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Definition of terms
DOI: 10.1097/WON.0b013e3182478e06
Originated By:
Wound, Ostomy and Continence Nurses Society (WOCN)
Wound Committee and the Association for Professionals
in Infection Control and Epidemiology, Inc. (APIC) 2000
Guidelines Committee
Updated/Revised: WOCN Wound Committee, 2011
Date Completed:
Original Publication Date: 2001
Review/Update: 2005
Revised: 2011
Purpose
To present an update on the status of information about
clean versus sterile dressing technique to manage chronic
wounds.
Background/History
This document originated in 2001 as a joint position statement from a collaborative effort of the Wound, Ostomy and
Continence Nurses Society and the Association for
Professionals in Infection Control and Epidemiology, Inc.1,2
Its purpose was to review the evidence about clean vs. sterile technique and present approaches for chronic wound
care management. Then as now, areas of controversy exist
due to a lack of agreement on the definitions of clean and
sterile technique, lack of consensus as to when each is
indicated in the management of chronic wounds, and lack
of research to serve as a guide. Wound care practices are
extremely variable and are frequently based on rituals and
traditions as opposed to a scientific foundation.
Discussion of Problems/Issue/Needs
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Definition of Wounds
Wound. A wound is any break in the skin that can
vary from a superficial to a full thickness wound. A partial
thickness wound is confined to loss of the epidermis and
partial loss of the dermis; whereas a full thickness wound
has a total loss of the epidermis and dermis and can involve the deeper subcutaneous and muscle tissues and/or
bone.19,20
Acute wound. Acute wounds occur suddenly and are
commonly due to trauma or surgery, which triggers blood
clotting and a wound repair process that leads to wound
closure within 2-4 weeks.14,19
Chronic wound. A chronic wound is a one that does
not does not proceed through an orderly and timely repair
process requiring more than 4 weeks to heal such as vascular wounds and pressure wounds.14,19
Surgical wound. A surgical wound that heals in an
orderly and expected fashion may be considered an acute
wound. Surgical wounds heal by primary closure or are left
open for delayed primary closure or healing by secondary
closure. Primary closure facilitates the fastest healing.
However, infected wounds should not be primarily closed.21
Overview of Research/Published
Expert Opinion
Few national guidelines have addressed the topic of clean
vs. sterile technique. Sterile technique and dressings have
been recommended for post-operative management of
wounds for 24-48 hours by the Centers for Disease Control
and Prevention.22 No recommendations are provided beyond 48 hours for wounds with primary closure.22,23
In 1994, clinical practice guidelines for pressure ulcer
treatment, published by the Agency for Health Care Policy
and Research, recommended use of clean gloves and clean
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dressings for pressure ulcers as long as the dressing procedures complied with the institutions policies.24 Sterile
instruments were recommended for debridement. Recent
guidelines for pressure ulcers have not addressed specifics
of clean or sterile technique other than to state that
tap water or potable water can be used to clean pressure
ulcers and that sterile instruments are needed for sharp
debridement.25
There is a paucity of research about clean vs. sterile
technique for wound care and studies have varied greatly
in their design and findings. Angeras, Brandberg, Falk, and
Seeman26 compared the use of sterile saline or tap water
for cleaning acute traumatic soft tissue wounds and found
that the infection rate in the tap water group was 5.4%
compared to 10.3% in the group using sterile saline (p .05)
with a 50% decrease in costs for the tap water group.
Two studies examined the strike through contamination in saturated sterile dressings. Alexander, Gannage,
Nichols, and Gaskins27 reported that when gauze sponges
were saturated directly in their wrapper, that contamination occurred in 100% of sponges in uncoated wrappers.
In the coated wrapped sponges, 80% exposed to
Staphylococcus epidermidis and 20% exposed to
Escherichia coli had strike through. In another study, cultures were taken from gauze sponges that were saturated
directly on their wrappers on hospital over-bed tables of
postoperative surgical patients.28 The saturated gauze
showed significant growth of microorganisms. The authors reported there was no significant difference in strikethrough contamination in gauze saturated on coated or
uncoated wrappers. Investigators in both these studies
concluded that the practice of saturating gauze sponges on
their wrappers was unacceptable.
In 1993, Stotts and colleagues conducted a descriptive,
exploratory survey of members of WOCN to obtain information regarding wound care practices in the United
States.29 Two hundred and forty-two (242) members responded to the survey. Of the respondents, 51.4% reported
use of sterile technique and 43% reported use of non-sterile technique. Sterile technique was performed more frequently in acute care than in other settings. It was also
reported that 90% of patients with open wounds being
discharged from hospitals were taught to perform nonsterile technique at home regardless of whether clean or
sterile technique was used during hospitalization.
In 1997, Stotts and colleagues compared the healing
rates and costs of sterile vs. clean technique in post-operative patients (N 30) who had wounds healing by secondary intentions following gastrointestinal surgery.30
The authors reported there was no statistically significant
difference in the rate of wound healing between the two
groups (p 0.55). The cost however was significantly
higher with sterile technique (p .05) compared with
clean technique.
Also, in 1997, Wise, Hoffman, Grant, and Bostrom surveyed staff nurses (N 723) in five health care agencies
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Conclusions
There is not a consensus of expert opinion on the use of
clean or sterile dressing technique in the management of
chronic wounds. Research is limited and inconclusive
about value of clean or sterile in healing outcomes. Limited
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Recommendations
Recommendations for Practice: Considerations for
Clean Versus Sterile Technique
1. The following factors should be considered when
planning and selecting dressing technique for
chronic wound care.2,34
a. Patient factors, immune status, acute vs. chronic
wound.
b. Type, location, and depth of the wound.
TABLE.
Instruments
Clean
Yes
Clean
Yes
Clean
Yes
Sterile
Sterile
Sterile
Intervention
Hand Washing
Gloves
Wound Cleansing
Yes
*Maintain clean per policy means that each health care setting must establish policies that address the parameters for use/maintenance of supplies/solutions,
taking into consideration such factors as expiration dates, costs, and manufacturers recommendations.
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chronic wounds. Continued research is needed that examines patient outcomes in terms of healing, infection rates,
and costs of clean vs. sterile techniques. Studies should
clearly describe methods and supplies used for clean or
sterile technique. Large multi-site, randomized studies
across health care settings are needed to insure appropriate patient outcomes are achieved in a cost effective manner that does not compromise patient safety.
References
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