Stepping towards a smarter CSSD

Key Elements and Best Practices for Effective Central Sterile Services (CSSD)

Central Sterile Services: Enhancing Healthcare Safety Through Sterilization & Storage

The Central Sterile Services / Storage Department (CSSD),is a cohesive component in hospitals performing sterilization and storing for distribution across the facility. It is one of the most critical component in the functioning of healthcare system.  It plays a critical the role to clean, disinfect, sterilize and store re-usable medico-surgical devices and instruments to ensure patient safety, compliance, efficiency and economy while doubling up to ensure infection control and prevent cross contamination is addressed across departments. 

Critical components to check before the first CSSD cycle would be proper structure (layout, flow), right equipment (for all stages), comprehensive processes, skilled and knowledgeable team. 

For a CSSD to carry out “6Rs” – Right place, Right time, Right quantity, Right package and labels, Right quality controls and Right economics of delivery, the following aspects need to be addressed –

  • Location – proximity to surgical areas, being the major user with a smooth transition of instruments in between (both ways); easily accessible to all care departments;
  • Departmental Area – drawn from combination of surgeries planned with escalation estimate, number of beds, complexity and variety of clinical services with procedures performed
  • Material Finish – water-tight, non-slip floor covering, hygienic surface through PVC welded sheet vinyl for easy daily cleaning; washable walls, durable polyurethane wall finish with corner protection; washable, water-tight, non-porous ceiling, no admission of airborne particles or other contaminants, impervious to humidity; 
  • Equipment – depending on operations performed annually, (by clinical services, as the trays and procedures varies in accordance), hospital beds, working hours of the department, type of goods (specially for selecting the washers, disinfectors and sterilizers), degree of automation; 
  • Zones and Barriers – Following WHO Guideline on “Decontamination and reprocessing of medical devices for health-care facilities” – physical separation between soiled, clean and sterile zones with independent staff addressing the need of these areas; respect the unidirectional flow (soiled to clean and sterile)
  • Ergonomics & Planning – Maximize daylight usage, reduce noise, height adjustable tables and trolleys for staff comfort, including automation in managing solutions, checking and controlling cycles in washers, sterilizers
  • Utilities – 24×7 stable electricity and quality water with back up to ensure uninterrupted cycles to ensure continuity of supply
  • Patient Safety Solutions – Barcodes and automation for traceability of each items sterilized, confirmation of cycle efficacy

Selection of the right equipment for each stage of CSSD is of vital importance. Requirements of routine and advance need to be understood and evaluated while selecting the same.

Few criteria while selecting the key equipment

CSSD, by its nature of functions is an imperishable process, enduring the same standards across cycles without an out an of doubt or risk to the end product, having humongous implications for patients and staff. The process is complex and the followings may be considered to be included in the processes – 

  • Addressing the most important part of the process – the staff – aligning them with the hospital and departmental policies and targets; continuous education to staff to develop their skills
  • Communication – with all internal stake holders – transparent communication on processes, test validation, sharing monitoring and reporting to build team engagement and collaboration
  • Utility Consumption – to quantify progress, saving water (minimize interval between procedures and cleaning, encourage users to soak used instruments, customize wash cycles, running eco-friendly cycles, using detergents in accordance to water hardness), saving electricity (operate in low energy hibernation when not in use, optimising machine running, reusing heated water from previous cycles, optimising drying time) and chemicals to optimally address the load type, statistics on equipment maintenance and recalibration
  • Optimizing workflow – to support correct actions, reduce risk of contamination, avoid unnecessary salvaging, identify factors affecting workflow, barrier strengths and stability
  • Enhancing Instrument Lifetime – careful implementation in all steps of pre-cleaning, cleaning, disinfection, inspection, lubrication (if necessary), function check and sterilization; repair or sharpen when necessary
  • Instrument availability – Documenting KPIs like instrument demand and usage, exact location and instrument handling to check availability for schedules surgeries, possible decentralized stock management in OR, setting category and requirement of instrument
  • Continuous Improvement through Performance Measurements using User Satisfaction Surveys on various functions, quality, communication, reports and monitoring of CSSD activities

Enhancements in functions and systems in CSSD – 

  • Endoscope Cleaning – with increased use of Endoscopes, the risk of infections linked to endoscope reprocessing increases. An area of “zero tolerance” towards cross contamination need to be ensured through automation systems – to be included in CSSD. Re-processing units with fast, efficient cycles, hands free operation, optimum traceability, separate chambers for multiple scopes, proper chemical handling, online access. 
  • Automation for Washer Disinfector – when using multiple units (for large CSSD), an optimal solution for better efficiency for loading through unobstructed access conducted through the system without any manual intervention maximising productivity. 
  • Automation for detergents / cleaning solution – connection to all sources and equipment, fitted with level sensors, optimising standard dosing system, pumps and flow meter network – all operated at single location without manual intervention at every loading point. Automatic data processing, reports and alerts to stake holders are the additional benefits. 

Descending order of resistance to germicidal activity of chemical disinfectants against various organisms – reproduced from “Decontamination and Reprocessing of Medical Devices for Healthcare facilities” – WHO 2016

Knowing Chemical Disinfectants Better 

  • Desired Characteristics – high germicidal activity; rapidly kills a wide range of microorganisms including spores; chemically stable; effective in the presence of organic compounds; compatible with surface being disinfected; ability to penetrate cervices; inexpensive and aesthetically acceptable
  • Commonly used – ortho-phthaldehyde OPA; formaldehyde (carcinogenic to human); glutaraldehyde; peracetic acid; hydrogen peroxide; chlorine based compounds; alcohol; chlorine dioxide

Monojit Mitra
Facility Director, FV Hospital, Ho Chi Minh City, Vietnam