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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 &amp; 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 &amp; 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: 

&gt; 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 

&gt; 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: 

&gt; ensuring the management of aseptic technique across SA Health is in accordance with this 
policy.  

Local Health Network (LHN) Governing Boards: 

&gt; 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 

&gt; ensure that sufficient resources are in place to enable effective systems for the management 
of an aseptic technique program 

&gt; ensure that the day-to-day responsibility for establishing and monitoring the implementation of 
this policy is delegated to the relevant senior managers. 

Staff 

&gt; 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 

&gt; ensure that relevant training is undertaken and competency in performing procedures 
requiring aseptic technique is maintained. 

  





 
 

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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: 

&gt; SA Health Hand Hygiene Policy Directive and Clinical Guideline 
&gt; SA Health Healthcare Associated Infection Prevention Policy Directive 
&gt; SA Health aseptic technique e-learning module  
&gt; SA Health aseptic technique resources 
&gt; 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: 

&gt; 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 

&gt; 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 

&gt; competency assessment and feedback of performance occurs in relation to clinical procedures 
requiring aseptic technique 

&gt; 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 

&gt; a register of staff who have successfully completed the online learning package competency 
assessment is maintained 

&gt; 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 

&gt; 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. 

  










 
 

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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: 

&gt; the aseptic technique online learning package 
&gt; 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 &amp; 
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 &amp; 
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: 

&gt; Asepsis means: free from pathogenic microorganisms 
&gt; 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 

&gt; Clinical procedure means: any clinical intervention that requires asepsis 
&gt; Hand hygiene means: a general term referring to the process of hand decontamination which 

includes hand washing and/or use of waterless disinfection product 
&gt; 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 &amp; Resources 

7.1. References 

&gt; Centers for Disease Control and Prevention (CDC). 2011.  Guidelines for the Prevention of 
Intravascular Catheter-Related Infections. 

&gt; 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 
&gt; NHMRC (2019).  Australian Guidelines for the Prevention &amp; Control of Infection in Healthcare, 

Australian Government 
&gt; Australian College of Perioperative Nurses (ACORN) Clinical Standards for Perioperative 

Nursing in Australia, 16th edition (2020) 

7.3. SA Health directives and guidelines 
&gt; SA Health Associated Infection Prevention Policy Directive 
&gt; SA Health Healthcare Associated Infection Prevention Policy Directive 
&gt; SA Health Hand Hygiene Policy Directive and Clinical Guideline 
&gt; SA Health Patient Incident Management and Open Disclosure Policy Directive 
&gt; SA Health System-wide Risk Management Policy Directive 

7.4. SA Health resources 
&gt; Aseptic Technique Staff Training and Self-assessment workbook (ward and haemodialysis 

settings) 
&gt; 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 &amp; 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 &amp; 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>
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