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CSSD Structural Design & Workflow

Dive into critical areas like decontamination, assembly, sterilization, and storage, and discover how a lean and green approach enhances efficiency and sustainability in CSSD operations.

Neena Kulkarni
Administrator, Wockhardt Hospital, Mumbai | + posts

Central Sterile Supply Department (CSSD) is a niche area in any hospital. This department is a cornerstone of Infection Prevention and very crucial to successful and safe (infection free) patient outcomes.
This department comprises that service within the hospital in which medical/surgical supplies and equipment, are cleaned, prepared, sterilized, stored, and issued for patient care.  cycles. A high degree of innovativeness and personalized attention makes the CSSD the nerve centre of the hospital’s drive for a 100% infection-free atmosphere.

Staff must know how to care for and operate all pieces of automated and mechanical equipment. In addition, they require a minimum of 6 months to 1 year on the job training, which can be reduced if one has an approved certificate or formal academic training in Central Service Technology. The number of staff and the category depends on the extent of automation and the type of facilities the hospital is catering to. However, the thumb rule is one staff for every ten beds. Kudos to these ‘sterilization experts” who are actually the unsung heroes within the hospitals.
Planning 

While planning the CSSD it is important to form a committee and take inputs from all stake holders such as surgical, nursing, materials, biomedical, laundry and administrators. Present requirementshould be discussed along with future plans for upgradation and technological advancements, keeping aside space for such needs is necessary.

Location and Layout
The size and location usually depend on the number of departments the CSSD will serve, as well as the number of beds, types of surgeries, quantum of the pre sterile material usage, and available inventory of instruments. However, seven to ten square feet per bed is recommended as an area of requirement for a CSSD.
CSSD has to mainly ensure adequate and timely provision of thoroughly cleaned, sterilized reusable items such as drapes, surgical instruments etc. for all areas such as procedure rooms, operation theatres and patient care units across the healthcare facility. This department should hence be preferably centrally located with proximity to the major departments such as Operation theatre and Intensive Care Units. Having an easy access to the Materials department as well as the laundry would be an advantage as they provide the raw material such as linen, dressings and consumables such as labels, indicators etc.
Ideally there should be a unidirectional flow of used material from the collection area also called Decontamination Area to Assembly Area for checking and packaging of items to Sterilization and Storage area for sterilization of the packaged sets which must be stored safely before they are dispatched for use. There should be a physical separation between these areas. It is important to have traffic restrictions in the CSSD. Areas beyond receipt and delivery counters should be limited to staff only.

It is imperative to have hand wash sinks located in each functional area. Placement of appropriate waste bins to collect all types of waste in line with local laws of waste segregation and disposal is also mandatory.  Linen hampers to be placed wherever required to collect the reusable linen.

Appropriate changing and locker room facilities with showers and toilets should be available for the restricted use of CSSD staff. Staff need to change into in house laundered uniforms as hospital policy regulations dictate before entering the department.  In the event of a power outage, feasible provision of emergency power to maintain the critical equipment in use should also be considered.

Further, all furniture and fixtures must be made of materials such as stainless steel which can be thoroughly cleaned. Alsosmooth surfaces without joints and crevices are preferred to avoid collection of any soil which can harbor millions of microorganisms. Walls and flooring too should be easily cleanable with minimum joints and coving to avoid collection of debris and soil. Use of antifungal paint and epoxy flooring is preferred.

Ventilation and Lighting
The most desirable method of the ventilation is air conditioning. The temperature desirable for the sterile storage room is as good as the temperature in the operation theatre i.e. 180 – 220 Celsius. This helps in maintaining low bio burden. Air Handling Unit should provide air pressure as per the OT set up. Also washing area should have at least 10 – 12 air changes per hour. The pressure difference between the sterile storage area and the adjacent room should be at a minimum of +2pa. It’s advantageous to have a positive airflow from sterile storage out into other areas.
Proper lighting is very essential in the CSSD to allow proper inspection of the instruments as well as the other packing material like linen while packaging.  Recommended Lighting should be 250 – 400 lux.

Decontamination Area 
The Decontamination Area is where reprocessibles such as instruments and other items used for surgeries or patient care are received from the point of use. Staff must be provided with appropriate personal protective equipment while handling these soiled items. The used material comes to the CSSD decontamination room via a designated doorway in contained manner to avoid spread of infection.  
This area has automated equipment such as washer disinfectors, ultrasonic cleaners and must have appropriate number of counter sinks. The counter is useful for placing the instruments for purpose of segregation and checking. Further the sink modules are used for manual soaking, hand washing, and rinsing of instrumentation. The sink may include a main and treated (Deionised or RO) water faucet, a spray rinser, water jet and air gun for cleaning lumens. The first sink is filled with water and an enzymatic cleaner. Here the surgical items are allowed to soak. The second sink is used for washing and scrubbing of the surgical devices and instruments if required to be cleaned manually. A third sink is required to rinse off adhering dirt and cleaning agent. Alternately soaking and washing can be carried out in the first sink, reserving the second one for rinsing

The instruments that have to be washed using machines are loaded in the washers. After the cleaning is done the items are dried in dryers and then passed into the Assembly area either through pass boxes or doors keeping the unidirectional flow intact.

Appropriate storage cabinets to store cleaning solutions and other items must be made available here. Provision to wash trolleys or carts too is required in Decontamination Area. 

An area to reprocess flexible endoscopes may be part of the decontamination area. The Scope Processing Area consists of an Ante Room, Decontamination, Scope Processing, and Clean Scope Storage. The equipment required is an Automatic Endoscope Reprocessor (AER) and a soaking station to perform High Level Disinfection. At times this area is part of the Endoscopy Suite.

Assembly Area
The Assembly Area is where the cleaned instruments and other items are inspected, re-assembled and packaged for sterilization. Packaging methods may include wrappers made of linen, sealable polypropylene pouches, crepe paper, tyvek material, non-woven material and rigid instrument containers. The wrapped sets are then sterilized using appropriate methods of sterilization such as steam, ETO, vaporized hydrogen peroxide etc.
Packing tables, sealing machines, trolleys for wrappers, storage for labels, indicators and other consumables is required here. This area also houses tables and chairs for the staff, telephones, bar code scanners, printers, computers depending on level of digitization in processes. Technological advances also include details of items being reprocessed and tracking systems, as well as automated equipment interfaces for decontamination and sterilization documentation.

Linen Packaging Area
The linen packing and dressing material area should be away from the main packing area and

Central Sterile Supply Department (CSSD) is a niche area in any hospital. This department is a cornerstone of Infection Prevention and very crucial to successful and safe (infection free) patient outcomes.
This department comprises that service within the hospital in which medical/surgical supplies and equipment, are cleaned, prepared, sterilized, stored, and issued for patient care.  cycles. A high degree of innovativeness and personalized attention makes the CSSD the nerve centre of the hospital’s drive for a 100% infection-free atmosphere.

Staff must know how to care for and operate all pieces of automated and mechanical equipment. In addition, they require a minimum of 6 months to 1 year on the job training, which can be reduced if one has an approved certificate or formal academic training in Central Service Technology. The number of staff and the category depends on the extent of automation and the type of facilities the hospital is catering to. However, the thumb rule is one staff for every ten beds. Kudos to these ‘sterilization experts” who are actually the unsung heroes within the hospitals.
Planning 

While planning the CSSD it is important to form a committee and take inputs from all stake holders such as surgical, nursing, materials, biomedical, laundry and administrators. Present requirementshould be discussed along with future plans for upgradation and technological advancements, keeping aside space for such needs is necessary.

Location and Layout
The size and location usually depend on the number of departments the CSSD will serve, as well as the number of beds, types of surgeries, quantum of the pre sterile material usage, and available inventory of instruments. However, seven to ten square feet per bed is recommended as an area of requirement for a CSSD.
CSSD has to mainly ensure adequate and timely provision of thoroughly cleaned, sterilized reusable items such as drapes, surgical instruments etc. for all areas such as procedure rooms, operation theatres and patient care units across the healthcare facility. This department should hence be preferably centrally located with proximity to the major departments such as Operation theatre and Intensive Care Units. Having an easy access to the Materials department as well as the laundry would be an advantage as they provide the raw material such as linen, dressings and consumables such as labels, indicators etc.
Ideally there should be a unidirectional flow of used material from the collection area also called Decontamination Area to Assembly Area for checking and packaging of items to Sterilization and Storage area for sterilization of the packaged sets which must be stored safely before they are dispatched for use. There should be a physical separation between these areas. It is important to have traffic restrictions in the CSSD. Areas beyond receipt and delivery counters should be limited to staff only.

It is imperative to have hand wash sinks located in each functional area. Placement of appropriate waste bins to collect all types of waste in line with local laws of waste segregation and disposal is also mandatory.  Linen hampers to be placed wherever required to collect the reusable linen.

Appropriate changing and locker room facilities with showers and toilets should be available for the restricted use of CSSD staff. Staff need to change into in house laundered uniforms as hospital policy regulations dictate before entering the department.  In the event of a power outage, feasible provision of emergency power to maintain the critical equipment in use should also be considered.

Further, all furniture and fixtures must be made of materials such as stainless steel which can be thoroughly cleaned. Alsosmooth surfaces without joints and crevices are preferred to avoid collection of any soil which can harbor millions of microorganisms. Walls and flooring too should be easily cleanable with minimum joints and coving to avoid collection of debris and soil. Use of antifungal paint and epoxy flooring is preferred.

Ventilation and Lighting
The most desirable method of the ventilation is air conditioning. The temperature desirable for the sterile storage room is as good as the temperature in the operation theatre i.e. 180 – 220 Celsius. This helps in maintaining low bio burden. Air Handling Unit should provide air pressure as per the OT set up. Also washing area should have at least 10 – 12 air changes per hour. The pressure difference between the sterile storage area and the adjacent room should be at a minimum of +2pa. It’s advantageous to have a positive airflow from sterile storage out into other areas.
Proper lighting is very essential in the CSSD to allow proper inspection of the instruments as well as the other packing material like linen while packaging.  Recommended Lighting should be 250 – 400 lux.

Decontamination Area 
The Decontamination Area is where reprocessibles such as instruments and other items used for surgeries or patient care are received from the point of use. Staff must be provided with appropriate personal protective equipment while handling these soiled items. The used material comes to the CSSD decontamination room via a designated doorway in contained manner to avoid spread of infection.  
This area has automated equipment such as washer disinfectors, ultrasonic cleaners and must have appropriate number of counter sinks. The counter is useful for placing the instruments for purpose of segregation and checking. Further the sink modules are used for manual soaking, hand washing, and rinsing of instrumentation. The sink may include a main and treated (Deionised or RO) water faucet, a spray rinser, water jet and air gun for cleaning lumens. The first sink is filled with water and an enzymatic cleaner. Here the surgical items are allowed to soak. The second sink is used for washing and scrubbing of the surgical devices and instruments if required to be cleaned manually. A third sink is required to rinse off adhering dirt and cleaning agent. Alternately soaking and washing can be carried out in the first sink, reserving the second one for rinsing

The instruments that have to be washed using machines are loaded in the washers. After the cleaning is done the items are dried in dryers and then passed into the Assembly area either through pass boxes or doors keeping the unidirectional flow intact.

Appropriate storage cabinets to store cleaning solutions and other items must be made available here. Provision to wash trolleys or carts too is required in Decontamination Area. 

An area to reprocess flexible endoscopes may be part of the decontamination area. The Scope Processing Area consists of an Ante Room, Decontamination, Scope Processing, and Clean Scope Storage. The equipment required is an Automatic Endoscope Reprocessor (AER) and a soaking station to perform High Level Disinfection. At times this area is part of the Endoscopy Suite.

Assembly Area
The Assembly Area is where the cleaned instruments and other items are inspected, re-assembled and packaged for sterilization. Packaging methods may include wrappers made of linen, sealable polypropylene pouches, crepe paper, tyvek material, non-woven material and rigid instrument containers. The wrapped sets are then sterilized using appropriate methods of sterilization such as steam, ETO, vaporized hydrogen peroxide etc.
Packing tables, sealing machines, trolleys for wrappers, storage for labels, indicators and other consumables is required here. This area also houses tables and chairs for the staff, telephones, bar code scanners, printers, computers depending on level of digitization in processes. Technological advances also include details of items being reprocessed and tracking systems, as well as automated equipment interfaces for decontamination and sterilization documentation.

Linen Packaging Area
The linen packing and dressing material area should be away from the main packing area and preferably in a contained room to avoid the lint or fibres of linen depositing on the Instruments.
Sterilization Area 
 After the sets are packed, they are sterilized using different methods of sterilization. Steam gas plasma/vaporized hydrogen peroxide and ethylene oxide are common methods.

It is important to know the capacity requirements of the facility to decide on number and type of sterilizers. There may be a need of large floor mounted units which can sterilize hundreds of instruments at one time or only a few sets, such as in a small surgery centre. In a large hospital it is preferred to have a combination of both large sterilizers and smaller units.
Adequate floor space with space between sterilizers to be able to service them periodically must be planned. Also, since steam sterilizers generate intense heat, extreme caution should always be used when in the area. Protective equipment to safeguard staff from burn injuries while loading or unloading the sterilizers is required here. 

When planning for sterilization the options are the two and three zone types. Depending on designthe architect and equipment planner will need to specify either a single door sterilizer or a double door sterilizer. It is pertinent to note that a single door sterilizer will be used in a two zone department that combines preparation or assembly and sterilization. They consider an area as dirty or clean (two zones). This is the typical model found in the U.S. whereas in Europe a trend of a department having a dirty, clean and sterile area (three zones) is observed. 

Further it is very important to understand utilities such as electrical power, drain location and  system, steam and water quality while deciding on the purchase and placement of sterilizing equipment.

Ethylene Oxide Sterilization Area

EtO sterilizers / aerators must be located in a fully contained room with sensors to alarm in case of any leakages. Local governing bodies regulate EtO waste emissions and typically require construction, installation, replacement and operating permits. 

Sterile Storage Area

This is where assembled sterilized instrument sets and associated hard goods to support surgery and other areas are stored until distribution to the areas of use. Provision for adequate space required for cooling of cart and its load must be considered. Also, a lot of heat will be dispersed into the sterilization area which needs to be managed.

The sterile storage must have wire mesh (stainless steel) racks to avoid sterile packs getting wet due to condensate formation during storage. For easy access and segregation pigeon-hole cabinets, bar code scanners, trolleys, case carts are also required. This place has to be ultra clean and have an environment similar to OT. Ideally there should also be entry restrictions in place such as change of footwear, clothes, donning PPE and hand hygiene.

Lean and Green Approach 

A Lean analysis, is recommended prior to planning and design. It is important to identify and eliminate unnecessary steps, streamline operational efficiencies and implement standardization at the very beginning. It thus becomes very important to check horizontal and vertical movements, have supply chain and all tracking systems for the various requirements working with the help of technology and digitization in place to enable shorter turnaround times (TAT).

It is of paramount importance that we reduce carbon footprints and promote green environment. Hence in a CSSD steps such as reusing water that gets drained after every cycle of steam sterilization, planning for a combination of big and small machines which can be appropriately used, having sensors to switch off lights in areas not in active use, use of appropriate fuels and solar panels, encouraging staggering of loads being sterilized, planning our sterilizer cycles which will allow an optimum usage of the capacity and avoiding running cycles at less capacity and so on and so forth can be the steps we take. The list is obviously dynamic and specific to each facility.
Selection of newer and better technology suitable for sustaining a clean and green environment should be the mantra while planning and designing a CSSD.

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