Central sterile supply department(cssd)

planning and operation of CSSD

1. Central sterile supply department(CSSD) By Dr. Anees fatima

2. Definition: The Central Sterile Supply Department (CSSD) is the service responsible for receiving, storing, processing, distributing and controlling the professional supplies and equipments (both sterile and non sterile) for all user unit of hospital for the care and safety of patient under strict quality control.

3. History & Development The development of concept of sepsis was coined by Lister and Koch as a result of discovery of microorganism. With this discovery, the need for aseptic technique in handling and sterilizing the equipment used in surgery and medicine was felt for the care of patient. The modern concept of CSSD was derived during second world war. 1928 • American College of Surgeon first started CSSD in their Hospital • 1965 – First CSSD in India – Safadarajung Hospital 

4. Aims : To provide the safe and sterile supplies to all the user unit of hospital. Objectives : To provide efficient, economic and uniform source of sterile supply for the care and treatment of sick To assist purchase department for decision making and selection of goods. To assist management of hospital in standardization of good Cleaning ,Packaging ,labeling and dating of material To supply equipments to highly specialized units. To educate students, Nurse and ancillary persons To save nursing time at nursing station To participate effectively in Hospital infection control committee. Applied research for improvement techniques

5. Planning of CSSD: Inputs for planning should be provided by a committee which should include representatives from administration, surgical staff, anaesthesiology, pathology and nursing. This committee should develop a written programme covering: The overall scope of the department, Departments to be served, Extent of services to be rendered, Process equipment to be procured, Preparation of procedure manual, and Organisational and administrative structure of the department.

6. Location: The location of CSSD should be convenient to its principal consumers. These are the nursing units, labour suites and operation theatres. It should be so located that supplies and equipment are brought to and taken away by the shortest route.

7. Space: A minimum of 7 sq ft on a per bed basis ( with 100 sq ft for the smallest hospital ) is considered essential for planning a CSSD with scope for future expansion. The area will be divided into: Receiving area Cleaning area Processing area Sterilisation Sterile storage Issuing area

8. Space required for planning a CSSD: Beds Space Upto 100 beds 10 sq ft per bed Upto 200 beds 9-10 sq ft per bed Upto 300 beds 8-9 sq ft per bed 300 beds and above 7 sq ft per bed

9. The activities comprise of following: Receipt of used supplies Accounting Washing, cleaning and drying Sorting Gauze cutting and assembling Packing Sterilisation Sterile storage issue

10. Physical facilities: The direction of work flow and economy of labour determines the layout of the physical facilities. Articles should move only in one direction through receipt, washing and cleaning, drying, sorting, reassembling and packing, sterilisation and storage.

11. Staffing: The number of workers will be influenced by the following: Method of collection and delivery Quantum of work – one shift, two shifts or one shift with only emergency issue counter after normal working time Hospital’s philosophy on use of disposables Availability of mechanical aids.

12. Bedded hospital Staff required Smallest hospital 1 supervisor 1 technologists 1 technical assistants 1 nurses aides 1 CSSD attendant 200 bedded hospital with door delivery system to user departments 1 supervisor 3 technologists 3 technical assistants 3 nurses aides 3 CSSD attendant 500 bedded hospital 1 supervisor 5 technologists 4 technical assistants 4 nurses aides 4 CSSD attendant

13. List of items commonly processed in CSSD: Instruments Appliances Dressings Sponges OT linen Special packs Gauze and cotton material Gloves Bowls and trays

14. Equipment: Autoclaves Dry oven Gauze cutter Ultrasound washer Needle flushing device Ethylene oxide steriliser Work benches with marble or stainless steel top Storage cupboards and racks Linen folding table Soaking sinks High pressure water jets

15. Ultrasonic cleaner

16. Ultrasonic cleaner: Its one of the essential equipment of CSSD. Ultrasonic cleaner cleans by bombarding the item with sound waves. These waves while passing through the detergent solution produce submicroscopic bubbles which collapse on themselves, generating tiny shock waves that knock debris off nooks and corners of instruments that are not easy to reach.

17. Autoclave (conventional)

18. Walk-in type of Autoclave

19. Autoclave: It’s the main equipment of CSSD At least one additional autoclave should be provided to cater for failure or extra workload. Instructions for installation and operation must be clearly understood They work on the principle of a pressure cooker. autoclaves are used to sterilize equipment and supplies by subjecting them to pressurized saturated steam at 121 °C (249 °F) for around 15–20 minutes. If temperature is raised to 126 ° C time can be reduced for 10 minutes. At 134 ° C it is 3 minutes. At 150 ° C its only a minute called flash sterilizers, for spot sterilisation in some operation theatres . Use of saturated steam under pressure is the safest and dependable method of sterilisation , in universal use for destruction of all forms of microorganisms.

20. Ethylene oxide steriliser

21. Ethylene oxide steriliser: There are at least three stages in a typical EtO sterilization cycle:  Preconditioning Sterilization Aeration (Degassing) Cycle time is usually more than 14 hours . Sterilization It’s the second stage . The EtO enters the chamber via evaporation with a certain amount of steam to keep the humidity level up as well as to make sure the EtO is reaching all parts of the load. When the required concentration in the chamber and load is achieved the actual sterilization stage starts. The lower the gas concentration in the chamber the longer is the sterilization time.  

22.  It is a colorless, poisonous gas that attacks the cellular proteins and nucleic acids of microorganisms. It is most commonly used to sterilize instruments with long lumens such as endoscopes, rubber, plastics, fibreglass and all materials that have to be sterilized but cannot withstand higher temperature.  Effective sterilisation by EtO depends on the following: Concentration of gas: 450 mg/ litre or more is required for effective sterilisation Temperature: exposure time can be reduced by increasing temperature. Two ranges of temperature is generally applied- 49 ° to 63 ° C and 30 to 37.8 ° C Humidity : it lowers exposure time. Steam is injected under vacuum before admitting gas. In some wet gauze/ sponge is placed Packing : the type of wrapping should be penetrable to gas and water vapour . Polyethylene is commonly used. Period of exposure : in automatic- 110 to 260 minutes. In others upto 12 hrs.

23. Sterilisation process: Sterilisation process goes through following phases- warming the chamber Evacuating residual air to partial vacuum Introduction of moisture to ensure that it penetrates the wrappings of material Introduction of EtO Raising the temperature Exposure for required time Release of chamber pressure Removal of gas under vacuum ( called purge cycle) Reestablishment of atmospheric pressure by introduction of filtered air into chamber

24. Advantages of EtO are: Low temperature High efficiency – destroys microorganisms including resistant spores Large sterilizing volume/ chamber capacity Non corrosive to: plastic, metal and rubber materials Disadvantages are: Excessively Long cycle Safety concerns  -  carcinogenic  to humans Toxicity issues - toxic residues on surgical instruments and tubing Not recommended for flexible scope EtO is flammable Requires special room conditions, safety equipment and separate ventilation system Relatively high annual costs for maintenance, servicing and consumables

25. Dry oven

26. Gauze cutter machines

27. High pressure water jets For cleaning

28. Quality control: Sterilisation checks: Colour index strips available for this purpose should be kept in each pack being autoclaved. Manufacturers instructions must be followed scrupulously regarding loading of autoclaves, temperature and pressure levels and timings. Sterility indicators: Mechanical indicators- pressure, temperature, record time, humidity and sterilisation cycle. C hemical indicators- Colour index strips, tapes- attached or implanted in packing material Biological indicators- they should be placed in most inaccessible location in the load and then cultured . Bacillus stereothermophilus is used for this purpose

29. Shelf life: Shelf life of sterilised packs i.e ; the time for which it can be stored safely before use, should be determined by a committee of experts including bacteriologists. If the pack is not used, during its shelf life, it should be again put through the autoclaving process without being opened. A pack is considered to be sterile for upto 4 weeks but experts opine that the pack should be reautoclaved without opening after 1 week.

30. CSSD distribution system: The following 4 systems are in use: Clean for dirty exchange : a sterilised article is issued at the CSSD issue counter on return of a used one at any time. Requisition system : articles needed are issued on a requisition given by the user department Grocery system : each users requirements for all items for a specific period are delivered at suitable interval irrespective of whether the contents have been used or not and previous basket or contents are withdrawn. Quota system: predetermined stock levels(quota) of various items for each user unit are maintained by a delivery personnel from CSSD through regular deliveries

31. Policies and procedures: Responsibility : the Responsibility for supervision of sterilising tasks should be clearly understood and vested with one person. Segregation : Segregation of sterile and unsterile supplies should never be carried on the same trolley or same staff. Standardisation of packs : the aim is to have a standard surgical pack containing all the items required for that procedure by the operating surgeon. Packing procedures : step by step packing procedure for each pack should be determined and should specify- i) the quantities of materials required and their arrangement ii) the sequence of packing operation.

32. Manual of operations : a procedure manual listing all procedures followed in the CSSD for each process and their correct sequence is essential for effective operation by the department. Packing material : linen, paper( kraft paper or news paper), stainless steel containers, cardboard box can be used.