The Central Sterile Supplies Department has come a long way from being an after-thought in the Hospital Planning process, to becoming centre-stage in the Hospital’s Infection Control Strategy. CSSD layouts are carefully planned to ensure unidirectional workflow, proximity and connectivity to the Operation Theatres, space provision for key equipment such as autoclaves, washer-disinfectors, ETO or Plasma Sterilisers, provision of key utilities such as RO water, electricity, ETO, and staff facilities such as changing rooms, recreation rooms, etc. The Missing Link is Digitisation of CSSD.
But hold on! Did I just say CSSD Digitisation? Yes, I did!
The CSSD processes several critical items for caregiving departments like Operation Theatres, ICUs etc. Starting from simple dressing material used in OPDs or emergency rooms to complex robotic instruments for operation theatres, the daily transaction volumes of the CSSD are humungous. The diversity of items processed also includes stainless steel instruments, linen, gowns, Single Use devices and so on. In fact, the CSSD is a production unit, receiving raw materials, and dispatching finished goods after performing various manufacturing processes. The job entails technical knowledge and management of process elements including inventory management, exception management, quality control, and people management.
But such a complex Department is currently managed entirely manually!
The Covid-19 pandemic gave a big fillip to digitisation of services provided by Hospitals. It is now considered normal to make an appointment and consult a doctor via virtual meeting platforms, to receive and send diagnostic reports or receive prescriptions on WhatsApp. Almost all patient facing processes now have a digital interface. The same cannot be said about intra-departmental processes that support all patient facing services.
The CSSD is a key example where, forget digitisation, even access to a computer system is missing! A CSSD may have one computer and a printer, mostly placed in the Manager’s cabin or in a corner of the packing area. Access to the internet is mostly curtailed, of course with good intention, but detrimental effect! Most CSSDs are also located in the basement, which means no access to WIFI network of the Hospital.
Consider some of the key challenges:
- Inventory management is at the heart of surgical instrument workflow. However hand-written registers contain data but provide no insight!
- What is the proportion of slow-moving inventory?
- Is the inventory level commensurate with surgical / patient volume? Are we facing frequent stockouts?
- Are we losing expensive instruments to pilferage, damage or even theft?
- Each surgical device or surgical instrument has its own associated Instructions for Use (IFUs). While most are straight-forward and intuitive, some complex devices require complicated assembly / disassembly, have specialised cleaning and disinfection protocols and inspection guidelines. How does a CSSD technician access these IFUs?
- Safe Recall management is a key requirement of all Hospital Infection Control. When an autoclave batch fails the biological indicator test, how does the CSSD staff trace back contents of the failed batch?
- Each surgical pack has a Use-by Date after which the pack needs re-sterilisation. How does the CSSD estimate and collate the volume of re-sterilisation each day? This often involves reading hand-written expiry dates off packs one by one.
The rapid adoption of information and communication technologies are changing the face of supply chains the world over and India is no exception. We routinely see delivery executives using hand-held devices to scan barcodes when delivering a package or, neighbourhood ‘kiranas’ using systems to find customers, service them and collect payments.
These ubiquitous technologies can change the face of CSSD and can empower the CSSD manager to contribute to intelligent supply chain optimisations:
These are the key components of the digitisation project for CSSD.
It is not enough to merely place a computer inside the CSSD. The CSSD technician is always hard-pressed for time in meeting the demands of critical departments such as Operation Theatres. Any system adoption will only happen if access to the computer system does not involve a long walk away from the workstation or waiting in queue for a turn to access it!
Ergonomic design principles should guide the number and placement of computer workstations in the department:
The Receiving Area of the CSSD is the entry point of all contaminated material into department. Space is always a constraint, with the existence of large carts, trays and washing equipment such as ultrasonic baths, washer disinfectors etc. The area also has a hot and humid work environment.
The key requirement is to accurately record receipt of materials and separate material based on priority, cleaning process and surgical schedule. Staff might also need access to IFUs or “how-to” videos for handling complex devices. The key design considerations are:
- All-in-one computer system with a small footprint and large display with touch controls
- Industrial grade rather than consumer grade peripherals, suitable for the harsh environment and ruggedised use
- Adequate number of workstations depending on the size of the receiving area, and the volume of work handled. Staff should have quick access to the system with minimum straying away from core work area
The Clean Area is where items are inspected and packed for sterilisation. Staff needs access to packing checklists and loads, device IFUs for proper quality checks, scanners for identifying items correctly, label printing, printing of forms, etc. This area is also the most critical area in the workflow since any errors during the packing process impact caregivers and patients
directly.
The key design considerations are:
- Adequate workstations at each packing table, so that users do not have to queue for resolving their query
- Convenient access to printers for printing labels and forms
- The CSSD layout also has separate packing areas for Single Use Devices, linen, and dressing material. The possibility of sharing computer systems should be studied based on volume estimates and schedule of activities.
The Sterilisation Station is the area where the sterilisation equipment is placed. Recording of batches and loads is a key requirement for this area. The key design considerations are:
- The Sterilisation Area is often close to or part of the packing area and can have a shared workstation, however, this depends on the load and prioritisation of activities.
- Integration of Sterilizers and Washer Disinfectors with a workflow system to document cycles, and record Time, Temperature and Pressure parameters from the Sterilizer.
The Sterile Area is where sterile goods are stored and issued to various user departments. Here the critical aspects are inventory management, expiry management, transaction recording and recalls management. The key design considerations are:
- A separate workstation since the sterile area is a limited access area
- Label scanners are a key requirement to correctly identify items being handed over.
As volume and complexity of surgeries and devices increase, the task of the CSSD Manager will become more and more complicated. The classical approach of adding more people to manage the tasks is fraught with inefficiencies that will only increase. Digitisation is no longer a “Good-to-have,” it’s a “Must Have” and the missing link in CSSDs today.
