CSSD Holds The Key To Control HAI

Though CSSD forms the backbone of a hospital, ensuring infection-free surgical instruments and hence operations, it is yet to take off in India, observes Shardul Nautiyal.

A bleeding travel agent Ramu Ketkar was rushed to the hospital after he met with a fatal road accident. Doctors realised that if Ramu’s life was to be saved, he had to undergo immediate surgery on his broken left leg. With not a moment to lose, doctors alerted the Central Sterile Services Department (CSSD) manager of the hospital for requisite supplies of surgical instruments, dressing and draping material required in the OT. The CSSD manager in turn pressed the CSSD staff into service for delivering the requirements on time. The operation was completed successfully and today Ramu lives a normal life.

The likes of Ramu are saved everyday because of co-ordinated effort orchestrated by CSSD personnel in sterilising equipment, dressing and draping material to ensuring the availability of required sterile goods and instruments in OTs and wards to monitoring the workflow of this supply.

"By having separate CSSD, we can decrease the cost of sterilisers through centralisation of equipment in one department" - Ganesh Devadiga, Head, CSSD, Dr L H Hiranandani Hospital	"One of the major impediments for CSSDs not taking off with Indian hospitals is that there is no uniform accreditation system in place" - R G Sawant, Head, CSSD, Tata Memorial Hospital

Why should a hospital have CSSD?

Since setting up of the first CSSD in India at Jaslok Hospital in July, 1973 by Nalini Gaithonde, much has changed. Today, nurses, who lacked expertise in sterilisation procedures, leading to manual errors, no longer carry out sterilisation.

The scope of CSSD has enlarged from that of a department, which was similar to an autoclave sterilisation unit to encompass hospital infection control and stands for a dedicated workflow of sterile supplies and goods. Ideally, CSSD is an independent department with facilities to receive, clean, pack, disinfect, sterilise, store and distribute instruments (both multi-use and single-use device), as per well-delineated protocols and standardised procedures. The workload in a CSSD varies from hospital to hospital.

But in this age of cost cutting and space constraints, why have a separate department for sterilisation? Says Ganesh Devadiga, Head, CSSD, Dr L H Hiranandani Hospital, Mumbai, “By having separate CSSD, we can decrease the cost of sterilisers through centralisation of equipment in one department. Besides, this would also ensure that a dedicated staff can effectively monitor the sterilisation process as per the Standard Operative Procedures (SOPs).”

Says Vishwanath Kokitkar, CSSD and Laundry In- Charge, S L Raheja Hospital, “CSSD requires technical competency, which implies that the department controls all the activities of asset management pertaining to selective procurement of general and specialised surgical instruments and other inventory. CSSD in Indian hospitals imply quality service with scarce resources.” An alarming rate of Hospital Acquired Infections (HAI) in Indian hospitals has highlighted the importance of CSSD. If the CSSD is not in place, there is a definite surge in HAI. Explains Gopinathan T, Manager, CSSD, Amrita Institute of Medical Sciences (AIMS), Kochi, “The rise in incidence of nosocomial infection with corresponding increase in mortality, length of stay and cost can be brought down by establishing a good CSSD set-up.”

Informs Rekha Batura, Asst Medical Superindentent, Tata Memorial Hospital (TMH), Mumbai, “CSSD was generally looked upon as an essential part of an OT as the use of sterile supplies in a hospital is maximum to the OT. However, all that has changed. CSSD is considered today, integral to the function of Out Patient Department (OPDs), wards and other departments.”

The most important factor in running a smooth CSSD is good workflow. According to Ruth Edwards, CSSD In-Charge, Christian Medical College (CMC), Vellore, “To maintain good workflow, sterilisation process implies proper functioning and co-ordination between four zones: dirty area, which is also called as washing area, assembly area or packing area, sterile area and finally the sterile goods storing area.” Manned with a staff of around 80 personnel, the CSSD at the 2700-bed CMC consistently upgrades itself to deal with huge patient flow. Hospitals, mainly government ones, which are built without a CSSD, end up in poor planning and design, when the department is incorporated as an afterthought.

Reality Check

Though new technology has arrived, CSSD is yet to take off in India. In Mumbai, only 30 per cent of big hospitals (with 100 or more beds) have CSSD. The infrastructure for CSSD is poor in other districts of Maharashtra. However, analysts say that 85 per cent of most of the upcoming hospitals have a well-equipped CSSD.

Says R G Sawant, Head, CSSD, TMH, “One of the major impediments for CSSDs not taking off with Indian hospitals is that there is no uniform accreditation system in place. The gulf between the concept and implementation of CSSD can also be attributed to paucity of funds and lack of expertise in this area.”

Besides, hospital management does not accord importance to CSSD as they consider it as a non-profitable venture. Setting up a CSSD costs Rs three lakh to five lakh for a small hospital and around one crore for a big hospital.

Latest trend

Today, the upcoming advanced sterilisers are all computer controlled with a backup that leaves no margin for error. Achieving cent per cent sterilisation is the biggest challenge. “Theoretically, one can achieve 100 per cent sterilisation, but practically achievement of true sterilisation is a factor that follows the law of chance. Hence, achieving 99.99 per cent log kill of bacterial spores is considered good enough to pronounce the material as sterile. There is a specific protocol called the spaulding classification, which is followed for sterilising or disinfecting critical and semi-critical items,” informs Sawant.

The latest trends in the West are to use single use devices (SUDs) and automated equipment in CSSD. A single use device is a medical device to be used only on one patient for a single procedure. The high cost of SUDs and CSSD automation is, however, a constraint in developing countries like India, informs Dr Umesh Gupta , Co-ordinator, Division of Innovations in Clinical Excellence, Indraprastha Apollo Hospitals, New Delhi.

Indian hospitals are generally known to clean, disinfect or sterilising SUDs. “This practice should be adopted only very judiciously to reduce disposable medical waste and costs, without compromising on patient safety,” remarks Dr Batura.

Another trend, very new in Indian hospitals is that the hospitals don’t outsource sterilisation of equipment to third party processors. US-FDA ensures that the hospitals, companies and third party processors, reprocessing of SUDs should meet the same standards used by the original manufacturer.

Some Indian hospitals even prefer using indigenous sterilisers for cost cutting. Says Vishwanath Kokitkar, CSSD and Laundry In-Charge, S L Raheja Hospital, Mumbai, “Maintenance cost is the most important factor governing the success of the CSSD. Therefore, Raheja Hospital has installed indigenous equipment. This will lead to optimisation on quality and cost-effectivity, with the cost of a CSSD running in crores.”

The trend for small size Indian hospitals is to use an indigenous autoclave, which may be difficult to monitor or validate. The automated steriliser on the other hand is equipped with quality control checks, gives an automated and digital output in the form of print-outs and graphs. There is a constant effort to bring out safer sterilisers and make them more reliable. Experts say that sterilisation involves a lot of variables, hence the effort should be to minimise the chances of an instrument not getting sterile, which can be a hazard to the patient.

What plagues CSSD?

Lack of training courses in CSSD plague this speciality.“Purdue University based in the US offers a six-months distance learning programme for Technicians and one year course for Supervisors in CSSD operations,” informs Chandrasekhar Ghadi, CSSD In-Charge, Jaslok Hospital, Mumbai. CMC, Vellore has introduced a one- year diploma course for autoclave operators, after HSC. Faced with lack of trained personnel, hospitals either depute OT attendants, who are not well qualified for the job to sterilise or train fresh B.Sc graduates for the job.

Suggestions

Though the government has laid down guidelines to protect sweepers and waste collectors, there is sheer absence of guidelines or a regulatory body to check if instruments used are properly sterilised. A ray of hope is perhaps the Government’s initiative in laying down guidelines for hospital hygiene.

In the absence of guidelines, according to Gauri Bhatia, manager, CSSD, Lilavati Hospital, Mumbai, “Most of the private and corporate hospitals (specially an Infection Control Committee) has its own protocols.” Experts recommend that hospitals should follow international guidelines like Association for the Advancement of Medical Instrumentation (AAMI), International Association of Healthcare Central Service Material Management (IAHCSMM), International Standard Organisation(ISO), Occupational Safety and Health Administration (OSHA), World Health Organisation (WHO) and Centre for Disease Control (CDC).

The Hospital Sterile Services Association (HSSA), which is an association of 40 hospitals and small nursing homes in Mumbai, is also working on laying down CSSD guidelines and encouraging hospitals to adopt latest technologies and techniques.

While hospitals are waking up to the importance of CSSD and the need for guidelines, some experts suggest that CSSD should also be installed at primary health centres. While that may take some time, what hospitals can start with is by taking the initiative to train their staff in using latest technologies and using available international guidelines in CSSD.

shardulnautiyal@rediffmail.com