Sterile vs. clean is a judgment call in home care settings

How much bacterial burden is OK?

Shorter lengths of stay in acute and rehab settings and alarm over drug-resistant pathogens have placed wound care clinicians in a precarious position: When should they use safer but more costly sterile techniques, and when should they rely on clean dressings? 

Managed care is moving wound patients into the home setting more quickly, and practices such as intravenous therapy that once were restricted to inpatient settings are being done routinely in the home. Patients returning home sicker are vulnerable to infections, yet policies and procedures for home care infection control are scarce. The issue at hand is how much bacterial burden a person can handle, says Nancy Stotts, RN, EdD, a professor in the Department of Physiological Nursing at the University of California School of Nursing in San Francisco. 

"The literature and clinical experience tell us that low levels of bacteria stimulate the immune system to respond. But at high bacterial levels, infections result, patients become septic and often will die," she says. "The question is how to contain the level of bacteria so that people don’t suffer the negative effects but [the bacteria] will stimulate the positive effects of the immune system."

Not always necessary

Stotts and others agree that sterile technique is not always necessary when caring for wound patients in the home. For instance, clean technique may be suitable when a patient is immunocompetent and has developed a substantial granulation bed in the wound. "That’s a situation where the bacterial load for the patient won’t be a problem and will probably only result in a little inflammation," says Stotts. 

Clean technique may be even more appropriate in the home than in the hospital, because people can grow tolerant of infectious agents that inhabit their own body, but they don’t develop such tolerances against bacteria carried by other patients. "When you hospitalize people, their bacterial flora change. They don’t have the normal resistance that they do against their own organisms," Stotts adds. 

The final decision on whether to use sterile or clean technique for wound patients in the home is a matter of judgment and professional experience, Stotts adds. "The variable is how knowledgeable the person doing the dressing change is. One of the problems in wound care today is that many who are taking care of patients are nonprofessionals with minimal training. That may be cost-effective, but these people don’t have the background to judge who should get clean technique and who should get sterile technique." 

What’s really worrisome is that "clean technique" means different things to different people, says Sandy K. Pirwitz, RN, MS, CIC, an infection control practitioner at Vencor Hospital in Detroit and chairwoman of the 1997 Association for Professionals in Infection Control and Epidemiology (APIC) guidelines committee. "Some people interpret that to mean it doesn’t matter what you do. You’re lowering a standard, and some people don’t know when to stop. There’s always a danger that when you say, Sterile technique isn’t needed,’ people will totally drop all of their defenses," Pirwitz says. "Clean means as free from pathogens as possible, and it doesn’t mean you can let a six-year-old change grandpa’s dressing." 

Nancy Faller, RN, PhD/c, MSN, an enterostomal clinical nurse specialist at the Rutland (VT) Regional Medical Center, questions the need for the universal application of sterile technique in wound care. "In our practice," she says, "we don’t use sterile technique for wounds we treat in home care, and we have not seen any secondary wound infections as a result. We have observed that wound infection is related to etiology. 

"In the first instance, you have a wound etiology that causes compromised tissue viability that leads to bacterial overgrowth in the tissue; for example, a surgical wound that is closed under tension or a case of pressure on soft tissue," Faller says. "In the second instance, if you don’t deal with the underlying etiology, you get continued tissue compromise with bacterial overgrowth; for example, the diabetic foot ulcer where the patient’s shoe is not adjusted or the venous leg ulcer where compression is not applied. 

"I don’t think the infection comes from the dressing technique that you use. No studies or research have ever been done that indicate that sterile dressings would allow a wound to heal more quickly and more cost-effectively. It’s something we do by habit and rit ual. Now we’re beginning to ask ourselves if we need to do it at all." 

While the sources contacted by Wound Care agree that research extolling the benefits of sterile technique is scant, they acknowledge the need for it under certain clinical scenarios. It’s essential under some circumstances, such as when treating fresh wounds, says Pirwitz. 

"A lot of people think that the ulcer dressing in the home is already [nonsterile], but that doesn’t mean you can add to that bacterial burden in the wound. It doesn’t matter what the setting, the principles of infection control are always the same. Risks are different in the home; they may be lower because the prevalence of pathogenic organisms, especially antibiotic-resistant bacteria, is likely to be much less than in the hospital," she says. 

The risk for infection in the home also might be lower because the health care worker is less likely to be carrying organisms from his or her last patient. In some cases, however, the risk of infection is higher in the home because the clinician has less control of sanitation and must rely on the home caregiver or the patient to keep the environment clean. Pirwitz adds that family caregivers should be taught to use good technique when changing dressings to maintain some continuity between visits by professionals. Setting up a sterile field in the home can be time- consuming, she says, but it can be done with a little ingenuity, care, and practice of the "no-touch" technique. 

Stotts agrees that hard data supporting the absolute need for sterile technique are lacking. She and colleagues completed a pilot study comparing sterile to clean technique and found no difference in the healing rates for sterile and clean dressing changes. (For results of the study, see story, p.54.) 

But there are other equally compelling reasons for maintaining a sterile field, she says. Sterile technique is the "gold standard" in the care of wounds, she says. Appropriate or not, it has come from a long tradition of surgical work, and clinicians have been taught throughout their education that sterile technique is often essential. 

"Today we are faced with the specter of antibiotic-resistant organisms, so clinicians no longer have the freedom to treat infected patients empirically," she says. "There are situations when you very clearly do not need to use sterile technique, but because sterile technique is expected, we risk liability if we don’t practice it. 

"I would really be concerned about using clean technique unless I had some data to show that it didn’t put the patient at increased risk for infection," Stotts says. "The possibility of getting sued is great."