[Skip to content]

.

Aseptic non touch technique (ANTT®) for intravenous therapy

The purpose of this guideline is to provide guidance about aseptic non touch technique (ANTT) for intravenous therapy at Great Ormond Street Hospital (GOSH).

Introduction

Asepsis is the prevention of microbial contamination by excluding/removing or killing micro-organisms (Xavier 1999). In the field of intravenous (IV) therapy, transmission of infection will only occur if the patients' IV access device is contaminated with sufficient numbers of pathogenic organisms.

Any invasive procedure, which bypasses the bodies’ natural defences, provides a means of potential contamination, as in the case of IV therapy. It is estimated that approximately 89 per cent of all hospital admissions receive some type of IV therapy as part of their treatment regimen and the risk of infection is one of the highest reported problems. It is therefore recommended that an aseptic technique should be adhered to throughout all intravenous procedures (Mallet & Bailey 2000).

The main focus of aseptic non touch technique (ANTT®) is to minimise the introduction of micro-organisms, which may occur during preparation, administration and delivery of IV therapy. In order to further reduce the potential for contamination, the technique follows some fundamental rules pertaining to infection control and staff/patient protection such as effective handwashing, maintaining an aseptic environment and the wearing of non-sterile gloves (Centers for Disease Control and Prevention (CDC) 2002; Control of Substances Hazardous to Health (COSHH) 1999; Dougherty 1999). The EPIC 2: National evidence-based guidelines for preventing  guidelines for preventing healthcare-associated infections in National Health Service (NHS) hospitals in England recommend that ANTT® must be used for catheter site care and for accessing the venous system (Pratt 2007).

However, other forms of aseptic technique are still needed for certain procedures, eg central venous catheter repair, and should be used appropriately.

Note: While this guideline refers to the ‘child’ throughout, all activities are applicable to young people.

Background

Asepsis is one of the main underlying principles of ANTT® and, when used correctly, prevents transmission of infection to the patient.

The term 'aseptic technique' within IV therapy itself was often misleading as nurses paid very little attention to possible contamination of equipment, believing the name of the technique and use of sterile gloves was protection enough.

Prior to the introduction of ANTT®, the 'aseptic technique' used to deliver IV therapy included using sterile gloves and dressing packs, even for basic IV therapy tasks, and required two nurses for the process. This was inefficient in terms of time and resources.

ANTT® is a technique that can be safely carried out in the ward or home environment, unlike sterile techniques which require highly controlled environments. Furthermore, ANTT® is basic in nature and clearly defined, focusing on the essentials of all IV therapy regardless of intravenous device, administration route or clinical condition (Rowley et al 2010).

The theory behind ANTT® focuses on the basic principles of infection control such as effective handwashing, maintaining asepsis of equipment and environment and the use of alcohol-based solutions for decontamination with adequate cleaning and natural evaporation of the alcohol. If alcohol-based products are not allowed to dry naturally, then the antibacterial properties of the agent will be ineffective, placing the patient at risk of developing an infection (Rowley et al 2010; Royal College of Nursing (RCN) 2003; Dougherty 1999; Maki 1991).

Currently at GOSH, wipes containing 2% chlorhexidine in 70% isopropyl alcohol are used to clean the hubs of venous access devices and the needle-free devices for 30 seconds with friction and allowed to dry prior to use. A study by Kaler & Chinn (2007) showed that prolonged contact with the wipe and the use of friction was effective in disinfecting needle-free devices. This chlorhexidine solution is recommended in the EPIC 2 guidelines with the aim of reducing catheter related bloodstream infections (Pratt 2007).

Well-fitting gloves are another essential part of ANTT®. They should be neither too small, with the potential to be punctured by wearer's fingernails, nor too large, as they may impede manual dexterity ( RCN 2010).

If ANTT® is performed correctly, it offers an alternative means of delivering IV therapy efficiently and effectively to patients.  Follow-up research is required to assess the long-term effects/benefits of this technique which should include catheter related sepsis and removal rates, financial costs/savings as well as the time saved for nurses (CDC 2002; Rowley et al 2010; Miyasaka 2000).

The underlying principles of ANTT are:

  • Always wash hands effectively.
  • Never contaminate key parts.
  • Touch non-key parts with confidence.
  • Take appropriate infective precautions (Rowley et al 2010).

Key parts

The concept of ‘key parts’ was applied to all types of IV therapy with the focus being on the equipment used and the protection of key equipment parts.

These key parts are the pieces of equipment that come into direct contact with the patient and therefore have the potential to transmit bacteria and/or microorganisms and are usually parts of equipment that come into direct contact with the infusate.

Listed below are many of the key equipment parts relevant to the process of IV therapy:

  • Syringe tip
  • Needle – both the needle tip and the needle hub
  • Needle-less access device attached on catheter lumen
  • IV infusion lines – includes several key parts such as fluid bag spikes, all bungs/caps/three-way taps, all infusion ports, the end of the infusion line which connects to the patient
  • Extension lines, eg Lectrocath® (both the end that attaches to the IV administration set and the point where tubing connects to the patient)
  • The hub of the central venous access device (CVAD)/venous access device (VAD)
  • The tip of the implanted port needle and the hub end
  • Dressings – the parts of dressings that come into direct contact with skin
  • Sponge sections of the 2% chlorhexidine/70% alcohol applicators (eg ChloraPrep®/Frepp®)
  • Sterile gauze – the centre of the sterile gauze squares (used for dressing changes)
  • Rubber tops of vials containing medications, etc.
This is not an exhaustive list.

Remember: identifying and protecting key parts and key sites is paramount.

Cleaning the IV trays

Correct decontamination of the IV trays is an essential part of the process. After the IVs have been administered, the IV trays are decontaminated as follows:

  • Wash tray with hot water and dishwashing detergent (Hibiscrub® or any other liquid hand soap is not suitable for this purpose).
  • Dry with a paper towel (do not leave tray to dry).
  • Store dry tray away from sink to avoid re-contamination.
  • If no sink or no dishwashing detergent is available: clean tray with a sanitising wipe (eg Tuffie 5) and allow to dry naturally.
  • Infectious patients: if the tray was used for an infectious patient, it must be decontaminated with Tuffie 5 wipes prior to being taken out of the room or bed space. Then continue as above.

Central venous catheter care bundle

CVAD maintenance should adhere to the 'Saving Lives program' High Impact Intervention number 1, central venous catheter care bundle (Department of Health (DH) 2007). This care bundle program aims to reduce catheter related blood stream infections.

Central venous care bundle poster

The high impact intervention approach helps trusts achieve this aim by providing a focus on elements of the care process and a method for measuring the implementation of policies and procedures. The risk of infection reduces when all elements within the clinical process are performed every time.

One of the elements in the ongoing care action include the use of aseptic techniques and that the ports and hubs are cleaned with 2% chlorhexidine/70% alcohol wipe (eg Clinell®) prior to catheter access.

Technique (step-by-step guide)

  1. Put on a plastic apron.
  2. Wash hands using appropriate cleansing solution and dry thoroughly (hand hygiene).
  3. Collect plastic tray/trolley suitable for procedure and clean all surfaces  with 70% alcohol wipes (eg Sani-Cloth 70) or sanitising wipes (eg Tuffie 5). Leave to dry completely. (Remember to clean from the inside of the tray to the outside.)
  4. Collect all necessary equipment, diluents, heparin, medications, etc. Calculate all medication dosages and any dilutions required. Write all labels (Rationale 2).
  5. When all equipment is collected and all medication calculations prepared, rewash hands using an appropriate cleansing solution and dry thoroughly. (Rationale 3).
  6. Put on pair of well-fitting non-sterile gloves straight from the box.
  7. Open equipment by carefully peeling back packaging. Place syringe ensuring key parts are uppermost/not in contact with tray (Rationale 4).
  8. Connect all needles to syringes and draw up and prepare all medications. Ensure all key parts remain uncontaminated. If at any time you think you may have contaminated a piece of equipment, dispose of it immediately and use a new piece.
  9. When ready to administer medications, remove all needles from syringes, keep key parts free from contamination.
  10. Clean the needle-free access device/bung attached to the end of the VAD with a 2% chlorhexidine/70% alcohol wipe (eg Clinell®) for 30 seconds using friction. Allow to dry naturally, visibly checking that it's dry (Rationale 5).
  11. Carefully remove white cap from the syringe taking care not to contaminate the syringe tip. Insert syringe(s) into the needle-free access device of the VAD and administer medications as prescribed. Remember to keep all syringe tips uppermost and not in contact with the plastic tray.
  12. When all medications have been administered, replace the child’s VAD to ensure safety (Rationale 6).
  13. Prior to taking the tray out of the room/bed space of an infectious patient, it must be decontaminated using Tuffie 5 wipes.
  14. Dispose of all used equipment appropriately (Rationale 7).
  15. Clean plastic tray after use by washing with liquid detergent and drying straight away, or clean the tray using the Tuffie 5 wipes. Store in appropriate area away from the sink to avoid re-contamination (Rationale 8).
  16. If not already done so, remove gloves and wash hands thoroughly using an appropriate cleansing solution and dry thoroughly (hand hygiene).
Remember never contaminate key parts.

Accessing venous access devices

When applying aseptic non touch technique to intravenous therapy procedures, the actions required are the same when accessing all venous access devices such as peripheral, midline or central.

It is essential that all staff who are involved in accessing venous access devices are deemed IV competent and are fully trained to undertake the procedure (this includes medical staff). If non-IV competent staff, eg post registration students, are to access the device, they must be supervised at all times throughout the entire procedure.

If the device to be accessed is one with which staff are not familiar, further advice must be sought from a more experienced individual.

Ensure all necessary documentation relevant to the procedure is available, eg prescription/fluid chart, test request forms.

Explain the procedure to the child and family allowing time for questions and explanations. The child may require play and distraction techniques to be utilised whilst accessing the catheter (Rationale 9).

Tips for maintaining ANTT   

  • Do not drop your equipment into your tray (Rationale 10).
  • Ensure other equipment in the tray does not come into contact with the key parts (eg white bungs, blood bottles rolling around tray, extension tubing being placed on top of equipment/key parts).
  • Remember to use the plastic trays/trolley. Always clean well before with a 70% alcohol wipe (eg Sanicloth 70) and after use (wash with soap and water and dry straight away with a paper towel).
  • Do not use paper trays for IV preparations.
  • Change gloves if they may have been contaminated.
  • Gloves are not a replacement for good hand hygiene; therefore, staff must decontaminate their hands before donning and after removing gloves.
  • Due to hand contamination that occurs when collecting equipment and touching cupboard handles, etc. the aseptic hand clean must occur after this part of the process has been completed.
  • Take care when inserting the needle into vials/ampoules not to touch the side.

Rationale

Rationale 1: Sanitising wipes (eg Tuffie 5) clean and disinfect, while 70% alcohol wipes (eg Sani-Cloth 70) only disinfect. Therefore, washing the trays with detergent is an essential prerequisite for disinfection as the presence of any organic matter may render decontamination ineffective.
Rationale 2: To reduce the risk of error.
Rationale 3: To ensure the alcohol based gel works effectively.
Rationale 4: To prevent contamination of key parts.
Rationale 5: To ensure adequate cleaning of the device/bung & enable the product to work effectively.
Rationale 6: Helps to prevent accidental dislodgement or damage to the VAD.
Rationale 7: To ensure clinical waste is disposed of according to hospital policy.
Rationale 8: To prevent cross contamination between patients.
Rationale 9: To keep child/family informed and that informed consent is obtained.
Rationale 10: There is a risk some key-parts will touch the tray and become contaminated.

References

Reference 1:

Rowley S, Clare S, Macqueen S, Molyneux R (2010) ANTT v2: An updated practice framework for aseptic technique. British Journal of Nursing 19 (5)

Reference 2:
Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SR, McDougall C, Wilcox MH (2007) epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 65 Suppl 1: S1-64.

Reference 3:
Mallett J., Bailey C. (Eds.) (2000) The Royal Marsden NHS Trust Manual of Clinical Nursing Procedures. 5th Ed. Oxford, Blackwell Science

Reference 4:

O'Grady, NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, Masur H, McCormick RD, Mermel La, Pearson ML, Raad II, Randolph A, Weinstein RA (2002) CDC - Guidelines for the Prevention of Intravascular Catheter-Related Infections. Morbidity and Mortality Weekly Report 51: 1-26.

Reference 5:
Dougherty, L. & Lamb, J. (Ed) (1999) Intravenous Therapy in Nursing Practice. Edinburgh, Churchill Livingstone

Reference 6:
Royal College of Nursing (2005) Standards for Infusion Therapy. London, Royal College of Nursing

Reference 7:
Miyasaka, K. Miller, C. & Fabien, B. (2000) Intravenous line management and prevention of catheter related infections in America: a cross cultural seminar. Journal of Intravenous Nursing 23: 170-5.


Reference 8:
Department of Health (2007) Saving Lives delivery program: High impact interventions. Viewed: 10/04/2012.

Reference 9:
Larwood KA, Anstey CM, Dunn SV (2000) Managing central venous catheters: a prospective randomised trial of two methods. Aust Crit Care13 (2): 44-50.

Reference 9:
Kaler, W. & Chinn, R (2007) Sucessful Disinfection of Needleless Access Ports: A Matter of Time & Friction. JAVA12: 140-7.

Reference 10:
Xavier, G. (1999) Asepsis. Nursing Standard 13: 49-53.

Document control information

Lead author(s)

Anne Ho, Specialist Nurse, Intravenous Therapy

Additional authors
Beth McCann, Former Senior Staff Nurse, Intravenous Therapy

Document owner
Anne Ho, Specialist Nurse, Intravenous Therapy

Approved by
Clinical Practice Committee

First introduced: February 2003
Date approved: 10 April 2012
Review schedule: Two years
Next review: 10 April 2014
Document version: 2.0
Replaces version: 1.0

Useful links