Minimising risk of CLABSI - Standard or Surgical ANTT®?
Effective implementation of Aseptic Non-Touch Technique (ANTT) is crucial in healthcare settings to mitigate the risk of Central Line-Associated Bloodstream Infections (CLABSI).
ANTT protocols are designed to maintain aseptic conditions during invasive procedures involving central venous catheters, reducing the likelihood of infections that can lead to serious complications. Following strict ANTT guidelines for central venous access device (CVAD) procedures improves patient outcomes and reduces healthcare costs associated with CLABSI.
There are two types of processes for ANTT® - Standard and Surgical. The decision regarding which process to use with CVAD management is based on a risk assessment by the practitioner according to the technical difficulty of ensuring key-part and key-site asepsis.
Standard ANTT is used for procedures where achieving asepsis is technically straightforward and short in duration. It involves thorough attention to hand hygiene, use of standard precautions, a general aseptic field such as a decontaminated and disinfected procedure tray, with the key-parts being protected by micro critical aseptic fields (e.g. sterilised caps, covers, and the inside of recently opened sterilised packaging) and the use of a non-touch technique. Sterile gloves do not need to be worn.
With CVADs, the Standard ANTT process is generally used for accessing and de-accessing, including administration set changes, blood sampling and administration of intravenous medications. Using a non-touch technique, the needleless connector (key-part) is scrubbed with a large 2% chlorhexidine gluconate (CHG) and 70% isopropyl alcohol swab for 15-30 seconds using vigorous friction and allowed to fully air dry before accessing.
In contrast, Surgical ANTT employs additional measures such as sterile gloves, draping, and a controlled environment. It is reserved for complex procedures such as central line insertion, dressings and removal of CVADs, where achieving asepsis is technically difficult and/or procedures are long in duration. Surgical ANTT involves a combination of meticulous hand hygiene, standard plus full barrier precautions, and use of a critical aseptic field (i.e. a sterilised drape). This aligns with the CVAD insertion bundle of care (ACI, 2021) which consists of the following five components known to reduce the risk of CLABSI in patients: strict hand hygiene, maximal barrier precautions, use of chlorhexidine as a skin antisepsis, optimal catheter site selection and daily review of the need for the CVAD, with prompt removal if unnecessary.
The insertion of CVADs should only occur in environments where a sterile technique can be easily maintained, with the proceduralist wearing a non sterile hat, mask and eye protection. A surgical scrub with antimicrobial soap and water is to be performed for two minutes, including hands and forearms, prior to donning a sterile gown and gloves. A wide sterile field is provided by using a sterile body drape and a long sterile cover over the ultrasound probe.
It is recommended that the skin be prepared with 2% CHG in 70% isopropyl alcohol for central line insertion, as well as for cleaning the insertion site when performing the dressing. A back-and-forth motion should be used for at least 30 seconds and then allowed to dry. Povidone-iodine in alcohol can be used where there is hypersensitivity or allergy to CHG.
Other strategies associated with reducing the risk of CLABSI include using catheters impregnated or coated with antimicrobial agents or antibiotic combinations, although patient sensitivities or allergies need to be checked before using these. CVAD dressings that contain CHG, polyhexamethylene biguanide (PHMB), and silver alginate are also effective tools in this effort. CHG and PHMB are potent antiseptics that reduce microbial colonisation around catheter insertion sites, while silver alginate dressings provide sustained antimicrobial activity. The use of chlorhexidine impregnated washcloths for patient hygiene are also useful in reducing the rates of CLABSI.
Changing CVAD dressings every 5-7 days or whenever the integrity is compromised, as well as add-on devices every 96 hours or immediately if contaminated or disconnected, will also decrease the risk of infection. Reducing the number of infusion sets and connectors where possible is also recommended.
For healthcare facilities aiming to enhance infection prevention strategies and minimise CLABSI risks, ensuring the correct ANTT processes are implemented alongside evidence-based strategies is paramount.
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References
ACI, (2021). Central venous access devices (CVAD) Clinical Practice Guideline. NSW Agency for Clinical Innovation. ACI Central venous access devices (CVAD) - Clinical Practice Guide
ASAP (n.d) Aseptic Non Touch Technique ANTT® Retrieved 01/07/2024 from https://www.antt.org/
CNSA (2024). Standard Skin and Dressing Management at the Central Venous Access Device (CVAD) site. Cancer Nurses Society of Australia. https://www.cnsa.org.au/documents/item/1611
eviQ (2023). Clinical procedure - central venous access device (CVAD) - dressing and needleless connector change. Retrieved 28/06/2024 from https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads/900-central-venous-access-device-dressing-and-n#references
NICE (2020). Tegaderm CHG securement dressing for vascular access sites. National Institute for Health and Care Excellence. https://www.nice.org.uk/advice/mib231/resources/tegaderm-chg-securement-dressing-for-vascular-access-sites-pdf-2285965567441861
Puig-Asensio, M., Marra, A. R., Childs, C. A., Kukla, M. E., Perencevich, E. N., & Schweizer, M. L. (2020). Effectiveness of chlorhexidine dressings to prevent catheter-related bloodstream infections. Does one size fit all? A systematic literature review and meta-analysis. Infection Control & Hospital Epidemiology, 41(12), 1388–1395. doi:10.1017/ice.2020.356 https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/abs/effectiveness-of-chlorhexidine-dressings-to-prevent-catheterrelated-bloodstream-infections-does-one-size-fit-all-a-systematic-literature-review-and-metaanalysis/860C122B7D0A19B21E5A0C279B7D47E3
Rowley ,S.& Clare, S. (2019) Guidance Document Standardising the Critical Clinical Competency of Aseptic, Sterile, and Clean Techniques with a Single International Standard: Aseptic Non Touch Technique (ANTT®), Association for Vascular Access. ava-position-statement.pdf (antt.org)
The AVATAR Group (2024) Alliance for Vascular Access Teaching and Research Group The AVATAR Group: Health and Medical Research
Jenny Browne, RN, Cert IV (TAE), CritCareCert, MN(AdvClinEd), has an extensive background in critical care nursing and education. Jenny has worked across a variety of Australian ICUs, including the John Hunter Hospital (Newcastle), Princess Margaret Hospital (Perth) and the Royal Adelaide Hospital. She has been an ALS and PALS instructor for over 12 years, including with the ACCCN, and is also a sessional academic at the University of Newcastle.
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