<html> <head> <meta charset="UTF-8"/> <meta name="tikaGenerated" content="true"/> <meta name="date" content="2020-09-29T06:08:34Z"/> <meta name="xmp:CreatorTool" content="Acrobat PDFMaker 17 for Word"/> <meta name="Company" content="SA Health"/> <meta name="DocLeg" content="DocLeg"/> <meta name="subject" content="Infection control clinical directive"/> <meta name="Objective-VersionComment" content="CDCB Director approved version prior to publishing"/> <meta name="Manager" content="Samantha.Butenko@sa.gov.au"/> <meta name="Objective-IsPublished" content="0"/> <meta name="Objective-IsApproved" content="0"/> <meta name="Objective-CreationStamp" content="D:20200929"/> <meta name="dc:title" content="SA Health Aseptic Techique Clinical Directive, v1.2"/> <meta name="Objective-Parent" content="Aseptic Technique Policy Directive"/> <meta name="modified" content="2020-09-29T06:08:34Z"/> <meta name="cp:subject" content="Infection control clinical directive"/> <meta name="Objective-VersionNumber" content="2.000000"/> <meta name="Objective-Classification (Confidentiality)" content="OFFICIAL"/> <meta name="meta:author" content="Irene.Wilkinson@sa.gov.au;Linda.Henderson@sa.gov.au;Lisa.Upton@sa.gov.au;Wendy.Peecock@sa.gov.au"/> <meta name="meta:creation-date" content="2020-09-29T06:08:33Z"/> <meta name="created" content="Tue Sep 29 15:38:33 ACST 2020"/> <meta name="Creation-Date" content="2020-09-29T06:08:33Z"/> <meta name="Objective-Version" content="1.1"/> <meta name="Author" content="Irene.Wilkinson@sa.gov.au;Linda.Henderson@sa.gov.au;Lisa.Upton@sa.gov.au;Wendy.Peecock@sa.gov.au"/> <meta name="producer" content="Adobe PDF Library 15.0"/> <meta name="Objective-VersionId" content="vA3524187"/> <meta name="Keywords" content="aseptic technique, clinical, directive,patient safety, procedure, infecton, prevention, control, AT, risk management"/> <meta name="Category" content="Official. 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A2 (Published)"/> <meta name="Objective-Path" content="Objective Global Folder:.Department for Health and Wellbeing:Public Health:Infection Management:Aseptic Technique Policy Directive:"/> <meta name="dc:creator" content="Irene.Wilkinson@sa.gov.au;Linda.Henderson@sa.gov.au;Lisa.Upton@sa.gov.au;Wendy.Peecock@sa.gov.au"/> <meta name="dcterms:created" content="2020-09-29T06:08:33Z"/> <meta name="Last-Modified" content="2020-09-29T06:08:34Z"/> <meta name="dcterms:modified" content="2020-09-29T06:08:34Z"/> <meta name="title" content="SA Health Aseptic Techique Clinical Directive, v1.2"/> <meta name="Last-Save-Date" content="2020-09-29T06:08:34Z"/> <meta name="Objective-State" content="Being Edited"/> <meta name="meta:save-date" content="2020-09-29T06:08:34Z"/> <meta name="Objective-Confidentiality" content="02 For Official Use Only [FOUO]"/> <meta name="Content-Type" content="application/pdf"/> <meta name="creator" content="Irene.Wilkinson@sa.gov.au;Linda.Henderson@sa.gov.au;Lisa.Upton@sa.gov.au;Wendy.Peecock@sa.gov.au"/> <meta name="dc:subject" content="aseptic technique, clinical, directive,patient safety, procedure, infecton, prevention, control, AT, risk management"/> <meta name="Comments" content="Aseptic Technique Policy Directive ensures that all hospitals maintain a sustainable, high quality care environment in which all clinical staff are aware of the importance of using the principles of aseptic technique when performing medical procedures on patients."/> <meta name="Objective-ModificationStamp" content="D:20200929"/> <meta name="Objective-Id" content="A2334771"/> <meta name="Objective-Owner" content="Tink, Michelle (CO)"/> <meta name="DocSenIA" content="-I2-A2"/> <meta name="xmpTPg:NPages" content="7"/> <meta name="_DocHome" content="-1707252612"/> <meta name="DocSen" content="Public"/> <meta name="Objective-Classification" content="[Inherited - none]"/> <meta name="Objective-FileNumber" content="2014-04504"/> <meta name="Objective-Workgroup" content="Infection Control Service CDC - HR&P [DHW]"/> <meta name="SourceModified" content="D:20200929053822"/> <meta name="meta:keyword" content="aseptic technique, clinical, directive,patient safety, procedure, infecton, prevention, control, AT, risk management"/> <meta name="DocConf" content="DocConf"/> <meta name="Objective-Title" content="Aseptic technique clinical directive_V1.2 (Sep2020)_FINAL"/> </head> <body> <pre> Clinical Directive No.: DO360 Aseptic Technique Clinical Directive Version No.: 1.2 Approval date.: 25 September 2020 Contents 1. Policy Statement .................................................................................................................. 3 2. Roles and Responsibility .................................................................................................... 3 3. Policy Requirements ........................................................................................................... 4 3.1. Risk management .................................................................................................................. 4 4. Implementation and Monitoring .......................................................................................... 5 4.1. Evaluation .............................................................................................................................. 5 5. National Safety and Quality Health Service Standards ..................................................... 5 6. Definitions ............................................................................................................................ 6 7. Associated Directives / Guidelines & Resources .............................................................. 6 7.1. References ............................................................................................................................ 6 7.2. National ................................................................................................................................. 6 7.3. SA Health directives and guidelines ....................................................................................... 6 7.4. SA Health resources .............................................................................................................. 6 8. Document Ownership & History ......................................................................................... 7 INFORMAL COPY WHEN PRINTED Aseptic Technique Clinical Directive, v1.2 Page 3 of 7 OFFICIAL I2-A2 Aseptic Technique Clinical Directive 1. Policy Statement The purpose of this policy directive is to: > establish a standardised approach to the management of an aseptic technique program across the public health sector as required by the National Safety and Quality Health Service Standards (NSQHS), ensuring that all clinical staff consistently adhere to the principles of aseptic technique whilst delivering all relevant health care, such as during insertion and management of therapeutic devices and performing wound care > provide governance that clearly outlines the responsibilities of individuals and health services in the management of aseptic technique. 2. Roles and Responsibility All SA Health clinicians and external contractors delivering services to a SA Health healthcare facility who perform any procedures requiring aseptic technique must adhere to this policy. This policy directive excludes procedures performed in the operating room. Refer to the Australian College of Operating Room Nurses (ACORN) Clinical Standards for Perioperative Nursing in Australia 2020 and other surgical asepsis guidelines for guidance on the requirements for asepsis within the perioperative environment. Chief Executive: > ensuring the management of aseptic technique across SA Health is in accordance with this policy. Local Health Network (LHN) Governing Boards: > ensure that the use of aseptic technique is embedded in practice and in a manner consistent with the SA Health aseptic technique online course and other SA Health aseptic technique resource tools > ensure that sufficient resources are in place to enable effective systems for the management of an aseptic technique program > ensure that the day-to-day responsibility for establishing and monitoring the implementation of this policy is delegated to the relevant senior managers. Staff > adhere to the principles and aims of this policy and ensure they operate in accordance with the principles outlined in the SA Health aseptic technique online course and other SA Health aseptic technique resource tools > ensure that relevant training is undertaken and competency in performing procedures requiring aseptic technique is maintained. INFORMAL COPY WHEN PRINTED Aseptic Technique Clinical Directive, v1.2 Page 4 of 7 OFFICIAL I2-A2 3. Policy Requirements Maintaining compliance with the principles of aseptic technique is one of the most important and effective interventions to reduce the incidence of healthcare associated infections. SA Health is committed to creating and maintaining a sustainable, high quality care environment in which all clinical staff are aware of the importance of using the principles of aseptic technique when required such as medical device access and performing procedures on consumers, e.g. patients and residents. This policy directive is to be read and administered in conjunction with the information provided in: > SA Health Hand Hygiene Policy Directive and Clinical Guideline > SA Health Healthcare Associated Infection Prevention Policy Directive > SA Health aseptic technique e-learning module > SA Health aseptic technique resources > Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019). With the implementation of this policy, all organisations and services in SA Health will maintain an aseptic technique program which ensures that: > health services use the Australian Commission on Safety and Quality in Healthcare (ACSQHC) aseptic technique risk matrix to assist in identifying areas where aseptic technique is required and prioritise how the organisation will respond to the risks identified > clinical staff receive education and training in aseptic technique according to the SA Health Safety and Quality aseptic technique e-learning module and other relevant SA Health aseptic technique resource tools > competency assessment and feedback of performance occurs in relation to clinical procedures requiring aseptic technique > competency assessment should be completed once by all clinical staff who perform aseptic technique; as part of orientation/initial training and assessment; and repeated as necessary depending on performance monitoring results; for example a cluster of medical device related infections in an intensive care unit (ICU) would prompt an audit of aseptic technique practices > a register of staff who have successfully completed the online learning package competency assessment is maintained > clinical staff who perform aseptic technique adhere to the principles of aseptic technique during all applicable clinical procedures performed outside of the operating theatre environment > relevant information regarding the prevention of healthcare associated infection is given to consumers, e.g. patients and residents, and the public. 3.1. Risk management All potential risks and hazards associated with the performance of procedures requiring aseptic technique must be identified, actioned, documented and reported to the Local Health Network s risk management unit, and the appropriate hazard controls applied. The effectiveness of the risk controls should be regularly assessed. INFORMAL COPY WHEN PRINTED Aseptic Technique Clinical Directive, v1.2 Page 5 of 7 OFFICIAL I2-A2 4. Implementation and Monitoring Process and competency audits must be conducted as per the facility s audit schedule and results reported at appropriate governance committees. Monitoring of healthcare associated infections such as blood stream infections and surgical site infections may identify potential non-compliance with aseptic technique and should provide a trigger to audit aseptic practice in the relevant clinical areas. Facilities should monitor and report to the appropriate governance committees the number of clinical staff who have completed: > the aseptic technique online learning package > relevant aseptic technique competencies. 4.1. Evaluation It is important that compliance with all elements of this policy is demonstrated. This will be achieved by completing scheduled audits of the processes addressed within this document. The audit results and an action plan to address identified deficiencies must be reported to the relevant governance committees. Compliance with this policy directive will be assessed by monitoring the hospital accreditation results for NSQHS Standard, Standard 3 Action 3.9 and address any recommendations made in relation to performance of aseptic technique. The SA Health Safety Learning System and Patient Incident Management and Open Disclosure can be used to demonstrate improvement in reporting and management of incidents related to breaches in aseptic technique. 5. National Safety and Quality Health Service Standards National Standard 1 Clinical Governance National Standard 2 Partnering with Consumers National Standard 3 Preventing & Controlling Healthcare- Associated Infection National Standard 4 Medication Safety National Standard 5 Comprehensive Care National Standard 6 Communicating for Safety National Standard 7 Blood Management National Standard 8 Recognising & Responding to Acute Deterioration ? ? ? ? ? ? ? ? INFORMAL COPY WHEN PRINTED Aseptic Technique Clinical Directive, v1.2 Page 6 of 7 OFFICIAL I2-A2 6. Definitions In the context of this document: > Asepsis means: free from pathogenic microorganisms > Aseptic technique means: to prevent pathogenic microorganisms, in sufficient quantity to cause infection, from being introduced to susceptible body sites by hands, surfaces and equipment > Clinical procedure means: any clinical intervention that requires asepsis > Hand hygiene means: a general term referring to the process of hand decontamination which includes hand washing and/or use of waterless disinfection product > Therapeutic devices means: catheters inserted for drainage (e.g. urinary catheter, wound drainage), intravascular access lines and devices (e.g. central or peripheral venous line, portacath) or other implantable devices with external access. 7. Associated Directives / Guidelines & Resources 7.1. References > Centers for Disease Control and Prevention (CDC). 2011. Guidelines for the Prevention of Intravascular Catheter-Related Infections. > Loveday H.P. et al. 2013. Epic3: National Evidence-Based Guidelines for Prevention Healthcare-Associated Infections in NHS Hospitals in England. Journal -of Hospital Infection. 8651 (2014)S1-S70. 7.2. National > NHMRC (2019). Australian Guidelines for the Prevention & Control of Infection in Healthcare, Australian Government > Australian College of Perioperative Nurses (ACORN) Clinical Standards for Perioperative Nursing in Australia, 16th edition (2020) 7.3. SA Health directives and guidelines > SA Health Associated Infection Prevention Policy Directive > SA Health Healthcare Associated Infection Prevention Policy Directive > SA Health Hand Hygiene Policy Directive and Clinical Guideline > SA Health Patient Incident Management and Open Disclosure Policy Directive > SA Health System-wide Risk Management Policy Directive 7.4. SA Health resources > Aseptic Technique Staff Training and Self-assessment workbook (ward and haemodialysis settings) > Applying Aseptic Technique in Haemodialysis presentation INFORMAL COPY WHEN PRINTED Aseptic Technique Clinical Directive, v1.2 Page 7 of 7 OFFICIAL I2-A2 8. Document Ownership & History Approval Date Version Who approved New/Revised Version Reason for Change 25/09/20 V1.2 Director, Communicable Disease Control Branch Update references and converted in updated template 1/05/17 V1.1 Director, Communicable Disease Control Branch Formally reviewed in line with 1-5 year scheduled timeline for review & and minor amendments 4/12/14 V1 Safety and Quality Operational Governance Committee Original SQOGC approved version. Document developed by: Infection Control Service, Communicable Disease Control Branch File / Objective No.: 2014-04504 | A2334771 Next review due: 26/09/2025 Policy history: Is this a new policy (V1)? N Does this policy amend or update and existing policy? Y If so, which version? V1.1 Does this policy replace another policy with a different title? N If so, which policy (title)? ISBN No.: 978-1-76083-326-8 1. Policy Statement 2. Roles and Responsibility 3. Policy Requirements 3.1. Risk management 4.1. Evaluation 7.1. References 7.2. National 7.3. SA Health directives and guidelines 7.4. SA Health resources </pre> </body> </html>