Editor's note: This blog by Margaret Heale, RN, MSc, CWOCN, is the recipient of the 2019 Blog of the Year Award. It has received the most views of any blog posted on WoundSource within the last year. The WoundSource Editors would like to congratulate Margaret on her award.

Having read a recent article on clean versus sterile dressing technique, commenting again on this issue seems highly appropriate. The conclusion of the paper essentially is that a clean technique for acute wound care does not affect the incidence of infection.¹ There is insufficient evidence in the literature relating to chronic wound care. I particularly appreciated the comment that nurses need to decide which approach to have by using critical thinking skills. I was reminded of a visit to a patient to utilize a fancy new dressing that I had never used before.

Case Report: Home Health Wound Dressing Change

I arrived and did the patient's assessment. While getting out the supplies for the wound dressing, the patient told me the doctor had discussed the dressing with her and provided a few things. I found two sterile towels, a nail brush, and a pair of sterile gloves, and the patient told me it was so I could remain sterile. Everything prepped and opened (which took a while), I opened the dressing pack (a very fancy, large Band-Aid) and went off to the bathroom to "scrub up." I returned, dried my hands with one paper towel, donned the sterile gloves connected the dressing to the sterile mini-suction device, and managed to discourage the patient's cat without contaminating anything. After cleaning the wound and drying the surrounding skin, I used the skin barrier wipe and placed the second sterile towel between me and the patient's wound. Finishing the procedure with a clean pair of gloves on (though I really dislike gloves and sticky-backed dressings), I smoothed the dressing onto the wound and placed the reinforcement strips.

Believe me, sterile procedures are for situations where there is at least one other person present to ensure asepsis. Between the cats, dogs, birds, phones ringing, and neighbors dropping by, sterile technique has no place in home health care. In this particular home, I had plenty of space and a reasonably sized area for open supplies, but that is not usually the case. Thank goodness for clean gloves (and may there be plenty of them).

Definition of Clean Dressing Technique

Outlining exactly what is meant by clean dressing technique is worthwhile because it does not mean the "five-second rule" applies; it is not a sloppy version of a sterile techniques. It is defined by Kent et al. as involving the use of a clean procedure field, clean gloves, with sterile supplies, and with avoidance of direct contamination of materials and supplies.¹ This short definition is simple and essentially covers the bases but raises some questions, particularly for home health care. What about re-using syringes and cannula? For how long? A gauze loaf once open cannot be considered sterile, and, although cleaning with it may be acceptable, is it okay to use as a primary dressing filler?

Looking at the technique in detail has been lacking. Some issues are obviously not acceptable if using a "clean technique;" there should not be cut pieces of foam dressings floating about in the supplies box, Xeroform dressings cut in half with the foil wrapper folded over, bits floating in the bottle of saline, and grubby, yellow-topped gel dressing tubes with no alcohol wipes in sight. Comparing outcomes of one technique with the other is of interest, but what about the actual technique and how well is it actually practiced?

Pitfalls And Problems of Clean Dressing Technique

What are the pitfalls and problems that may lead to a wound dressing procedure that is, questionably, a clean one? To list a few:

• No access to a clean field to work from or one that is impermeable to moisture
• Gloves stored in bathrooms
• Bags, rather than appropriately sized boxes, for supply storage in home care
• Insufficient or inappropriate bedside storage in facilities
• Use of scissors on multiple patients
• Nothing to secure opened dressing packages (plastic baggies)
• No space to put supplies or position well (big problem in home care in the home of hoarders)
• Pets investigating what is happening
• Re-use of syringes, cannulas, and bottles of saline for irrigation
• Opening packages (Q-tips, gauze, gels, and creams) with gloves on

Procedure To Promote A Clean Dressing Technique

Addressing the foregoing issues can make the possibility of a truly clean technique more likely, as can organizing the procedure into three distinct parts:

FIRST Prep dressing supplies, prep the patient, remove dressing, and place a protective field.

THEN Clean the wound and periwound skin. Apply a skin protective barrier, and place a dry protective field.

LAST Dress the wound by tucking in a filler, placing an absorbent secondary layer, and securing with tape or wrap.

Clean Dressing Technique Versus Asepsis

1. The wound, any supplies, and the environment should not be contaminated by each other.
2. Wash hands before starting a procedure and decontaminate before and after glove changes.
3. Contamination of the wound is minimized by not touching it.
4. Fresh clean gloves are required if it is necessary to touch the wound directly. These gloves should not contact anything other than the wound or the sterile products being used on it.
5. Contamination of the local environment and supplies is avoided by organizing the procedure to ensure that anything coming into contact with the wound does not contact jars, bottles, tubes, bedside table, or supplies to be kept for use at a later date.
6. A clean, non-porous material needs to catch any runoff from the wound during cleansing and should be replaced with a clean, dry field before dressing placement.
7. The outer surface of the dressing should not be touched by gloves used to clean the wound. This applies to tape and any wraps used for the dressing.
8. Fresh clean gloves should be worn to tuck or pack a primary dressing into a wound.
9. Provided a primary dressing is dry and not contaminated, it may be kept for the same patient's next dressing change. This means it should be cut with clean scissors, stored in the original package, dated, and fully secured in an appropriately sized bag.
10. All dressing supplies should be stored off the floor, away from heat or light, and secure from pets. Gloves used for wound care should not be stored in the bathroom or under a sink.

Finally, an excellent way of keeping your wound dressing technique truly clean is to perform it as you would if teaching a student the best procedure possible. Personally critically analyzing the dressing technique you use is essential to optimal care.

References

1. Kent DJ, Sardillo JN, Dale B, Pike C. Does the use of clean or sterile dressing technique affect the incidence of wound infection? J Wound Ostomy Continence Nurs. 2018;45(3):265-9.

2. Wound, Ostomy and Continence Nurses Society (WOCN) Wound committee; Association of Professionals in Infection Control and Epidemiology, Inc (APIC) 2000 Guidelines Committee. Clean vs. sterile dressing techniques for management of chronic wounds: a fact sheet. J Wound Ostomy Continence Nurs. 2012;39(2 Suppl):S30-4.

About the Author

Margaret Heale has a clinical consulting service, Heale Wound Care in Southeastern Vermont and draws on her extensive experience as a wound, ostomy and continence nurse in acute and long-term care settings to provide education and holistic care in her practice.