Challenges in setting up a CSSD
CSSD, also called sterile processing, an integral part of any hospital or health care facility It comprises that service within the hospital in which surgical supplies and equipment are cleaned, prepared, sterilized, stored, and issued for patient care. CSSD stands for Central Sterile Supply Department.
The design and administration of the CSSD must allow for a high level of flexibility and anticipate continued change and improvement. As the ailing heart makes a man falter, a poor Central Sterile Supply Department (CSSD) makes a hospital sick. The world that we live in today is a globalized world and yes, in the western world too, CSSD is fighting for its place in the sun in the sphere of Infection Prevention.
With my focus on CSSD during over 40 years of my career and over 200 hospital visits, I have noticed a great positive change in the attitude of Hospital Managements towards the Central Sterile Supply Department (CSSD). However, in most cases we are far from achieving our goal of a well set up, optimally functioning department. Importantly, there are similarities in the challenges faced in setting up and running most CSSDs. The following are a few observations, shortcomings and solutions which may sound familiar to my colleagues in the field.
Challenge No 1: Traditionally, CSSD staff members were treated as dishwashers, and the CSSD is treated, as the “social workshop” of the hospital where employees are parked which are rejected from the Operation Theatre, and who are not totally fit. This immediately lowers the quality of service provided.
Solution:Only certified personnel should be employed in CSSD. Certification courses and training programs including on line and distance learning ones are available. The two main certifying organizations are the IAHCSMM and the CBSPD. Both require you to pass an examination after study of the material provided by them.Associations (HSSA, HSSAI and ISHA to name a few) exist, which provide seminars and courses. Ongoing training at the institute level also is imperative The CSSD In Charge should address his staff at least twice a week for imparting theoretical knowledge and updating them on changes/complaints during the past few days.
Challenge No 2: The space allotted for CSSD is usually grossly inadequate. This compromises the quality of the sterile material produced. Also, basements and terraces are strictly not recommended. Basements are dark, dirty, dust prone areas and terraces would have make shift walls and ceilings at best.
Solution:The CSSD should be located in the main building, close to O.T., and have a similar infrastructure in terms of flooring, walls, air conditioning and air changes. It should be planned at the inception of the Hospital, not squeezed in later.
Challenge No 3: There is no Legislation in India regarding CSSD. It is not governed by the FDA or any regulatory body, unlike in the rest of the world. Hence every hospital sets up and runs their CSSD as per their whims and fancies. Accrediting bodies like JCI and NABH are also not able to play a great role in setting things right, as they need to accredit the whole hospital, not just the CSSD. They may contribute to a few positive changes at best.
Solution:National Guidelines need to be issued by the Government and Government legislation is compulsory with enforcement agencies to ensure compliance.
Challenge No 4: There are no international standards made available to staff. It is desirable to adhere to evidence-based standards. Otherwise, it is challenging for the CSSD Manager and his / her team to develop procedures and protocols for the department.
Solution:Sterile processing employees should follow standards set by professional organizations such as the Association for the Advancement of Medical Instrumentation (AAMI), The Joint Commission and CDC. These need to be purchased by the management and kept as a guideline around which policies are developed, customised to the needs of the institute.
Challenge No 5: The infrastructure, layout and interiors are planned and executed without any inputs from a qualified or experienced CSSD person. Architects and MDs/CEOs/Owners alone would not be able to design a good Department due to lack of experience and knowledge. Later modifications are made but these sometimes can never lead to an ideal situation. A CSSD Manager is hired at the last stage. Even instruments are purchased arbitrarily. I have known instruments which cannot be cleaned or sterilized, making them worthless or at best disposable.
Solution:It would save a lot of heart burning and expense if a CSSD person was involved in the designing and purchase from initial stages. In future too, in every purchase of instruments/devices which need to be sterilized there should be a representative of CSSD to ensure that the vendor is made responsible for giving the methodology and instructions for reprocessing his product to ensure its long life, and does not make any false claims in terms of the number of uses etc.
Challenge No 6: Sometimes space is allotted to CSSD but there is no proper physical segregation of areas. If the 3 basic sections given below do not exist, it is not a CSSD worth its name! I must warn you though, that it requires careful planning and some expertise to allocate the appropriate space for each with the right flow of material. It is at best, tricky.
Solution: Areas could be divided as given below.
a) Decontamination Area:– Instruments and other reusable devices are received from various patient care areas and cleaned here.
b) Assembly Area:- Instruments are inspected and assembled together to form sets and packs here. The Assembly area may also house sterilizers.
c)Sterile Storage Area:– The sterile materials are stored in this area prior to issuing them to the user departments.
Challenge No 7: For a well functioning CSSD, the right equipment is very important. However, since it eats into a large chunk of the budget, cost cutting measures are usually employed here. This is false economy. Often, equipment is purchased which turns out to be totally unsuitable for the purpose and has to be scrapped. Pray, how can one get quality material out of a defunct machine? Also, whatever seems more reasonably priced while purchasing, may last for a short while only, not making it cost effective in the long run!
Solution: Please select equipment with latest technology, as this itself would be outdated shortly. Reprocessing of gloves, hypodermic syringes and needles is a thing of the past, so please do not purchase any machines for the same. Given below are some insights on commonly used equipment:
- Ultrasonic Washer: This is mainly used for washing instruments with joints. Every CSSD should have one.
- Washer Disinfector: It could be located in the Operation Theatre or the CSSD. It is very useful as it minimizes the handling of contaminated material, which increases employee safety.
- Hot Air Oven: This can be used as a Dryer and Dry Heat Sterilizer.
- Steam Sterilizers: Horizontal, rectangular, air removal types are almost mandatory now. (Carriages and trolleys are required for these sterilizers). Vertical (or Drum) Sterilizers are a thing of the past. Do not even consider them.
- Low Temperature Sterilizers: EO and Gas Plasma are desirable, at least n medium sized and large set ups.
- Clean Air System for Sterile Storage Area: This helps to deliver filtered air and maintain positive air pressure as compared to adjacent areas.
- Trolleys: Table Trolleys are required to transport instrument within the department and can be used as a worktable. Closed Collection & Distribution Trolleys are required to transport material to and from user departments.
Challenge No 8: While budgeting for cost of expendables, items like disposable Packaging Materials are not planned for. This results in dangerous practices like use of linen for packing which could lead to disastrous consequences in terms of infections.
Solution: Stainless steel drums, trays and the green cloth used in operation theatres be replaced immediately by standardized packaged material like nonwovens, peel packs and rigid containers. I would like to suggest here that these individual packs, packed in disposable packing material, be charged directly, though nominally to patients, to cover the cost as well as to prevent wastage, misuse and pilferage in the user department. In fact, every set, linen pack or dressing material packet should be charged independently to the patient instead of inclusion in bed or OT charges. This will result in huge cost savings due to reasons cited above and portray the CSSD as a Revenue Centre.
Challenge No 9: Minimum safety needs of CSSD staff are not taken care of. Personal Protective Equipment (PPE) is either not available or inadequate due to so called “cost constraints”.
Solution:PPE like General purpose utility gloves (not surgical gloves), Liquid resistant covering with sleeves (for example, a backless gown, jumpsuit, or surgical gown)., Liquid resistant shoe covers, Fluid resistant face mask, Eye protection like Goggles or Full-length face shields should be freely available.
Challenge No 10: Not every Central Sterile Supply Department is computerized due to a lack of funds or even a belief it is not needed.
Solution : It is time to digitize our CSSDs! This again will result in efficiency and cost savings.
Conclusion: All those interested in “Infection Prevention” have to make a joint effort for the patient’s sake, to bring the CSSD out of the shadows to its due place. Hospital managements should appreciate the tireless efforts of the staff in CSSD to keep OT running smoothly and infection free.
The responsibility placed on the staff within the department is great, because every stage of the process must be signed for by the member of staff completing it to ensure equipment is properly disinfected, sterilized and returned for surgery complete for that procedure. They can do this if their morale is kept high and their work recognized as on par with nurses to say the least. It is challenging for the CSSD Manager and his / her team to develop procedures and upgrade and modify these at the drop of a hat, this being a dynamic department. I hope this article will throw some light on the challenges faced by us and go some distance in giving this department its due.