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Aseptic Non Touch Technique (ANTT) policy Version No.2 of 20

ASEPTIC NON TOUCH TECHNIQUE (ANTT) POLICY

Infection Prevention & Control

Document Author Authorised Signature Written By: Infection Prevention & Control Team Date: October 2014

Authorised By: Chief Executive Date: 19th May 2015 Lead Director: Executive Director of

Nursing Effective Date: 19th May 2015

Review Date: 18th May 2018

Approval at: Policy Management Group

Date Approved: 19th May 2015


DOCUMENT HISTORY (Procedural document version numbering convention will follow the following format. Whole numbers for approved versions, e.g. 1.0, 2.0, 3.0 etc. With decimals being used to represent the current working draft version, e.g. 1.1, 1.2, 1.3, 1.4 etc. For example, when writing a procedural document for the first time – the initial draft will be version 0.1)

Date of Issue

Version No.

Date Approved

Director Responsible for Change

Nature of Change Ratification / Approval

24 Oct 14 0.1 Executive Director of Nursing & Workforce

New Policy Ratified by Infection, Prevention & Control Committee by voting buttons

07 Nov 14 0.1 Executive Director of Nursing & Workforce

Ratified at Clinical Standards Group

18 Nov 14 0.1 Executive Director of Nursing & Workforce

Ratified at Policy Management Group

01 Dec 14 1.0 01 Dec 14 Executive Director of Nursing & Workforce

Approved at Trust Executive Committee

11 May 15 2 19 May 15 Executive Director of Nursing

Slight amendments to Appendices due to current procedures

Approved at Policy Management Group

NB This policy relates to the Isle of Wight NHS Trust hereafter referred to as the Trust.


Contents Page 1. Executive Summary 4 2. Introduction 5 3. Scope 5 4. Purpose 5 5. Roles and Responsibilities 5 6. Policy detail / course of action 6 6.1 Manage the environment 6 6.2 Decontaminate & Protect 6 6.3 Use aseptic fields 7 6.4 Use non touch technique 7 6.5 Prevent cross infection 7 7. Consultation 7 8. Training 7 9. Dissemination Process 7 10. Equality Analysis 8 11. Review and Revision arrangements 8 12. Monitoring Compliance and Effectiveness 8 13. Links to Other Organisation Policies/Documents 8 14. References 8 15. Disclaimer 9

Appendices:

A. Key definitions 10 B. The ANTT approach – key part/key site assessment 11 C. The ANTT approach – safe aseptic technique 12 D. Checklist for the development and approval of controlled documentation 13

E. Impact assessment forms on policy implementation (Including Checklist) 15 F. Equality analysis and action plan 18


1. EXECUTIVE SUMMARY

Effective infection prevention and control must be embedded in everyday practice. This policy provides a clear practice standard for undertaking aseptic procedures using an aseptic non touch technique (ANTT) approach. It applies to all staff working within The Trust who undertake aseptic procedures as part of their role. The policy covers:

• Guidance and rationale for the ANTT approach

• Responsibilities for ensuring ANTT policy is in place monitored and complied with

• Requirements for staff training and education and in ensuring policy compliance.


2. INTRODUCTION 2.1 Developed in University College Hospital London, ANTT is a unique and contemporary

practice framework for aseptic technique. It has become the accepted practice standard for aseptic technique in the UK National Health Service and it is now used widely internationally (ANTT 2014).

2.2 ANTT aims to prevent the contamination of wounds and other susceptible sites, by ensuring that only uncontaminated equipment or sterile fluids come into contact with susceptible or sterile body sites during clinical procedures. The Trust has identified ANTT as a key skill to be achieved by staff who carry out aseptic procedures as part of their role.

2.3 A cascade approach will be used to train ANTT assessors in the workplace.

2.4 The Health & Social Care Act (Department of Health, DoH 2008) stipulates that:

• ANTT should be carried out in a manner that maintains and promotes the principles of asepsis

• The technique should be standardised across the organisation

• All staff undertaking procedures involving asepsis should be provided with education, training and assessment

• Yearly audits should be undertaken to monitor compliance (DoH 2008).

3. SCOPE 3.1 Applies to all healthcare workers in The Trust and in all healthcare settings.

Also applies to healthcare workers in contracted services, visiting healthcare workers and students.

4. PURPOSE 4.1 To provide guidelines to establish ANTT as the safe and effective technique for all aseptic

procedures.

5. ROLES AND RESPONSIBILITIES 5.1 Chief Executive

Has ultimate responsibility for all aspects of Infection Prevention and Control within the

Trust.

5.2 Director of Infection Prevention & Control (DIPC) The DIPC oversees this policy and its implementation. 5.3 Heads of Clinical Services

Are accountable for the infection control practices and standards within their directorate. Directorate ownership is an essential component of clinical governance.

5.4 Infection Prevention & Control Team

Are responsible for review and updating this policy and working with clinical education team to initiate cascade training of ANTT assessors in clinical practice. Will ensure that their training, policies, guidelines are ANTT compliant.


5.5 Clinical Education Team Are responsible for leading a programme of training of ANTT assessors in clinical practice. Will ensure that their training, policies, guidelines are ANTT compliant.

5.6 Managers/Matrons/Ward Sisters

Managers and clinical leaders are responsible for

• Identifying and releasing appropriate staff to be trained as ANTT assessors.

• Ensuring that there is a robust plan for roll out of training and competency assessment for relevant staff in their area of responsibility.

• Ensuring that training records are maintained.

• Ensuring that job descriptions include a statement making clear requirements to comply with policies for prevention and control of infection.

• At appraisal checks should be made of training attendance, competency achievement and compliance with policy standards.

5.7 Individual Responsibility All healthcare workers have an ethical and legal duty to comply with these guidelines and protect the health and safety of themselves, co-workers and patients. They should understand their personal responsibility to comply with key policies and to promote good practice and challenge poor compliance.

6. POLICY DETAIL / COURSE OF ACTION

The main focus of ANTT is to minimise the introduction of micro-organisms, which may occur during any invasive procedure. To reduce the potential for contamination, the technique follows some fundamental rules such as carrying out risk assessment, effective hand hygiene and the appropriate wearing of personal protective equipment and maintaining an aseptic environment.

The ANTT approach can be considered as surgical or standard (see Appendix A). The need for Surgical or Standard ANTT is determined by risk assessment based on the technical difficulty of achieving asepsis (the procedure environment, procedure invasiveness, the number & size of Key-Parts & Key-sites and length of procedure). While these two approaches differ to accommodate different levels of procedure complexity they both adhere to the same principles of ANTT.

The two types of ANTT can be simplified into ‘The ANTT-Approach’. The ANTT-Approach highlights and promotes the essential elements of safe aseptic technique (see Appendix B).

6.1 Manage the Environment A clean working environment is essential for all invasive clinical procedures. Aseptic procedures should be carried out in environments where there is no other activity being undertaken that could increase the risk of contamination such as bed making, environmental cleaning or patients using commodes in the immediate vicinity. For many procedures where there are minimal small key parts/sites to protect (venepuncture, cannulation, IV medication administration) standard ANTT (micro critical aseptic field) will be effective. Where there are more or larger key parts/sites to protect (surgical procedures, central line insertion, urethral catheterization), surgical ANTT (critical field) such as sterile drapes/sterile tray of equipment is necessary.

6.2 Decontaminate and protect Effective hand decontamination is essential to ANTT and should take place before and after invasive clinical procedures and after removal of gloves.


All equipment (including hubs and ports, trolleys and trays, surgical equipment) must be appropriately decontaminated. Personal protective equipment (PPE) provides a barrier between micro-organisms on hands, clothing and the susceptible site. Standard precautions must always be adhered to when performing ANTT. Non sterile gloves can be used for where it is possible to undertake the procedure without touching any key parts/susceptible sites. Where this is not possible, sterile gloves must be used.

6.3 Use Aseptic Fields

For many procedures where there are minimal small key parts/sites to protect (venepuncture, cannulation, IV medication administration) a micro aseptic field will be effective. Where there are more or larger key parts/sites to protect (surgical procedures, central line insertion, urethral catheterization, surgery), a critical field such as sterile drapes/sterile tray of equipment are necessary.

6.4 Use Non-Touch Technique

The only way to protect a key-part or site is not to touch it. If these must be handled sterile gloves must be worn.

6.5 Prevent Cross Infection Safe and effective equipment disposal and hand decontamination is essential at the end of every procedure.

7. CONSULTATION 7.1 This policy has been shared with the Infection Prevention & Control Committee, Specialist

Nurses and Clinical skills trainers who provide training in aseptic procedures as part of their role, Matrons Action Group, Clinical Nurse Leaders Forum (Continence team, Tissue Viability Lead), Clinical Directors for Consultation.

8. TRAINING 8.1 This ANTT policy has a mandatory training requirement which is detailed in the Trust’s

mandatory training matrix and is reviewed on a yearly basis. Training will be provided to all staff who undertake aseptic procedures as part of their role through a cascade approach using ANTT trainers and ANTT e-learning package. Staff will be required to undertake competency assessment following training.

9. DISSEMINATION 9.1 When approved this document will be available on the Intranet and will be subject to

document control procedures. Approved policies will be placed on the Intranet within five working days of date of approval once received by the Risk Management Team. All other procedural documents will be handled by the Quality Team.

9.2 When submitted to the Risk Management Team (for polices) or the Quality Team (all

other procedural documents) for inclusion on the Intranet this document will have fully completed document details including version control. Keywords and description for the Intranet search engine will be supplied by the author at the time of submission.

9.3 Notification of new and revised documentation will be issued on the Front page of the

Intranet, through e-bulletin, and on staff notice boards where appropriate. Any controlled documents noted at the Trust Executive Committee will be notified through the e-bulletin.


9.4 Staff using the Trust’s intranet can access all procedural documents. It is the

responsibility of managers to ensure that all staff are aware of where, and how, documents can be accessed within their areas of work.

9.5 It is the responsibility of each individual who prints a hard copy of any document to ensure

that the printed hardcopy is the current version. Current versions are maintained on the Intranet.

10. EQUALITY ANALYSIS 10.1 This procedure has undergone an equality analysis please refer to Appendix F.

11. REVIEW AND REVISION ARRANGEMENTS 11.1 This policy will be reviewed by the authors every three years (or sooner if new national

guidance is issued).

12. MONITORING COMPLIANCE AND EFFECTIVENESS 12.1 Matrons/Managers will ensure audit of implementation of this policy is undertaken as

directed by the Infection Prevention & Control Team Operational Group and feed results through their directorate and the Infection Prevention & Control Operational Group.

12.2 It is the responsibility of directorates to ensure that action plans are devised, implemented

and reviewed for areas of non-compliance.

13. LINKS TO OTHER ORGANISATION POLICIES/DOCUMENTS

IPC: Standard Precautions – Use of Personal Protective Equipment policy IPC: Hand Hygiene policy IPC: Blood Culture Collection policy IPC: Venepuncture procedure Urethral Catheterisation guideline

14. REFERENCES

Department of Health (2009) The Health and Social Care Act 2008. Code of practice for health and adult social care on the prevention and control of infections and related guidance. London

Dougherty L. Lister S (2011) Aseptic Technique In: L Dougherty & S Lister (eds) The Royal Marsden Hospital Manual of Clinical Nursing Procedures 7th Ed. UK Wiley-Blackwell 110-112 Chapter 3

http://antt.org/ANTT_Site/Home.html


15. DISCLAIMER 15.1 It is the responsibility of all staff to check the Trust intranet to ensure that the most recent

version/issue of this document is being referenced


Appendix A

KEY DEFINITIONS FOR DOCUMENTATION

Asepsis Absence of micro-organisms. Aseptic Technique A practice that ensures only uncontaminated items make contact with sterile/susceptible sites. Aseptic Non Touch Technique A standardised approach using a safe and effective non-touch technique for all aseptic procedures. Critical aseptic field (ensuring asepsis): Is used when an open, invasive procedure requires a large working area and could not be undertaken without touching key parts (for example procedures in the operating theatre, urethral catheterisation, insertion of long/mid lines). Sterile drapes/trays must be used form the aseptic field. Only equipment that has been sterilised and is aseptic can be introduced onto the critical aseptic field and sterile gloves must be used for handling items in the field. The whole area becomes a key part that can only come into contact with other aseptic equipment (critical management).

Micro Critical Aseptic Fields Aseptic field (disinfected or disposable tray) is managed generally – key parts are protected with individual micro critical aseptic fields (caps and covers). Essential but non-sterilized equipment may be placed in the aseptic field (general management).

Key Part/Sites Any part or site which if contaminated during aseptic technique, will increase the risk of infection. Examples include the tip of a needle or the surface of a wound.

Example of a critical aseptic field

Example of a micro critical aseptic field


Appendix B

* See Appendix A


Appendix C


Appendix D

CHECKLIST FOR THE DEVELOPMENT AND APPROVAL OF CONTROLLED DOCUMENTATION

To be completed and attached to any document when submitted to the appropriate committee for consideration and approval. Title of document being reviewed:

Y/N/ Unsure

Comments

1. Title/Cover

Is the title clear and unambiguous? Y

Does the title make it clear whether the controlled document is a guideline, policy, protocol or standard?

Y

2. Document Details and History

Have all sections of the document detail/history been completed? Y

3. Development Process

Is the development method described in brief? Y

Are people involved in the development identified? Y

Do you feel a reasonable attempt has been made to ensure relevant expertise has been used?

Y

4. Review and Revision Arrangements Including Version Control

Is the review date identified? Y

Is the frequency of review identified? If so, is it acceptable? Y

Are details of how the review will take place identified? Y

Does the document identify where it will be held and how version control will be addressed?

Y

5. Approval

Does the document identify which committee/group will approve it? Y

If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document?

Y

6. Consultation

Do you have evidence of who has been consulted?

7. Table of Contents

Has the table of contents been completed and checked? Y

8. Summary Points

Have the summary points of the document been included? Y

9. Definition

Is it clear whether the controlled document is a guideline, policy, protocol or standard?

Y

10. Relevance

Has the audience been identified and clearly stated? Y

11. Purpose

Are the reasons for the development of the document stated? Y

12. Roles and Responsibilities

Are the roles and responsibilities clearly identified? Y

13. Content

Is the objective of the document clear? Y


Title of document being reviewed:

Y/N/ Unsure

Comments

Is the target population clear and unambiguous? Y

Are the intended outcomes described? Y

Are the statements clear and unambiguous? Y

14. Training

Have training needs been identified and documented? Y

15. Dissemination and Implementation

Is there an outline/plan to identify how this will be done? Y

Does the plan include the necessary training/support to ensure compliance?

Y

16. Process to Monitor Compliance and Effectiveness

Are there measurable standards or Key Performance Indicators (KPIs) to support the monitoring of compliance with and effectiveness of the document?

Y

Is there a plan to review or audit compliance within the document? Y

Is it clear who will see the results of the audit and where the action plan will be monitored?

Y

17. Associated Documents

Have all associated documents to the document been listed? Y

18. References

Have all references that support the document been listed in full? Y

19. Glossary

Has the need for a glossary been identified and included within the document?

Y

20. Equality Analysis

Has an Equality Analysis been completed and included with the document?

Y

21. Archiving

Have archiving arrangements for superseded documents been addressed?

Has the process for retrieving archived versions of the document been identified and included within?

22. Format and Style

Does the document follow the correct style and format of the Document Control Procedure?

Y

23. Overall Responsibility for the Document

Is it clear who will be responsible for co-ordinating the dissemination, implementation and review of the documentation?

Y

Committee Approval

If the committee is happy to approve this document, please sign and date it and forward copies for inclusion on the Intranet.

Name of Committee

Policy Management Group Date 19th May 2015

Print Name Mark Price Signature of Chair


Appendix E

IMPACT ASSESSMENT ON DOCUMENT IMPLEMENTATION

Summary of Impact Assessment (see next page for details)

Document title

Aseptic Non Touch Technique (ANTT)

Totals WTE Recurring

£ Non

Recurring £ Manpower Costs

NA NA NA

Training Staff

NA NA £1,000 initial training session for trainers (already financed in 2013)

Equipment & Provision of resources

NA NA NA

Summary of Impact: Initial one off £1000 training cost for session delivered by ANTT expert to key trainers. Already taken place and financed. Rough estimate of 1 hour training session for all staff for whom this training is mandatory is £46044. Benefits / Savings to the organisation: Standardised approach to ANTT. Implementation of best practice Equality Impact Assessment � Has this been appropriately carried out? YES / NO � Are there any reported equality issues? YES / NO If “YES” please specify:

Use additional sheets if necessary.


IMPACT ASSESSMENT ON POLICY IMPLEMENTATION Please include all associated costs where an impact on implementing this policy has been considered. A checklist is included for guidance but is not comprehensive so please ensure you have thought through the impact on staffing, training and equipment carefully and that ALL aspects are covered.

Manpower WTE Recurring £ Non-Recurring £

Operational running costs

Additional staffing required - by affected areas / departments:

NA NA NA

Totals: NA NA NA Staff Training Impact Recurring £ Non-Recurring £

NA 18 staff for 1 day to train as key

trainers – already taken place

£1000

All clinical staff 1 hour ANTT training Rough estimate of 1 hour training

session for all staff for whom this training is mandatory is

£46044. Totals: NA £47044

Equipment and Provision of Resources Recurring £ * Non-Recurring £

*

Accommodation / facilities needed

Building alterations (extensions/new) NA NA IT Hardware / software / licences NA NA Medical equipment (ANTT reuseable trays) NA £1000 Stationery / publicity NA NA Travel costs NA NA Utilities e.g. telephones NA NA Process change NA NA Rolling replacement of equipment NA NA Equipment maintenance NA NA Marketing – booklets/posters/handouts, etc NA Printing of

posters – approx £175

Totals: NA As above

• Capital implications £5,000 with life expectancy of more than one year.

Funding /costs checked & agreed by finance: Signature & date of financial accountant: Funding / costs have been agreed and are in place: Signature of appropriate Executive or Associate Director:


IMPACT ASSESSMENT ON DOCUMENT IMPLEMENTATION - CHECKLIST

Points to consider

Have you considered the following areas / departments?

• Have you spoken to finance / accountant for costing?

• Where will the funding come from to implement the policy?

• Are all service areas included? o Ambulance o Acute o Mental Health o Community Services, e.g. allied health professionals o Public Health, Commissioning, Primary Care (general practice, dentistry,

optometry), other partner services, e.g. Council, PBC Forum, etc. Departments / Facilities / Staffing

• Transport

• Estates o Building costs, Water, Telephones, Gas, Electricity, Lighting, Heating, Drainage,

Building alterations e.g. disabled access, toilets etc

• Portering

• Health Records (clinical records)

• Caretakers

• Ward areas

• Pathology

• Pharmacy

• Infection Control

• Domestic Services

• Radiology

• A&E

• Risk Management Team / Information Officer – responsible to ensure the policy meets the organisation approved format

• Human Resources

• IT Support

• Finance

• Rolling programme of equipment

• Health & safety/fire

• Training materials costs

• Impact upon capacity/activity/performance


Appendix F

Step 1. Identify who is responsible for the equality analysis.

Name: Michelle Ould

Role: Infection Prevention & Control Nurse

Step 2. Establishing relevance to equality

Show how this document or service change meets the aims of the Equality Act 2010?

Equality Act – General Duty Relevance to Equality Act General Duties Eliminates unlawful discrimination, harassment, victimization and any other conduct prohibited by the Act.

Treats every person undergoing aseptic procedure equally

Advance equality of opportunity between people who share a protected characteristic and people who do not share it


Foster good relations between people who share a protected characteristic and people who do not share it.


Step 3. Scope your equality analysis

Scope

What is the purpose of this document or service change?

To adopt a standardised approach across the Organisation

to undertaking aseptic procedures. To promote a safe and

effective technique for all aseptic procedures

Who will benefit? All service users undergoing aseptic procedures

Relevance

Protected Groups Staff Service Users Wider Community

Age NA NA NA Gender Reassignment NA NA NA Race NA NA NA Sex and Sexual Orientation NA NA NA Religion or belief NA NA NA Disability NA NA NA Marriage and Civil Partnerships NA NA NA Human Rights NA NA NA Pregnancy and Maternity NA NA NA

Equality Analysis and Action Plan This template should be used when assessing policies and strategic documents


What are the expected outcomes?

Preventing contamination of wounds and susceptible sites

thus reducing the risk of infection

Why do we need this document

or do we need to change the

service?

To promote best practice guidance

It is important that appropriate and relevant information is used about the different protected groups that will be affected by this document or service change. Information from your service users is in the majority of cases, the most valuable. Information sources are likely to vary depending on the nature of the document or service change. Listed below are some suggested sources of information that could be helpful:

• Results from the most recent service user or staff surveys.

• Regional or national surveys

• Analysis of complaints or enquiries

• Recommendations from an audit or inspection

• Local census data

• Information from protected groups or agencies.

• Information from engagement events.

Step 4. Analyse your information. As yourself two simple questions:

• What will happen, or not happen, if we do things this way?

• What would happen in relation to equality and good relations? In identifying whether a proposed document or service changes discriminates unlawfully, consider the scope of discrimination set out in the Equality Act 2010, as well as direct and indirect discrimination, harassment, victimization and failure to make a reasonable adjustment.

Findings of your analysis

Description Justification of your analysis No major change Your analysis

demonstrates that the proposal is robust and the evidence shows no potential for discrimination.

All persons treated equally. No discrimination identified.

Adjust your document or service change proposals

This involves taking steps to remove barriers or to better advance equality outcomes. This might include introducing measures to mitigate the potential effect.

Continue to implement the document or service change

Despite any adverse effect or missed opportunity to advance equality, provided you can satisfy yourself it


does not unlawfully discriminate.

Stop and review Adverse effects that cannot be justified or mitigated against, you should consider stopping the proposal. You must stop and review if unlawful discrimination is identified

5. Next steps. 5.1 Monitoring and Review.

Equality analysis is an ongoing process that does not end once the document has been published or the service change has been implemented. This does not mean repeating the equality analysis, but using the experience gained through implementation to check the findings and to make any necessary adjustments.

Consider: How will you measure the effectiveness of this change

Successful training of relevant individuals

When will the document or service change be reviewed?

3 years or sooner if new guidance available

Who will be responsible for monitoring and review?

Clinical leads/Matrons for implementation. Authors for policy review

What information will you need for monitoring? Training records, successful completion of competency assessments, aseptic technique audit data

How will you engage with stakeholders, staff and service users

Disseminate draft amongst groups described in policy consultation. Make final version available on Intranet Ensure poster resources available in workplace for staff and service users

5.2 Approval and publication

The Trust Executive Committee / Policy Management Group will be responsible for ensuring that all documents submitted for approval will have completed an equality analysis. Under the specific duties of the Act, equality information published by the organisation should include evidence that equality analyses are being undertaken. These will be published on the organisations “Equality, Diversity and Inclusion” website.

Useful links:

Equality and Human Rights Commission http://www.equalityhumanrights.com/advice-and-guidance/new-equality-act-

guidance/equality-act-guidance-downloads/