Despite the unprecedented advances in the medical field, hospital-acquired infection still remain hospitals serious concern.

Even in advanced countries, approximately 5% of all hospital patients suffer from hospital acquired infection. Thus to combat this omnipresent menace of infection, hospitals over the years have developed a scientific method commonly called as central sterile and supply system. This system works in and as a separate department called as Central Sterilization and Supply Department (CSSD).

Since ours is a state-of-art hospital, with all specialist facilities, CSSD is a must have for our hospital.

Definition
CSSD is the department which deals with receiving, cleaning, packing, disinfecting, sterilizing, storing and distributing all operational instruments and equipment (both multi-use and single-use devices), as per welldefined protocols and standardized procedures.

Important facts
First CSSD was set in India at Jaslok Hospital, in July 1973 by Nalini Gaithonde. There is still no uniform accreditation guidelines in India for CSSD facilities. In Mumbai, only 30% of big hospitals (with 100 or more beds) have CSSD. Since its the need of the hour, a large no of upcoming hospitals have a well-equipped CSSD. ( around 85%)

Main Objectives
To provide sterilized material from a central department where sterilizing practice is conducted under conditions, which are controlled, thereby contributing to a reduction in the incidence of hospital infection. To take some of the work of the Nursing staff so that they can devote more time to their patients. To avoid duplication of costly equipments, which may be infrequently used. To maintain record of effectiveness of cleaning, disinfection and sterilization process. To monitor and enforce controls necessary to prevent cross infection according to infection control policy. To maintain an inventory of supplies and equipment. To stay updated regarding developments in the field in the interest of efficiency, economy, accuracy and provision of better patient care. To provide a safe environment for the patients and staff.

Depts. Associated with CSSD

Depts. which are dependent on CSSD for supplies: Wards Out-patient dept. Surgical service dept. (OT) CSSD is dependent on following Depts. HIS Purchase Dept. Laundry

Organizational Structure
The CSSD manager liaise with infection control team, OT manager and clinical departments. He is administratively responsible to the head of the health care facility. Head of the Health Care Facility CSSD Manager Shift Supervisor CSSD Personnel

Staffing
Superintendent In-charge of department Trained CSSD assistant CSSD technicians Clerk Aides Orderlies Sweeper

The in-charge is a member of the hospital infection control committee.

Space
Since the bed strength is 180.The space allocated is 1600 sq.ft, as per the protocol Number of Beds Area/bed (sq.ft) 75-99 10 100-149 9 150-199 8.5 200-249 8 250-299 7.5 >300 7

Location
Located at the 3rd floor of the hospital, just above the operation theatres situated on the 1st and 2nd floor, so that soiled and sterile items can be transferred in between CSSD and OT with out any hassle using two separate lifts. Situated next to corridor, along with the length of the corridor to have separate entries for the staff and the materials. It also ensures that all functional areas are kept separate and there is no back tracking of the sterile goods. The specific layout also ensure that there is a continuous flow of materials from the receiving door, through the department to the dispensing area. Easily accessible to elevator, dumbwaiter and stairs because of the specific location in our hospital.

Lay Out
As per the ideal set-up, we have three organized zones: Soiled area, Clean area and Sterile area. 1. Soiled items from the various user departments of the hospital are received at the reception area. The dirty lift carries the dirty material from the OT at 1st and 2nd floor directly to the receiving area.

2. In the clean area, clean disinfected materials are sorted, inspected and packed. The double-door pass through autoclaves of the required size are built into the wall between the clean and sterile areas. Materials are loaded on the clean side and unloaded on the sterile side. 3. After sterilization, the autoclaves are unloaded in the sterile area and the materials stored there. The clean lift to OT carries the material straight to the OT at the 1st and 2nd floor. Material is also dispensed through the counter to the various departments.

Specific Areas in CSSD

1) Reception and clean-up area
The reception and clean-up area is used for: Receiving supplies and equipment from other units. Processing and distributing them to the clean work-room or storage.

2) Clean Work Area

In the clean work area various processes which are done are Cleaning Drying Packing Sterilizing

3) Sterile storage area In this area sterile items are kept and are dispensed to various departments as per the need. The Sterile materials are stored at least 8 to 10 inches from the floor, at least 18 from the ceiling and at least 2 from the outside wall. All sterile packs are handled as little as possible, to reduce the possibility of microbial contamination of the contents. The arrangement of the sterile pack is done in the sequence of First in, first out.

The Sterile Supply Cycle

Financial Considerations
The cost of establishing a CSSD are of 2 types: 1. Capital Cost : cost of premise, processing and other extra equipment which may be required. 2. Running Cost : labor for processing and packaging, dressing and packaging materials, maintenance of equipment and cost of distribution and collection.

Financial Considerations ( cont)

1. Capital cost : Double-door Autoclave :- 3 lac Washer-disinfector:- 7.8 lac Steam sterilizer ETO sterilizer Plasma sterilizer:- 16 lac 2. Running cost :

Salaries :- around 1.3 lac/ month Maintenance :- around 30,000/month

QUALITY CONTROL
Quality control of the CSSD procedure depend on :
1. Cleaning the CSSD The CSSD is regularly cleaned with appropriate antimicrobial solutions. Fumigation is also done at frequent intervals.

2. Staff Measure The staff is provided with uniform which is used always when working in CSSD. Changing of clothes when they move from one area to other, is strictly followed. All Staff is immunized and it is firmly ensured that they always pracitce adequate safety measures.

Quality control (Cont.)

3) Handling materials
Materials is always handled with gloves

4) Back-tracking of material
Is avoided under any circumstances.

5) Routine measures
Routine preventive, maintenance protocol for equipment are strictly followed.

6) Record keeping
Records of all kind are diligently prepared, maintained and kept for future references.

Frequent Problems in CSSD

1) Breakdown of instruments : Instruments undergo regular wear and tear and there are also incidences of sporadic breakdowns affecting the normal functioning of CSSD. To deal with the situation, an Annual Maintenance Contract is undertaken to take care of all these possible deviations. 2) Non compliance with the quality and infection control methods: Strict measures are taken to ensure that everybody complies with the quality and infection control methods. Monthly review meetings and orientation programs are undertaken to ensure the same. Provisions for serious actions which can be taken against those who breach the code of conduct for CSSD, is also kept in place. 3) Pilferage and theft: Surgical instruments are usually not a target for pilferage, and for others pilferage can be prevented by maintaining strict control over the stock

Role of Managers
1) Plan, develop and implement sound Quality Management Systems. 2) Improve the quality of staff employed. Invest in staff orientation, training and performance management competency assessment programs. 3) Try to automate the processes as much as possible and to minimize double handling wherever practicable. 4) Maintain reasonable inventory levels to combat any emergency and to ensure that fast track reprocessing is not required 5) Ensure to comply with best record keeping practices.

Double Door Autoclave

Washer Disinfector

Plasma Sterilizer

Steam Sterilizer

ETO Sterilizer