It is now being widely accepted that efficient pre-washing / cleaning is essential in the sterilization process. Moreover, with the current technologies in the CSSD, the demanding thermo disinfection processes are possible to assure high levels of disinfection in perfectly dry materials, deeply reducing the time factor.
Mishandling and improper sterilization of the instruments can be fatal. Safe and effective disinfection and sterilization can be guaranteed with clean medical products. CSSD provides tangible tools for securing high quality infection control because it is equipped with disinfectors and sterilization facilities.
Muralikrishnan Nair concedes, “CSSD breaks the chain of infection in the hospital and the maintenance department helps achieve it.” Experts emphasize that the rise in incidence of nosocomial infection with corresponding increase in mortality, length of stay and cost can be brought down by establishing a good CSSD set-up. CSSD was generally looked upon as an essential part for supporting the OT, Cathlab & ICU as the use of sterile supplies in a hospital is more applicable in these areas. However, it is considered today, integral to the function of Out Patient Department (OPDs), wards and other patient care areas, wherever any surgical or invasive procedure takes place.
The scope of CSSD has expanded from a department similar to an autoclave sterilisation unit to encompass hospital infection control and stand for a dedicated workflow of sterile supplies and goods.
The Central Sterile Supply Department (CSSD) plays a key role in providing the items required to deliver quality patient care. CSSD within a hospital receives, cleans, packs, sterilizes, stores and distributes the material to make reliably sterilized articles available at the right place and at the right time to all departments. Identifying and completing the many tasks performed in CSSD require development of effective policies and SOPs that are supported by industry standards and guidelines. Training CSSD team members to follow these policies and procedures will ensure a consistent and high-quality product and enhance service level. This in turn will support quality patient care.
Any compromise in terms of cleanliness and hygiene could lead to nosocomial infection. Asian Heart has various processes in place to achieve cleanliness & hygiene, but the challenge lies in the form of competency and expertise of staff, says Nair. “Their training and orientation therefore is a continual process,” he adds.
“At Asian Heart, we are even conducting examinations on hygiene practices, protocols and giving soft skill training to make the staff conscious about their relationship with patients and their relatives, so that ownership is inculcated amongst them.”
Today, there is no need for nurses to divert their attention to other mundane activities and they can focus more of their time in their primary responsibility of patient care.
Towards achieving quality
AHIRC has today achieved the distinction of the lowest infection rate by virtue of the stringent protocols and training of the cleaning and the CSSD staff.
The administration department of AHIRC has outsourced competent building service contractors (BSCs) to attain desired hygiene levels and to ensure consistent infection control practices. The contractor is selected on the basis of certification, documentation, competence, customer satisfaction and their credibility in the market.
For effective management and administration purpose, the current practice prevailing in AHI is that they have a well orchestrated and integrated system of staff comprising of CSSD and Maintenance Personnel to achieve the same.
The service provided by the BSCs is expected to be patient centric and aligned as per the goal and expectations of the hospital. To achieve this, ownership is inculcated among these contractors so that they do the job in a desired way. Rare Hospitality is providing services at Asian Heart presently.
The cleaning support staff in CSSD is also called Patient Care Assistants. They help the technical staff in CSSD and are also involved in activities like lifting, laying and transporting instruments from one machine to other and from one area to the other.
In the wash area, they can help in the cleaning and collection of material. “The people required during the cleaning process are trained under the supervisor of the maintenance department. There is a mandatory minimum of nine hours training in a month.”
They need to follow proper protocols while changing positions in the CSSD area. For example, when they are finished with their job in the washing area, they have to remove their gloves, attire and wash their hands. They have to remove their plastic aprons and ensure that they wear specific attire for better identification, so that contamination is prevented.
“Cleaning of instruments, transport of dirty instruments, receiving at the user area and distribution are done in a seamless fashion by the support staff and the outsourced cleaning staff. CSSD department has a team of 12 people, which comprises the following staff – Manager, Deputy Manager, Team Leader and Technicians.
“We have a dedicated manpower which works 24 x 7 in three shifts. We refrain from using detergents in the sterilizers for cleaning them. Microfibre wet wipe is specially designed for the sterilizers for manual cleaning once a week. These wipes are of very good strength and can last up to three months,” says Nair.
Infection Control and Nosocomial committee
Areas which come under infection control are Maintenance, Engineering, Nursing, CSSD, Pathology and Clinical Administration. It is chaired by the Medical Director along with a team of Nursing Director, Nurse Managers of separate areas, most importantly surgical areas, pathologists, microbiologists, Hospitality Manager, CSSD Manager and Maintenance Executives.
The Infection Control Doctor/Nurse, who is assigned the job of infection control management collects data at different levels, analyzes and presents it to the infection control committee on a monthly or quarterly basis as per the requirement. If there is any serious non-compliance, corrective action is taken in accordance with international and local standards.
AHI is India’s Highest Accredited Hospital with JCI, ISO and NIAHO & also recognized as ‘India’s Best Private Cardiac Hospital’ (separate, All India survey by ICICI Lombard General Insurance & CNBC TV-18 & The WEEK). Even the lowest level of the housekeeping staff and all the other outsourced staff are thoroughly trained in such a way that they are clear about purpose of every single activity they perform.
Work Flow and Training
To maintain good workflow, sterilisation process involves proper functioning and co-ordination between four zones: dirty area, which is also called as washing area, assembly area or packing area, sterile area and finally, the sterile goods storing area.
CSSD’s dedicated workflow design aims at meeting microbiological demands. The Central Sterile Processing is generally based on three areas for soiled, cleaned/disinfected and sterile goods with products designed for a pass-through processing flow, serving as barriers between the areas.
The first barrier, used in the fight against pathogenic microorganisms is between the washing area and the assembly area where the inspection and packing take place.
The physical barrier itself consists of high-capacity, pass-through washer-disinfectors. Since soiled, cleaned and disinfected goods are handled in entirely separate rooms by separated operators, the risk of cross-infection due to staff and the surroundings is minimised.
There is a provision for mandatory training of nine hours in a month for all the personnel involved in CSSD and cleaning. The training for the staff is however customised based on the workload.
The second barrier between the assembly area and the sterile storage area includes pass-through sterilizers. Once again, the operators are physically separated between the two areas. An effective workflow also requires the use of standardised goods carriers by and between the various work procedures.
The in house staff maintains the work flow in CSSD. The instrument set has to be packed by the designated technician followed by wrapping to maintain sterility. Post sterilization, by means of double door system of modern sterilizers, the packs are unloaded to the sterile storage area and finally issued to the user departments. SOPs need to be strictly followed in CSSD so that right instruments get assembled in respective sets after a thorough checking of the instruments. In Sterile Storage area, sterile material is kept till it is being issued to the concerned departments like Operation Theatre (OT). Here, cleaning material is kept separately with clear identification in order to avoid using it in the dirty area and contaminate the sterile storage area. To avoid this, the hospital has a Janitors room where back up cleaning supplies are kept.
Since outsourced housekeeping agencies at Asian Heart have their own set of targets to meet and well defined protocols, the hospital management checks their activities for compliance or non- compliance on a periodic basis. Corrective and preventive action is followed, if required.
Basic cleaning practices that need to be followed in CSSD entail following daily, weekly and monthly schedules by the staff in maintenance and usage of different materials in designated areas. In house training is given to the cleaning staff to address any emergency before the CSSD staff and management could realise the discrepancy and send alerts on the same.
Human Resource and Efficiency
In case of an emergency, not only the clinical and nursing representatives rush to the patient, but, even the maintenance supervisor and concerned staff join them to complete a dedicated team effort.
Specialized Manpower Application required for CSSD is two to three per cent of the housekeeping department, which can be shared tentatively with other departments based on the patient influx. There is a requirement of more people at patient care areas considering more application of service in this area, which housekeeping department needs to attend to. “That is why you can draw an inference that ever since its inception as a centre of excellence in cardiac care nine years ago, the standard has never come down at AHI,” explains Nair.
Every area in the hospital has got checklist that is shared between BSCs, supervisors and process owners of the respective area. There is a provision for back up staff to be in place to take care of any emergency arising during the workflow. Based on certain parameters, the performance of the contractor is evaluated periodically and assessed which helps them to improve their services. Meetings and discussions are conducted to address the gaps.
Bio-medical Waste Disposal
At Asian Heart, waste that can be discarded at the point of use like Single Use Devices (SUDs), which includes needles and glass pieces, are fed into the sharp container in the washing area for disposal. In most of the public and government hospitals, only dustbins are used for such purposes. Different colour bags are in place at AH for disposal of other wastes.
Designated workers, specialised in collecting municipal waste are recruited by Maharashtra Pollution Control Board (MPCB). The vehicle used for the purpose is designed in such a way that there is no chance of spillage or contamination.
Dump Waiter, an automated Vertical Transport System (VTS) facilitates the transport of sterile material from the Sterile Storage Area to the Operation Theatre. Moreover, there is a window opening to the Dump Waiter, which is an interface between the OT and CSSD to maintain proximity of the VTS to OT.
The system is set up in the initial stage of the construction of the hospital because it entails a lot of civil work to be performed. A shaft has to be made through which the lift moves to deliver sterile goods to OT. The size of the VTS can be customized depending on the volume of sterile goods and the number of OTs in the hospital.
The dirty instruments from the OT, once the operation is done are transported through the service lift for reprocessing in the washing area.
Indian hospitals are generally known to clean, disinfect or sterilize Single Used Devices (SUDs). This practice should be adopted judiciously to reduce disposable medical waste and cost, without compromising on patient safety. Another trend, very new in Indian hospitals is that hospitals don’t outsource sterilisation of equipment to third party processors. US-FDA ensures that the hospitals, companies and third party processors, reprocessing of SUDs should meet the same standards used by the original manufacturer. Some Indian hospitals even prefer using indigenous sterilisers for cost cutting.
Regulation and Guidelines
Though the government has laid down guidelines to protect sweepers and waste collectors, there is sheer absence of guidelines or a regulatory body to check if instruments used are properly sterilised. A ray of hope is perhaps the Government’s initiative in laying down guidelines for hospital hygiene. In the absence of guidelines, most of the private and corporate hospitals (especially an Infection Control Committee) have its own protocols.
While hospitals are waking up to the importance of CSSD and the need for guidelines, some experts suggest that CSSD should also be installed at primary health centres. This may take some time; however what hospitals can start with is taking the initiative to train their staff in using latest technologies and using available international guidelines in CSSD.
Maintaining high standard of maintenance practices is no more a luxury in hospitals, but a necessity, especially in a department like CSSD. Being a back office, there may be a tendency to cut the corners which needs to be addressed separately. Any compromise in hygiene in these sensitive areas should be avoided to achieve quality patient care.