Hospital Management course Session V

1. HOSPITAL MANAGEMENT
SESSION V- CSSD, OT, ICU
THURSDAY, FEBRUARY 16, 2012
DR. ASHFAQ AHMED BHUTTO
MBBS, MBA, MAS, DCPS, MRCGP, (PHD)

2. CSSD
CENTRAL STERILE SUPPLY DEPARTMENT
2

3. THE CENTRAL STERILIZATION & SUPPLY
DEPARTMENT (CSSD)
• Mission of CSSD (customer oriented)
• Timely delivery of sterile goods
• Quality (according to European Standards – EN)
• Efficiency (line process)
• Activities of the CSSD (Spaulding)
• Cleaning
• Disinfection of semi- / non critical items (mucosa – non
intact skin contact)
• Sterilization of critical items (high risk for infection)
• Supply of sterile materials
3

4. AIMS
• To provide sterilized material from a central
department where sterilizing process is
carried out under properly controlled
conditions
• To alleviate the burden of work of the
nursing personnel, there by enabling them
to devote more of their time to patient
care .
4

5. THE CENTRAL STERILIZATION & SUPPLY
DEPARTMENT (CSSD)
• Building Blocks
• Well trained employees
• Information System
• Planning system: information available OR CSSD
• Tracing: set level / instrument level
• Standardization
• Processes: SOP
• Equipment and Instruments
• Infrastructure
• (External) Validation
• “Just in time” delivery – pull from the OR
5

6. DECONTAMINATION LIFE CYCLE
6

7. FLOW PROCESS : CSSD
7

8. MAIN RESULTS OF THE ANALYSIS
8

9. DEFINITION OF CSSD
Service, with in the hospital, catering for the
sterile supplies to all departments , both to
specialized units as well as general wards and
OPDs.
9

10. HISTORY
• 1928 – American College Of Surgeons –
CSSD.
• 1942 – World War II .Cairo, British SDS Unit .
• 1955 – Cambridge Military Hospital – Regular
CSSD in UK.
• 1965 – First CSSD in India – Safadarajan
Hospital
10

11. ADVANTAGES
1. Bacteriological safe sterilization.
2. Less expensive.
3. Elimination of unsound practices & establishment
of standard procedures.
4. Assurance of adequate supply of sterile products
immediately and constantly available for
sometime as well as emergency use.
5. Conservation of trained staff.
6. Better quality control
7. Better good of material flow
8. Prolonged life by proper care of equipment
11

12. ITEMS COMMONLY HANDLED BY
CSSD STORES
1. Syringes
2. Procedure Sets
3. Lumbar puncture ; sternal puncture ;
venesection ; paracentesis ; aspiration ;
catheterization ; tracheotomy ; suturing ;
dressing ; biopsy ; incision & drainage ;
aortography ; cardiac resuscitation ; etc
4. Needles
5. Gloves
12

13. ITEMS COMMONLY HANDLED BY
CSSD STORES-CONT.
6. I.V. Fluids.
7. Treatment Trays.
8. O.T Instruments.
9. O.T. Linen
10. Infusion Fluids for Renal Dialysis.
11. At times LINEN. (other than O.T)
NB: Diet , drugs , bedpans & urinals are not
included by convention .
13

14. PLANNING A CSSD DEPT
1. Physical Planning.
2. Functional Planning.
3. Personnel Planning.
4. Equipment Planning.
5. Financial Planning.
6. Quality Control.
7. Preventive Maintenance.
14

15. PHYSICAL PLNG
1. Location & Grouping .
2. Lay Out & Space Reqts.
3. Fixturtes & Furniture .
15

16. AREA REQUIREMENT
RULE OF THE THUMB-ROUGHLY – 10 SQFT / BED
ADM & STORAGE (UNSTERILE) 21² M
AREA SCALES FOR
RECEPTION,CLEANING,CHECKING, 35² M HOSPITALS > 700
ASSEMBLY & PACKING AREA BEDS
AUTOCLAVING AREA 28 ² M
STERILE STORAGE & ISSUE AREA 28 ² M
TOTAL 1,320 ² ft
16

17. EQUIPMENT'S IN CSSD
1. Jet water cleaning gadgets.
2. Ultrasonic Washers
3. Glove sharpener
4. Needle sharpener.
5. Gas, Chemical or steam autoclaves.
6. Testing apparatus for efficiency of
sterilization
17

18. OTHERS
1. Maintenance & Repair Equipment
2. Adequate number of cabins & Furniture
3. Telephone or intercom.
4. Adequate no of syringes & procedure sets.
18

19. NUMBER OF SETS/SYRINGES
A - 1½ Daily requirement in use at wards / Departments
B - 1 Daily requirement in sterile state at CSSD, ready for issue
C - 1 Daily requirement being processed at CSSD
D – 1to 1½ Daily requirement held in reserve – dome in CSSD,
some in medical stores
Total: 4.5 to 5 times of the daily requirement
19

20. TYPES OF STERILIZATION
TECHNIQUES
1. Dry Heat
2. Steam High Pressure-Autoclaves operated by Gas,
K.oil or Electricity ( Flash, Pulse)
3. Ethylene Oxide Sterilization.
4. Chemical Sterilization.
5. Radiation Sterilization.
6. Infra Red Radiation – Syringes
7. Ultra Violet Radiation – Decontamination of Air
8. Ionizing Radiation / Gamma Radiation
20

21. 21

22. CHEMICAL
• CIDEX
• A Glutaraldehyde derivative is most effective as it destroys
spores too.
• ETHYLENE OXIDE (ETO)
• Quite effective against spores too.
• Useful for delicate instruments and item which can’t be
immersed in liquids
• - Low Boiling Point (10 degree C)
• - Prolonged Aeration
• - Highly Expensive / Explosive / Toxic
22

23. STERILISATION
• It is a process of freeing an article from
all living organisms including bacteria
,fungal spores and viruses.
• A material is pronounced sterile if it
achieves 99.99% kill of bacterial spores.
23

24. STEAM STERILATION
- Water  Saturated  Wet vapor  Dry saturated
Vapor  Super Heated Vapor / Steam
- Steam with <0.95 Dryness Factor is not useful for
Sterilization.
- Superheated Steam acts like Dry Hot Air only . (
Strength Of Steam is its Latent Heat)
24

25. OPERATION OF POROUS LOAD
STERILIZERS
The operating cycle of a porous load sterilizer
normally has five stages.
a. Air removal
b. Steam admission
c. Holding time
d. Drying
e. Air admission
25

26. ADVANTAGES OF STEAM
STERILISATION
1. Rapid heating & penetration of loads.
2. Destruction of all forms of microbial life
3. No residual toxicity.
4. No damage to supplies being sterilised.
5. Easy Quality Control
6. Economical & Reliable
7. This method is unsuitable for heat sensitive
and non- permeable material
26

27. MODE OF ACTION.
Dry Heat  Oxidation
Steam  Denaturation = Coagulation of Proteins
Sterilization Time Pressure Temperature (
(Holding Time + Safety (PSI) C )
Time)
2' + 1′ = 3' 30 134
8' + 2' = 10' 20 126
12' + 3' = 15' 15 121
27

28. TYPES OF AUTO CLAVING MACHINES
1. Downward Displacement
2. Vacuum Assisted.
3. Pulsed Steam Dilution
28

29. TESTS FOR EFFICENCY OF
STERILISATION
1. Specially treated paper strip.
2. Pressure sensitive tape to be fixed to the
final fold
3. Brown indicator tubes - (very expensive)
4. Biological. Green strip containing bacteria
(Color must change to black)
29

30. TESTS FOR EFFICENCY OF
STERILISATION
5. Cellophane wrapped tablet containing
6. Lactose - 75%
7. Starch - 24%
8. Magnesium Trisilicate – 1% (Tablet turns
brown during autoclaving)
9. Microbiological examination of finished
products.
10. Thermo - couples .
30

31. RADIATION STERILISATION
1. Dose - 2.5 Mega Rhontgen; Source – Cobalt-60
/Caesium – 137/ Electron Beam (generated by
linear accelerator)
2. Reliable, can penetrate all types of packing.
Large & diverse shaped articles can be sterilised.
No residual radio activity at 2.5 mega rhontgens.
3. Glass becomes dark, cotton looses tensile
property, food gets undesirable flavor. Not
practicable in hospitals
31

32. STAFFING :CSSD
SUPERVISORS (sister/male ward masters) 4
STAFF NURSES 5
TECHNICIANS (ORA) 6
ATTENDANTS 24
SWEEPER 4
CLERK 1
Total 44
CENTRALISED SUPPLY (RULE OF THUMB 2 PER 100 BEDS)
32

33. DISTRIBUTION SYSTEMS :
1. Regular issue of one day’s requirement.
2. Clean for dirty exchange.
3. Milk round system (topping up
predetermined stock level)
4. As on required basis. (Grocery system)
33

34. OPERATION OF DRY-HEAT
STERILIZERS
A dry-heat sterilizer will typically have the following
operating cycle.
A. Heating-up. Hot air is heated electrically and circulated
through the chamber.
B. The plateau period starts when the chamber temperature,
recorded by a sensor located in the part of the chamber
known to be the slowest to heat up, reaches the sterilization
temperature.
A. In the first part of this period, the equilibration time, all parts of the
load attain the sterilization temperature.
B. The moment when the temperature in all parts of the load finally
attains the sterilization temperature marks the end of the
equilibration time and the start of the holding time.
C. Cooling. The load is cooled by circulating cold, filtered air
through the chamber or through a jacket.
34

35. SERVICE OBJECTIVES
• Decontaminate to a level compatible with the intended use
of the product.
• Minimize adventitious contamination through control of the
environment, personnel and materials.
• Produce items that are fit for their intended purpose within the
specified life-time.
• Within the constraints of the service, provide products in a
timely manner.
• Ensure the location and facilities provide a high quality and
cost-effective service.
• Provide adequate labelling and instructions for safe use.
• Ensure the process is validated, controlled and monitored.
• Hold appropriate documentation/records to demonstrate
compliance.
35

36. CSSD IS DIVIDE INTO 5 MAIN
AREAS
• Decontamination
• Assembly and processing
• Sterilization
• Sterile storage and
• Distribution
36

37. CSSD FUNCTIONING
37

38. CSSD
layout:
single-
door
sterilizer
configurati
on and
flow chart
38

39. CSSD
layout:
double-door
sterilizer
configuratio
n and flow
chart
39

40. INDIVIDUAL SPACES WITHIN AN SSD
• Entrance areas • Sterilizer loading area
• Contaminated returns lobby • Sterilizer plant room
• Contaminated returns holding area • Unloading/cooling area
• Wash room: gowning room/area • Processed products store
• Wash room • Despatch area
• Wash room: domestic services room • Manager’s office
• IAP gowning room • Deputy manager’s office
• Inspection, assembly and packing • Office(s): general
(IAP) room • Staff room
• IAP domestic services room • Training room
• Materials store • Staff changing/WC/shower room
• Materials transfer room • General areas: domestic services
• Packed product transfer facility room
• General waste disposal/laundry
returns
• Test equipment and data room.
40

41. 41

42. 42

43. OPERATION THEATERS
43

44. GENERAL PLANNING
PRINCIPLES-OTS
1.The internal layout based on the traffic flow within the
department
A. A single corridor to carry patients, staff, clean and used equipment
(suitably bagged) to and from the operating theatres and out
through a separate theatre exit. OR
B. Clean and dirty streams of traffic can be segregated.
2.Rooms arranged in continuous progression from the entrance
through zones of increasing sterility.
3.Staff within the department should be able to move from one
clean area to another without passing through unprotected or
unclean areas.
4.Patients, staff and services should enter through the same
control point.
5.Air for air-conditioning should move from cleanest to less clean
areas.
6.The operating theatre should be at positive pressure in relation 44
to adjacent rooms.
7.Reduced air movement – to reduce airborne infections

45. CONSIDERATIONS AT THE INITIAL
PLANNING STAGE
• Consider modular construction methods.
• Infection control teams should be consulted from
the outset of any new-build or renovation project
and should remain integral planning team members
throughout.
45

46. CONSIDERATIONS AT THE INITIAL
PLANNING STAGE
 Bench-top sterilizers in theatres are replaced by central
sterile service department (CSSD).
 Operating departments should ensure that they have
adequate stocks of surgical instruments to overcome
issues associated with dropped instruments.
 Some surgical operations necessitate exposing patients in
ways that they find distressing and embarrassing.
Protecting their dignity is therefore a critical function.
 A number of measures can be taken to minimise the
invasion of privacy including the design and fitting of the
building.
46

47. CONSIDERATIONS AT THE INITIAL
PLANNING STAGE
• An increasing number of patients undergo surgery
without a general anaesthetic, remaining conscious
throughout the entire procedure, and hence
remain aware of their surroundings even in the
operating theatre.
• Designers should aim to create an environment that
is conducive to making patients feel at ease and
giving them confidence, thus aiding the healing
process. At the same time it should facilitate
efficient working, and contribute to staff morale. 47

48. NATURAL LIGHTING
 Natural light is of particular importance to the wellbeing of
patients and staff. All surgical facilities, where possible, should
have natural daylight directly from windows, or by means of
borrowed light from windows across corridors. Lack of natural
light is one of the most common complaints made by staff
about their working environment.
 Where natural light is not available through conventional
means, consideration should be given to using recently-
developed technology, which allows natural light to be
ducted to internal rooms even in multi-storey buildings.
 Where possible, the following areas within the department
should have natural light:
 operating theatres;
 recovery unit;
 staff rest room. 48

49. CAPACITY PLANNING- LATER
• A separate sheet is provided to you to presents a
method of determining the number of operating
theatres that will be needed for a new, or for a
reconstructed, operating department for in-
patients. The method also provides an estimate of
unused capacity.
• In the calculations, using the model of eight
theatres, it is assumed that at least one theatre will
be reserved for emergencies.
• One session (half a day) per theatre each week
should be reserved for planned preventive
maintenance and cleaning.
49

50. OT ZONING
Outermost protective zone:
Generally at level of hospital cleanliness
 Patient waiting,
 OT reception,
 Staff change rooms and toilets,
 Trolley-bay,
 Patient traffic area,
 Cafeteria. Positive air-pressure relative to rest of hosp. maintained.
Clean zone: Higher Positive air-pressure level than outer zone.
Aseptic or sterile zone: Higher Positive air-pressure relative to other
areas so as to exclude entry of air from any other areas.
Communicate with dirty corridor or disposal area through inter-
lock hatch system.
Disposal zone: less air press than sterile zone. Instruments temporary
stored/collected before being sent for sterilization. 50

51. SITING CONSIDERATIONS
• Ideally, all the operating theatres in the hospital should
be in one location with one recovery unit. This helps with
flexibility of operation, efficiency of staffing, clinical
governance and safe management of emergencies.
• Operating theatre departments that admit patients for
emergency surgery should have the following services
on the hospital site as a minimum standard
• emergency care (A&E department);
• 24-hour access to imaging, including scanning;
• critical care;
• laboratory services (pathology);
• in-patient acute services; and
• orthopaedic/trauma services.
51

52. SITING CONSIDERATIONS
52

53. ANAESTHETIC ROOMS
• In the UK it is common practice for each operating
theatre to have its own anaesthetic room.
• It is common practice in the US, in some European
countries and Pakistan to exclude the traditional
anaesthetic room from the operating department
layout. Patients are prepared for their operation in
the operating theatre. This has been taken up in the
UK by a small number of trusts.
53

54. PREPARATION ROOMS
• One preparation room for each theatre
• Where the laying-up of trolleys is undertaken under
the protection of the ultra-clean ventilation canopy
it is imperative that the ultra-clean ventilation
system is operating at full duty
• Under no circumstances should two or more
operating theatres share a single preparation room,
due to the potential risk of cross-infection via the
ventilation airflows.
54

55. RECOVERY UNITS OR PACU (POST
ANAESTHETIC CARE UNIT)
• Most patients are transferred from the operating
theatre to the recovery unit.
• This will affect the size of each space, as it should
be large enough to accommodate an adult bed
with additional space for the monitoring equipment
and to ensure immediate access for staff in case of
emergency
• Provision is required for quiet dark spaces (using
adjustable lighting levels) in which patients can
recover from specific anaesthetics
• The need to segregate male from female patients
should also be considered. 55

56. ACCOMMODATION IN AN EIGHT ROOM THEATER
• Integral
• communications base;
• eight operating theatres
• eight anaesthetic rooms;
• patient support facilities (admissions lounge with
changing facilities, waiting area, interview room);
• recovery unit with 16 bed spaces (with associated
ancillary accommodation);
• staff support facilities (porters’ base, changing facilities,
rest rooms, reporting room);
• storage areas (equipment, bulk store);
• disposal areas (dirty utility, disposal hold, housekeeping
room).
• Integral or co-located
• education and training facilities;
• anaesthetic department;
• administrative offices. 56

57. FUNCTIONAL RELATIONSHIPS
57

58. TRAFFIC FLOW IN OPERATING
DEPARTMENT
58

59. A LAPORSCOPY SETUP IN OT
59

60. SCRUB SINK WITH NON-TOUCH TAPS
60

61. RECOVERY AREA
61

62. THEATRE CONTROL PANEL
62

63. MEDICAL GAS AND EQUIPMENT
• 12 socket-outlets and • anaesthetic machine
connection to the UPS/IPS located on anaesthetic
systems medical supply unit only;
• PAS theatre record • flat-screen monitor and
system networked to recording system for
hospital mainframe; patient records;
• 1 oxygen outlet; • 2 infusion pumps;
• 1 nitrous oxide outlet; • 3 syringe pumps;
• 1 medical air outlet; • blood warmer;
• 1 surgical air outlet; • feeding pump
• 2 medical vacuum
points;
• anaesthetic gas
scavenging points.
63

64. CEILING MOUNTED PENDANTS
64

65. MEDICAL GAS OUTLETS
65

66. DOORS WITHIN THE OPERATING
SUITE
Doors through which beds or trolleys
will pass should be wide enough to
allow easy passage with attachments,
including sterile drapes. It should be
possible for them to stand in the open
position. All doors should be fitted
with vision panels capable of being
obscured, and have laser-proof
blinds. All doors
should close quietly
66

67. EXIT BAY
67

68. STAFF ACCOMMODATION
• Theatre staff work in stressful situations every day. The
provision of well-designed facilities will be a morale
boaster.
• There are five main categories of staff facilities, all of
which should be designated clearly as non-clinical
areas:
• rest facilities;
• changing rooms and associated facilities;
• office accommodation;
• facilities for education and training;
• storage.
• Areas 1 and 2 should be located within the operating
department.
68

69. STORAGE ROOM FOR SUPPLIES AND
EQUIPMENT
69

70. CEILING
• A minimum clear height of 3000 mm between the
finished floor level and ceiling is required to allow
unrestricted adjustment of the operating luminaire and
other ceiling-mounted equipment.
• The building structure should be capable of supporting
the loads generated when the ceiling mounted medical
supply unit is installed.
• Modular ceilings are not acceptable in the operating
theatre. The ceiling in the operating theatre should also
be able to withstand an occasional wash and have a
completely sealed finish to maintain microbiological
standards.
70

71. FLOOR
• Carpets are not acceptable anywhere in an operating
department. Floors should be able to withstand harsh
treatment, including:
• the rolling loads of heavy mobile equipment;
• frequent spillages with subsequent “mopping-up”; and
• regular hard cleaning.
• Flooring should also have the following
• characteristics:
• hygienic finishes;
• slip-resistant;
• continuous;
• smooth;
• impervious;
• sealed joints;
• easily cleanable;
• wear-resistant
71

72. VENTILATION STRATEGY
The ventilation system in the operating theatre suite has four
main functions:
• dilution of bacterial contamination;
• control of air movement within the theatre suite such that
the transfer of airborne bacteria from less clean to cleaner
areas is minimized;
• control of space temperature and humidity;
• to assist in the removal and dilution of waste anaesthetic
gases.
Room Pressure To
Preparation room Positive Theater
Theater Positive All other rooms
excluding
preparation room
Anesthetist room Positive Corridor
Disposal Negative Corridor 72
Corridors Neutral

73. AIR HANDLING UNIT
73

74. OT LAYOUT
74

75. INTENSIVE CARE UNIT
(ICU)
75

76. ICU INTRODUCTION
• The intensive care unit is for critically ill patients who need
constant medical attention and highly specialized equipment,
to control bleeding, to support breathing, to control toxaemia
and to prevent shock. They come either from the recovery
room of the operating theatre, from wards or from the
admitting Section of the hospital.
• This unit requires many engineering services, in the form of
controlled environment, medical gases, compressed air and
power sources. As these requirements are very similar to those
in the operating department, it is advisable to locate the
intensive care unit adjacent to the recovery room of, the
operating department. If engineering provisions are to be
centralized for economy, the recovery room and the intensive
care unit should be on either side of the support area.
76

77. SHOULD EVERY HOSPITAL HAVE
ICU?
• The number of beds in ICU should correspond to approximately 1-2%
of the total beds in the hospital. In small hospital of 50-100 beds, this
would mean only one or two beds.
• This number would not warrant the provision of an intensive care unit.
Such a unit should contain no fewer than six beds in order to justify
the highly sophisticated equipment and highly specialized
manpower involved.
If so what alternatives to considered?
• A patient who requires long-term intensive care should be referred to
a higher-level hospital.
• Intensive care beds can be provided within the recovery room of the
operating department.
• Patients who are highly dependent on nursing can be given beds or
rooms very close to the nurses' station in the ward, sustained with a
portable oxygen tank and monitoring equipment.
77

78. DEPARTMENTAL RELATIONSHIPS
78

79. FUNCTIONAL RELATIONSHIPS
79

80. ENTRANCE
80

81. 81

82. 82

83. 83

84. 84

85. 85

86. BED SPACE LAY OUT PLAN
86

87. THANK YOU
87