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  • 1. INTERNSHIP PROJECT ONDEPARTMENT OF CENTRAL STERILESUPPLY DEPARTMENTDEPARTMENT OF MHA & M, DMIMS, SAWANGIWARDHAPREPARED BYDR MANJIT RAMESHBARSAGADEMHA & M 1ST YEAR
  • 2. TABLE OF CONTENTSR NO PARTICULARS PAGE NO1 INFORMATION ABOUT SHRIKRISHNA HRUDALAYA & CRITICALCARE HOSPITAL2 AIMS & OBJECTIVES3 METHODOLOGY4 INTRODUCTION OF CSSD5 FUNCTION OF CSSD6 LOCATION OF CSSD7 STAFF8 WORK FLOW AND SPACE PLANING9 RECEVING AREA
  • 3. TABLE OF CONTENTSR NO PARTICULARS PAGE NO10 CLEANING AREA11 PACKING AREA12 STERILIZING AREA13 STORE14 DISTRUBATION AREA15 SUPPORT AREA IN CSSD16 CSSD AT SHRI KRISHNA HRUDALAYAAND CRITICAL CARE1718
  • 4. INFORMATION ABOUT SHRI KRISHNAHRUDALAYA & CRITICAL CARE HOSPITAL INTRODUCTION PATIENT CAREEVERY YEAR NEARLY 6,000 PATIENTS VISIT THE CLINICS FROM MAHARASHTRA, MADHYAPRADESH, CHHATTISGARH, AND ANDHRA PRADESH AND FROM NEIGHBORING COUNTRIES. MANYPATIENTS ARE REFERRED TO US AFTER RECEIVING TREATMENT INITIALLY AT THEIR NATIVEPLACE. THIS GROUP OF PATIENTS IS REFERRED FOR VARIOUS INVESTIGATIONS LIKE 2DECHOCARDIOGRAM, TREAD MILL TEST, HEMATOLOGICAL AND BIOCHEMICAL INVESTIGATIONS,CARDIAC CATHETERIZATION (FOR CORONARY, VASCULAR AND VALVULAR INTERVENTIONS).EQUAL NUMBER OF SUCH PATIENTS ARRIVES DIRECTLY TO US. WE HAVE BEEN DOINGINTERVENTIONS FOR ALL ACUTE CORONARY EVENTS LIKE UNSTABLE ANGINA AND MYOCARDIALINFARCTION (HEART ATTACK). WE PERFORM MORE THAN 100 CORONARY ANGIOGRAPHIESEVERY MONTH. SIGNIFICANT POPULATION UNDERGOES PRIMARY ANGIOPLASTY FOR HEARTATTACK AND WE HAVE A SIZABLE NUMBER OF PATIENTS COMING TO US FOR PLANNED PCI(PERCUTANEOUS INTERVENTIONS). WE HAVE INFRASTRUCTURE, EQUIPMENTS AND STAFF TOMANAGE ALL TYPE OF CARDIAC EMERGENCIES LIKE HEART FAILURE, PULMONARY EDEMA,PULMONARY EMBOLISM, ETC. OUR SURGICAL UNIT HAS TEAM O CARDIOVASCULAR SURGEON,PERFUSIONIST, CARDIAC ANESTHETIST AND SUPPORTIVE STAFF. AT SHRIKRISHNAHRUDAYALAYA, EVIDENCE BASED MEDICINE IS THE KEYSTONE OF OUR ENDEAVOUR. APARTFROM THE PATIENT CARE AND SERVICE, CLINICAL RESEARCH PROGRAMMES AND RANDOMIZEDTRIALS CONTRIBUTE INCREASINGLY TO IMPROVED DELIVERY OF CARE AND HIGHESTSTANDARDS OF WORK ETHICS. THE STRATEGIES FOR PREVENTION, EARLY DIAGNOSIS,TREATMENT MANAGEMENT AND REHABILITATION HAVE BEEN ESTABLISHED IN ACOMPREHENSIVE AND MULTIDISCIPLINARY APPROACH FOR A TOTAL CARDIAC CAREPROGRAMME.
  • 5. INFORMATION ABOUT SHRI KRISHNAHRUDALAYA & CRITICAL CAREHOSPITAL PATIENT CARE MANY ADVANCES HAVE TAKEN PLACE IN EVERY SPECIALTY. IN CARDIOVASCULARSURGERY, CONCEPTS HAVE CHANGED TAKING INTO ACCOUNT THE ADVANCESAND AVAILABILITY OF NEWER TECHNIQUES. WE HAVE TRAINED ANDEXPERIENCED CVTS TO TACKLE CHALLENGING AND COMPLEX CARDIOVASCULARSURGERIES. THERE IS SPECIALIZED UNIT FOR INTERVENTIONAL RADIOLOGY FORPATIENTS WITH STROKE, ARTERIAL AND VENOUS THROMBO EMBOLISM ANDDISEASES OF THE VESSELS LIKE VARICOSE VEINS. SUPPORTIVE CARE IN THEFORM OF TOTAL REHABILITATION AND COUNSELING OF PATIENTS IS WIDELYRECOGNIZED TO BE VERY IMPORTANT ASPECTS OF THERAPY. EXCELLENT WORKHAS BEEN CARRIED OUT IN AREAS OF REHABILITATION, PHYSIOTHERAPY,OCCUPATIONAL THERAPY, PSYCHOLOGY AND MEDICAL SOCIAL WORK.
  • 6. INFORMATION ABOUT SHRI KRISHNAHRUDALAYA & CRITICAL CAREHOSPITAL ABOUT HOSPITAL SHRIKRISHNA HRUDAYALAYA AND CRITICAL CARE CENTRE WAS STARTED BY DR. MAHESHFULWANI IN 1998, WITH THE VISION OF SERVING THE SUFFERING MANKIND AND TO BRINGTHE LATEST MEDICAL TECHNOLOGY AVAILABLE TO CATER THE CHALLENGES IN THE FIELDOF CARDIOVASCULAR DISEASES. INITIALLY IT WAS RELATIVELY SMALL UNIT PROVIDINGSERVICES IN CARDIOLOGY. IT FLOURISHED IN FEBRUARY 2008 AND TOOK A SHAPE OFHUGE CENTRE PROVIDING TERTIARY CARE FOR ‘EVERY ALIMENT IN CARDIOLOGY ANDCRITICAL CARE’ UNDER ONE ROOF. THE HOSPITAL IS WELL EQUIPPED WITH ROUND THE CLOCK CARDIAC CATHETERIZATIONLAB. IN ADDITION, 24 HOURS’ AVAILABILITY OF SKILLED STAFF AND INTERVENTIONALCARDIOLOGISTS. THE CRITICAL CARE UNIT HAS FULL TIME INTENSIVISTS AND CRITICALCARE PHYSICIANS TO TAKE CARE OF CRITICALLY ILL PATIENTS. WE ARE RECOGNIZED BY,EMPANELLED ON VARIOUS LEADING CORPORATE, SEMI-GOVERNMENT AND GOVERNMENTORGANIZATIONS, AND ARE ENGAGED IN PROVIDING ROUND THE CLOCK SERVICE AT MUCHAFFORDABLE COST TO EVERYONE.
  • 7. INFORMATION ABOUT SHRI KRISHNAHRUDALAYA & CRITICAL CARE HOSPITAL SERVICES KEEPING PACE WITH RECENT ADVANCES IN INFORMATIONTECHNOLOGY, SHRIKRISHNA HRUDAYALAYA AND CRITICALCARE CENTRE IS ALSO A TECHNO-SAVVY AND HASESTABLISHED A COMPREHENSIVE COMPUTERIZATION OFMEDICAL PRESCRIPTIONS, RECORDS, MATERIAL MANAGEMENTAND ADMINISTRATION. THE PATIENTS CAN COMMUNICATE ONTELEPHONE ROUND THE CLOCK AND QUALIFIED DOCTORS TOGET THEIR QUERIES ANSWERED WILL ATTEND THEM. THERE ISFACILITY OF SENDING THE REPORTS/ DATA VIA FAX OR E MAIL IFYOU WISH TO REVIEW YOUR RECORDS PRIOR TO VISIT HOSPITALOR ANYTIME YOU FEEL IT IS URGENT TO MAKE A DECISIONABOUT THE TREATMENT MANAGEMENT.
  • 8. INFORMATION ABOUT SHRI KRISHNAHRUDALAYA & CRITICAL CARE HOSPITAL SPECALITY SERVICES ECHOCARDIOGRAPHY INTERVENTIONAL CARDIOLOGY CARDIAC CATHETERIZATION ANDINTERVENTIONAL CARDIOLOGY CARDIAC AND VASCULAR SURGERY PREVENTION AND REHABILITATION
  • 9. INFORMATION ABOUT SHRI KRISHNAHRUDALAYA & CRITICAL CARE HOSPITAL CORONARY ANGIOGRAPHY & ANGIOPLASTY BYPASS OPERATION 2D ECHO AND COLOUR DOPPLER BALOON VALVE TREATMENT FETAL ECHO ARRYTHMIA CLINIC ICCU COMPUTERISED TMT PACEMAKER HUT TEST 24 HOURS EMERGENCY CRITICAL CARE UNIT NEURO SURGERY ORTHO SURGERY TRAUMA CARE GENERAL SURGERY DIALYSIS 24 HOURS AMBULANCE
  • 10. INFORMATION ABOUT SHRI KRISHNAHRUDALAYA & CRITICAL CARE HOSPITAL CLINICAL RESEARCH EVERY MOLECULE HAS TO BE EXTENSIVELY SUBJECTED TO RESEARCH BEFORE IT ENTERSINTO THE MARKET ANY PARTICULAR DISEASE. CENTRAL ETHICS COMMITTEE CRITICALLYREVIEWS THE PROPOSED RESEARCH PROGRAMMES AND PROJECTS IN DETAIL ANDENSURES THAT THE RESEARCH EFFORTS ARE AT PAR WITH ICH-GCP GUIDELINES. ETHICSCOMMITTEE CONSISTING OF DOCTORS AND SCIENTIFIC OFFICERS, EXPERT MEMBERS INTHE FIELD OF MEDICINE, LAW AND SOCIAL SCIENCE CRITICALLY EVALUATE THE RESEARCHAND MEDICAL PRACTICES FOLLOWED IN THE HOSPITAL. A SEPARATE DATA MONITORINGAND SAFETY COMMITTEE, IN ADDITION, EVALUATE AND MONITORS ALL OFFICIALLYSANCTIONED INTRAMURAL RESEARCH PROGRAMMES. PATIENT’S SAFETY IS OF PRIMECONCERN FOR US WHILE CONDUCTING BIOMEDICAL RESEARCH. COMPLETED PROJECTS: PHASE III CLINICAL STUDY ENTITLED EFFICACY AND SAFETY OF INTRAVENOUSADMINISTRATION OF CONIVAPTAN HYDROCHLORIDE IN THE TREATMENT OF EUVOLEMICHYPONATREMIA - A MULTICENTRE, OPEN LABEL, NON-COMPARATIVE, PHASE III STUDY. A PHASE III, ACTIVE (WARFARIN) CONTROLLED, RANDOMIZED, DOUBLE-BLIND, PARALLELARM STUDY TO EVALUATE EFFICACY AND SAFETY OF APIXABAN IN PREVENTING STROKEAND SYSTEMIC EMBOLISM IN SUBJECTS WITH NONVALVULAR ATRIAL FIBRILLATION(ARISTOTLE: APIXABAN FOR REDUCTION IN STROKE AND OTHER THROMBOEMBOLICEVENTS IN ATRIAL FIBRILLATION)
  • 11. LOCATION SHRIKRISHNA HRUDAYALAYA AND CRITICAL CARE CENTER TIKEKAR ROAD, CONGRESS NAGAR SQUARE, OPP. NEW ENGLISH HIGH SCHOOL, DHANTOLI, NAGPUR - 440 012. TEL. NO. : +91-712-2444434, 2442136 FAX: +91-712-2440120 E-MAIL: INFO@SHRIKRISHNAHRUDAYALAYA.COM
  • 12. AIMTO STUDY THE PLANNING, ORGANISATIONAL STRUCTURE, MANAGEMENT,EVALUATION AND GIVE RECOMMENDATIONS IF ANY OF CENTRAL STERILESUPPLY DEPARTMENTOBJECTIVES•TO STUDY ORGANISATION AND WORKING OF CENTRALSTERILE SUPPLY DEPARTMENT.•TO SEE THE FACILITY AND SERVICES PROVIDED BY CENTRALSTERILE SUPPLY DEPARTMENT.•TO FIND OUT ANY NEED TO IMPROVE BASIC SERVICESPROVIDED BY CENTRAL STERILE SUPPLY DEPARTMENT.
  • 13. METHODOLOGY•AN OBSERVATIONAL STUDY WASCARRIED OUT IN CENTRAL STERILESUPPLY DEPARTMENT AT SHRI KRISHNAHRUDALAYA & CRITICAL CARE NAGPUR.•THE DATA HAS BEEN COLLETEDTHROUGH OBSERVATIONAL ANDINFORMAL DISCUSSION WITH DOCTORS,NURSES, PATIENTS & OTHER STAFFS.
  • 14. INTRODUCTION OF CSSD ENSURING A HIGH STANDARD OF STERILIZATION AND DISINFECTION TO MINIMIZE THE INCIDENCE OFHOSPITAL INFECTION HAS BEEN UPPERMOST IN THE MINDS OF CLINICIANS AS WELL AS HOSPITALADMINISTRATORS. STANDARDIZATION OF SURGICAL DRESSINGS, AND CENTRALIZING ALL SURGICALSUPPLIES FROM ONE POINT OF ORIGIN WERE NECESSITATED DURING THE SECOND WORD WAR BECAUSEOF THE REQUIREMENT OF A LARGE NUMBER OF CASUALTIES IN DIFFERENT THEATERS OF WAR. THECONCEPT OF A STERILE SUPPLY ORGANIZATION, IN THE FORM OF AN INDEPENDENT UNIT OR ONEATTACHED TO LARGE BASE HOSPITALS CAME INTO BEING. STERILIZATION ACTIVITIES IN A HOSPITAL AREBETTER CENTRALIZED IN ONE SINGLE DEPARTMENT FOR EFFICIENCY AND EFFECTIVENESS. THISDEPARTMENT, CALLED THE CENTRAL STERILE SUPPLY DEPARTMENT (CSSD) BECOMES RESPONSIBLE FORPROCESSING, STERILIZING AND DISPENSING OF ALMOST ALL ITEMS OF STERILE EQUIPMENT, SETS ANDDRESSINGS IN THE HOSPITAL. CENTRALIZATION OF STERILIZING ACTIVITIES IN ONE DEPARTMENT HASRESULTED IN MANY ADVANTAGES, THE CHIEF AMONG THESE ARE (I) IMPROVED EFFICIENCY, (II) STERILESUPPLIES AVAILABLE AT ALL TIMES OF THE DAY OR NIGHT, (III) ECONOMY OF TRAINED MANPOWER, (IV)STERILIZATION SAFETY AND (V) QUALITY CONTROL. THE OBJECTIVE OF ESTABLISHING A CENTRAL STERILE SUPPLY DEPARTMENT IS TO MAKE RELIABLYSTERILIZED ARTICLES AVAILABLE AT THE REQUIRED TIME AND PLACE FOR ANY AGREED PURPOSE IN THEHOSPITAL AS ECONOMICALLY AS POSSIBLE, HAVING REGARD TO THE NEED TO CONSERVE THE TIME OFUSERS [ESPECIALLY DOCTORS AND NURSES]. THE STERILE SUPPLY DEPARTMENT WITHIN A HOSPITALRECEIVES STORES, STERILIZES AND DISTRIBUTES TO ALL DEPARTMENTS INCLUDING THE WARDS,OUTPATIENT DEPARTMENT [OPD] AND OTHER SPECIAL UNITS SUCH AS OPERATING THEATRE [OT]. MAJORRESPONSIBILITIES OF CSSD INCLUDE PROCESSING AND STERILIZATION OF SYRINGES, RUBBER GOODS[CATHETERS, TUBING], SURGICAL INSTRUMENTS, TREATMENT TRAYS AND SETS, DRESSINGS ETC. IT ISRESPONSIBLE FOR ECONOMIC AND EFFECTIVE UTILIZATION OF EQUIPMENT RESOURCES OF THE HOSPITALUNDER CONTROLLED SUPERVISION. THE CSSD ALSO AIMS AT ASSUMING TOTAL RESPONSIBILITY FOR PROCESSING HOSPITAL ITEMS THEREBYASSURING THAT ALL OF THEM RECEIVE THE SAME DEGREE OF CLEANING AND STERILIZATION. IT ALSOCONTRIBUTES TO THE EDUCATIONAL PROGRAM WITHIN THE HOSPITAL RELATING TO INFECTION CONTROLAND DEVELOPS A COST-EFFECTIVE PROGRAM BY COST ANALYSIS OF PERSONNEL, SUPPLIES ANDEQUIPMENT.
  • 15. FUNCTIONS OF CSSD RECEIVING AND SORTING SOILED MATERIALS USED IN THE HOSPITAL. DETERMINING WHETHER THE ITEM SHOULD BE REUSED OR DISCARDED. CARRY OUT THE PROCESS OF DECONTAMINATION OR DISINFECTION PRIOR TOSTERILIZATION. CARRY OUT SPECIALIZED CLEANING OF EQUIPMENTS AND SUPPLIES. INSPECTING AND TESTING INSTRUMENTS, EQUIPMENTS AND LINEN. ASSEMBLING TREATMENTS TRAYS, INSTRUMENT SETS, LINEN PACKS, ETC. PACKING ALL MATERIALS FOR STERILIZATION. STERILIZING. LABELING AND DATING MATERIALS. STORING AND CONTROLLING INVENTORY. ISSUING AND DISTRIBUTING.
  • 16. LOCATION IN HOSPITALS WITH WELL-UTILIZED SURGICAL SERVICES, THEOPERATION THEATERS (OT) REQUIRES HUGE SUPPLIES OFSTERILE SURGICAL INSTRUMENTS AND STERILE LINEN ANDTHEY ARE THE MAJOR USERS OF CSSD. THE OTHER USERS OFCSSD INCLUDE WARDS, ICUS, EMERGENCY AND LABOR ROOMETC. THEREFORE THE LOCATION OF CSSD SHOULDPREFERABLY BE IN PROXIMITY TO OT AND SHOULD HAVE EASYACCESS TO OTHER USER DEPARTMENTS. IN SOME HOSPITALS,THE OT COMPLEX HAS ITS OWN STERILE SUPPLY UNIT WITHINOR JUST ADJACENT TO IT. THIS IS KNOWN AS THEATER STERILESUPPLY UNIT (TSSU). THE AUTOCLAVE MACHINES IN THE CSSDEMIT LOT OF HEAT SO THE FACILITY SHOULD HAVE AT LEASTONE SIDE EXPOSED TO OPEN SPACE. BECAUSE OF SHORTAGEOF SPACE, NOW A DAY’S MANY HOSPITALS ESTABLISH THECSSD IN THE BASEMENT. THE CSSD CAN BE CONNECTED TO OTCOMPLEX THROUGH SMALL ELEVATORS.
  • 17. STAFF THE STAFF IN CSSD COMPRISE OF TECHNICIANS WHO OPERATE THEAUTOCLAVE AND ETO MACHINES. ASSISTANTS WHO PERFORM THECLEANING AND PACKING, GAUGE CUTTING AND COTTON BALL MAKINGASSIST THEM. THERE MAY BE CLERKS OR STOREKEEPERS TO MANAGETHE INVENTORY AND STERILE STORES. ONE OR MORE HOUSEKEEPINGSTAFFS MAY BE REQUIRED. A MANAGER SUPERVISES THEM ALL. CSSD IN CHARGE/ MANAGER CSSD TECHNICIANS CSSD ASSISTANTS HOUSEKEEPING STAFF
  • 18. WORK FLOW AND SPACE PLANNING MAJOR ACTIVITIES IN A CSSD ARE: RECEIVING THE USED ITEMS FROM USER DEPARTMENTS CLEANING PACKING STERILIZING STORING (TEMPORARY) DISTRIBUTING TO USER DEPARTMENTS THESE ACTIVITIES ARE CARRIED OUT IN ABOVE SEQUENCE ANDEFFORTS ARE MADE TO MAINTAIN A UNI-DIRECTIONAL FLOW OFACTIVITIES SO THAT STERILE AND UNSTERILE ITEMS REMAINSEPARATE. ACCORDINGLY THE SPACE PROGRAMMING IS DONE. EACHAREA IS DESCRIBED BELOW:
  • 19. RECEIVING AREA USED ITEMS FROM VARIOUS DEPARTMENTS OF THE HOSPITAL ARESHIFTED TO CSSD FOR CLEANING AND STERILIZATION. IDEALLY THEITEMS THAT GET SOILED WITH BLOOD OR BODY FLUIDS SHOULD BEDECONTAMINATED WITH SODIUM HYPOCHLORITE SOLUTION IN THEUSER DEPARTMENTS ITSELF SO THAT THE STAFFS WHO HANDLETHESE ITEMS FOR TRANSPORTATION OR CLEANING ARE NOT EXPOSEDTO THE RISK OF CONTACTING INFECTIONS. AFTER DECONTAMINATION,THEY ARE SHIFTED TO CSSD. THE STAFF OF THE USER DEPARTMENTOR THROUGH CENTRALIZED STAFF CAN TRANSPORT THESE ITEMS TOCSSD EITHER. THE RECEIVING AREA OF CSSD SHOULD HAVE ACCESS TO OUTSIDETHROUGH A WINDOW WITH A COUNTER. THE ITEMS (ESPECIALLY FORINSTRUMENTS IN TRAYS) ARE COUNTED AND RECEIVED. THEREAFTERTHE INSTRUMENTS ARE INSPECTED AND BLUNT/ UNSUITABLEINSTRUMENTS ARE SEGREGATED/ DISCARDED. NECESSARY ENTRIESARE MADE FOR RECORDS. THEREAFTER THE ITEMS ARE SHIFTED TOCLEANING AREA.
  • 20. CLEANING AREA HERE THE INSTRUMENTS ARE WASHED EITHER MANUALLY OR IN MACHINES. FOR MANUAL,WASHING SINKS WITH WATER SUPPLY AND WORKING COUNTERS ARE ORGANIZED.DETERGENTS AND BRUSHES OF VARIOUS SIZES AND SHAPES ARE REQUIRED IN THIS AREA.ULTRASONIC WASHER IS A MACHINE USED FOR CLEANING SURGICAL INSTRUMENTS. ITCONVERTS HIGH FREQUENCY SOUND WAVES INTO MECHANICAL VIBRATION THATPRODUCES SMALL BUBBLES THAT BURST ON THE INTERNAL SURFACES OF INSTRUMENTSAND DISLODGE THE WASTE PARTICLES. TUNNEL WASHER IS HIGHLY SOPHISTICATED AND EXPANSIVE MACHINE THAT ALLOWSTOTALLY HAND-OFF PROCESSING. INSTRUMENTS IN PERFORATE OR MESH BOTTOM TRAYSCOMING FROM OPERATING ROOM OR OTHER DEPARTMENTS ARE PLACED INTO THE TUNNELWASHER WITHOUT ANY FURTHER HANDLING. THE INSTRUMENTS ARE SUBJECTED TOCYCLES WASHING, RINSING, ULTRASONIC CLEANING AND DRYING. MOST OF THE HOSPITALSCANNOT AFFORD THESE WASHERS. AFTER THE INSTRUMENTS ARE WASHED, THEY ARE DRIED IN OVEN DRYER AND SHIFTED TOPACKING AREA. IF USED ITEMS ARE NOT DECONTAMINATED IN USER DEPARTMENT THAN BLOOD/ BODYFLUID SOILED SHOULD BE DECONTAMINATED WITH SODIUM HYPOCHLORITE BEFOREHANDLING FURTHER.
  • 21. PACKING AREA CLEAN AND DRY INSTRUMENTS ARE PACKED BEFORE STERILIZATION SO THAT THEY ARENOT CONTAMINATED WHILE HANDLING AFTER THEY ARE STERILIZED. WORKING COUNTERSARE REQUIRED IN THIS AREA. MOST OF THE INSTRUMENTS ARE PACKED IN TRAYS (TRAYASSEMBLY) THAT ARE WRAPPED WITH DOUBLE LAYER OF COTTON CLOTH. PAPERENVELOPES ARE ALSO AVAILABLE FOR PACKING THE INSTRUMENTS. THESE ARE EQUALLYEFFECTIVE BUT EXPANSIVE. PLASTIC BAGS (ETO BAGS) ARE USED FOR PACKING THEITEMS FOR ETO STERILIZATION. THE PACKS ARE LABELED INDICATING DATE OFSTERILIZATION AND DATE OF EXPIRY (WHEREVER POSSIBLE). SEALING MACHINE IS USED FOR THE SEALING THE PLASTIC BAGS IN WHICH INSTRUMENTSARE PACKED. AFTER PACKING AND SEALING, THE INSTRUMENTS ARE SHIFTED FORSTERILIZATION. A LARGE QUANTITY OF COTTON BALLS AND GAUGE PIECES ARE USED IN VARIOUS PATIENTCARE AREAS AND ARE REQUIRED TO BE STERILIZED BEFORE USING THEM. TRADITIONALLYTHESE ARE PREPARED IN THE CSSD. CUTTING THE GAUGE IS VERY ARDUOUS JOB AND ISDONE WITH THE HELP OF GAUZE CUTTING MACHINE. DURING THE PROCESS OF GAUGECUTTING, THE COTTON FIBERS ARE DISPERSED IN THE AIR AND MAY GET SETTLED ON THESTERILIZED ITEMS SPOILING THEM. THEREFORE, A SEPARATE ROOM IS REQUIRED FORCUTTING THE GAUGE AND PREPARING COTTON BALLS ADJACENT TO THE PACKING AREA.
  • 22. STERILIZING AREA STERILIZATION IS DONE BY EITHER OF THE TWO METHODS IN CSSD: STEAM STERILIZATION BY AUTOCLAVES GAS STERILIZATION BY ETO (ETHYLENE OXIDE) MACHINES AUTOCLAVE: STEAM UNDER PRESSURE IS THE MOST COST-EFFECTIVE METHOD OF STERILIZATION, THEREFORE, MOSTCOMMONLY USED FOR STERILIZATION OF INSTRUMENTS AND LINEN IN HOSPITALS. “AUTOCLAVE” IS THE NAME OF THE MACHINETHAT GENERATES STEAM AT A TEMPERATURE OF 121 DEGREE CENTIGRADE UNDER 15 POUNDS OF PRESSURE. AN EXPOSURE OF20 MINUTES IS REQUIRED FOR STERILIZATION. BEFORE FEEDING THE STEAM, VACUUM IS GENERATED IN THE CHAMBER OF THEAUTOCLAVE SO THAT NO AIR POCKET REMAINS IN THE FOLDS OF LINEN AND THE STEAM IS DISTRIBUTED UNIFORMLY IN THECHAMBER.1. AUTOCLAVE IS AVAILABLE WITH SINGLE DOOR OR DOUBLE DOORS. DOUBLE DOOR AUTOCLAVES HAVE TWO DOORS ON TWOOPPOSITE SIDES AND HAVE THE ADVANTAGE OF MAINTAINING UNI-DIRECTIONAL MOVEMENT OF MATERIALS. THE UNSTERILEITEMS ARE FED INTO THE CHAMBER THROUGH ONE DOOR AND THE STERILIZED ITEMS ARE TAKEN OUT FROM THE OTHER DOOROF THE AUTOCLAVE.2. THE AUTOCLAVES OF DIFFERENT CAPACITIES ARE AVAILABLE- 1/2, 1, 2 TON ETC. AND CAN BE SELECTED DEPENDING ON THEWORK LOAD. ETO STERILIZER: THE ITEMS LIKE CARDIAC CATHETERS ARE THERMO SENSITIVE (DAMAGED BY HEAT) AND THEREFORE CANNOTBE STERILIZED BY STEAM. SUCH ITEMS ARE STERILIZED BY ETHYLENE OXIDE (ETO) GAS STERILIZATION. THE ETO IS ANEXPANSIVE AND TOXIC GAS. THE ITEMS THAT ARE TO BE STERILIZED ARE PLACED IN A CHAMBER THAT IS FILLED WITH ETO. AS ARESULT OF THE EXPOSURE TO THE GAS ALL ORGANISMS ATTACHED TO THE ITEM GET KILLED BUT THE ITEM GETS COATEDWITH GAS MOLECULES. IT IS ABSOLUTELY NECESSARY TO ENSURE THAT THESE ITEMS ARE MADE FREE OF GAS MOLECULESBEFORE USING THEM ON A PATIENT. THIS IS ACHIEVED BY SUBJECTING THE ITEMS TO FORCED VENTILATION. THE ENTIRE CYCLEOF STERILIZATION AND VENTILATION IS LONG AND MAY TAKE ABOUT 8- 12 HRS. FOR EACH CYCLE OF GAS STERILIZATION ONEETO CARTRIDGE IS REQUIRED THAT IS FIXED WITH THE MACHINE BEFORE STARTING THE CYCLE. FLASH STERILIZER: THIS IS A SPECIAL TYPE OF AUTOCLAVE THAT HAS A VERY SHORT STERILIZATION CYCLE OF ABOUT 3 - 5MINUTES BECAUSE OF ITS ABILITY TO RAISE THE TEMPERATURE TO 132 DEGREE CENTIGRADE. THE MACHINE IS GENERALLYKEPT IN THE OT. DURING THE OPERATIONS IF THERE IS URGENT A REQUIREMENT OF STERILIZING AN INSTRUMENT, IT IS DONEON FLASH STERILIZER.
  • 23.  STORE AFTER STERILIZATION, THE ITEMS ARETEMPORARILY STORED IN A CLEANSTORE (ON RACKS) FROM WHERE THEYARE DISTRIBUTED TO USERDEPARTMENTS
  • 24. DISTRIBUTION AREA IT SHOULD BE AWAY FROM THERECEIVING AREA AND MAY COMPRISE OF AWINDOW WITH COUNTER. IN MODERNHOSPITALS, THERE MAY BE A SEPARATE LIFTFOR TRANSPORTING THE STERILE MATERIALSTO USER DEPARTMENTS.
  • 25.  SUPPORT AREAS IN CSSD THE FOLLOWING SUPPORT AREAS WOULD BEREQUIRED IN A CSSD1. CSSD MANAGERS OFFICE2. WORKERS REST ROOM WITH LOCKERS AND TOILETFACILITY3. UNSTERILE STORES FOR COTTON, GAUGE, LINEN ANDINSTRUMENTS
  • 26.  QUALITY ASSURANCE IN ORDER TO ENSURE THE QUALITY OF STERILIZATION THE FOLLOWING MEASURES ARE TAKEN: ENSURE THE EQUIPMENT IS FIT I.E. IN AUTOCLAVE THE TEMPERATURE IS MAINTAINED AT 121 DEGREESCENTIGRADE, 15-POUND PRESSURE AND HOLDING TIME IS MINIMUM 20 MINUTES. MODERN MACHINESASSURE THAT AND ARE FITTED WITH GOOD QUALITY MONITORS. THEY PROVIDE PRINT OUTS OF READINGS.THE DOORS OF THE AUTOCLAVE DO NOT OPEN UNLESS THE CYCLE IS COMPLETE. BOWIE DICK’S TAPES ARE FIXED WITH EVERY PACK OF ITEMS TO BE STERILIZED. THIS TAPS CHANGES THECOLOR WHENEVER THE REQUIRED TEMPERATURE IS ATTAINED. AFTER A CYCLE, THE TAPES ARECHECKED FOR CHANGE OF COLOR. HOWEVER, THE CHANGE IN COLOR ONLY INDICATES THAT THESPECIFIC TEMPERATURE HAS BEEN ACHIEVED DURING THE CYCLE BUT CANNOT GUARANTEE THAT THEITEMS ARE STERILIZED. INDICATORS ARE ALSO AVAILABLE FOR CHECKING THE QUALITY OF ETOSTERILIZATION. PERIODICALLY BACTERIOLOGICAL TESTS ARE TO BE DONE. A CAPSULE CONTAINING BACILLUSSTEREOTHERMOPHILUS (FOR AUTOCLAVE) AND BACILLUS SUBTILIS (FOR ETO) ARE PUT ALONG WITH THELOAD. THESE BACTERIA ARE CONSIDERED MOST RESISTANT TO STEAM OR GAS RESPECTIVELY. AFTERTHE CYCLE IS OVER THESE CAPSULES ARE TESTED IN MICROBIOLOGY LAB FOR PRESENCE OF LIVEORGANISMS. IF THERE ARE NO LIVE ORGANISMS IN THE CAPSULES, IT INDICATES THE STERILIZATIONPROCESS WAS EFFECTIVE. THE STAFFS WHO WORK ESPECIALLY IN STERILIZATION AREA, STERILE STORE AND DISTRIBUTION AREASHOULD CHANGE SLIPPERS AND THEIR DRESS, AND WASH THEIR HANDS BEFORE RESUMING WORK.
  • 27. LIFE OF STERILIZED ITEMSTHE LIFE OF THE STERILE MATERIALS DEPENDS ONTHE QUALITY OF PACKING MATERIALS USED AND THESTATUS OF CLEANLINESS OF STORING AREA.GENERALLY, THE ITEMS STERILIZED BY STEAMAUTOCLAVE CAN BE USED FOR ONE WEEK AND ETOPACKS CAN BE USED FOR 6 MONTHS.
  • 28. HOSPITAL MANAGEMENTINFORMATION SYSTEMNO OF CYCLE PER EQUIPMENTWORKLOAD PER EQUIPMENT- NO OF PACKS PERCYCLEDEPARTMENT WISE UTILIZATIONCOST INCURRED ON STERILIZING ONE PACK ONAUTOCLAVE AND ETONO OF PACKS EXPIRED AND RE-STERILIZED
  • 29. ROLE OF CSSD MANAGER MAINTENANCE AND REPAIR OF EQUIPMENT INVENTORY MANAGEMENT OF SUPPLIES AND CONSUMABLE ENSURE QUALITY OF STERILIZATION ENSURE PROPER DISTRIBUTION AND TRANSPORT COST CONTROL MEASURE, TO ANALYZE AND REDUCE THE NUMBER OF CYCLE RECORD KEEPING AND DATA ANALYSIS OPTIMAL UTILIZATION OF MANPOWER AND EQUIPMENT MOTIVATION OF STAFF AND TRAINING INTER DEPARTMENTAL COORDINATION
  • 30. MATERIALS TO BE STERILIZED SOME OF THE TRAYS/ INSTRUMENTS USED FOR DIFFERENT PROCEDURES IN DIFFERENT AREA OF THE HOSPITAL ARE: OT INSTRUMENTS AND DRAPES GLOVES DRESSING SET/ TRAY SUTURE REMOVAL SET SUTURING SET CUT DOWN TRAY TRACHEOTOMY SET LUMBAR PUNCTURE SET BONE MARROW/ LIVER/ KIDNEY BIOPSY SET CVP SET BURN PACK INTRA COSTAL DRAINAGE (ICD) PROCEDURE SET OP SUPPLIES- SIMS SPECULUM, SPATULA, ENT SETS, PROCTOSCOPES, DENTAL INSTRUMENTS
  • 31. CSSD AT SHRI KRISHNA HRUDALAYA &CRITICAL CARELOCATION OF CSSD•CENTRAL STERILE SUPPLY DEPARTMENT IS SITUATED ON TERRACE OF THE HOSPITALSTAFF IN CSSD•CSSD INCHARGE - 1•CSSD TECHNICIAN - 1•INCHARGE OF CSSD – DR PIYUSH NAIDUINSTRUMENTS USED IN CSSD•AUTOCLAVE MACHINE – 2•ETO SERILIZER (ETHYLENE OXIDE STERILIZER) – 2•SEALING / PACKING MACHINE•WATER FILTER – 2
  • 32. LAYOUT OF CENTRAL STERILE SUPPLYDEPARTMENTENTRANCEETHYLENE OXIDE STERALIZER 1ENTRANCEAUTOCLAVEMACHINE 2AUTOCLAVEMACHINE 1ETHYLENE OXIDESTERALIZER 2SEALINGMACHINEWASHING AREASTERILE + PACKING AREAWASHING ROOMOPEN AREA OF TERRACE HAVINGROOF OF PLASTIC SHED
  • 33. CSSD CONSIST OF•CSSD CONSIST OF 2 ROOMSOPEN AREA OF TERRACE HAVING ROOF OF PLASTIC SHEDSTERILE + PACKING AREAWASHING ROOMOPEN AREA OF TERRACE HAVINGROOF OF PLASTIC SHED•IT CONSIST OF 2 AUTOCLAVE MACHINES•THESE AUTOCLAVE MACHINES ARE KEPT UNDER PLASTICSHED.
  • 34. STERILE AREA + PACKINGAREA•IT CONSIT OFETO STERILIZER MACHINE.SEALING MACHINE.RACKS FOR MAINTANANCE OF CSSD REGISTER.PACKING IS ALSO DONE IN THIS AREA.
  • 35. WASHING ROOM IT CONSIST OF ETO STERALIZER MACHINE WATER TAPS FOR CLEANING OF INSTRUMENTS, FORFLUSHING OF CATHERATER ETC TWO WATER FILTERS WHICH ARE CONNECTED TOTWO SEPARATE TANKS WHICH IS USED FORCATHERATER FLUSHING
  • 36. SHIFT OF CSSD STAFF CSSD INCHARGE – 2PM TO 11PM CSSD TECHNICIAN – 11AM TO 11PM
  • 37. LIST OF ITEMS & SPECIAL TRAY COMMONLY PROCESSED INCSSD INSTRUMENTS APPLIANCES DRESSINGS SPONGES OT LINEN SPECIAL PACKS GAUZE AND COTTON MATERIALS GLOVES BOWLS AND TRAYS
  • 38. REGISTERED MAINTAINED INCSSD AUTOCLAVE IN TIME – OUT TIME REGISTER ETHYLENE OXIDE STERILIZER IN TIME - OUT TIME REGISTER OT REGISTER CARDIAC OT REGISTER CCU + ICU REGISTER WARD REGISTER DUTY ROOSTER REGISTER
  • 39. PROCEDURE COLLECTION OF MATERIALS FROM VARIOUSDEPARTMENTSCSSDNURSINGUNITCAT LABOTOPDIPDLABOURROOM
  • 40. PROCEDURE RINSING: RINSING OF ARTICLES AFTER USE SHOULD NOT BE PERMITTED IN PATIENT CARE AREAS UNLESSCARRIED OUT BY A TRAINED MEMBER OF THE STAFF INSPECTION AND ASSEMBLY: EACH ITEM SHOULD BE INSPECTED FOR FUNCTIONALITY, DEFECTS, BREAKAGE ANDTHEN APPROPRIATELY ASSEMBLED CLEANING: ALL REUSABLE MEDICAL DEVICES SHOULD BE THOROUGHLY CLEANED PRIOR TO DISINFECTION ORSTERILIZATION. DRYING: ALL ARTICLES SHOULD BE DRIED APPROPRIATELY. PACKAGING: ARTICLES SHOULD PREFERABLY BE PACKED IN POROUS MATERIAL. LABELLING: EACH PACK SHOULD BE MARKED WITH NOMENCLATURE OF THE ARTICLE, CONTENTS OF THE PACK,INITIALS OF THE PERSON WHO PACKED IT, DATE AND INITIALS OF THE PERSON WHO CARRIED OUT THESTERILIZATION. STERILIZATION: THE OPERATION OF THE STERILIZER SHOULD BE ENTRUSTED TO A RESPONSIBLE AND FULLYTRAINED PERSON. IT SHOULD BE KEPT IN A STATE OF GOOD MAINTENANCE AND REPAIR. AFTER STERILIZATION, STERILE MATERIALE IS TAKEN TO STORES STORAGE: SHOULD BE PROPERLY MANAGED SEPARATELY FOR STERILE AND NON-STERILE STORES. FORSTERILE GOODS, CLEAN ROOM CONDITIONS SHOULD BE FOLLOWED. DISTRIBUTION: REFERS TO CLEAN AND DIRTY ARTICLES EXCHANGE SYSTEM. A PROGRAM SHOULD BEESTABLISHED FOR THE COLLECTION OF USED ITEMS FROM PATIENT CARE AREAS AND DISTRIBUTION OFSTERILIZED GOODS.
  • 41. STERILITY INDICATORS MECHANICAL INDICATORS: ARE MONITORING INSTRUMENTS WHICH RECORD TIME, TEMPERATURE,HUMIDITY AND PRESSURE DURING THE STERILIZATION CYCLE. CHEMICAL INDICATORS: ARE DEVICES WITH A SENSITIVE CHEMICAL OR DYE TO MONITOR ONE OR MOREPARAMETERS OF A STERILIZATION CYCLE. BIOLOGICAL INDICATORS: EMPLOY THE PRINCIPLE OF INHIBITION OF GROWTH OF MICROORGANISM OF HIGHRESISTANCE TO THE MODE OF STERILIZATION. SUBSEQUENT FAILURE OF GROWTH OF MICRO-ORGANISMSINDICATES ADEQUACY OF STERILIZATION. NO SINGLE METHOD IS CAPABLE OF MONITORING COMPLETELY ALL PARAMETERS NECESSARY FOR AFOOLPROOF STERILIZATION. RECORDING INSTRUMENTS ON THE AUTOCLAVE THAT GIVE A GRAPHIC RECORD OF TEMPERATURE,PRESSURE, ETC. CAN BE INSPECTED IMMEDIATELY AFTER A LOAD HAS BEEN AUTOCLAVED. IN ADDITION, CHEMICAL INDICATORS PLACED INSIDE CHANGE COLOR WHEN CONDITIONS NECESSARY FORSTERILIZATION HAVE BEEN MET. THESE ARE AVAILABLE AS TAPES AND STRIPES, AND ARE ATTACHED ORIMPLANTED INSIDE THE PACKING MATERIAL. THIS SHOULD BE SUPPLEMENTED WITH PERIODICAL USE OF BIOLOGICAL INDICATORS TO DETECT (WHICHMAY TAKE SEVERAL DAYS) FAILURE OF THE AUTOCLAVE. BIOLOGICAL INDICATORS SHOULD BE PLACED INTHE MOST INACCESSIBLE LOCATION IN THE LOAD AND THEN CULTURED. THEY PROVIDE POSITIVEASSURANCE, ALBEIT RETROSPECTIVELY, THAT EACH PACKAGE HAS BEEN SUBJECTED TO PROPERSTERILIZING CONDITIONS.
  • 42. TOTAL TIME REQUIRED AUTOCLAVE – 45 TO 50 MIN ETO STERILIZER – 11 TO 12 HOURS
  • 43. OBSERVATION CSSD IS SITUATED ON TERRACE OF HOSPITAL. CSSD HAS TWO ROOMS STERILE + PACKING ROOM AND WASHING ROOM PLASTIC BAGS ARE USED TO BRING THE UNSTERILED MATERIAL FIRE EXTINGUISHERS ARE NOT INSTALLED. ONLY 1 STAFF WORKING IN CSSD STERILE + PACKING ROOM AREA 13*13 SQ FT WASHING ROOM AREA 13*10 SQ FT AUTO CLAVE SIGNAL LOCK & ETO SIGNAL LOCK USED TO INDICATE THAT MATERIAL ISSTERILISED MASK, HEAD CAP ARE USED BY CSSD TECHNISIAN FOR SAFTEY AFTER STERILISATION STERILE MATERIAL IS TAKEN TO STORE
  • 44. RECOMMANDATION PACKING ROOM, STERILE ROOM SHOULD BE SEPRATE. AN ETO IS A TOXIC GAS. BREATHING APPARATUS FOR EMERGENCIES MUST BE STORED INAN,EASILY ACCESSIBLE PLACE NEAR ETO AREA. USE OF EXHAUST SYSTEM TO EXHAUST GAS TO OUTSIDE, ALARMS TO ALERT IN CASE OF LEAK SPILL OF GAS. FIRE EXTINGUISHER SHOULD BE INSTALLED STAFF SHOULD BE INCREASED IN CSSD STERILE SUPPLIES AND PACKS AND CONTAMINATED ARTICLES SHOULD NEVER BE CARRIEDON THE SAME TROLLEY OR BY THE SAME STAFF. ELECTRICAL WIRES SHOULD BE PROPERLY INSTALLED AND ELECTRICAL MAIN SWITCHSHOULD BE INSTALLED OUTSIDE CSSD
  • 45. RECOMMANDATION THERE SHOULD BE SEPRATE ROOM FOR GAUGE CUTTING & MAKING COTTONBALLS. SEPRATE SLIPPERS SHOULD BE USED IN CSSD CSSD SHOULD BE SHIFTED FROM TERRACE CLEANING SHOULD BE PROPER IN CSSD ONE ATTENDANT SHOULD BE THERE IN CSSD TO BRING UNSTERILISEDMATERIAL FROM ALL DEPARTMENT TROLLEY SHOULD BE USED TO BRING UNSTERILISED MATERIAL
  • 46. THANKYOU