The role of the medical assistant
Aseptic techniques: preventing disease transmission
Asepsis means free from infection or infectious material.
Medical asepsis is defined as the reduction of disease-causing organisms. By using the principles of medical asepsis, we can prevent the spread of disease. The goal is to eliminate or minimize pathogens by following OSHA’s Bloodborne Pathogens Standard and disinfecting objects as soon as possible after contamination. This creates a healthcare environment as free of pathogens as possible.
Surgical asepsis is the destruction of all organisms. This technique is used for any procedure that enters the body’s skin or tissues, such as surgery or injections. Anytime the skin or a mucous membrane is punctured, pierced, or incised, surgical aseptic techniques are practiced.
Everything that comes in contact with the patient should be sterile:
- Gowns
- Drapes
- Instruments
- Gloves
Minor surgery, urinary catheterization, injections, and some specimen collections, such as blood collection and biopsies, are performed using surgical aseptic technique.
Normally, two types of microorganisms are found on the skin: normal resident flora and transient flora. Normal resident flora lives harmlessly on the skin. Transient flora includes bacteria, viruses, and other organisms picked up on the hands. Resident flora is firmly attached to the skin, whereas transient flora is not. This means that transient flora is easily removed by thorough hand hygiene, preventing the transfer to patients.
The most effective barrier against infection is intact skin. If the skin and mucous membranes are intact, medical asepsis can be used for most noninvasive procedures, such as pelvic and proctologic examinations. Instruments and objects used in medical aseptic procedures must be sanitized and disinfected or sterilized before being used on another patient.
Medical aseptic procedures may include the use of gowns and masks, but these are not sterile and are worn to protect the healthcare worker more than the patient. Many healthcare facilities are providing masks for patients to use if they present with productive cough, fever, and other influenza-like symptoms. In addition to masks, hand sanitizer stations are provided. Both of these measures can help prevent the spread of disease.
Another practical application of medical aseptic technique is to set up work areas in the medical office’s laboratory. One side of the laboratory is the “clean” side, where only noninfectious procedures are performed. The other side is the “dirty” side, where potentially infectious materials are processed or cleaned.
Hand hygiene
Because skin cannot be sterilized, the goal of hand hygiene is to reduce the number of microorganisms, protecting yourself from infection and preventing cross-contamination from one patient to another. Hand hygiene can be accomplished in two different ways. If the hands are visibly soiled, they must be washed using a medical aseptic technique with mechanical friction, soap, and warm, running water. If the hands are not visibly soiled, alcohol-based hand sanitizer can be used; the alcohol kills the microorganisms. Hand hygiene, using the correct technique, must be done before and after each patient is examined or treated and also when stipulated by the Bloodborne Pathogens Standard.
When you wash your hands for the first time in the morning, spend at least 1 minute on the scrub. For subsequent hand washing, the CDC recommends 15 seconds. Each office sink should be equipped with a liquid soap dispenser. A water-soluble lotion may be rubbed into the hands after they have been washed and dried. Dry, cracked, chapped skin is no longer intact and can provide a means of entry for microorganisms.
Proper handwashing depends on two factors: running water and friction. The water should be warm. Water that is too hot or too cold causes the skin to become chapped. Friction is the firm rubbing of all surfaces of the hands and wrists. Remember that your fingers have four sides, and fingernails have two sides. For medical aseptic hand washing, all jewelry except a plain wedding band is removed. A wristwatch may be left on if it can be moved up on the forearm away from the wrist area. The hands are washed under running water with the fingertips pointing downward. Soap and friction are applied to the hands and wrists. The water is allowed to wash debris away from the wrists and down toward the fingertips.
When you use an alcohol-based hand sanitizer, it should take 20 to 30 seconds to rub all of it into the skin. Be sure to cover all surfaces and continue rubbing it in until your hands are dry. Evidence suggests that hand hygiene with an alcohol-based hand sanitizer is more effective at reducing nosocomial infections than plain hand washing. Antimicrobial-impregnated wipes (e.g., towelettes) are not a substitute for an alcohol-based hand sanitizer or soap.
When to use hand hygiene
Medical aseptic hand washing or alcohol-based hand sanitizer should be used in the following situations, even if disposable gloves are worn:
- After you finish with one patient and before you attend to another patient, and before and after contact with the patient’s immediate care environment
- After you finish handling one specimen and before you handle another specimen
- Before performing an aseptic task (e.g., giving an injection, drawing blood)
- After contact with blood, body fluids, or contaminated surfaces
- When hands move from a contaminated body site to a clean body site during patient care
- After you use toilet facilities
- Whenever you touch something that causes your hands to become contaminated
- When you arrive at work and before you leave the facility
- After removing gloves
- Before and after eating
Sanitization
Sanitization is the cleaning process that reduces the number of microorganisms to a safe level. You must carefully clean instruments and other items used in the healthcare facility before proceeding with disinfection or sterilization. This cleansing process removes debris such as blood and other body fluids from instruments or equipment. This debris can protect the microorganisms from disinfection or sterilization.
The medical assistant should always wear gloves while performing sanitization. Thick utility gloves will help protect your hands when you work with instruments that have sharp or pointed edges. Gloves prevent possible personal contamination with other potentially infectious materials (OPIM) that may be present on the articles being cleaned. The procedure should be completed immediately after the use of the instruments. A separate workroom, or the “dirty” side of the utility room, is used to prevent cross-contamination of clean instruments and equipment. If sanitization cannot be done immediately, rinse the used items under cold water immediately after the procedure and place them in a detergent solution. Never allow blood or other substances to dry on an instrument.
When you are ready to sanitize instruments, rinse each instrument in cold running water. Sharp instruments should be kept separate from the other instruments. Metal instruments may damage the cutting edges, and sharp instruments may damage other instruments or injure you. Clean all sharp instruments at the same time when you can concentrate on preventing injury. Open all hinges, and scrub serrations and ratchets with a small scrub brush or toothbrush. Rinse the instruments in hot water and then carefully check that they are in proper working order before they are disinfected or sterilized. The items should be hand dried with a towel to prevent spotting and allowed to air dry before further processing.
Sanitization is a very important step, and it cannot be overlooked or done carelessly. The use of disposable instruments minimizes the need for sanitization, disinfection, and sterilization.
Ultrasonic sanitization
Sound waves can be used to sanitize instruments. The instruments are placed in an ultrasonic bath of cleaner and water. Sound waves cause the solution to vibrate, which loosens the materials attached to the instruments. Ultrasonic cleaners are beneficial because they do not damage even the most delicate instruments, and workers do not run the risk of an accidental sharps injury.
Disinfection
Disinfection is the process of killing pathogenic organisms or of rendering them inactive. It is not always effective against spores, tuberculosis bacilli, and certain viruses. Some disinfectant chemicals can kill microbes within a short time, but they are usually hard on instruments. Some chemicals, such as Cidex, are effective enough to kill all organisms, but the usual immersion time is 10 hours or longer. For exam tables and countertop surfaces, there are two common disinfectants: hydrogen peroxide and bleach. Both are low cost and effective.
Many other types of disinfecting agents are available for instruments and equipment. It is important to follow the manufacturer’s guidelines on the following factors:
- How to use each product properly
- Advantages and disadvantages
- Possible sources of error
Levels of disinfectants
The CDC defines three levels of disinfectants:
- Low-level disinfectants can kill most vegetative bacteria, some fungi, and some viruses. They are used for exam tables and countertops. Example: hydrogen peroxide.
- Intermediate-level disinfectants can kill mycobacteria, vegetative bacteria, most viruses, and most fungi, but they do not kill spores. They are used for noncritical items, such as stethoscopes and percussion hammers. Example: isopropyl alcohol.
- High-level disinfectants will kill all microorganisms except large numbers of bacterial spores. They are used for semicritical items, such as a flexible fiberoptic sigmoidoscope.
- Example: Cidex OPA.
Here are common errors that can cause chemicals to lose their effectiveness:
- Instruments are not thoroughly sanitized. Attached organic matter inhibits or prevents the action of the disinfectant. No chemical can kill unless it reaches all instrument surfaces; therefore, complete sanitization is absolutely necessary.
- The disinfectant solution is left in an open container, and evaporation changes its concentration.
- Solutions are not changed after the recommended period for use has expired.
- The manufacturer’s recommended temperature for use and storage is not maintained.
Chemical disinfectants cannot be used on skin or tissues because they can damage them. Therefore antiseptics, such as alcohol, are used on the skin to reduce the number of pathogens. Alcohol is the most widely used antiseptic, but studies indicate that it is not as effective as other products in inhibiting the growth and reproduction of microorganisms on the skin’s surface. Other antiseptic chemicals, such as povidone-iodine solution (Betadine), are effective antimicrobial agents that are safe to use on a patient’s skin.
Sterilization
Sterilization is essential for surgical asepsis. Sterilization can be achieved with moist heat, dry heat, ultraviolet light, ionizing radiation, gas, or chemicals. Medical facilities typically use the autoclave method, which uses moist heat. Steam under pressure in the autoclave offers an excellent method of sterilization because it kills all pathogens and spores. You will learn more about surgical asepsis and the sterilization process in another chapter.
Patient coaching
The medical assistant should take every opportunity to educate patients about the infection process and ways to prevent the transmission of disease. The best time to instruct a patient in aseptic techniques that can be used at home is while performing the aseptic procedure.
Legal and ethical issues
Medical asepsis and infection control in ambulatory care practices give rise to numerous legal and ethical concerns. Personal discipline is the primary concern in medical asepsis. Typically, the medical assistant is alone when performing an aseptic procedure; therefore, if contamination occurs, the medical assistant is the only one who knows.
If contamination should occur, the medical assistant must start over again with clean supplies.
A primary reason for performing aseptic procedures completely and effectively is to prevent the development of nosocomial infections in susceptible patients. These infections, which are acquired in the healthcare environment, can be especially dangerous for older or debilitated patients. Ignorance of the various aseptic techniques or carelessness can be dangerous and is inexcusable before the law.
Standard precautions and the transmission-based PPE categories used with them are covered in the next chapter, Workplace safety and protective measures.