Does Sterile or Nonsterile Technique Make a Difference in Wounds Healing by Secondary Intention?
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I n the spring of 1998, nursing staff on two surgical units at a major medical center noticed inconsistencies in the care of open surgical wounds. Some nurses used sterile while others employed a clean dressing change technique. Because the nursing staff felt that existing wound care literature did not support the selection of one technique over another, they wanted to establish their own consistent guidelines based on infection rates and costs. Surgical site infections for wounds healing by secondary intention for more than 5,000 patients during the previous 15 months on the two surgical units showed a 1.2% wound infection rate. Because the surgical site infection rate was low, the nursing staff wanted to know if the infection rate would remain low if everyone practiced clean technique in order to provide a more consistent cost-effective practice.
The clean-versus-sterile technique debate has been waged among clinicians for years with no consensus of opinion. The terms "sterile" and "clean" have many different meanings among healthcare providers.1,2 Sterile technique involves methods to reduce exposure to micro-organisms, including hand washing, and using a sterile field, instruments, gloves, and sterile dressing. Sterile dressing change may be defined as the replacement of the wound dressing using sterile technique and supplies. Clean technique involves employing methods to reduce the overall number of micro-organisms. Clean technique involves hand washing, preparing a clean field, and using clean gloves and instruments. Clean dressing change may be defined as the replacement of the wound dressing using clean technique and supplies. When considering which technique to use, the major concern is reducing the infection risk to the patient. Universal precautions should be the most essential component regardless of the technique used.
In 1993, Stotts et al3 surveyed members of the Wound Ostomy Continence Nurses Society regarding wound care practices. Of the 240 members who returned the surveys, 51% reported using sterile technique and 43% reported using nonsterile technique. However, these percentages varied widely when type of wound and setting were taken into consideration. Sterile technique was performed more frequently in the acute care facilities. Also, with the exception of immunosuppression, risk factors such as impaired perfusion were not deemed sufficient to warrant the use of sterile technique.
Wounds healing by secondary intention require dressings to provide a moist environment, debride necrotic tissue, absorb exudate, and protect the wound from trauma and contamination. In preparing patients for hospital discharge, respondents reported that 90% of patients with open wounds were taught to perform nonsterile technique regardless of the method used during hospitalizations. Consistency between what patients and caregivers are taught and actual practice during hospitalization is important in reinforcing home care instructions.
In 1997, the Nursing Consortium for Research and Practice4 surveyed 743 staff nurses from five healthcare agencies in San Francisco, Calif. regarding glove use. Sixty-one percent of respondents (n = 427) indicated that their choice of sterile or nonsterile gloves varied. Sterile gloves were chosen more often than nonsterile gloves for packing wounds and for dressing purulent wounds, tunneling wounds, and exposed orthopedic wounds. Clean gloves were generally used for dressing changes over intact surgical wounds and pressure ulcers. Acute care nurses indicated they were likely to use sterile gloves about 80% of the time (n = 544). Technique choices among staff nurses were based on the educational level of the provider and perception of the infection risk to the patient. A scientific foundation for wound care practice choices was not evident.
1. Faller NA. A survey exploring the ET nursing art of wound care: factors associated with clean versus sterile technique. Amherst, Mass.: University of Massachusetts, Doctoral Dissertation, 1997.
2. Gray M, Doughty D. Clean versus sterile technique when changing wound dressings. JWOCN. 2001;28:125-128.
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7. Rossoff LJ, Lam S, Hilton E, Borenstein M, Isenberg HD. Is the use of boxed gloves in an intensive care unit safe? Am J Med. 1993;94(6):602-607.