on either a clean table or on a plastic surface to prevent wicking. A plastic apron could be utilised.8 [C] Finding 96 The plastic lid of a storage container can be wiped and used as a clean surface on which to set up a sterile surface for a procedure in a home setting.64 [C] Finding 97 Community nurses choose clean hard surfaces at wound height to create a sterile field, however this is often on the floor for a leg ulcer dressing.11 [C]

Finding 98 Application of wound field principle treats the wound as an extension of the dressing field.7 [C] Finding 99 Wound field concept is guided by the principle that wounds themselves are not sterile, and products from a wound cannot contaminate itself; however external objects can contaminate the wound.7 [C] Finding 100 Maintain a sterile field by only placing sterile objects within it, considering everything outside the field to be contaminated and not returning items to the field once they leave the field.57 [UE] Finding 101 Use a critical aseptic field into which only sterile equipment is introduced for open, invasive or technical procedures.61 [US] Finding 102 Use a general aseptic field in which key parts can be individually protected for non-invasive basic wound care.61 [US]

Category 23 Once established, the wound management field must not be contaminated.

Synthesis 9

A wound management field can be established on a clean surface in a space at low risk of environmental contaminants. Once established, introduction of contaminated external objects should be avoided.

Category 22 The surface on which a sterile field will be set up should be clean and free from sources of contamination

Finding 110 A wound cleanser should be effective in the presence of organic material and reduce microorganisms.63 [UE] Finding 111 Wound cleaners should reduce microorganisms and remove organic material effectively. 42 [UE]

Category 26 A wound cleanser should adequately clean the wound.

Category 25 A wound cleanser should have a long shelf life.

Synthesis 10

An ideal wound cleanser should adequately clean the wound, not cause cell damage or sensitivity and have a long shelf life.

Finding 103 A wound cleanser should be non-toxic and not cause sensitivity.63 [UE] Finding 104 Wound cleansers may be toxic to cells and their use should be carefully considered.63 [C] Finding 105 Wound cleaners should be non-toxic and not cause sensitivity to tissue.42 [C] Finding 106 Use the principle of do no harm and prevent infection when selecting an irrigation solution.9 [UE]

Category 24 A wound cleanser should not cause damage or sensitivity.

Finding 107 Wound cleaners should have a long shelf life.42 [C] Finding 108 Wound cleaners should have a long shelf life.63 [C] Finding 109 Do not use expired or damaged irrigation fluids.57 [UE]




8



Finding 112 Only cleanse wounds that are visibly contaminated with debris, excess exudate, necrotic tissue or slough, because these encourage infection.39 [C] Finding 113 Only remove bacteria from a wound through cleansing in the presence of clinical signs of infection.39

[US] Finding 114 When no contaminants are present, a wound may heal better without cleansing.58 [US]

Category 27 Wound beds only need cleansing in the presence of visible contamination or signs of infection.

Finding 115 The interdisciplinary care team should work together to determine the best wound cleansing options for specific individuals.58 [C] Finding 116 Decisions about cleansing strategy for patients with DFU should be made by the multidisciplinary collaborative team.9 [C] Finding 117 Assess whether a wound needs cleansing.39 [C]

Synthesis 11

An assessment should be conducted by the interdisciplinary team to determine if a wound bed should be cleansed, and if so, the cleansing process to use.

Category 28 The interdisciplinary team should assess if and how a wound should be cleansed.

Finding 118 Normal saline is the only completely safe wound cleanser as it is isotonic and does not draw fluid from the wound.42 [C] Finding 119 As an isotonic solution, saline does not impact osmotic pressure or impede normal healing as it has no impact on blood flow, granulation tissue, collagen formation or DNA synthesis. 46 [C] Finding 120 Sterile saline should be the preferred irrigation fluid in hospital settings. 46 [C] Finding 121 The choice of saline for wound irrigation is based on tradition rather than evidence.62 [C] Finding 122 Use sterile saline solution for complex and vulnerable wounds.9 [C]

Category 29 Normal saline is a safe and traditional wound cleansing solution.

Synthesis 12

Normal saline, potable tap water, sterile water and low concentration antimicrobial solutions are safe and effective wound cleansers. Antiseptics are not a good choice for wound cleansing.

Finding 123 Use tap water or normal saline to cleanse wounds because antiseptics are ineffective and can delay healing.56 [C] Finding 124 Appropriate irrigation fluids include normal saline and sterile water.57 [UE] Finding 125 Water may be the best option for irrigation when using dressing products with which saline is contraindicated. 46 [C] Finding 126 Tap water is an acceptable alternative to saline.42 [C] Finding 127 Water and saline are ineffective cleansers for reducing the wound bioburden or improving wound healing.67 [C]

Category 30 Tap water, sterile water or normal saline are acceptable options for wound cleansing, although they do not reduce bioburden.

Category 31 Antimicrobial solutions are effective cleansers that play a role in reducing bioburden, although they are toxic in higher concentrations.

Finding 128 All antimicrobials are effective in reducing wound contamination.67 [C] Finding 129 Polyhexamethylene biguanide (PHMB), povidone-iodine, and ionised silver are wound cleaners that are effective for promoting wound healing.67 [C]

Finding 130 All antimicrobials are toxic to wounds (PHMB has lowest toxicity).67 [UE] Finding 131 Antimicrobials (e.g. Dakin’ solution and povidone-iodine) are toxic to cells and if used as a wound cleanser the concentration should be carefully considered.63 [C]

beds

bed


9



Finding 132 Antiseptics should be used with caution for wound cleansing, particularly those deemed toxic or carcinogenic to tissues.42 [UE] Finding 133 Using antiseptics to cleanse wounds is controversial because they can negatively influence wound healing.63 [C] Finding 134 Skin cleansers are cytotoxic to cells and are not appropriate wound cleansers.63 [C] Finding 135 Antiseptics are not in contact with a wound surface sufficiently long to reduce bacteria.39 [C] Finding 136Antiseptics can damage healing wounds.39 [UE] Finding 137 Excessive use of antiseptics may be associated with antibiotic resistant bacteria.39 [C] Finding 138 Using antiseptics for wound cleansing can be detrimental to the wound healing process.58 [C]

Category 32Antiseptics and skin cleansers are toxic to wound healing and not appropriate for wound cleansing.

Finding 139 Low pressure irrigation using normal saline and a syringe is the preferred method for wound cleansing.42 [US] Finding 140 Irrigation is the preferred cleansing method.56 [C] Finding 141 When irrigating with tap water, use tubing attached to the faucet if the wound cannot be placed under the tap.62 [C] Finding 142 When cleansing or irrigating, suitable pressure to remove exudate, loose tissue and contaminants should be applied. However, pressure should not be high enough to disrupt granulation.65 [C]

Category 33 Low pressure irrigation removes debris without disrupting granulation.

Finding 143 When irrigating with tap water ensure it is lukewarm.62 [C] Finding 144 Rewarm refrigerated wound cleansing fluids before use.45 [UE] Finding 145 Cooler irrigation fluids may lead to impaired healing associated with local vasoconstriction.66 [UE] Finding 146 Because wound healing optimally occurs at 33°C, irrigation fluids should be warmed to between 37°C and 42°C before use.46 [UE] Finding 147 Consider refrigerating wound cleansers after opening to reduce bacterial growth.45 [C] Finding 148 Cleansing with cool fluids can increase risk of infection as the body’s defence mechanisms are lower due to vasoconstriction.9 [C] Finding 149 Fluid temperature should be considered when selecting a cleansing method.54 [C]

Synthesis 13

Apply a wound cleanser at a lukewarm temperature with consideration to the potential for cross infection and using low pressure to irrigate the wound bed.

Finding 150 Cross infection risk should be considered when deciding if cleansing a wound in a shower is appropriate.58 [C] Finding 151 The practicalities of cleansing techniques, including the difficulty in managing fluid flow direction should be considered when selecting a cleansing method.54 [C]

Finding 152 Consider cross infection risk when determining if a person with a diabetic foot ulcer can cleanse a wound in a shower (particularly in a multi-dwelling residence).9 [UE]

Category 35 There is a risk of cross infection when cleansing a wound.

Category 34 A wound cleanser should be lukewarm on application.





Category 37 The quality of water used for wound cleansing is important.

Category 39 Tap water may cause pain or damage cells due to its hypotonicity.

Category 38 It is cost effective to use tap water for wound cleansing.

Finding 153 Soap and water is acceptable for cleansing sutured wounds.39 [C] Finding 154 Bathing and showering can be undertaken once wound edges are sealed.39 [C] Finding155 Water should only be used occasionally.42 [US] Finding 156 Tap water has the advantage of providing a greater volume of fluid, at a constant high pressure when provided from city water mains.62 [C] Finding 157 Soaking the leg in a bucket of water is an option for cleansing legs with venous ulcers.58 [C] Finding 158 Tap water is sufficient for cleansing sacral, perianal wounds, open traumatic wounds and leg ulcers.56 [C] Finding 159 Soap and water are sufficient for removing transient flora in wounds.56 [C] Finding 160 When irrigating with tap water, place the wound under running water for 30 seconds.62 [C]

Finding 165 Tap water is cheaper than saline and eliminates the need for additional equipment including syringes.62 [C] Finding 166 Using tap water for wound cleansing is likely to have a large financial benefit.54 [C] Finding 167 Patient satisfaction, time and cost effectiveness should all be considered when selecting a wound cleanser.66 [UE] Finding 168 Water may be more cost-effective than saline.46 [C]

Category 36 Running tap water or water in a bucket is sufficient for cleansing dirty wounds, chronic wounds and wounds with closed or sutured edges.

Finding 161 Quality of drinking water should be considered when determining where to use it for wound cleansing. [UE]

Finding 162 Tap water should be from a clean, monitored supply.56 [C]

Finding 163 It is safe to use clean uncontaminated tap water to cleanse wounds.54 [C]

Finding 164 In major cities tap water is chlorinated therefore the risk from pathogens is minimal.62 [US]

Synthesis 14

Good quality tap water is a cost effective option for cleansing dirty wounds, chronic wounds and wounds with closed or sutured edges, although it may cause pain.

Finding 169 As a hypotonic solution, water can increase osmotic pressure within wounds and may be detrimental to cells during healing due to potential of excessive moisture absorption and exudate production.46 [C] Finding 170 Irrigating wounds with water can cause pain.46 [C] Finding 171 Irrigating wounds with water can cause loss of intracellular fluid and substances that promote wound healing.46 [C] Finding 172 Water may cause wound pain because it is hypotonic and therefore causes cells within the tissue to swell and rupture.42 [US]





Finding 173 The risk of potential infection from tap water, particularly in immunocompromised patients and in the hospital environment should be considered when determining how to cleanse a wound.41 [UE] Finding 174 Biofilm in pipes, faucets and sinks are a potential source of contamination of running tap water.41 [C] Finding 175 Exposure to tap water during bathing (either from direct contact or inhalation) is a potential source of infection in hospitals.41 [C] Finding 176 Pseudomonas Aeruginosa, Acanthamoeba, Mycobacteria and Leptospira are common water-related pathogens that be transmitted via contact with water.41 [UE] Finding 177 More virulent bacteria may enter water sources in hospital environments.41 [C] Finding 178 When determining the infection risk of tap water, consider how the water was stored and delivered (consider the variation in water purity in different geographic locations and clinical settings).9 [UE] Finding 179 Hospitals do not always have high quality water.41 [C]

Category 40 Tap water may be a source of contamination in homes and hospitals.

Synthesis 15

Precautions can be taken to reduce the risk of potential contamination of water sources.

Category 41 Filters, autoclaving and running the faucet to remove bacteria can reduce the risk of contamination from water supply.

Finding 180 Tap mounted water filters reduce the number of microorganisms in tap water. 41[C] Finding 181 Holy water should be autoclaved due to risk of pathogens.56 [C] Finding 182 A tap should be run properly for a few minutes before the water is used for wound cleansing, to reduce risk of bacterial contamination.42 [US]



12



Category 43 Selection of the technique for performing a wound dressing should be guided by the complexity or invasiveness of the procedure being performed.

Synthesis 16

Selection of sterile /surgical ANTT or clean/standard ANTT is determined by the level of risk posed to the patient by his or her health status, the environment, factors associated with the wound and the type of wound management procedure being performed.

Finding 183 The use and storage of dressing supplies and solutions influences the type of dressing technique selected. If materials are not stored in a way to ensure sterility, conditions for sterile and no touch techniques cannot be met.68 [UE] Finding 184 In selecting a dressing technique consider the clinical setting (e.g. surrounding environment, health professional skills).68 [UE] Finding 185 Aseptic non touch technique framework is based on assessing the risk the patient faces of infection from the health professional and environment.60 [C] Finding 186 Decision regarding technique is guided by the environment.57 [C] Finding 187 In deciding between clean and aseptic technique consider the healthcare setting.48 [C] Finding 188 Assess risks of contamination from the local environment.60 [C] Finding 189 Concern about potential infection is a barrier to uptake of clean technique in community settings.37

[C] Finding 190 Not all care environments require the strict asepsis that was developed for sterile operating rooms.7 [C]

Finding 198 In selecting a dressing technique consider patient factors (e.g. immune status, acuity).68 [C] Finding 199 In deciding between clean and aseptic technique consider the patient’s immune status.48 [C] Finding 200 Consider the patient’s context when selecting appropriate dressing technique.7 [C] Finding 201 Historically the selection of technique has been based on perceived patient risk of infection.60 [C] Finding 202 Patient-related factors to consider when determining technique include immune status; age; use of steroids patient lifestyle; concurrent skin conditions; nutritional and status.57 [C]

Finding 191 Decision regarding technique is guided by complexity of the procedure.57 [C] Finding 192 In selecting a dressing technique consider the invasive level of the procedure. 68 [UE] Finding 193 Selection of dressing technique should be guided by the intervention required to the wound.68 [C] Finding 194 In deciding between clean and aseptic technique consider the level of invasion of procedure (e.g. extensive debridement or packing).48 [C] Finding 195 Determine the level of risk of contamination with consideration to level of contact with the patient, when selecting a hand hygiene methods.51 [C] Finding 196 In deciding what technique to use, assess the complexity of the procedure and necessity to touch key parts.60 [US] Finding 197 Aseptic non touch technique (ANTT) framework is based on assessing the risk the patient faces of infection from the procedure.60 [C]

Category 42 Selection of technique for performing a wound dressing should be guided by the risk to the patient of infection from the surrounding environment.

Category 44 Selection of the technique for performing a wound dressing should be guided by patient factors that influence infection risk.



13



Finding 203 In deciding between clean and aseptic technique consider the type of wound (e.g. acute vs chronic) and its location and depth.48 [C] Finding 204 In selecting a dressing technique consider wound factors (e.g. acuter versus chronic, depth, location).68 [C] Finding 205 Consider the wound history when selecting appropriate dressing technique.7 [C] Finding 206 Chronic wounds cannot become contaminated from “clean” products because they are already colonised with microbes.50 [US] Finding 207 Clean technique may be more appropriate than rigorous asepsis in caring for chronic wounds.57 [C] Finding 208 Clean wound care technique using non-sterile gloves and tap water could be used for some wound types.56 [C] Finding 209 Patient factors to consider when determining technique type of wound; depth, location and size of wound.57 [C]

Category 45 Selection of the technique for performing a wound dressing should be guided by the type and condition of the wound.

Category 47 Sterile/ surgical ANTT is appropriate for individuals at infection risk due to compromised immunity, and/or when the procedure is invasive, complex or breaches the skin (e.g. sharp debridement) or is of longer duration. It requires sterile gloves, sterile equipment and sterile cleansing solutions.

Finding 210 Use clean technique (handwashing, clean gloves, solutions, equipment maintained as clean) for dressing changes with mechanical, chemical or enzymatic debridement.68 [C] Finding 211 Use clean technique (handwashing, clean gloves, solutions and equipment maintained as clean) for routine dressing changes without debridement.68 [C] Finding 212 Use standard aseptic non-touch technique, critical micro-field and non-sterile gloves with a non-touch technique for a simple wound dressing that is less than 20 minutes in duration.61 [US] Finding 213 Clean technique allows irrigation or bathing with saline or tap water and use of a clean surface.37 [C] Finding 214 Use clean technique (handwashing, clean gloves, solutions and equipment maintained as clean) for irrigating wounds.68 [C]

Synthesis 17

Simple wound management procedures on low risk patients can be performed with non-sterile but clean equipment, solutions and gloves. More complex procedures or procedures in higher risk patients require surgical aseptic non-touch technique, using sterile gloves, solutions and equipment.

Category 46 Clean technique/standard ANTT is appropriate for irrigating and wound dressings without debridement. It requires clean gloves and equipment and cleansing solutions maintained as clean.

Finding 215 Use sterile technique (handwashing, sterile gloves, sterile solutions and equipment) for routine dressing changes with sharp conservative debridement.68 [C] Finding 216 Aseptic wound care using sterile equipment and wound cleansers prevents transmission of bacteria and is the standard recommended practice.56 [US] Finding 217 Surgical aseptic technique or aseptic non-touch technique is required when undertaking an invasive procedure when the patient’s defences are compromised.57 [C] Finding 218 Surgical aseptic technique or aseptic non-touch technique is required when undertaking an invasive procedure that breaches the skin.57 [C] Finding 219 Use surgical aseptic non-touch technique with an aseptic field, sterile gloves and barrier precautions for attending a complex or large dressing with key parts that require asepsis or procedures longer than 20 minutes.61 [US] Finding 220 Aseptic technique requires a sterile dressing pack and sterile cleansing solution.37 [C] Finding 221 Sterile technique is the most appropriate technique for patients at high infection risk.68 [C]





Finding 229 Use a secondary container for fluids being used in a procedure to avoid contaminating a larger container with syringes.45 [C] Finding 230 Pressurised multi dose canisters can be used for sterile solution irrigation and reduce risks associated with using needle/ syringe or cotton/gauze. 65 [C] Finding 231 Open wound cleaner containers without contaminating the inside of the bottle, place the cap face up when using the container and replace the cap as soon as possible.45 [C] Finding 232 To reduce risk of contamination of irrigation containers used in home care settings, use smaller containers.45 [C]

Synthesis 18

Wound management equipment should be single use or cleaned with alcohol preparations. Using cleansers and wound dressings in smaller packages reduces waste and contamination risk.

Category 48 Wound management equipment should be single use or decontaminated using detergent and water or alcohol preparations.

Category 50 Use wound cleansers from smaller containers to prevent contaminating the wound cleanser supplies.

Category 49 Pre-packaged, standardised dressing packs can be wasteful or increase risk of contamination.

Finding 222 Equipment can be cleaned through sterilization, disinfection or decontamination. 64 [UE] Finding 223 Decontamination of equipment can be performed with detergent and water, or with alcohol wipes.64 [C] Finding 224 When cleaning equipment use 70% alcohol /2% chlorhexidine impregnated wipe and scrub the equipment hard using different parts of the wipe.61 [US] Finding 225 Single use equipment can be more practical in homecare environments where there is not ready access to facilities to adequately sterilise reusable equipment.64 [C] Finding 226 Consider cleaning the sachet before opening irrigation fluids.57 [C]

Finding 227 Sterile packs that contain standardised equipment choices and/or gloves of the incorrect size leave community nurses at risk of contaminating the sterile field.8 [C] Finding 228 Lack of choice in dressing packs from the formulary hinders the performance of asepsis in community settings.11 [C]





Finding 233 In aseptic non touch technique used equipment must not re-enter the sterile field.51 [C]

Finding 234 When implementing sterile technique, sterile objects must not touch non-sterile objects.68 [UE] Finding 235 An aseptic technique requires all objects and fluid that come on touch with the wound to be sterile.7 [UE] Finding 236 To perform aseptic technique the health professional must: understand when an object is or is not sterile; maintain the dressing field separate from the wound; remove contaminated or non-sterile items from the field; ensure non-sterile items do not cross into to the sterile field and correct infractions if the sterile field becomes contaminated.7 [UE]

Finding 237 The concept of clean and dirty (hands and/or forceps) is incorporated into aseptic techniques.7 [UE] Finding 238 To maintain aseptic technique the process of cleansing with tap water and washing the surrounding skin (e.g. VLU leg) should be separate from applying a dressing.8 [C] Finding 239 Equipment that only touches the wound or the sterile field cannot be a source of contamination to the wound.43 [C]

Category 52 Because using forceps can be difficult, some clinicians use gloved hands in the wound dressing procedure.

Finding 240 Gloves have replaced the use of sterile forceps.56 [C] Finding 241 Use a dressing aid to remove the old wound dressing and use gloves and a clinical sheet to dry the leg, before commencing aseptic technique.8 [C] Finding 242 Forceps are difficult to manoeuvre and health professionals often become confused or are unable to prevent contamination of the clean forceps by the dirty forceps when applying aseptic non-touch technique.7 [UE]

Synthesis 19

When performing sterile/surgical ANTT the wound management field must remain free of non-sterile items, including equipment, cleansing fluids and gloved hands that have touched a non-sterile object.

Category 51 In sterile/surgical aseptic non-touch techniques the wound management field must remain free of non-sterile items, including equipment and cleansing fluids.





Finding 251 Dressing packs should be stored in a clean, dry place and not used if they are damaged or soiled.56 [C] Finding 252 Support the strategies patients develop for storing equipment in a way that reduces contamination.64 [US]

Category 57 Gloves should be stored in a manner that reduces contamination.

Finding 253 There is no set timeframe after which an opened irrigation solution needs to be disposed.45 [C] Finding 254 If using larger irrigation fluid containers reduce the risk of contamination by dating on opening, discarding according to organisation policy and destroying any fluid containers that visually appear contaminated.45 [C]

Synthesis 21

Wound management products should be stored in dry, clean environments to reduce risk of contamination and cleansers should be dated on opening and discarded if visually contaminated or according to organisation policy.

Category 55 Wound products and equipment should be stored in a clean dry place that reduces risk of contamination.

Category 56 Wound cleaners should be dated on opening and destroyed when they are visually contaminated.

Finding 255 Gloves should be used and stored in a way that reduces risk of damage.50 [C] Finding 256 Gloves from damp boxes are at risk of contamination from mould.62 [US]

Finding 243 In a home with an MRSA infected wound, disinfect surfaces with bleach and water or an appropriate detergent.49 [C]

Finding 244 When caring for a wound infected with MRSA, clean reusable equipment with an intermediate disinfectant before returning it the bag.49 [C]

Finding 245 Dispose of MRSA-infected waste at the patient’s home, using double-bagging and labelling as hazardous waste if there is significant wound drainage.49 [C]

Finding 246 When caring for a wound infected with MRSA, use disposable equipment where possible to prevent MRSA spread.49 [C]

Finding 247 To prevent spread of MRSA in the community place a plastic sheet underneath the equipment bag when caring for a patient with MRSA.49 [C]

Category 53 Strategies to prevent contamination of equipment should be taken if a patient has MRSA.

Synthesis 20

Extra infection control precautions should be taken for patients with known infection.

Finding 248 In a home with an MRSA infected wound, the health professional should avoid using the patient’s soap or towels.49 [C]

Finding 249 Use personal protective equipment when caring for a wound infected with MRSA 49 [C]

Finding 250 When caring for an MRSA infected wound, hand washing and gloves are important in preventing the spread of MRSA in the community. 49 [UE]

Category 54 Pay extra attention to personal hygiene to prevent cross infection when a patient has MRSA.





Finding 257 Ongoing education is required to improve asepsis skills.48 [C] Finding 258 Regular infection control training should include hand hygiene, asepsis, decontamination and cleaning, waste and laundry disposal, sharps management and use of personal protective equipment.64 [C] Finding 259 Education is an effective strategy in promoting best hand hygiene practice.64 [C] Finding 260 All health professionals involved in wound care should be offered training, regardless of discipline.38 [C] Finding 261 Nurses often have superficial and incomplete knowledge of principles underpinning wound care and this leads to ritualistic practice.39 [C] Finding 262 Education is an important factor in reducing hospital acquired infection.51 [UE] Finding 263 Good base knowledge and ongoing education are important to ensure health professionals have perform good handwashing technique.50 [UE] Finding 264 Provide education to the patient and caregivers on preventing spread of MRSA.49 [UE] Finding 265 Regular education contributes to improving infection control behaviour and compliance in hand hygiene.59 [C] Finding 266 Clinical staff require education and training in aseptic technique.8 [UE] Finding 267 Community nurses display confusion regarding clean technique and the use of tap water, often leading to sterile field contamination due to failure to separate wound washing from aseptic procedure.11 [C] Finding 268 Community nurses receive no guidance in how to adapt the principles of aseptic technique to the home setting and patient preferences.11 [C] Finding 269 Aseptic technique principles are ingrained in initial nurse training and community nurses maintain knowledge of important principles.11 [C] Finding 270 Appropriate education, training and skill assessment is required for all health professionals undertaking aseptic technique.57 [UE]

Synthesis 22

Staff education that incorporates skills practice, simulation learning, theoretical knowledge update and procedures for different clinical settings is essential in promoting best practice in aseptic technique and infection control.

Finding 271 District nurses are aware that performing aseptic technique in community settings is a challenge.11

[C] Finding 272 Community nurses perceive they have a lack of control over cleanliness and therefore risk of infection.10 [C] Finding 273 Community nurses use the term aseptic technique vaguely as they perceive asepsis as impossible in the home environment. 10 [C] Finding 274 Some community nurses view infection as unavoidable.10 [C]

Category 58 Staff education, including education on application in different clinical settings, is an essential component in ensuring best practice in aseptic technique and infection control.

Category 59 Nurses in the community experience frustration and fatalism when negotiating aseptic procedures.





Finding 275 Students should first learn clean and aseptic wound care in simulation.57 [C] Finding 276 Observing clinical practice to provide feedback is an effective strategy in promoting best hand hygiene practice.64 [C] Finding 277 Students require a combination of didactic theory and opportunities for practical simulation to learn aseptic non touch technique.53 [C] Finding 278 Visual education strategies such as coloured dye and talcum powder activities helps health professionals visualise the spread of infection.59 [C]

Category 60 Skills practice and simulation learning can be used for infection control training and education.



19



Synthesis 23

Best practice in aseptic technique and infection control procedures is promoted through development of facility policies, regular risk surveillance, annual auditing of staff practice, engaging with staff and patients and provision of acceptable hand hygiene products.

Finding 283 Engaging wound champions are a strategic strategy to promote infection control and appropriate dressing practices.38 [C] Finding 284 Quality practice can be achieved using linkage programs through which infection champions disseminate key messages.64 [C]

Finding 285 Partnership and understanding between the individual, informal carers and health professionals is essential to ensure effective infection prevention and control.64 [C]

Finding 286 Patients could be empowered to promote hand hygiene by asking health professionals about their practice. 59 [C] Finding 287 Adequate staffing is an important factor in reducing hospital acquired infection.51 [C]

Finding 279 Health professionals have a responsibility to identify infection risks and intervene to reduce that risk.50 [UE] Finding 280 Assessments of infection risk should be conducted in health facilities.59 [C] Finding 281 Continuous quality improvement through regular auditing, risk assessment and education is essential in maintaining appropriate wound care practices.7 [C] Finding 282 Infection surveillance and quality improvement using root cause analysis is essential for continuous quality improvement.64 [C]

Category 62 Engaging with staff members and patients promotes best practice in aseptic technique and infection control procedures.

Category 63 Annual auditing clinical practice of staff contributes to continuous improvement in aseptic technique and infection control procedures.

Finding 293 Standardising the technique used in a facility is one way to prevent and control hospital acquired infection.8 [C] Finding 294 There is insufficient evidence to make recommendations on approach to wound care therefore facilities should develop their own policies regarding wound care.48 [C] Finding 295 Health professionals should continue current practice consistent with their facility policies.48 [C] Finding 296 Standardising aseptic care reduces infection.61 [C]

Finding 288 Annual assessment of dressing technique should be a required organisational policy.38 [C]

Finding 289 Ongoing practice audits contribute to improving infection control behaviour.59 [C] Finding 290 Auditing of practice increases compliance with the standardised aseptic technique.8 [C] Finding 291 Facilities should periodically monitor hand hygiene. 40,55 [C] Finding 292 Annual auditing of aseptic non touch technique practises should be conducted a part of continuous quality improvement.38 [C]

Category 61 Regular risk surveillance within a health service promotes continuous improvement in aseptic technique and infection control procedures.

Category 64 Standardised policies and procedures increase compliance with best practice in aseptic technique and infection control procedures.



20



Category 65 Providing low irritant products increases compliance with hand washing.

Finding 297 Plain detergent, warm water and paper towels reduce skin irritation and increase acceptability of handwashing.51 [C] Finding 298 Providing efficacious hand hygiene products with low irritancy and favourable aesthetics increases compliance with hand washing. 40,55 [C]



1

Tabl

e 1:

Sum

mar

y of

rese

arch

pap

ers

Ref

T

ype

of

Stud

y Sa

mpl

e In

terv

entio

n(s)

O

utco

me

Mea

sure

s &

Len

gth

of F

ollo

w-u

p R

esul

ts

Cle

ansi

ng so

lutio

ns

Bansal,

2002

RC

T co

mpa

ring

irriga

tion with

no

rmal saline to

irriga

tion with

tap water fo

r man

agem

ent o

f laceratio

ns in

ch

ildren

Paed

iatric patients recruited in US em

erge

ncy

room

(n=4

5)

Inclusion crite

ria:

• ch

ildren ag

ed 1 to

18 ye

ars

• presen

ted with

in 8 hou

rs of injury

• simple laceratio

n (no muscle, bon

e or jo

int

invo

lvem

ent)

Exclusion crite

ria:

• la

ceratio

n from

dog

bite

•

hand

laceratio

n •

curren

tly ta

king

antibiotic

s Ch

aracteristics:

• ag

e rang

e 2 to 15

• sharp an

d blun

t injury laceratio

ns

• 64

% of laceration ≤ 3 cm

and

7% >6cm

• 64

% lo

cated on

leg, 22%

located on

arm

, 11

% lo

cated on

foot, 4

% lo

cated on

han

d

• All pa

rticipan

ts had

a w

ound

swab

co

nduc

ted pre an

d po

st irriga

tion

• All laceratio

ns w

ere sutured, had

an

tibiotic

cream

and

dressing ap

plied

• Pa

tients were rand

omised

to receive

: o

Group

1: irrigation of th

e laceratio

n with

normal saline at a pressure of

25 to

40 psi (n=2

4) or

o Group

2: irrigation of th

e laceratio

n with

tap water at a

pressure of 25 to

40 psi (n

=21)

Participan

ts re-‐attend

ed ER in 48 ho

urs

to assess for co

mplications

• Wou

nd culture perform

ed

post irriga

tion

• Infection rate at 4

8 ho

urs

using the follo

wing crite

ria to

defin

e a laceratio

n as in

fected

: o

cellulitis or erythe

ma of th

e wou

nd m

argin of m

ore than

4 mm w

ith te

nderne

ss,

o purulen

t disch

arge

from

the

wou

nd,

o ascen

ding

lymph

angitis

, o

deh

iscenc

e of th

e wou

nd

with

wou

nd sep

aration of

>2mm

Positive

post irriga

tion

wou

nd culture

(thresho

ld: a

ny growth)

No sign

ificant differen

ce betwee

n grou

ps in

po

st-‐irriga

tion wou

nd cultures: normal

salin

e 29

% versus tap water 51%

, p=0

.20

Infected

laceration

at 48

hou

rs

No sign

ificant differen

ce in

infected

laceratio

ns at 4

8 ho

urs: normal saline 8%

ve

rsus ta

p water 10%

, p=n

s

JBI lev

el of

eviden

ce:

1.c

JBI q

uality:

Mod

erate

Fernan

dez,

Giffiths

2001

and

Fe

rnan

dez,

Griffiths

2004

System

atic

review

of

controlle

d clinical

trials exp

loring

effic

acy of

clea

nsing

solutio

ns and

tech

niqu

es

In 200

1 review

, 9

RCTs in

clud

ed

In 200

4, 14 RC

Ts

includ

ed

The includ

ed trials w

ere co

nduc

ted in adu

lts

and ch

ildren in Australia, S

wed

en, T

anzania

and UK

Inclusion crite

ria:

• Adu

lts or ch

ildren with

wou

nds (e

xcluding

bu

rns)

Cha

racteristic

s:

• 4 stud

ies includ

ed peo

ple with

laceratio

ns

• 1 trial e

ach for trau

matic w

ound

s, ope

n fractures or ulcers

• 7 trials post-‐op

surgical w

ound

s

• Co

mpa

risons of d

ifferen

t clean

sing

solutio

ns

• Co

mpa

rison of sho

wering ve

rsus non

show

ering

• Infection rates

• Wou

nd deh

iscenc

e •

Wou

nd hea

ling

• Co

st

Tap water versus no

rmal saline

• Infection in

acu

te w

ound

s (1 RCT

):

favo

urs tap water odd

s ratio

(OR) 0.52

(95%

con

fiden

ce in

terval [C

I] 0.28

to

0.96

), p=

0.04

• Infection in chron

ic w

ound

s (1 RCT

): no

sign

ificant differen

ce; O

R 0.14

(95%

CI

0.01

to 2.94), p

=0.21

• Infection in children with

laceratio

ns (2

RC

TS): no sign

ificant differen

ce, O

R 1.07

(95%

CI 0

.42 to 2.75), p

=0.89

• Infection in all type

s wou

nds (4 RCT

s):

favo

urs tap water, O

R 0.60

(95

% CI 0

.37

to 0.99), p

=0.05

• Co

st ana

lysis: normal saline $1

.43 vs ta

p water $1.16

/dressing (currenc

y no

t repo

rted

) Sh

owering/ba

thing ve

rsus no show

ering

• Infection in post-‐op

erative wou

nds (5

RCTs): no sign

ificant differen

ce, O

R 0.80

(95%

CI 0

.29 to 2.23), p

=0.67

• Wou

nd hea

ling in post-‐op

erative wou

nds

(3 RCT

s): n

o sign

ificant differen

ce, O

R 1.21

(95

% CI 0

.29 to 5.10), p

=0.80

JBI lev

el of

eviden

ce:

1.a

JBI q

uality:

Mod

erate

Tab

le 1

: S

umm

ary

of r

esea

rch

pap

ers



2

Ref

T

ype

of

Stud

y Sa

mpl

e In

terv

entio

n(s)

O

utco

me

Mea

sure

s &

Len

gth

of F

ollo

w-u

p R

esul

ts

• Wou

nd deh

iscenc

e in post-‐op

erative

wou

nds (1 RCT

): no sign

ificant differen

ce,

OR 1.14

(95

% CI 0

.10 to 12.69

), p=

0.91

1%

pov

idon

e-‐iodine

versus no

rmal saline

• Infection rate in

laceratio

ns/ po

stop

wou

nds in small trials (2 RCT

S): favou

rs

povido

ne-‐io

dine

, OR 0.15

(95%

CI 0

.05 to

0.43

) p<0

.05

• Infection rate in

laceratio

ns and

postop

wou

nds in la

rge trials (1

RCT

): no

sign

ificant differen

ce, O

R 0.62

(95%

CI

0.25

to 1.53) p=0

.29

• Wou

nd hea

ling in post-‐op

erative wou

nds

(1 RCT

): fa

vours no

rmal saline, OR 4.46

(95%

CI 1

.45 to 13.68

) p<0

.05

1% pov

idon

e-‐iodine

versus no

clean

sing

Infection in con

taminated

trau

matic w

ound

s (1 RCT

): no sign

ificant differen

ce, O

R 1.00

(95%

CI 0

.05 to 19.3), p

=1.00

Fernan

dez

and Giffiths

2012

System

atic

review

of R

CTs

and qu

asi-‐R

CTs

exploring effic

acy

of w

ater fo

r clea

nsing

11 RCT

s includ

ed

Trials w

ere prim

arily con

ducted

in emerge

ncy

room

s (10/11

) Pa

rticipan

t cha

racteristic

s:

• Age

ran

ge 2 to

95 ye

ars

• Wou

nd ty

pes: 5 trials – la

ceratio

ns, 1

trial

– op

en fractures; 1 trial -‐ chron

ic w

ound

s;

4 trials – surgical w

ound

s

• 3 trials com

pared tap water to

no

clea

nsing

• 8 trials com

pared tap water to

other

clea

nsing solutio

n

• Wou

nd in

fection

• Wou

nd deh

iscenc

e •

Wou

nd hea

ling

• Co

st

Tap water versus no

clean

sing

•

Wou

nd in

fection (3 RCT

s): n

o sign

ificant

differen

ce, relative risk (R

R) 1.06, 95%

CI

0.07

to 16.50

•

Wou

nd deh

iscenc

e (2 RCT

s ): no

sign

ificant differen

ce, R

R 1.26

, 95%

CI

0.18

to 8.66

Tap water versus salin

e •

Wou

nd in

fection in acu

te w

ound

s that

were sutured (3 RCT

s): n

o sign

ificant

differen

ce, R

R 0.66

, 95%

CI 0

.42 to 1.04,

p=0.16

•

Wou

nd in

fection in chron

ic w

ound

s that

were no

t sutured

(1 RCT

): no sign

ificant

differen

ce, R

R 0.16

, CI 0

.01 to 2.96,

p=0.22

•

Wou

nd hea

ling in chron

ic w

ound

s that

were no

t sutured

1 RCT

): no sign

ificant

differen

ce, R

R 0.57

, CI 0

.30 to 1.07, p=n

s •

Cost ana

lysis (2 RCT

s): b

oth foun

d redu

ction in costs assoc

iated with

tap

water

Distille

d water vs co

oled

boiled water

Wou

nd in

fection in ope

n fractures (1 RCT

):

no signific

ant d

ifferen

ce, R

R 1.69

, 95%

CI

0.68

to 4.2, p

=ns

Distille

d water versus isoton

ic saline

JBI lev

el of

eviden

ce:

1.a

JBI q

uality:

Mod

erate



3

Ref

T

ype

of

Stud

y Sa

mpl

e In

terv

entio

n(s)

O

utco

me

Mea

sure

s &

Len

gth

of F

ollo

w-u

p R

esul

ts

Wou

nd in

fection in ope

n fractures (1 RCT

):

no signific

ant d

ifferen

ce, R

R 0.49

, 95%

CI

0.19

to 1.26, p=n

s Co

oled

boiled water versus isoton

ic saline

Wou

nd in

fection in ope

n fractures (1 RCT

):

no signific

ant d

ifferen

ce, R

R 0.83

, 95%

CI

0.37

to 1.87, p=n

s Distille

d or coo

led, boiled water versus

norm

al saline

Wou

nd in

fection in ope

n fractures (1 RCT

):

no signific

ant d

ifferen

ce, R

R 0.65

, 95%

CI

0.31

to 1.37, p=n

s Lakshm

i et

al 201

1 RC

T co

mpa

ring

tap water and

sterile

saline for

clea

nsing ch

ronic

wou

nds

Participan

ts recruite

d in outpa

tients an

d surgical w

ards in

India (n=8

2 recruited, n=6

1 co

mpleted

) Inclusion crite

ria:

• Ch

ronic wou

nd of ≥

3 w

eeks

• Up to date tetanu

s im

mun

isation

Exclusion crite

ria:

• Se

riou

s med

ical disorde

r • Malnu

trition

(BMI <

15 or >3

6)

• Im

mun

o-‐co

mprom

ised

• pressure ulcer

• diab

etic fo

ot ulcers with

• osteom

yelitis

Patie

nt cha

racteristic

s:

• mea

n ag

e 46

yea

rs

• co

mpa

rable bioc

hemical param

eters

except ta

p water group

had

signific

antly

high

er to

tal p

rotein (p

=0.02)

• most w

ound

s were VL

Us

• mea

n ulcer du

ratio

n ap

prox

. 49 da

ys (n

ot

differen

t betwee

n grou

ps)

• Sa

line grou

p ha

d sign

ificantly la

rger m

ean

wou

nd le

ngth at b

aseline (4cm

vs 2.94

cm,

p<0.05

)

• Pa

rticipan

ts w

ere rand

omised

to

receive:

o Saline grou

p: w

ound

irriga

tion with

sterile

saline de

livered

in a 50m

l syring

e an

d ne

edle at p

ressure of

8ppi (n

=39 co

mmen

ced, n=3

0 co

mpleted

and

rep

orted) or

o Tap

water: drinka

ble qu

ality

tap

water delivered

to w

ound

via PVC

pipe

and

irriga

ted 10

mins after

runn

ing the tap for 5 mins to clear

potential con

tamination (n

=43

commen

ced, n=3

1 co

mpleted

and

repo

rted

) •

All wou

nds trea

ted with

pov

idon

e-‐iodine

impreg

nated ga

uze an

d seco

ndary sterile

gau

ze pad

.

• Infection rate m

easured with

cu

lture ta

ken at 0 w

eeks and

co

mpletion of fo

llow up (5-‐6

wee

ks)

• Ra

te of h

ealin

g mea

sured as

percen

t decrease in w

ound

area

at 2

wee

kly intervals an

d mea

sured with

ruler and

tracings

Wou

nd hea

ling rate

• No sign

ificant differen

ce in

wou

nd

healing rate betwee

n grou

ps at w

eek 2,

wee

k 4 or w

eek 5-‐6.

• En

d trial result: normal saline 45

.34%

(m

ean size: 8

.42±

6.57

) versus tap water

40.58 % (m

ean size of 5

.36±

7.89

), p=

ns

Post irriga

tion

culture

• No sign

ificant differen

ce betwee

n grou

ps

Salin

e grou

p 64

.51%

versus tap water

grou

p 58

.06%

, p=0

.40

• Pa

rticipan

ts w

ith a pre-‐irriga

tion ne

gativ

e cu

lture and

a post-‐irriga

tion po

sitiv

e cu

lture did not differ (saline 13

.3% versus

tap water 9.6%)

JBI lev

el of

eviden

ce:

1.c

JBI q

uality:

Low

Valen

te,

2003

RC

T co

mpa

ring

tap water and

sterile

saline for

clea

nsing simple

laceratio

ns in

ch

ildren

presen

ting to an

emerge

ncy

depa

rtmen

t (ED

)

Conv

enienc

e sample of children with

laceratio

ns presenting at an ED

(586

eligible,

530 rand

omised

, 490

com

pleted

follo

w up,

equivalent lo

ss to

follo

w up be

twee

n grou

ps)

Inclusion crite

ria:

• Age

d 1 to 7 yea

rs

• Simple wou

nds of < 8 hou

rs duration

• Wou

nd lo

cated on

face, scalp, trunk

or

extrem

ity

• All pa

rticipan

ts receive

d an

aesthe

sia

as app

ropriate

• After irriga

tion wou

nd w

ere repa

ired

with

staples, sutures or skin glue

• Pa

rticipan

ts w

ere rand

omised

to

receive:

o M

inim

um 100

ml saline solutio

n irriga

tion using a 30

-‐60m

L syring

e (271

ran

domised

, 251

com

pleted

follo

w up)

• Dev

elop

men

t of w

ound

infection assessed

at 4

8 to 72

hours in person by

blin

ded

clinicians using

clin

ical signs

and symptom

s.

• Fo

r pa

tients un

able to

return,

a ph

one interview w

ith paren

t was con

ducted

to determine

infection (ED rev

iew: 1

65

salin

e irriga

tion grou

p ve

rsus

Dev

elop

men

t of in

fection

• No sign

ificant differen

ces be

twee

n grou

ps, saline grou

p 2.8%

(95%

CI 1

.1 to

5.7%

) versus tap water group

2.9% (9

5%

CI 1.2 to

5.9%)

• Ba

sed on

wou

nd lo

catio

n, fo

ot w

ound

s were 4.4 tim

es m

ore likely to be infected

if irriga

ted with

tap water (relative risk

4.4, 95%

CI 0

.6 to

33.1, p=n

ot rep

orted)

Volum

e of fluid used

JBI lev

el of

eviden

ce:

1.c

JBI q

uality:

Mod

erate



4

Ref

T

ype

of

Stud

y Sa

mpl

e In

terv

entio

n(s)

O

utco

me

Mea

sure

s &

Len

gth

of F

ollo

w-u

p R

esul

ts

• Re

quiring sutures, staples or skin glue

Exclusion crite

ria:

• Im

mun

ocom

prom

ised

• Co

mplicated

laceratio

ns (e

.g. joints;

tend

on ,cartilag

e, fa

scia or muscle

invo

lvem

ent; visco

us cavity

, gen

itourinary,

eyelids, m

outh, fractures, foreign

bod

ies)

• Cu

rren

t or prop

hylactic use of a

ntibiotic

s Pa

rticipan

t cha

racteristic

s:

• No sign

ificant differen

ce in

age

, gen

der,

ethn

icity

, wou

nd duration, w

ound

mecha

nism

, typ

e of ana

esthesia or type

of

wou

nd closure.

• Ta

p water group

had

more ha

nd

laceratio

ns (9

.2% versus 21

.3%)

o Minim

um of 1

0 seco

nds (a4p

prox

. 1.5 mL) ta

p water irriga

tion, w

ith ta

p run for 30

secon

ds before

commen

cing

irriga

tion an

d wou

nd

placed

directly

und

er fa

ucet or whe

n no

t possible, tu

bing

from

fauc

et w

as

used

to irriga

te w

ound

ove

r a ba

sin

(259

ran

domised

, 239

com

pleted

follo

w up (151

in ED and

88 by

ph

one)

152 in ta

p water group

; pho

ne

review

86 in saline irriga

tion

grou

p ve

rsus 88 in ta

p water

grou

p)

More flu

id w

as used in th

e tap water group

7,14

0mL (in

terqua

rtile

ran

ge [IQR] 3,570

to

14,280

) com

pared with

the salin

e grou

p 30

0mL 25

% to

75%

(IQR 18

0 to 400

)

Bee, 200

9 System

atic

review

includ

ing

4 RC

Ts

compa

ring

tap

water to

saline

for wou

nd

clea

nsing

4 RC

Ts in

clud

ed

(all includ

ed in

othe

r SR

s an

d this rev

iew)

Trials w

ere prim

arily con

ducted

in emerge

ncy

room

s in Australia, U

S an

d Sw

eden

Stud

y inclusion:

• Limite

d to RCT

s an

d qu

asi-‐R

CTs

• 4 RC

Ts com

paring

use of tap

water w

ith

use of sterile saline were iden

tified for

inclusion

• No exclusion crite

ria ba

sed on

partic

ipan

t ch

aracteristics

Participan

t cha

racteristic

s:

• To

tal 1

228 pa

rticipan

ts across 4 stud

ies

(636

trea

ted with

saline, 592

trea

ted with

tap water)

• Wou

nds varied

betwee

n stud

ies bu

t co

vered acute, chron

ic and

soft tissue

wou

nds, sim

ple wou

nds an

d trau

matic

laceratio

ns

• Ta

p water clean

sing

versus

sterile

salin

e clea

nsing

• Po

sitiv

e wou

nd culture

• Wou

nd in

fection iden

tified via

objective or sub

jective

outcom

e mea

sures

Positive

wou

nd culture (2

RCT

s, n = 662

) • No sign

ificant heterog

eneity

• Non

-‐signific

ant favou

ring

of S

aline (3.1%

versus 4.4%, relative risk [R

R] 1.53, 95%

CI 0.79 to 2.99, p=0

.21)

Infected

wou

nd (4 RC

Ts, n

=122

8)

• No sign

ificant heterog

eneity

• Sign

ificant fa

vouring of ta

p water (4

.3%

versus 7.1%, R

R 0.62

, 95%

CI 0

.39 to 1.01,

p=0.05

)

JBI lev

el of

eviden

ce:

1.a

JBI q

uality:

Low

Day

ton,

2013

System

atic

review

includ

ing

9 stud

ies that

compa

red

bathing to not

bathing po

st

surgical fo

ot

wou

nds

(9 case series or

prospe

ctive

observationa

l stud

ies)

Locatio

n no

t rep

orted.

Stud

y inclusion:

• Limite

d to case series and

prospectiv

e ob

servationa

l studies

• Stud

ies co

mpa

red no

rmal hygiene

to

abstaining

from

bathing

follo

wing surgery

on fo

ot or an

kle

• Se

arch

includ

ed resea

rch focu

sed on

differen

t soa

p prod

ucts but results not

presen

ted

Participan

t cha

racteristic

s:

Not rep

orted

• Normal hygiene

versus ab

staining

from

washing

follo

wing surgery

• Th

e no

rmal hygiene

group

s rang

ed

from

immed

iate permission

to w

ash to

waitin

g up

to 5 days, alth

ough

most

stud

ies ha

d a tim

e pe

riod

of w

ashing

with

in 1-‐2 days (n=1

639 pa

rticipan

ts)

• Th

e co

ntrol group

s ge

nerally abstained

from

washing

until after

stap

les/sutures were remov

ed (n

=511

pa

rticipan

ts)

• Stud

ies ap

peared

to use ta

p water but

no spe

cific

details w

ere prov

ided

• Su

rgical site

infection – the

metho

d of assessing

was not

repo

rted

Surgical site infection

There was no sign

ificant differen

ce in

infection rates be

twee

n washing

the

surgical site

in ta

p water w

ith ban

dage

remov

ed to

abstaining from

hygiene

in any

of th

e 9 includ

ed studies

JBI lev

el of

eviden

ce:

1.b

JBI q

uality:

Low



5

Ref

T

ype

of

Stud

y Sa

mpl

e In

terv

entio

n(s)

O

utco

me

Mea

sure

s &

Len

gth

of F

ollo

w-u

p R

esul

ts

Quieros,

2014

System

atic

review

co

mpa

ring

sterile

salin

e with

tap

water fo

r redu

cing

wou

nd

infection an

d prom

oting

healing

3 RC

Ts in

clud

ed

The stud

ies were RC

Ts con

ducted

in US an

d Australia.

Participan

ts w

ere ad

ults w

ith la

ceratio

ns,

acute or chron

ic w

ound

s presen

ting in an

emerge

ncy de

partmen

t in tw

o stud

ies.

Inclusion crite

ria:

Both studies only includ

ed w

ound

s with

out

sign

ificant com

plication (e.g. n

ot fu

ll thickn

ess, not in

volving joints, n

ot req

uiring

surgical deb

ride

men

t)

Exclusion crite

ria:

• In both stud

ies pa

tients with

signific

ant

comorbiditie

s (e.g. d

iabe

tes,

immun

osup

pressed) w

ere exclud

ed

• Pa

tients taking

antibiotic

s were exclud

ed

• Sterile

saline wou

nd irriga

tion (n=3

26)

versus

• Ta

p water irriga

tion (n=3

57)

In one

study

, fluids were at roo

m

tempe

rature

In both stud

ies, fluid was delivered

with

force using syring

e

• Wou

nd in

fection (the

trials

used

differen

t criteria to

defin

e infection)

Wou

nd in

fection rate (2

RCT

s, n=6

83)

Tap water w

as m

ore effective than

saline in

prev

entin

g wou

nd in

fection, how

ever th

e result was not signific

ant (OR 0.79

, 95%

CI

0.36

to 1.72, p=0

.55)

JBI lev

el of

eviden

ce:

1.a

JBI q

uality:

High qu

ality

Griffiths ,

2001

RC

T co

mpa

ring

tap water to

no

rmal saline for

irriga

ting wou

nds

Participan

ts w

ere recruited from

two

commun

ity hea

lth cen

tres in

Australia (n

=43

patie

nts with

60 wou

nds rand

omised

, n=3

5 pa

tients with

49 wou

nds co

mpleted

follo

w

up)

Inclusion crite

ria:

• Acu

te or ch

ronic no

n-‐sutured wou

nd of

Grade

II (p

artia

l thickne

ss skin loss dow

n to

epidermis and

/or de

rmis) o

r Grade

III (full

thickn

ess skin lo

ss dow

n to but not

includ

ing fascia)

Exclusion crite

ria:

• Im

mun

osup

pressed

• Existin

g infected

wou

nd

• Skin graft, skin graft d

onor site

s, w

ound

s with

sinus, u

nbroke

n skin w

ound

s, fu

ll thickn

ess wou

nds extend

ing into m

uscle,

bone

or supp

ortin

g structures

• Use of a

ntibiotic

s Pa

rticipan

t cha

racteristic

s:

• Mea

n ag

e 78

.9 yea

rs (S

D 12.63

) • Mea

n wou

nd duration 81

.70 (ran

ge 3 to

36

5) days in ta

p water group

and

21.6.15

(ran

ge 14 to 209

8) days in saline grou

p • Mea

n wou

nd size 50

3.04

mm2 (ran

ge 9 to

21

23) in tap water group

and

323

.38m

m2

(ran

ge 14 to 169

5) in

saline grou

p • More laceratio

n in saline grou

p (16 ve

rsus

8)

• All wou

nds received

irriga

tion via

syring

e an

d cann

ula with

fluid at

wou

nd te

mpe

rature

• All wou

nds ha

d exud

ate remov

ed w

ith

gauze prior to clean

sing

•

Participan

ts w

ere rand

omised

to

receive either:

o Clean

sing

with

tap water dispe

nsed

from

the he

alth cen

tre fauc

et w

ithin

the prev

ious 24 ho

urs an

d stored

in

an empty, clean

ed saline bo

ttle

(n=2

3 wou

nds)

o N

ormal saline stored

in th

e same

type

bottle

that had

its seal

remov

ed w

ithin th

e prev

ious 24

hours (n=2

6 wou

nds)

• Wou

nds were dressed with

ap

prop

riate dressing

s an

d pa

tients

kept dressing dry

• Assessm

ent o

f wou

nd at

baselin

e an

d 6 wee

ks by

research

er and

by co

mmun

ity

nurse at each dressing

cha

nge

using a stan

dardised

tool

• Assessm

ent o

f hea

ling do

ne

with

a w

ound

grid an

d a

cotton

bud

to m

easure dep

th

• Wou

nd classified

as he

aling

whe

n ep

ithelial tissue presen

t •

Wou

nd in

fection was

determ

ined

using

Cuttin

g’s

crite

ria an

d pu

rulent exu

date

was con

side

red to in

dicate

infection

Wou

nd in

fection rate at 6 wee

ks

• Ove

rall incide

nce 6.1%

(all in saline

grou

p)

• No sign

ificant differen

ce in

infection rate

betw

een grou

ps (p

>0.05)

Wou

nd hea

ling at 6 w

eeks

No sign

ificant differen

ce in

com

plete

healing be

twee

n he

aling in ta

p water group

ve

rsus saline grou

p (34.7%

versus 61

.5%,

p>0.05

) Amou

nt of irrigation flu

id used

No sign

ificant differen

ce betwee

n vo

lume of

water used co

mpa

red to saline (p>0

.05)

JBI lev

el of

eviden

ce:

1.c

JBI q

uality:

Mod

erate

quality



6

Ref

T

ype

of

Stud

y Sa

mpl

e In

terv

entio

n(s)

O

utco

me

Mea

sure

s &

Len

gth

of F

ollo

w-u

p R

esul

ts

• More ve

nous ulcers an

d pressure in

juries

in ta

p water group

(11 ve

rsus 7)

Fello

ws,

2006

An ob

servationa

l stud

y exploring

contam

ination

rate of h

ome-‐

mad

e salin

e solutio

n

Samples w

ere prep

ared

in a hom

e he

alth

agen

cy and

tested

by a registered

hospital

labo

ratory

• Sa

mples w

ere mad

e of saline using a

1-‐ga

llon (3

.78 litres) bottle

of d

istilled

water w

ith 8 te

aspo

ons of ta

ble salt to

mak

e isoton

ic saline

• Storag

e: 2 bottle

s were stored

in th

e refrigerator at 9°C an

d 5 bo

ttles were

stored

at roo

m te

mpe

rature (2

6°C)

• Sa

mples w

ere cu

ltured wee

kly

for 4 wee

ks at a

hospital

labo

ratory

Culture results room

tem

perature

• At 1

wee

k the salin

e at roo

m

tempe

rature 50%

con

tained

600

0 cfu/mL ba

cillu

s species

• At 2

wee

ks 50%

sam

ples con

tained

50

%>5

0,00

0 cfu/mL Pseudo

mon

as

pickettii and

50%

con

tained

>25

,000

cfu/mL ba

cillu

s species

Culture results refrigerator

• No grow

th until 4 wee

ks

• At 4

wee

ks 1 sam

ple co

ntaine

d 60

0 cfu/mL Pseu

domon

as spe

cies

JBI lev

el of

eviden

ce:

3.e

JBI q

uality:

Low qua

lity

Moscati,

2007

RC

T exploring

infection rate in

wou

nd irriga

ted

with

sterile saline

versus ta

p water

Participan

ts w

ere a no

n-‐co

nsecutive sample

of peo

ple attend

ing em

erge

ncy de

partmen

ts

(ED) in three ho

spita

ls in

US (n=7

11

rand

omised

, n=6

34 com

pleted

follo

w-‐up an

d an

alysed

) Inclusion crite

ria:

• Age

d ≥ 18

yea

rs

• Unc

omplicated

skin laceratio

n requ

iring

sutures or staple repa

ir

Exclusion crite

ria:

• Pu

ncture w

ound

s, self-‐inflicted

wou

nds

• Wou

nd ≥ 8 hou

rs old on presen

tatio

n •

Wou

nd in

volving tend

on, joint or bo

ne

• Wou

nd w

ith gross con

tamination requ

iring

scrubb

ing or deb

ride

men

t •

Periph

eral vascu

lar disease,

immun

ocom

prom

ised

, cortic

osteroids

• Preg

nanc

y •

Taking

antibiotic

s Pa

rticipan

t cha

racteristic

s:

• App

roximately 27

% w

ound

s on

hea

d/ne

ck,

66% on up

per extrem

ity, 7

% on lower

extrem

ity

• Prim

arily sha

rp fo

rce injuries

• Mea

n wou

nd le

ngth 2.8 to

3cm

(ran

ge 0.5

to 15)

• All pa

rticipan

ts receive

d an

aesthe

sia

prior to irriga

tion an

d closure of

wou

nd w

ith sutures or stap

les

follo

wing irriga

tion

• No pa

rticipan

ts receive

d an

tibiotic

s •

Participan

ts w

ere rand

omised

to

receive:

o Tap

water irriga

tion directly und

er

fauc

et (e

xtremities) o

r using a clea

n tube

. Partic

ipan

ts atten

ded ow

n irriga

tion an

d were instructed

to

irriga

te und

er ta

p water fo

r a

minim

um of 2

minutes (n

=300

) o

Irriga

tion by

clin

ician with

sterile

salin

e via 35

mL syring

e an

d splash

shield (n

=334

)

• Wou

nd in

fection assessed

at

follo

w-‐up be

twee

n 5 an

d 14

da

ys la

ter assessed

in ED by

blinde

d he

alth professiona

ls

or, for patients no

t returning

to ED, a

ssessed ov

er th

e ph

one by

blin

ded calle

rs

• Co

st of interve

ntion,

estim

ated

based

on co

st of

supp

lies at one

of the

cen

tres

Wou

nd in

fection rate

• Sterile

saline 3.3%

versus tap water 4.0%

• Differen

ce in

wou

nd in

fection rate w

as

0.7%

(95%

CI –

2.25

% to

3.64%

, p=n

ot

sign

ificant)

• Re

lativ

e risk fo

r infection in ta

p water

grou

p was 1.21 (95%

CI 0

.5 to

2.7)

Irriga

tion

costs

Includ

ing co

sts for eq

uipm

ent, w

ater and

ad

ditio

nal u

se of a

ntibiotic

s associated

with

high

er in

fection rate, costs of tap

water w

as

estim

ated

at $

US 0.91

/patient versus $U

S 9.11

for sterile

saline

JBI lev

el of

eviden

ce:

1.c

JBI q

uality:

Mod

erate

quality

Reu

se o

f wou

nd d

ress

ing

prod

ucts

(inc

ludi

ng r

eusi

ng ir

riga

tion

fluid

s)

Ara

s and

Su

ssm

an,

2000

Observatio

nal

stud

y exploring

the

contam

ination of

Samples of three

produ

cts:

• Hyd

roge

l in a plastic

pack with

long

nozzle

with

sna

p tip

(Instrasite

) •

Amorph

ous ge

l in a plastic

tube

with

screw

• Tw

enty packs of e

ach ite

m w

ere

open

ed after han

d washing

and

using

clea

n disposab

le la

tex glov

es and

away

from

the pa

tient

• Amou

nt of b

acterial growth

compa

red to a con

trol growth

environm

ent

• No co

ntam

ination in any

packs on da

y 1

• On da

y 14

, on pa

ck of intrasite gel th

at

had be

en used on

day 1 and

7 had

JBI lev

el of

eviden

ce:

2.c



7

Ref

T

ype

of

Stud

y Sa

mpl

e In

terv

entio

n(s)

O

utco

me

Mea

sure

s &

Len

gth

of F

ollo

w-u

p R

esul

ts

hydrog

els after

open

ing

on cap

(Solug

el)

• Hyroa

ctive ge

l with

metal tu

b an

d plastic

screw on cap (Duo

derm

hyd

roactiv

e ge

l)

• Sm

all sam

ple placed

on a tong

ue

depressor for ap

plication

• Pa

ckag

e recapp

ed and

put in

to origina

l pa

ckag

ing

• Proc

edure repe

ated

on da

ys 1, 7

, 14,

21 (n

ote, procedu

re w

as in

fron

t of

patie

nt on da

y 21

) •

On da

y 7,14

,21 an

d 28

a sterile syringe

was used to w

ithdraw

a 1ml sam

ple

from

the pa

ckag

ing of 5 of the

20

packs for testing for co

ntam

ination

grow

th

• On da

y 21

no samples had

growth

• On da

y 28

no samples had

growth

JBI q

uality:

Mod

erate

quality

Zw

anzi

ger

and

Rop

er,

2002

Observatio

nal

stud

y exploring

contam

ination of

reusab

le

prod

ucts stored

in patient hom

es

Conv

enienc

e sample of 17 ho

me sites with

in

one ho

mecare ag

ency in

the US

Samples:

47 w

ound

care prod

ucts w

ere selected

for

inclusion in th

e stud

y.

• Su

pplie

s were used

in th

e ho

me

setting by

nurses, careg

ivers an

d pa

tients.

• Su

pplie

s were either:

o ope

ned, unu

sed ite

ms (e.g. g

auze

squa

res, irriga

tion solutio

n) (n

=12)

or

o re

usab

le item

s such

as scissors,

plastic

wou

nd m

easure guide

s that

were clea

ned with

alcoh

ol betwee

n uses. (n=

35)

• Eq

uipm

ent w

as stored in th

e ho

me in

a variety of differen

t con

tainers

• Sw

abs were take

n from

the

prod

ucts in

the ho

me on

day 7

(n=2

6) and

day 14 (n=2

1)

• Sw

abs were take

n from

3

control p

rodu

cts (uno

pene

d ga

uze) stored at th

e ho

me

agen

cy office.

• Sterile

equ

ipmen

t, procedu

re

and storag

e used

to attain

samples fo

r testing.

• Cu

lture swab

s were take

n from

all prod

ucts.

Control sam

ples

No ba

cterial colon

y grow

th fo

und in con

trol.

Samples from

hom

e sites

Day 7

• 5 type

s of organ

isms iden

tified in cultures

Day 14

• 7 type

s of organ

isms iden

tified

• 75

% of sam

ples w

ere co

ntam

inated

•

The long

er th

e sample was stored in th

e ho

me, th

e more co

ntam

inan

ts fo

und

• More virulent bacterial strains w

ere

located on

reu

sable prod

ucts (e

.g.

scissors)

JBI lev

el of

eviden

ce:

3.e

JBI q

uality:

Very low

quality

Gou

veia

, 20

07

Observatio

nal

stud

y inve

stigating

leve

l of

contam

ination on

reused

saline

flasks

Conv

enienc

e sample of ran

domly selected

salin

e bo

ttles in 22 he

alth care centres in

Spain (n=4

4)

• Sa

line fla

sks were rand

omly selected

from

the em

erge

ncy room

(ER) and

an

outpatient clin

ic at 2

2 centres

• Sa

line solutio

n fla

sks were mixed

, the

top was disinfected

with

sod

ium

hypo

chlorite and

5 m

l sam

ples

remov

ed w

ith a syringe

and

nee

dle.

• Sw

abs were also ta

ken from

the salin

e fla

sk tran

sfers

• Sam

ples w

ere seed

ed on sterile

aga

r plates

• Leve

l of c

ontamination (colon

y form

ing un

its [C

FU]/ml)

• 54

.5% of saline solutio

n fla

sks were

contam

inated

(CFU

/ml ran

ged from

1 to

23

0)

• 50

% sam

ples con

taminated

in saline

solutio

ns, 3

7.5%

con

taminated

on

tran

sfer and

12.5%

con

taminated

at b

oth

sources

• ER

flasks w

ere sign

ificantly m

ore likely to

be con

taminated

com

pared to outpa

tient

flasks (p=0

.01)

• Co

ntam

ination is like

ly due

to th

e use of

the salin

e fla

sks for multip

le patients

JBI lev

el of

eviden

ce:

3.e

JBI q

uality:

low qua

lity

Wou

nd d

ress

ing

prac

tice

Lawson,

2003

Co

hort study

co

mpa

ring

sterile

versus clean

dressing

proc

edure for

open

surgical

wou

nds

Participan

ts w

ere ga

strointestinal, traum

a,

tran

splant, g

eneral surge

ry and

urology adu

lt pa

tients

Inclusion crite

ria:

• op

en surgical w

ound

hea

ling via seco

ndary

intention

• Dressing ch

ange

s three tim

es daily w

ith

• In th

e first 3 m

onth period nu

rses

were attend

ing op

en surgical w

ound

s using sterile

tech

niqu

e (not described

bu

t procedu

re req

uired sterile

glove

s,

scissors or bo

wls) (1,07

0 ad

mission

s,

unkn

own ho

w m

any ha

d op

en surgical

wou

nd)

• Wou

nd swab

for cu

ltures –

unclea

r ho

w it w

as

determ

ined

if a w

ound

sho

uld

be swab

bed

• Su

rgical site

infection rate iden

tified via

wou

nd culture th

roug

h infection co

ntrol

tracking

was not signific

antly

differen

t (0.84%

versus 0.83

%, p

=ns)

• Su

rgical sup

ply bu

dget w

as $38

0 less in

on

e un

it of th

ree mon

ths

• Time to atten

d dressing

s de

crea

sed from

JBI lev

el of

eviden

ce:

3.c

JBI q

uality:

Very low



8

Ref

T

ype

of

Stud

y Sa

mpl

e In

terv

entio

n(s)

O

utco

me

Mea

sure

s &

Len

gth

of F

ollo

w-u

p R

esul

ts

norm

al saline

Exclusion crite

ria:

• Non

e stated

Pa

rticipan

t cha

racteristic

s:

• Non

e supp

lied

• In th

e seco

nd 3 m

onths nu

rses

received

edu

catio

n in atten

ding

clean

dressing

s an

d used

this te

chniqu

e for

open

surgical w

ound

s (not described

bu

t procedu

re did not req

uire sterile

glov

es, scissors or bow

ls) (96

3 ad

mission

s, unk

nown ho

w m

any ha

d op

en surgical w

ound

)

approx

imately 13

mins to app

roximately

10 m

ins

Mer

cei,

2004

RC

T co

mpa

ring

dressing

versus

no dressing

follo

wing surgery

Consecutive sample of children un

dergoing

surgery ov

er a 4 yea

r pe

riod

in a hospital in

Jordan

(n=4

51)

Inclusion crite

ria:

Clea

n surgical w

ound

Exclusion crite

ria:

Central ven

ous catheter in

sertion

Participan

t cha

racteristic

s:

• 11

.3% abd

ominal w

ound

s, 80%

groin

wou

nds, 6.4% hea

d an

d ne

ck w

ound

s,

2.2%

thoracic w

ound

s No furthe

r de

mog

raph

ics repo

rted

Participan

ts w

ere rand

omized

by birth

date to

: • Wou

nd dressing follo

wing surgery

(n=2

16)

• Wou

nd le

ft exp

osed

follo

wing surgery

(n=2

35)

• Pa

rticipan

ts w

ith exp

osed

wou

nds

were pe

rmitted

to sho

wer, d

oes no

t repo

rt if th

ose with

dressings also

show

ered

.

• Fo

llow-‐up was con

ducted

in

the ou

tpatient dep

artm

ent 1

wee

k after discha

rge from

ho

spita

l but w

ithin 30 da

ys of

surgery

• Fo

r pa

tients no

t presenting to

outpatients, fo

llow-‐up was via

teleph

one co

nsultatio

n • Definition

of a

wou

nd

infection was not rep

orted

Wou

nd in

fection rate

There was no sign

ificant differen

ce in

infection rate betwee

n wou

nd le

ft exp

osed

an

d wou

nds co

vered (1.7% versus 1.4%

. p=

ns)

JBI lev

el of

eviden

ce:

1.c

JBI q

uality:

Low

Selim

200

1 Action research

qu

alita

tive stud

y aimed

at

prom

oting

effective clinical

practic

e with

respect to

clea

nsing wou

nds

in th

e co

mmun

ity

Three co

mmun

ity nursing

reg

ions in

Australia

Commen

ced with

7 partic

ipan

ts but

decrea

sed to 3-‐4 m

embe

rs after in

itial

mee

tings.

Participan

ts w

ere co

mmun

ity hea

lth nurses

enga

ged in th

e research

and

qua

lity

improv

emen

t process.

• Pa

rticipatory actio

n research

includ

ing

literature review

, foc

us group

s,

survey

s an

d attempted

RCT

. • Data is rep

orted as a com

men

tary of

the actio

n research

process and

includ

es som

e qu

antitative repo

rting

of surve

y results

and

som

e qu

alita

tive/op

inion ev

iden

ce on

ratio

nale fo

r ch

anging

practice an

d effectiven

ess of edu

catio

n.

• N/A

Major find

ings

• Aseptic te

chniqu

e requ

ires a sterile

dressing

pack an

d sterile

clean

sing

solutio

n.[C]

• Clea

n tech

niqu

e allows irriga

tion or

bathing with

saline or ta

p water and

pe

rforming using a clea

n surface for

dressing

equ

ipmen

t.[C]

• Pa

tients with

VLU

s may fe

el m

ore

comfortab

le w

hen the who

le le

g is

washe

d with

warm ta

p water rathe

r than

co

nfining clea

nsing to th

e wou

nd bed

. [C]

• Co

ncern ab

out p

oten

tial infectio

n is a

barrier to uptak

e of clean

tech

niqu

e in

commun

ity settin

gs. [C]

• Influ

encing

sustained

cha

nge in dressing

tech

niqu

e practic

e requ

ires lo

ng te

rm

strategies. [UE]

•

JBI lev

el of

eviden

ce:

3 (mea

ning

fuln

ess)

JBI q

uality:

High qu

ality

Poole an

d Co

ughlan

, 20

02

Cross-‐sectiona

l survey

on ch

ange

in practice for

asep

tic te

chniqu

e

Conv

enienc

e sample of 2 gen

eral practices in

UK (total pop

ulation served

, n=2

3,15

0)

Inclusion crite

ria:

• Prescribed

for district nurses, practice

nurses and

at lea

st one

nursing

hom

e with

> 60

bed

s • Able to provide

data from

com

puter

• Ed

ucation session de

livered

to nurses

in th

e sample practic

es on a ch

ange

d proc

edure for asep

tic te

chniqu

e that

requ

ires use of a

sterile plastic field

and sterile

glove

s in place of a

dressing

pack.

• Nurses were give

n 3 mon

ths to

• Su

rvey

collected

data for the 3

mon

th prior to

practice

chan

ge and

3 m

onth after

practic

e ch

ange

. •

Data includ

ed:

o N

umbe

r dressing

packs used

• Dollars spe

nt on dressing

Num

ber of dressing pa

cks used

Re

duced in both practic

es fo

llowing ch

ange

of procedu

re

(practice on

e from

240

to 10 dressing

packs,

practic

e 2 from

405

to 130

dressing pa

cks)

Mon

ey spe

nt on dressing

packs

Redu

ced in both practic

es fo

llowing ch

ange

JBI lev

el of

eviden

ce:

4.b

JBI q

uality:

Very low

quality



9

Ref

T

ype

of

Stud

y Sa

mpl

e In

terv

entio

n(s)

O

utco

me

Mea

sure

s &

Len

gth

of F

ollo

w-u

p R

esul

ts

system

Pa

rticipan

t cha

racteristic

s:

No de

scription of partic

ipan

ts or wou

nds

invo

lved

in th

is study

implem

ent n

ew practice

packs

of procedu

re

• (practice on

e from

154

to 23 UK po

unds,

practic

e 2 from

261

to 130

UK po

unds)

Edu

catio

n in

ase

ptic

tech

niqu

e

Jackson

2012

Be

fore/after

stud

y inve

stigating

effectiven

ess of

asep

tic te

chniqu

e ed

ucation an

d factors

influ

encing

kn

owledg

e

Med

ical stude

nts in ne med

ical sch

ool in UK

were invited to partic

ipate (pha

se 1 to

tal 1

12

stud

ents, p

hase 2 to

tal 7

2 stud

ents)

Inclusion an

d ex

clusion crite

ria no

t rep

orted

Participan

t cha

racteristic

s:

Year 3 and

Yea

r 5 med

ical stude

nts

• Ph

ase on

e: Yea

r 3 med

ical stude

nt

participan

ts w

ere traine

d an

d assessed

in aseptic non

touc

h tech

niqu

e in

wee

k 1 of clin

ical placemen

t. A

sub

-‐sample were reassessed

and

interviewed

in w

eek 7-‐10

. (n=

112,

assessed

in w

eek 1 an

d n =4

6 un

derw

ent rea

ssessm

ent in wee

k 10

) • Ph

ase tw

o: Yea

rs 3 and

5 stude

nts

participated

in a w

ritten

que

stionn

aire

on aseptic te

chniqu

e du

ring

fina

l exam

s (n=7

2). F

ocus group

was held

with

4 stude

nts an

d interviews with

3

nurse ed

ucators/man

ager

• Co

nten

t of e

ducatio

n prog

ram w

as not

detaile

d in dep

th but w

as based

on 4

key principles:

o a

lways wash ha

nds effectively

o to

uch no

n-‐ke

y pa

rts with

con

fiden

ce

o ta

ke app

ropriate in

fective

precau

tions

o nev

er con

taminate ke

y pa

rts

• Observatio

n of clin

ical

proc

edure using a no

n-‐valid

ated

tool w

ith 11 ite

ms.

Stud

ents given

a pass or fa

il grad

e (unc

ertain how

this

score was determined

) • Que

stionn

aire in

pha

se 2 had

63

item

s with

stron

g internal

consistenc

y of α=0

.76

• Metho

ds fo

r interviewing no

t de

scribe

d in detail.

Phase on

e results – tw

o co

horts

• Th

ere was a signific

ant d

ecrease in pass

rate from

wee

k 1 to w

eek 10

(coh

ort 1

: 95

% vs 9%

, p<0

.001

; coh

ort 2

: 96%

vs

33%, p

<0.001

) • Most c

ommon

error le

ading to fa

ilure

was fa

ilure to

use clean

surface

• 46

% of p

artic

ipan

ts stated in in

terview

that a con

tributing factor to

failu

re w

as

not u

sing

aseptic non

touc

h tech

niqu

e in

daily practice

Phase tw

o qu

estion

naire an

d interviews

• 9.7%

had

not receive

d form

al aseptic non

touc

h tech

niqu

e training

• Stud

ents exh

ibite

d do

ubt a

bout th

e valid

ity of a

septic non

touc

h tech

niqu

e • Stud

ents exp

ressed

difficulty in

remem

bering

steps of a

septic non

touc

h tech

niqu

e • Po

or role mod

ellin

g was id

entified as a

contribu

ting factor to

failu

re to

perform

asep

tic non

touc

h tech

niqu

e co

rrectly

• Lack of resou

rces w

as id

entified as a

contribu

ting factor to

failu

re to

perform

asep

tic non

touc

h tech

niqu

e co

rrectly

JBI lev

el of

eviden

ce:

2.d

JBI q

uality:

Very low

quality

Ribu

, 200

3 Observatio

nal

stud

y exploring

the ways in

which

nurses

attend

leg ulcers

in com

mun

ity

care

Participan

ts w

ere recruited in a m

unicipality

in Norway.

Inclusion crite

ria (patients, n=3

2):

• Adu

lts ≥ 21 ye

ars

• Living

at h

ome an

d receiving ho

me care

• ≥ on

e leg or fo

ot ulcer

Inclusion crite

ria (nurses, n=3

1):

• Re

gistered

nurse in

com

mun

ity care

• Trea

ted foot/leg

ulcer during stud

y

Participan

t cha

racteristic

s:

• Pa

tient m

ean ag

e 79

±0.47 ye

ars

• Ulcer duration rang

ed 6 w

eeks to

20 yrs

• Nurses ha

d mea

n practic

al exp

erienc

e rang

ing 3 mon

ths to 32 yrs

Nurse m

ean ag

e rang

e 23

to 54

• Stud

ent n

urses (n=3

0) volun

teered

to

be observe

r da

ta collectors, w

orking

in

pairs

• Observe

rs receive

d training

in th

e ob

servation tool (n

=35 wou

nd care

even

ts observe

d)

• Se

mi-‐struc

tured ob

servationa

l instrumen

t dev

elop

ed to

aud

it actual practice ag

ainst

reco

mmen

ded practic

e • Data includ

ed han

dwashing

an

d asep

tic te

chniqu

e, as well

as care practic

e for ulcers

• Data was collected

by 2 raters

in pairs w

ho observe

d the

same proc

edure then

co

mpleted

the da

ta collection

tool in

depe

nden

tly (o

verall,

89% observatio

ns w

ere in

agreem

ent, 83%

han

d washing

ob

servations w

ere in

Wou

nd clean

sing

•

63% used no

rmal saline to clean

se ulcer

• 20

% clean

sed with

tap water

Han

d washing

•

43% w

ashe

d ha

nds be

fore and

after

proc

edures

• 60

% w

ashe

d ha

nds be

fore procedu

re

• 60

% w

ashe

d ha

nds after proc

edure

App

roximately 10

% of n

urses with

poo

r ha

nd hygiene

exp

lained

it as a result of th

e un

hygien

ic nature of th

e pa

tient hom

e

JBI lev

el of

eviden

ce:

3.e

JBI q

uality:

Very low

quality



10

Ref

T

ype

of

Stud

y Sa

mpl

e In

terv

entio

n(s)

O

utco

me

Mea

sure

s &

Len

gth

of F

ollo

w-u

p R

esul

ts

agreem

ent)

• Data was qua

lified with

interviews after the proc

edure

Staf

f att

itude

s and

beh

avio

urs

Unsworth

and Co

llins

2011

Qua

litative stud

y exploring ho

w

nurses neg

otiate

performing

asep

tic te

chniqu

e in com

mun

ity

settings

Nurse practition

ers in com

mun

ity settin

gs

(n=1

0)

Inclusion crite

ria:

• nu

rse practitione

r qu

alificatio

n • minim

um of 2

yea

rs’ e

xperienc

e • pe

rforms asep

tic te

chniqu

e in com

mun

ity

setting

Participan

t cha

racteristic

s:

• med

ian ag

e 44

.8 yrs (ran

ge 33-‐58

) • Initial training

in asepsis con

ducted

mea

n 26

yrs prior (ran

ge 12 to 34 yrs)

• All pa

rticipan

ts w

ere interviewed

rega

rding ho

w th

ey ada

pt th

eir clinical

care and

neg

otiate th

e ho

me setting

to m

aintain asep

sis

• Re

search

ers ob

served

each nu

rse

attend

ing proc

edures req

uiring

aseptic

tech

niqu

e for three differen

t patients

• Re

search

ers used

an au

ditin

g tool

based on

the stan

dardised

procedu

re

man

ual to do

cumen

t ways nu

rses

prob

lem solve

d pe

rforming asep

tic

tech

niqu

e

• N/A

Major find

ings

• District n

urses are aw

are that perform

ing

asep

tic te

chniqu

e in com

mun

ity settin

gs

is a cha

lleng

e.[C]

• Aseptic te

chniqu

e principles are in

graine

d in in

itial nurse training

and

com

mun

ity

nurses m

aintain kn

owledg

e of im

portan

t principles.[C

] • Co

mmun

ity nurses receive no

guida

nce in

how to

ada

pt th

e principles of a

septic

tech

niqu

e to th

e ho

me setting an

d pa

tient preferenc

es. [C]

• Lack of c

hoice in dressing pa

cks from

the

form

ulary hind

ers the pe

rforman

ce of

asep

sis in com

mun

ity settin

gs. [C]

• Co

mmun

ity nurses ch

oose clean

hard

surfaces at w

ound

heigh

t to crea

te a

sterile

field, how

ever th

is is often

on the

floor fo

r a leg ulcer dressing

. [C]

• Co

mmun

ity nurses display co

nfusion

rega

rding clea

n tech

niqu

e an

d the use of

tap water, o

ften

lead

ing to sterile field

contam

ination du

e to fa

ilure to

sep

arate

wou

nd w

ashing

from

aseptic

proc

edure.[C]

JBI lev

el of

eviden

ce:

3 (mea

ning

fulness)

JBI q

uality:

Mod

erate qu

ality

Hallett 200

0 Qua

litative

research

exploring

fatalistic

attitud

es to

asep

tic te

chniqu

e

Commun

ity hea

lth nurses in th

e UK (n=7

) Inclusion crite

ria:

Not rep

orted

Participan

t cha

racteristic

s:

Nurses were from

a ran

ge of d

ifferen

t expe

rien

ce le

vels

• Pa

rticipan

ts w

ere selected

to eng

age

in sem

i-‐struc

tured interviews with

4

research

ers

• Fa

talistic

philosoph

ical perspectiv

e,

phen

omen

olog

ical m

etho

dology,

semi-‐struc

tured interviews an

d interpretativ

e da

ta ana

lysis using a

pred

etermined

stanc

e of fa

talism

• N/A

Major find

ings

• Co

mmun

ity nurses pe

rceive

they

have a

lack of c

ontrol ove

r clea

nliness an

d therefore risk of infectio

n. [C

] • Co

mmun

ity nurses use the term

aseptic

tech

niqu

e vagu

ely as th

ey perceive

asep

sis as im

possible in

the ho

me

environm

ent. [C

] • Asepsis is viewed

as bo

th a process th

at

includ

es spe

cific

beh

aviours an

d practic

es

(e.g. sterile field an

d glov

es) a

nd a

phen

omen

on (b

eing

con

taminan

t free).

[C]

• So

me co

mmun

ity nurses view

infection

as una

voidab

le. [C]

JBI lev

el of

eviden

ce:

3 (mea

ning

fulness)

JBI q

uality:

Mod

erate qu

ality

11

Ref

T

ype

of

Stud

y Sa

mpl

e In

terv

entio

n(s)

O

utco

me

Mea

sure

s &

Len

gth

of F

ollo

w-u

p R

esul

ts

• Aseptic te

chniqu

e is a te

rm used to

describe

a rou

tinized

practice that

includ

es id

entifying

a dirty han

d an

d a

clea

n ha

nd. [C]



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Wound Practice and Research

THANK YOU

On behalf of the Editorial Board, Joint Editors Allison Cowin and Michael Woodward sincerely thank all reviewers who contributed to the 22 manuscripts that were published this year in Volume 24.

Thank you to Donna Angel, Judith Barker, Keryln Carville, Kerrie Coleman, Ann Marie Dunk, Kathleen Finlayson, Laurence Foley, Nikki Frescos, Anne Gardner, Chris Jackson, Chloe Jansz, Donald MacLellan, Kerry May, William McGuiness, Sue McLennan, Katy Melrose, Charne Miller, Julie Miller, Stuart Mills, Pam Morey, Geraldine Moses, Rachael Murray, Jenny Prentice, Tabatha Rando, Jan Rice, Dianne Smith, Terry Swanson, Sue Templeton and Lyn Thomas.

Special thanks to those who reviewed multiple manuscripts.

The voluntary contribution that each reviewer makes contributes greatly to the high standards that Wound Practice and Research strives to achieve.

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Documents

Haesler E et al. A systematic review of the literature ... · addressing asepsis in wound management ... of aseptic technique in wound management over the ... A systematic review