With the growing incidence of microbial antibiotic resistance, preventing hospital-acquired (nosocomial) infections is more important than ever. Despite general expert opinion, primary research doesn’t conclusively indicate which patient care situations require sterile rather than clean technique. Without conclusive research and an accepted standard of care—especially in regard to dressing changes—practice among nurses varies significantly.

About 15% of nosocomial infections stem from surgical site infections, making these the most common infection type in surgical patients and the third most common type of nosocomial infection. (One study found that 17% of surgical wounds become infected.) To help prevent infection, the Centers for Disease Control and Prevention recommends using a sterile dressing for 24 to 48 hours after surgery and sterile technique for dressing changes. However, little definitive research has explored whether sterile technique is needed to prevent infection. Also, beyond the first 48 postoperative hours, recommendations and evidence vary as to whether the incision needs to be covered.

Previous studies
In the past decade, only two studies have explored the effect of clean vs. sterile technique on infection rates; neither study generated definitive data.

• In 1997, a pilot study of 30 patients with open surgical wounds found no difference in wound healing when dressing changes were performed using clean vs. sterile technique.
• In 2003, researchers at a university-based medical center gathered data for 3 months before and 3 months after a planned switch from a sterile- to a clean-technique policy. The study, which involved 963 patients with open surgical wounds, found that using clean technique didn’t raise infection rates; what’s more, it produced cost savings. Based on these findings, the hospital permanently implemented a clean-technique policy for open surgical wounds. Surgical-site infections were monitored for 1 year afterward, with no measurable increases found. However, these results haven’t been replicated by other studies.

Purpose of our study
We undertook research to:

• determine which technique (sterile or clean) nurses use more frequently for dressing changes
• explore nurses’ rationales for deciding which technique to use
• identify specific conditions under which nurses use sterile or clean technique
• shed light on practice discrepancies among nurses.

Methodology
We recruited participants from a list of Magnet™ hospitals, because these facilities use evidence-based practices. Seventeen of the 130 hospitals we contacted requested that we send them surveys to distribute to their acute-care nurses; 14 hospitals returned completed surveys, providing a total of 423 individual participant surveys. About 50% of respondents had bachelor degrees in nursing, 30% had associate degrees, and the remainder were split between master’s degrees and nursing diplomas.

Procedures
We received Institutional Review Board approval before contacting facilities to ask them to participate. Once a facility agreed to participate, we sent a survey regarding dressing change practices, along with an information sheet about the study and its purpose.

The survey contained four open-ended questions, which asked respondents to state their rationale for using clean instead of sterile technique, under what conditions they typically use clean technique, and under what conditions they typically use sterile technique. We used content analysis to analyze the qualitative data these questions generated. We also gathered data on the types and frequency of dressing changes performed, as well as demographic data on respondents.

Results
Nearly half the respondents (46%) reported they use sterile technique for less than half the dressing changes they perform; 7% said they use sterile technique all the time and 5% said they never use it. Respondents reported using clean technique 93% of the time in home-care settings. All respondents said they use sterile technique for wounds that are deep and invasive or that expose bone, muscle, and organs.

When a “no-touch” technique is possible (meaning the dressing can be changed without direct contact with the wound), respondents reported using clean technique 100% of the time. When a drain or tube is present, 53% said they use clean technique. However, 92% use sterile technique if the patient has a chest tube and 73% use it for vacuum-assisted wound closure. When wound packing is present, 84% use sterile technique; for initial dressing changes, 9% use sterile technique.

Some respondents said they take the patient’s health status into consideration, with 100% choosing sterile technique for immunocompromised patients and 86% choosing it for diabetic patients. In some cases, respondents said their choice of technique depends on physician order or facility policy.

Rationales for using sterile vs. clean technique
Respondents listed the following as their main rationales for using clean technique:

• The wound isn’t sterile or dirty.
• The dressing-change environment isn’t sterile.
• A “no-touch” clean technique can be used instead of sterile technique for chronic wounds.
• Clean technique is faster than sterile technique.
• The patient will be using clean technique on his or her own at home.
• Studies don’t support the use of sterile over clean technique

Respondents listed the following as their main rationales for using sterile technique:

• Preventing or reducing the risk of infection is paramount for patient in question.
• The hospital setting has more antibiotic-resistant bacteria and high infection rates.
• Foreign material (such as packing or an invasive line) has been introduced into the patient’s body.

Discussion
Our respondents reported striking differences in practice as well as several areas of agreement, as noted above. Inconsistent patient outcomes may reflect differences in practice. To significantly affect patient outcomes, practices need to be consistent.

Study limitations
The qualitative data we gathered are subject to researcher interpretation. Also, because we used the survey technique to collect data, respondents weren’t able to clarify or expound on their responses. In addition, we received 293 unusable responses to specific survey questions. Also, respondents probably completed the surveys at work, which might have limited their ability to focus on them thoroughly. Finally, this survey involved only Magnet hospitals and its results may not apply to other facilities.

Where should we go from here?
Aside from proper handwashing and use of universal precautions, nurses’ dressing-change practices vary considerably. Lack of research-based recommendations may play a role in this variability.

To fully evaluate the impact of bedside nursing care on patient outcomes, we need to make practices consistent. The nursing profession must determine whether sterile technique or clean technique provides the best quality of care without increasing costs. Future research should address this area and explore whether sterile technique is more likely than clean technique to improve healing and prevent infection.

We encourage nurses to examine their facility’s policies to ensure that these are based on evidence or available research. We also recommend that nurses compare the dressing-change practices of nurses in their own facility or in particular units to delineate practice variances.

Selected references

Lawson C, Juliano L, Ratliff C. Does sterile or nonsterile technique make a difference in wounds healing by secondary intention? Ostomy Wound Management. 2003;49(4):56-60. Available at: www.o-wm.com/article/1544. Accessed March 4, 2007.

Mangram A, Horan T, Pearson M, Silver L, Jarvis W. Guideline for prevention of surgical site infection. Infect Control Hosp Epidemiol. 1999;20(1):247-287. Available at: www.cdc.gov/ncidod/dhqp/pdf/guidelines/SSI.pdf. Accessed February 18, 2007.

St. Clair K, Larrabee J. Clean versus sterile gloves: which to use for postoperative dressing changes? Outcomes Manag. 2002;6(1):17-21.

Stotts N, Barbour S, Griggs K, Bouvier B, Buhlman L, Wipke-Tevis D, et al. Sterile versus clean technique in postoperative wound care of patients with open surgical wounds: a pilot study. Wound Care. 1997;21(1):10-18.

For a complete list of selected references, visit www.AmericanNurseToday.com.

Jeanne M. Gemender, BSN, RN, is a Staff Nurse on the Surgical-Intensive Care Unit at Indiana University Hospital/Clarian Health Partners in Indianapolis. Deanna L. Reising, PhD, APRN-BC, is an Associate Professor at Indiana University School of Nursing in Bloomington.

This study was supported by an Undergraduate Research and Creative Activity Partnership grant through the Office of Research and the University Graduate School at Indiana University in Bloomington.