CSSDCSSDCentral Sterile Central Sterile

Supply DepartmentSupply Department

“ “ No Stronger Condemnation of No Stronger Condemnation of any hospital or ward could be any hospital or ward could be pronounced than the simple fact pronounced than the simple fact that ZYMOTIC DISEASE has that ZYMOTIC DISEASE has originated in it or that such originated in it or that such disease attack other patients than disease attack other patients than those brought-in withthose brought-in with ” ”

- - FLORENCE NIGHTINGALEFLORENCE NIGHTINGALE

BHATTA CHARJEE DEFINES – BHATTA CHARJEE DEFINES – CSSD CSSD

as that service, with in the as that service, with in the hospital, catering for the sterile hospital, catering for the sterile supplies to all departments , both supplies to all departments , both to specialized units as well as to specialized units as well as general wards and OPDs. general wards and OPDs.

1928 – American College Of 1928 – American College Of Surgeons – CSSD.Surgeons – CSSD.

1942 – World War II .Cairo, British 1942 – World War II .Cairo, British SDS Unit .SDS Unit .

1955 – Cambridge Military Hospital 1955 – Cambridge Military Hospital – Regular CSSD in UK.– Regular CSSD in UK.

1965 – First CSSD in India – 1965 – First CSSD in India – Safadarajan HosptialSafadarajan Hosptial

AIMSAIMS To provide sterilized material from To provide sterilized material from

a central department where a central department where sterilizing process is carried out sterilizing process is carried out under properly controlled conditionsunder properly controlled conditions

To alleviate the burden of work of To alleviate the burden of work of the nursing personnel, there by the nursing personnel, there by enabling them to devote more of enabling them to devote more of their time to patient care .their time to patient care .

ADVANTAGES ADVANTAGES ; ;

1.1. Bacteriological safe sterilization.Bacteriological safe sterilization.

2. Less expensive.2. Less expensive.

3. Elimination of unsound practices & 3. Elimination of unsound practices & establishment of standard procedures.establishment of standard procedures.

4. Assurance of adequate supply of sterile 4. Assurance of adequate supply of sterile products immediately and constantly products immediately and constantly available for sometime as well as available for sometime as well as emergency use.emergency use.

5. 5. Conservation of trained staff.Conservation of trained staff.

6. Better quality control6. Better quality control

7. Better good of material flow7. Better good of material flow

8. Prolonged life by proper care of 8. Prolonged life by proper care of equipment equipment

ITEMS COMMONLY HANDLED BY ITEMS COMMONLY HANDLED BY

CSSD STORESCSSD STORES

1. Syringes1. Syringes

2. Procedure Sets2. Procedure Sets Lumbar puncture ; sternal puncture ; Lumbar puncture ; sternal puncture ;

venesection ; paracentesis ; aspiration ; venesection ; paracentesis ; aspiration ; catheterization ; tracheotomy ; suturing ; catheterization ; tracheotomy ; suturing ; dressing ; biopsy ; incision & drainage ; dressing ; biopsy ; incision & drainage ; aortography ; cardiac resuscitation ; etcaortography ; cardiac resuscitation ; etc

3. Needles3. Needles

4. Gloves4. Gloves

5. I.V.Fluids.5. I.V.Fluids.

6. Treatment Trays.6. Treatment Trays.

7. O.T Instruments.7. O.T Instruments.

8. O.T. Linen8. O.T. Linen

9. Infusion Fluids for Renal Dialysis.9. Infusion Fluids for Renal Dialysis.

10. At times LINEN. (other than O.T)10. At times LINEN. (other than O.T)

NB: Diet , drugs , bedpans & urinals are NB: Diet , drugs , bedpans & urinals are not included by convention .not included by convention .

PLANNING A DEPTPLANNING A DEPT ; (COPP) ; (COPP)

1. Physical Planning.1. Physical Planning.

2. Functional Planning.2. Functional Planning.

3. Personnel Planning.3. Personnel Planning.

4. Equipment Planning.4. Equipment Planning.

5. Financial Planning.5. Financial Planning.

6.Quality Control.6.Quality Control.

7.Preventive Maintenance.7.Preventive Maintenance.

PHYSICAL PLNGPHYSICAL PLNG

1. Location & Grouping .1. Location & Grouping .

2. Lay Out & Space Reqts.2. Lay Out & Space Reqts.

3. Fixturtes & Furniture .3. Fixturtes & Furniture .

ADM & STORAGE ADM & STORAGE (UNSTERILE) AREA(UNSTERILE) AREA

21² 21² MM

SCALES OF SCALES OF ACCN FOR ACCN FOR ARMED ARMED FORCES FORCES HOSPITALS HOSPITALS AH/CH/ SAY > AH/CH/ SAY > 700 BEDS700 BEDS

RECEPTION,CLEANING,RECEPTION,CLEANING,CHECKING,ASSEMBLY CHECKING,ASSEMBLY & PACKING AREA& PACKING AREA

3535²² M M

AUTOCLAVING AREAAUTOCLAVING AREA 28 28 ²² M M

STERILE STORAGE & STERILE STORAGE & ISSUE AREAISSUE AREA

28 28 ²² M M

TOTALTOTAL 1,320 1,320 ²² ft ft

(COPP)(COPP)

RULE OF THE THUMB

ROUGHLY – 10 SQFT / BED - MCGIBONY

EQPT IN CSSDEQPT IN CSSD 1.Jet water cleaning gadgets.1.Jet water cleaning gadgets.

2.Ultrasonic Washers2.Ultrasonic Washers

3.Glove sharpener3.Glove sharpener

4.Needle sharpener.4.Needle sharpener.

5.Gas, Chemical or steam autoclaves.5.Gas, Chemical or steam autoclaves.

6.Testing apparatus for efficiency of 6.Testing apparatus for efficiency of sterilizationsterilization

OTHERSOTHERS

1.Maint & Repair EQPT1.Maint & Repair EQPT

2.Adequate number of cabins & 2.Adequate number of cabins & FurnitureFurniture

3.Telephone or intercom.3.Telephone or intercom.

4.Adequate no of syringes & 4.Adequate no of syringes & procedure sets.procedure sets.

NUMBER OF SETS/SYRINGESNUMBER OF SETS/SYRINGES

A - 1A - 1½ Daily requirement in use at wards / ½ Daily requirement in use at wards / DepartmentsDepartments

B - 1 Daily requirement in sterile state at CSSD, ready B - 1 Daily requirement in sterile state at CSSD, ready for issuefor issue

C - 1 Daily requirement being processed at CSSDC - 1 Daily requirement being processed at CSSD

D – 1to 1½ Daily requirement held in reserve – dome D – 1to 1½ Daily requirement held in reserve – dome in CSSD, some in medical storesin CSSD, some in medical stores

Total: 4.5 to 5 times of the daily requirement

Methods Of Sterilization / DisinfectionMethods Of Sterilization / Disinfection

Natural Chemical PhysicalSun Light (UV)

Air (Desiccation)

Solids

Lime, Bleeching Powder, KMNO4

Liquids

Formalin, Phenol , Alcohol , Glutaraldehyde

Gases

Formaldehyde, Ethylene Oxide

Dry Heat

Burning or Dry Air

(160°C for 60 Min)

Moist Heat

Boiling Steam

Radiation

Ionising Radiation U V Rays

CHEMICALCHEMICAL

CIDEXCIDEX – A Glutaraldehyde derivative is most – A Glutaraldehyde derivative is most effective as it destroys spores too.effective as it destroys spores too.

ETHYLENE OXIDE (ETO) ;ETHYLENE OXIDE (ETO) ;- Quite effective against spores too.Quite effective against spores too.- Useful for delicate instruments and item which Useful for delicate instruments and item which

can’t be immersed in liquidscan’t be immersed in liquids

- Low Boiling Point (10 degree C)- Low Boiling Point (10 degree C)

- Prolonged Aeration- Prolonged Aeration

- Highly Expensive / Explosive / Toxic- Highly Expensive / Explosive / Toxic

Types Of Sterilization TechniquesTypes Of Sterilization Techniques 1.Dry Heat1.Dry Heat

2.Steam High Pressure Autoclaves operated by Gas, K.oil or 2.Steam High Pressure Autoclaves operated by Gas, K.oil or Electricity ( Flash, Pulse)Electricity ( Flash, Pulse)

3. Ethylene Oxide Sterilization.3. Ethylene Oxide Sterilization.

4. Chemical Sterilization.4. Chemical Sterilization.

5. Radiation Sterilization5. Radiation Sterilization..

- - Infra Red Radiation – SyringesInfra Red Radiation – Syringes

- Ultra Violet Radiation – Decontamination of Air- Ultra Violet Radiation – Decontamination of Air

- Ionising Radiation / Gamma Radiation- Ionising Radiation / Gamma Radiation

ISOMED at BARCISOMED at BARC

STERILISATION .STERILISATION .

It is a process of freeing an article from It is a process of freeing an article from all living organisms including all living organisms including bacteria ,fungal spores and viruses. bacteria ,fungal spores and viruses.

A material is pronounced sterile if it A material is pronounced sterile if it

achieves 99.99% kill of bacterial spores.achieves 99.99% kill of bacterial spores.

STEAM STERILATIONSTEAM STERILATION

- Water - Water Saturated Saturated Wet vapor Wet vapor Dry Dry saturated Vapor saturated Vapor Super Heated Vapor / Steam Super Heated Vapor / Steam

- Steam with <0.95 Dryness Factor is not useful - Steam with <0.95 Dryness Factor is not useful for Sterilization. for Sterilization.

- Superheated Steam acts like Dry Hot Air only . - Superheated Steam acts like Dry Hot Air only . ( Strength Of Steam is its Latent Heat)( Strength Of Steam is its Latent Heat)

MODE OF ACTION.MODE OF ACTION.

Dry Heat Dry Heat Oxidation Oxidation

Steam Steam Denaturation = Coagulation of Proteins Denaturation = Coagulation of Proteins

Sterilization Time Sterilization Time

(Holding Time + Safety (Holding Time + Safety Time)Time)

PressurePressure

(PSI)(PSI)

Temperature Temperature ( C( C° )° )

22'' + 1 + 1′ = 3'′ = 3'

8' + 2' = 10'8' + 2' = 10'

12' + 3' = 15'12' + 3' = 15'

3030

2020

1515

134134

126126

121121

TYPES OF AUTO CLAVING TYPES OF AUTO CLAVING MACHINESMACHINES

1. 1. Downward DisplacementDownward Displacement

2. Vacuum Assisted.2. Vacuum Assisted.

3. Pulsed Steam Dilution3. Pulsed Steam Dilution

TESTS FOR EFFICENCY OF TESTS FOR EFFICENCY OF STERILISATIONSTERILISATION

11.. Specially treated paper strip.Specially treated paper strip.

2.2. Pressure sensitive tape to be fixed to the Pressure sensitive tape to be fixed to the

final foldfinal fold

3.3. Brown indicator tubes - (very expensive) Brown indicator tubes - (very expensive)

4. 4. Biological. Green strip containing bacteria Biological. Green strip containing bacteria

(Color must change to black) (Color must change to black)

5.5. Cellophane wrapped tablet containingCellophane wrapped tablet containing

- Lactose - 75%- Lactose - 75%

- Starch - 24%- Starch - 24%

- Magnesium Trisilicate – 1% (Tablet turns - Magnesium Trisilicate – 1% (Tablet turns brown during autoclaving)brown during autoclaving)

6.6. Microbiological examination of finished Microbiological examination of finished products.products.

7.7. Thermo - couples . Thermo - couples .

ADVANTAGES OF STEAM ADVANTAGES OF STEAM STERILISATIONSTERILISATION

11. Rapid heating & penetration of . Rapid heating & penetration of loads.loads.

2.2. Destruction of all forms of Destruction of all forms of microbial lifemicrobial life

3.3. No residual toxicity. No residual toxicity.

4. 4. No damage to supplies being No damage to supplies being sterilised.sterilised.

5.5. Easy Quality Control Easy Quality Control

66. Economical & Reliable. Economical & Reliable

This method is unsuitable for heat This method is unsuitable for heat sensitive and non- permeable materialsensitive and non- permeable material

RADIATION STERILISATION RADIATION STERILISATION ; ;

‘ ‘ ISO MED ‘ at ‘BARC’ ISO MED ‘ at ‘BARC’ Trombay; dose - 2.5 Trombay; dose - 2.5 Mega Rhontgen; Source – Cobalt-60 /Caesium Mega Rhontgen; Source – Cobalt-60 /Caesium – 137/ Electron Beam (generated by linear – 137/ Electron Beam (generated by linear accelerator) accelerator)

Reliable, can penetrate all types of packing. Reliable, can penetrate all types of packing. Large & diverse shaped articles can be Large & diverse shaped articles can be sterilised. No residual radio activity at 2.5 sterilised. No residual radio activity at 2.5 mega rhontgens. mega rhontgens.

Glass becomes dark, cotton looses tensile Glass becomes dark, cotton looses tensile property, food gets undesirable flavor. Not property, food gets undesirable flavor. Not practicable in hospitalspracticable in hospitals

STAFFING :CSSDSTAFFING :CSSD

BHATTA CHARJEE RECOMMENDS BHATTA CHARJEE RECOMMENDS : :

SUPERVISORS SUPERVISORS (sister/male ward masters) 4(sister/male ward masters) 4

STAFF NURSES 5STAFF NURSES 5

TECHNICIANS (ORA) 6TECHNICIANS (ORA) 6

ATTENDANTS 24ATTENDANTS 24

SWEEPER 4SWEEPER 4

CLERK 1CLERK 1

TOTAL 44TOTAL 44

CENTRALISED SUPPLY (RULE OF THUMD 2PER 100 BEDS)

DISTRIBUTION SYSTEMSDISTRIBUTION SYSTEMS : :

1. 1. Regular issue of one day’s requirement.Regular issue of one day’s requirement.

2. Clean for dirty exchange.2. Clean for dirty exchange.

3. Milk round system (topping up 3. Milk round system (topping up

predetermined stock level)predetermined stock level)

4. As on required basis. (Grocery system)4. As on required basis. (Grocery system)

FLOW PROCESS : CSSD

WARDS/DEPTS BULK STORES

DIRTY RECEIPT CLEAN RECEIPT COTTON & GAUGE

DISASSEMBLY

INSTRUMENT GLOVES RUBBERWARE

WASHING AREAS

ASSEMBLY

PRE – STERILE STORAGEINSPECTION

STERILISATION STERILESTORAGE

DISTRIBUTION

A SUGGESTED LAYOUTOF

CSSD

INTRA MURAL COMMUNICATION LINERAMP

ASSEMBLY

(PARKING)

CLEANING&

WASHING

AUTOCLAVE ROOM

GLASS PARTITION

STERILE STORAGE

STERILE ISSUE

clean reception

Clean storage

Supervisors office

Verandah

disassembly

Dirty reception

° ° °

° 0 ° ° ° °

Thermal Death Time (TDT)Thermal Death Time (TDT)

TDT is the time required to kill a known TDT is the time required to kill a known population of microorganisms in a specific population of microorganisms in a specific suspension at a particular temperaturesuspension at a particular temperature

Increasing temperature decreases TDTIncreasing temperature decreases TDT

Lowering the temperature increases TDTLowering the temperature increases TDT

Thermal Death TimeThermal Death Time ( cont.) ( cont.)

Acidic or basic pHs decrease TDTAcidic or basic pHs decrease TDT

Fats and oils slow penetration and increase Fats and oils slow penetration and increase TDTTDT