Examining Central Sterile Services Department’s role in patient safety

The fundamental role of the CSSD is to receive, clean, decontaminated, packaged, and sterilised medical devices that can be distributed.

June 12, 2019 Ammar Widitaputra, Secretary, Himpunan Sterilasi Sentral Indonesia (HISSI), Jakarta, Indonesia

Picture this. A patient comes home to gather with family members for an occasion such as Eid Al Fitr or Eid Al Adha. But before that a patient is given service in the hospital or any other healthcare facilities directly by the doctor, nurse or health workers. However, before the process starts, the doctor, nurse or health workers need sterile supplies provided by Central Sterile Services Department (CSSD).

CSSD process reusable instrument or medical device from all areas such as the operating theatre, wards, critical care, outpatient, endoscopy, etc. The department also sterilises supply such as gauze or linen. Even though CSSD doesn’t meet the patient directly, the finish products from them are directly used by the patient. Therefore, CSSD must understand the patient safety concept thoroughly, as it supports patient safety by breaking the chain of infection.

The fundamental role of the CSSD is to receive, clean, decontaminated, packaged, and sterilised medical devices that can be distributed. These devices are reprocessed in reprocessing equipment, such as washer-disinfectors and sterilisers that are routinely maintained and validated in order to prevent cross-contamination and infection in patients. This is achieved by well-trained and knowledgeable staff working in the CSSD under the supervision of experienced and trained managers who understand and implement strategies of risk management and quality assurance. 

Culture of patient safety

A culture of patient safety should be built in CSSD. Culture is defined as the deeply rooted assumptions, values, and norms of an organisation that guide the interactions of the member through attitudes, customs, and behaviour.

A culture of patient safety involves: leadership, teamwork and collaboration, evidence-based practices, effective communication, learning, measurement, a just culture, systems thinking, human factors, and zero tolerance.Leaders in CSSD are responsible for establishing safety. Leaders set patient safety as priority and motivate staff to perform. They ensure all the standards are followed, and no short-cuts are taken. Leaders provide tools to ensure all steps are done seamlessly. Leadership is critical to the success of patient safety in CSSD.

Decontamination process in CSSD cannot be done by one person. Teamwork and collaboration combines the talents and skills of each member of a CSSD team and serve as a check and balance method, making sure every process is done the right way. CSSD must encourage thinking, suggestion and action from all staff. Teamwork and collaboration in the department also decrease risk to staff.

Also, communication is a vital aspect. Open communication between leaders and staff or between staff encourage sharing technological and environmental information. Communication is based on mutual trust and setting the best practices in CSSD. Communication includes written, verbal, or electronic, and can be used for sharing data, sharing policies and procedures, literature studies and also reporting systems.

Sterilisation should be used for evidence-based literature. Sterilisation cannot be done only as a habit; a generation-to-generation practice has shown that people don’t use evidence-based standard. Evidence based practice in CSSD is a basic element of patient safety. Evidence based guideline for CSSD best practice is available from World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), and Asia Pacific Society of Infection Control (APSIC). Adoption of best practices sometimes meets resistance. Leadership together with staff must increase awareness, improve the desire to change to meet the standard, and even ask for incentives.

All members of CSSD should learn. Learning together can improve the ability to create desired results. The department’s staff should encourage participating in learning the formulating policies and procedures. They can schedule monthly meetings when a group of staff presents one topic, while others pay attention and ask questions to the presenter group.

To monitor compliance with best practices and to identify gaps in care, CSSD must collect and report reliable data. The staff must collect any problem when reprocessing instrument, particularly in cleaning, disinfection or sterilisation. CSSD can also get information from users. Any report that shows lack of compliance from best practice should be analysed and managed to improve cleaning, disinfection or sterilisation practice.

All processes in healthcare facilities are systems, involving interconnected components, people, supplies and equipment. CSSD practice seems simple, however it is really complex. It needs trained technicians, facilities, supplies, and water. Systems change or system thinking should be done to achieve and sustain success in CSSD practices.

A CSSD practice is not only done using machine but needs staff; human factors should be considered. Some principles in human factors include simplifying the process, standardising the process, reducing dependence on memory, using forcing function, and working toward reliability.

To err is human and some will inevitably make errors. CSSD can review the systems and learn from errors. These errors can be addressed by providing feedback and encouraging productive conversation and critical analysis to prevent future errors. The no blame culture focuses on systems that led to the error rather than on the individual. Blaming personnel only creates anxiety and fear and does little to solve current problems or prevent them.

However, in a condition that shows purposeful disregard of the rules, zero tolerance culture is used. Leaders must not tolerate non-adherence. When best practices are known, these should be expected of all staff. If staff takes a short-cut in cleaning, disinfection or sterilisation process, these behaviours should be addressed and not ignored.  

The department’s staff should encourage participating in learning the formulating policies and procedures.

Challenges of CSSD

Complex instruments, for example air powered endoscopes, instruments with lumens or channels, are difficult to clean. When there is a failure in cleaning, the instrument cannot be sterilised or disinfected. While reprocessing complex instruments, always look for written instructions from device manufacturer and follow completely.

Written instruction from manufacturers known as Instructions for Use (IFU), include how to clean, disinfect or sterilise. Some reckless practice includes never reading the IFU and practicing only using sense or experience. CSSD should have this on paper, share with the whole team, and practice every step in reprocessing the instrument.

Immediate Use Steam Sterilization (IUSS), known before as flash sterilization, should be used only when there is insufficient time to process by the preferred method. IUSS should not be used as a substitute for insufficient instrument inventory. However, in many developing countries IUSS is often used.

Also, reusing Single Use Device (SUD) happens in developing countries. Reusing SUD usually has a high cost, high volume, and high demand criteria. Reusing SUD gives challenges in the cleaning process. Mostly SUD cannot be cleaned, there are a lot of channels or lumens. Healthcare facilities must have policies and procedure to reuse SUD and follow local guidelines. Tracking single use devices that can be used again should done correctly.

References available on request.