‘It’s all about technique’: Monitoring compliance with standardised aseptic technique practices at a large Australian health service

Ms Shirley Leong1, Ms Pauline Bass1, Associate Professor Leon Worth1, Ms Jackie Miley2, Ms Gemma Klintworth1, Ms Stephanie Spilsbury1, Ms  Kerrie Watson1

1Alfred Health, Prahran, Australia,

2Erin Street Orthopaedics, Richmond, Australia

Background: Maintenance of aseptic technique (AT) by the clinical workforce ensures optimal practice to reduce risk of infections associated with medical devices and procedures. This is supported by international standards. However, robust tools to enable regular AT auditing in Australian healthcare facilities are not widely available. The objective of this study was to evaluate, improve and standardise the practice and governance of AT.

Methods: Focus group feedback indicated that staff knowledge of AT was sound but practices varied and were inconsistent with current guidelines. Gaps included lack of formal training, assessment and auditing. A standardised and weighted tool for auditing a range of practices across all clinical departments was developed and auditors trained using a Train the Trainer method. Resourcing was supported by hospital Executive with funding for a full time project position for 2 years.

Results: Baseline AT audits were conducted across all departments. Over 500 audits were conducted, with a compliance rate of 88%.  Hospital AT guidelines were updated and an electronic audit tool was developed. Data was collated centrally, and reports generated for quarterly feedback to managers. Mandatory completion of an online learning package by clinicians performing invasive procedure was established. An annual target of 80% staff EFT audited was applied. Post-intervention auditing revealed a significant improvement with 97% compliance.

Conclusions: Key elements included the use of a Train the Trainer method, a standardised electronic audit tool, regular reporting, and the setting of internal targets. Successful implementation of an organisation-wide program to enhance aseptic technique was achieved.


Shirley has a background in cssd and perioperative services. She has a special interest in education and quality improvement and has more recently been the Aseptic Technique project co-ordinator at Alfred Health in Melbourne for the past 2 years. Shirley has played a critical role in the development of compliance monitoring, standardised training and auditing in aseptic technique.

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