The Central Sterile Supply Department (CSSD) is the service responsible for receiving, storing, processing, distributing and controlling the professional supplies and equipment (both sterile and non-sterile) for all user unit of hospital for the care and safety of patient under strict quality control. It is an important facility of hospital that supplies sterile instruments and materials for dressing and procedures carried out in ward and other departments of hospital [1].

The CSSD department of IGMC came into functioning in the year 1966 with the start of the hospital [2,3].

Aim 

To provide the safe and sterile supplies to all the user unit of hospital

Functions

• To provide efficient, economic and uniform source of sterile supply for the care and treatment of sick

• To assist purchase department for decision making and selection of goods

• To assist management of hospital in standardization of good

• Cleaning, packaging, labelling and dating of material

• To supply equipment to highly specialized units

• To educate students, nurse and ancillary persons

• To save nursing time at nursing station

• To participate effectively in Hospital infection control committee

• Applied research for improvement techniques

Location 

CSSD is centrally located which is easily accessible to other departments like Operation Theatres, ICU etc. It is located on the Ground floor of the C- wing of the hospital. It is located just adjacent to the Surgical ICU and the Operation Theatres are just below the CSSD.

Clean Corridor

There is a long corridor of 30×8 ft. after the entrance to the CSS department. There is no unilateral flow of direction according to the guidelines. CSSD was constructed in 1966 with the start of the hospital and the layout of the department is traditional. The uniform flow in the department is not taken care of. No separation of dirty to clean to sterile area are kept into consideration. This can cause a high risk of hospital acquired infection. There is space for separate receiving and delivery area.

Receiving Area 

It is of Size - 10×8 ft. On the left side of the corridor there is an entrance to the receiving area and the dispatch area of the department. The receiving and the delivery area is common which is not ideal according to the guidelines.

Sterile Area

It is of Size - 50×20 ft. The sterile area consists of the autoclaves, transportation trolleys, electricity control units of the machinery, etc. There are 6 autoclave machines in the department with their control units on the front wall. There are two packing steel shelves at the end of the sterile area which is not in compliance to the guidelines. There is an exit door from the sterile area to the outside area of the hospital. The doors and windows are of old traditional style made up of wood which could be a major source of infection. There are 4 exhaust fans at the outer end of the sterile area.

Supervisor Room 

It is of Size - 10×10 ft. There is a supervisor room just adjacent to the sterile area. The technician supervisors keep a check on the functionality of the department and maintain records in the register.

Toilet 

It is of Size - 6×10 ft. There is a toilet adjacent to the supervisor’s room for the staff.

Drainage System 

There are separate drainage pipes for the water and steam evacuation from the autoclaves. The steam pipes run upwards leading to an exhaust fan at the end. The water drainage pipes run underground and lead to a common drainage pipe.

Organizational Structure 

• CSSD Superintendent: There is one CSSD Superintendent in the department for managing the functioning of the department. He keeps the records of maintenance of the equipment. He supervises the working of the department and controls the manpower of the CSSD. Work shift- between 9 a.m-5 p.m

• CSSD Supervisors: There are two senior technicians working as supervisors in the department. They supervise the sterility, packaging and supply related protocols of the department. They supervise supportive staff which includes hospital attendants and sanitary workers. Working Shift between 8 am-2 pm and 2 pm-8 pm. They work in rotational shifts

• Supportive Staff: There are three hospital attendants and two sanitary workers in the department. They work in two rotational shifts i.e., 8 am-2 pm and 2 pm-8 pm

• Hospital attendants: They are trained in handling various equipment, autoclave and machinery involved in the sterilization process. They keep record of the articles received from various departments, time of receiving the articles. They also keep a record of what articles they have put in which autoclave and note the timings

• Sanitary workers: They are responsible for keeping the department clean. They work in two rotational shifts.

• The interns from technician courses and OT also come on regular basis for their training in weekly rotations

Theatre Sterile Supply Cleaning, Package and Storage System 

• Cleaning: The cleaning of the used equipment is not done in the CSSD. The various departments/wards clean the equipment and the articles in their department’s washing area itself. The linen from the departments is sent to the housekeeping department for washing.

• Package: There is no separate packing area in the CSSD. The supportive staff of various departments cleans and pack the equipment, linen, dressing material in their department. After packing the articles in drums or trays, the supportive staff of the various departments drops them in CSSD for sterilization

• Storage: The storage of the sterilized material is done in the storage room of the CSSD. The record of the material is maintained with name of the clinical department by the technician supervisors so as to prevent misplacing of the articles

Decontamination Process of the Major Equipments such as ITU and Ventilators

Decontamination of major equipment is not performed by the CSSD. Hospital attendants of the various department are responsible for sterilization of these equipment. Decontamination of the equipment is done by disinfectant solution, spirit swabs and fumigators, etc on a regular basis.

CSSD Delivery System

The supportive staff of various departments receives the sterilized material from the CSS Department. The hospital attendants in the department keeps a note of the amount of material received and to be delivered to avoid misplacing of the items. Record register of the receiving and delivery of the material is maintained by the technician of the department.

Sterilization Alternative for Heat Labile Equipments

There is one plasma sterilizer available in the Cardiac OT in which heat labile equipment are sterilized. Other departments rely on the same sterilizer for the sterilization of heat labile equipment. ETO treatment is done for some of the equipment which cannot tolerate high temperatures.

Sterilization Process: Steam Sterilization, Sterilization by Ethylene Oxide Gas (ETO), Sterilization by Gas 

• Steam Sterilization: Steam sterilization is achieved by exposing the items to be sterilized with saturated steam under pressure. Steam enhances the ability of heat to kill microorganisms by reducing the time and temperature required to denature or coagulate proteins in the microorganisms. The autoclave works on the principle of moist heat sterilization where steam under pressure is used to sterilize the material present inside the chamber. The high pressure increases the boiling point of water and thus helps achieve a higher temperature for sterilization. Water usually boils at 100°C under normal atmospheric pressure (760 mm of Hg); however, the boiling point of water increases if the pressure is to be increased. Similarly, the high pressure also facilitates the rapid penetration of heat into deeper parts of the material and moisture present in the steam causes the coagulation of proteins causing an irreversible loss of function and activity of microbes. This principle is employed in an autoclave where the water boils at 121°C at the pressure of 15 psi or 775 mm of Hg. When this steam comes in contact on the surface, it kills the microbes by giving off latent heat. The condensed liquid ensures the moist killing of the microbes. Once the sterilization phase is completed (which depends on the level of contamination of material inside), the pressure is released from the inside of the chamber through the whistle. The pressure inside the chamber is then restored back to ambient pressure while the components inside remain hot for some time

• Sterilization by Ethylene Oxide Gas: Chambers are heated by electrical resistance or by steam contained in a jacket surrounding the chamber. The sterilization cycle usually consists of four phases: conditioning, exposure (sterilizing), exhaust and air purge. In the conditioning phase, a vacuum pump or water ejector withdraws air from the chamber and allows controlled amounts of moisture or steam to be released by a chamber heating system, thereby raising the relative humidity. Typically, after humidification, EtO or an EtO/diluent mixture is injected into the chamber, initiating the exposure phase. In the exhaust phase, the vacuum system vents the gas from the chamber to an exhaust drain and/or directly to the outside. Most sterilizers purge the chamber with fresh, filtered air to prevent gas buildup from items degassing in the chamber. The sterilized contents are then aerated to remove EtO residue either within the sterilizer chamber or in a separate aerator

• Use of Ethylene oxide sterilizer: Ethylene oxide sterilizers are used to sterilize heat- and moisture- sensitive devices that would be damaged by pure steam or liquid chemical sterilization, including most plastic or rubber products (e.g., catheters, resuscitation bags, anaesthesia masks, most fibre optic instruments)

Sterilization by Plasma 

Plasma sterilizes by a process called oxidation. The plasma produces a chemical reaction in which all microorganisms are deactivated. The high heat turns the molecules of the hydrogen peroxide into free radicals, which are highly unstable. In their “search” for returning to a stable state, they latch on to the microorganisms in the load-thus effectively destroying the components of their cells, such as enzymes, nucleic acids and DNA.

Use of Plasma Sterilization 

Common applications for hydrogen peroxide plasma sterilizers include sterilizing the following:

• Non-hollow loads, such as electrocautery instruments, dopplers, laser probes, defibrillator paddles, thermometers, Ophthalmic lenses and harmonic cables

• Hollow loads, such as Laryngoscopes and their blades, shaver handpieces, fibre optic light cables and surgical power drills

• Endoscopes, such as rigid and flexible endoscopes

Use of Autoclave

There is total six autoclaves in the CSS department:

• Steri Fully Automatic Steam Sterilized (YORCO)-1 Size-1200×700 mm

• Pressure Sterilizer Horizontal Rectangular type (SURGICON)-2 Size-750×110 mm

• Pressure Sterilizer Horizontal Cylindrical type (YORCO)-2 Size-600×400 mm

• Horizontal High-Pressure Sterilizer (PRECISION)-1 Size-150×80 mm

Control Unit 

There is a Control Unit on the opposite wall of the autoclaves in the sterile area. The Hospital Attendants has been trained to operate autoclaves under the supervision of technicians.

Handling, Collection and Transportation of Soiled Material

• Handling: They are handling approximately 300-350 kg of linen, 100 kg of dressing material and 200-250 packs of surgical equipment on a daily basis. CSSD does not have the provision of ETO or plasma sterilization. This is handled by the individual departments on their own. The Cardiology department has the provision of plasma sterilization for the heat labile materials

• Collection: The Hospital Attendants from individual departments drops the soiled material to the CSS department. The Hospital Attendants of various departments are responsible for dropping andcollection of their departments’ material. CSSD keeps the record of the materials delivered for sterilization, department name and the name of the person who is delivering and collecting the material in their record registers

• Transportation: The transportation of the soiled and sterile material to the CSSD is done by steel trolleys. No separate dumbwaiters are provided for the transportation of material. The soiled and the sterile materials are transported in the common lifts used by the patients. The transportation is done by the hospital attendants of various departments and they have to sign the register on delivering and collecting of the material to prevent misplacing

Method to be Adopted for Reusable Materials Prior to Disinfection or Sterilization, Chemical Disinfection

Chemical Methods of Sterilization

• Gaseous sterilization: Ethylene oxide and Formaldehyde

• Liquid sterilization: Hydrogen Peroxide-35-90% concentration and Hypochlorite-0.5% concentration

Chemical and Biological Indicators

Both chemical and biological indicators are used in the department for the routine monitoring of the steam sterilization process. Autoclave tape which is a chemical indicator is put on the packed drum before putting it in the autoclave. If the tape turns from white to black, it implies that the sterilization is performed at an optimum temperature. A biological indicator i.e., bacteria spore vial is used to ensure proper sterilization process. The Geobacillus stearothermophilus (GS) vial is purple colored initially. After the process of sterilization, the vial turns yellow thereby ensuring proper sterilization.

Dress Code of CSSD Staff

The supportive staff working in the sterile area of the CSSD was not following any dress code. The staff mentioned that there is no provision of changing room in the CSSD, so they don’t change into sterile scrubs while changing. The staff was not wearing head caps, gloves, shoe caps and gown while handling the sterile equipment.

Staff Training Methods

Technician students, OT interns and nursing students get practical exposure in the department. They observe the functioning of the department and help in maintaining the records of the department. The CSSD supervisors give training to these students about the functioning of the equipment. When a new machinery is installed in the department, the staff is given training about the handling, working and maintenance of the machine. This training is usually conducted by the technician of the brand of machinery installed.

Maintenance and Repair of Equipment

The maintenance and repair of the equipment is done by the regular mechanics of the hospital. On a major fault in machinery or replacement of any parts of the machine, mechanics are called from Chandigarh for repair. A record book is maintained in which the date of service, repair, maintenance is mentioned of each machinery.

List of Books and Formats Available

• Department material receiving and delivery record register

• Regular equipment operating record register 

• Articles and equipment overbook

• Equipment maintenance and repair record register

• Attendance book of staff

• Complaint register

An alarming rate of hospital acquired infections (HAI) in Indian hospitals has highlighted the importance of CSSD. Despite all measures and advancements in technology, hospital acquired infections remain a challenge in healthcare. In this scenario, Tertiary care Institutes like IGMC giving more importance to CSSD and properly plan to provide all the departments of a hospital with guaranteed sterile equipment ready and available for immediate use in patient care-a step towards the prevention of hospital acquired infections (HAI’s).

1. Kumar, Sunil, et al. “Study of Quality Control in Central Sterile Supply Department of a Tertiary Care Teaching Hospital.” Investigations in Gynecology Research & Women’s Health, vol. 4, no. 2, 2021, p. 000584. https://doi.org/10. 33140/IGRWH.04.02.08.

2. Banu, A., and G.T. Subhas. “Central Sterile Supply Department - Need of the Hour.” Journal of Public Health Medical Research, vol. 1, no. 2, 2013, pp. 58-62.

3. Jing, W., et al. “Central Sterile Supply Department (CSSD) Management Quality Sensitive Index Constructed by Management Mode under the Guidance of Key Point Control Theory and Its Effect on CSSD Management Quality: A Retrospective Study.” Annals of Palliative Medicine, vol. 11, no. 6, 2022, pp. 2050-2060. https://doi.org/10.21037/ apm-22-629.