Dr.

Ram Manohar Lohia

Combined Hospital , Lucknow
Quality Operating
rocess
Document No :
RML/CSSD/01
Manual of Operations
CSSD
Date of Issue :
15/1/2008
Service Name :
CSSD
Operational olic!
Date Created : 15-01-2008
Approved By :
Chief Medical Superintendent
Name :
Signature :
Reviewed By :
Incharge CSSD
Name :
Signature :
Issued By :
Director
Name :
Signature :
Responsibility of pdating :
Incharge CSSD
Name :
Signature :
a"e of Contents:
Sl#Or$er articulars
Manual of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
rocess
Document No :
RML/CSSD/01
Manual of Operations
CSSD
Date of Issue :
15/1/2008
!
urpose
"
#cope
C
Responsibility
D
olicy
$.%eneral Considerations
&.%eneral Cleaning o' the Department
(.%eneration o' )tems to #terili*e
%# urpose + ,he purpose o' the Central #terile #upply Department is to make reliably sterili*ed
articles a-ailable at the re.uired time and place 'or any agreed purpose in the Hospital as
economically as possible, ha-ing regard to the need to conser-e the time o' users.
,he ob/ecti-es o' the department are+
Manual of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
rocess
Document No :
RML/CSSD/01
Manual of Operations
CSSD
Date of Issue :
15/1/2008
,o pro-ide sterili*ed material 'rom a central department where sterili*ing practice is
conducted under conditions, which are controlled, thereby contributing to a reduction in
the incidence o' hospital in'ection.
,o take some o' the work o' the 0ursing sta'' so that they can de-ote more time to their
patients.
,o a-oid duplication o' costly e.uipment1s, which may be in're.uently used.
,o maintain record o' e''ecti-eness o' cleaning, disin'ection and sterili*ation process.
,o monitor and en'orce controls necessary to pre-ent cross in'ection according to in'ection
control policy.
,o maintain an in-entory o' supplies and e.uipment.
,o stay updated regarding de-elopments in the 'ield in the interest o' e''iciency, economy,
accuracy and pro-ision o' better patient care.
,o pro-ide a sa'e en-ironment 'or the patients and sta''.
&# Scope + )t is a centrali*ed department catering to the sterili*ation need o' the entire hospital.
C# Responsi'ilit!: Incharge Nurse
D# olic!:
1# (eneral Consi$eration
a# Dress Co$e+
!ll sta'' o' the Central #terile #upply Department is re.uired to 'ollow a strict dress code, no sta'' is
allowed to enter the department with the normal clothes. rior to the entry o' the sta'' to the
department, each an e-ery sta'' o' the Central sterile #upply department is re.uired to change into
appropriate departmental dress code with the re.uired personal protecti-e e.uipments.
'# Receipt an$ Issue of ac)s+
Receipt o' items 'rom -arious point o' generation + 2rom 3.44 am to $.44 pm.
)ssue o' sterile packs 'rom the C##D + 2rom (.44 pm to 5.44 pm.
Howe-er in departments like O,, )C6, 7mergency Department etc are e8empted 'rom the abo-e
mentioned time dimensions since it is di''icult to restrict their acti-ity within speci'ic time limit due to
the emergency nature o' care pro-ided by them.
2#(eneral Cleanin" of t*e Department :
Manual of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
rocess
Document No :
RML/CSSD/01
Manual of Operations
CSSD
Date of Issue :
15/1/2008
,o prepare a clean en-ironment 'or preparing items 'or sterili*ation, to maintain the cleanliness in
C##D 9 to reduce and minimi*e source o' in'ection.,he general working area o' the C##D is
mopped e-eryday including the 'ollowing area within the C##D en-ironment.
a# ac)in" area
:ipe working table, shel-es and trolleys with the recommended disin'ectant.
:ipe the machines with damp cloth.
'# Sterile pac)s Storin"
:ipe the shel-es and walls with recommended disin'ectant weekly.
Mop the 'loor twice daily and ensure that the mop that is used is only meant 'or the sterile
store.
c# Decontamination area an$ sluice room
:ipe the trolleys with recommended disin'ectant daily.
:ipe the machines with a damp cloth daily.
Mop twice and as and when re.uired with the recommended disin'ectant.
,he 'loors are cleaned thoroughly and polished whene-er re.uired.
+# (eneration of Items to Sterili,e
,he items to be sterili*ed at the Central #terile #upply Department are washed ;with detergent or
chemical as applicable<, sorted and packed at the respecti-e point o' generation ;:ards, )C6s,
7mergency Department, O,s, ODs etc <.,he Housekeeping sta'' is responsible 'or transporting
the prepared packs 'rom the point o' generation to the Central #terile #upply Department.
O, linen are send directly to the laundry 'or cleaning. ,he laundry washed linen are recei-ed ,
packed and 'orwarded to the C##D 'or sterili*ation.
a# rocess+
,he C##D technician recei-es the unsterile packs, inspects them to check the status o' the item
;torn, punctured, cracked etc< and places them at the unsterile packs storing plat'orm. 7ntry is
made in C##D receipts register including date, time, type o' instruments in the pack, its source,
procedure used 'or, and case in'ected or not, name and signature o' person handing o-er, and
name and signature o' person recei-ing it.
,he autocla-e indicator is pasted in the packs by the C##D technician and the packs are taken to
the main sterili*ing area where the sterili*ing units are placed .,he C##D technician places the
unsterile packs under appropriate temperature and pressure speci'ications in the sterili*ing units.
,he temperature, pressure speci'ications and accordingly the temperature period are as 'ollows+


,emperature ressure #terili*ing eriod
Manual of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
rocess
Document No :
RML/CSSD/01
Manual of Operations
CSSD
Date of Issue :
15/1/2008

0ormal #terili*ation+ $&$=C $> lb (4 minutes
Rapid #terili*ation + $?4=C &4 lb &4 minutes
!t the end o' the sterili*ation period the packs are remo-ed 'rom the sterili*ing units, the autocla-e
indicators are checked to con'irm ade.uate sterili*ation o' the packs, incase the sterili*ation is not
ade.uate the process is repeated. acks which are ade.uately sterili*ed are stored in the sterile packs
storing area. ,he 'ollowing procedure is 'ollowed 'or storing the sterile packs+
$. acks are pushed directly to the sterile store to maintain sterility
&. #terility o' the pack is checked as 'ollows +
i. acks are not torn.
ii. 0o attempts at opening the pack ha-e been made.
iii. acks are not wet or dirty.
i-. ,he chemical indicator tape color changes
-. )' any o' the abo-e is detected, the instruments are cleaned, dried and re@packed
again.
(. ,he sterile packs are kept o-er trolleys to allow them to get cool prior to their arrangement in the
shel-es. #terile packs are always handled wearing glo-es.
?. )n-entory o' sterile packs are checked e-eryday to ensure that they are stored without being
distributed to the respecti-e user department.
>. Once the temperature o' the sterile packs 'all they are stored in appropriate racks in the sterile
packs storing area.
,herea'ter the sterile packs are issued to the user departments and an entry o' the same is entered
in the packs issue register.
'# Return of -nutili,e$ ac)s:
)ncase the packs which are sterili*ed in the C##D remains un utili*ed in the respecti-e user
departments 'or a period o' A& hours , the same are returned to the C##D department 'or re@
sterili*ation.
c# Maintenance an$ Cali'ration of ./uipment
Maintenance o' the e.uipments are done as per the annual maintenance contract ;!MC< entered
into with the -endor o' the respecti-e C##D e.uipments. !ll details in these regard are maintained
by the "iomedical 7.uipments 7ngineering and Maintenance Department o' the hospital.
!ll e.uipments used in the department are appropriately calibrated at periodic inter-als to ascertain
whether they are per'orming at the e8pected le-el and a record o' the same is documented in the
department as well as with the concerned clerk in the administrati-e Department o' the hospital.
d. Recall roce$ure :
Manual of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
rocess
Document No :
RML/CSSD/01
Manual of Operations
CSSD
Date of Issue :
15/1/2008
:hene-er a breakdown in the sterili*ation system is noted all packs sterili*ed by the 'aulty
machine is immediately called back 'rom the respecti-e area where the sterile packs has
been supplied.
,he packs called back are sent 'or re sterili*ation using a proper machine#
e# Documents (enerate$+
$. C##D receipt register
&. C##D issue Register
(. 7.uipment Maintenance Record
?. 7.uipment Calibration Record
>. 7.uipment "reak down Record.
Manual of Operations