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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 10
| Issue : 2 | Page : 43-47 |
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A study on the understanding of sterilisation in the central sterile services department by the healthcare personnel in a tertiary care hospital in Sikkim
Sunu Hangma Subba
Department of Clinical Microbiology, STNM Hospital, Gangtok, Sikkim, India
| Date of Submission | 17-May-2022 |
| Date of Acceptance | 12-Jan-2023 |
| Date of Web Publication | 01-Mar-2023 |
Correspondence Address:
Dr. Sunu Hangma Subba
Department of Clinical Microbiology, STNM Hospital, Gangtok, Sikkim
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jpsic.jpsic_24_22
Background: Globally, hundreds of millions of people are affected every year by avoidable infections in healthcare (healthcare-associated infections, [HAIs]). Through knowledge, best practices and infection prevention and control (IPC), we can prevent HAI to patients and health workers. Following recent threats caused by widespread epidemics and increasing awareness about the spread of antimicrobial resistance, several countries are paying more attention and investing resources to strengthening IPC infrastructures and improving practices.
Objective: The objective was to assess the practices by the healthcare staff regarding the sterilisation process in the central sterilisation service department (CSSD) and to bring about improvements in the practices in the hospital.
Materials and Methods: A cross-sectional study was conducted where the healthcare staff were given a set of questionnaires on sterilisation in the CSSD. The staff who participated in the study included doctors, intensive care unit nursing staff, infection control nurses, operation theatre nursing staff, CSSD staff and outpatient department nursing staff.
Results: The questionnaire was administered to 120 health staff. All the staff agreed that instruments should be cleaned at the source. The majority of the participants (82%) believed that medical devices should be reprocessed centrally in CSSD; however, very few of them (18%) have felt otherwise. Almost 70% of staff did not know about the indicators used in CSSD and the zones in CSSD. The expiry date of the items once received from CSSD, 60% said it is not mentioned on the pack and 40% of participants agreed that it is mentioned on the pack.
Conclusion: The processes of sterilisation and decontamination are complex, require specific infrastructure and equipment and involve several steps that need to be correct, from device collection, receipt by the unit, processing, storage and distribution them throughout the facility. Quality control measures to evaluate the proper functioning of the equipment are of the utmost importance.
Keywords: Central sterilisation service department, infection control, knowledge, sterilisation
How to cite this article:
Subba SH. A study on the understanding of sterilisation in the central sterile services department by the healthcare personnel in a tertiary care hospital in Sikkim. J Patient Saf Infect Control 2022;10:43-7 |
How to cite this URL:
Subba SH. A study on the understanding of sterilisation in the central sterile services department by the healthcare personnel in a tertiary care hospital in Sikkim. J Patient Saf Infect Control [serial online] 2022 [cited 2023 Mar 30];10:43-7. Available from: https://www.jpsiconline.com/text.asp?2022/10/2/43/370884 |
| Introduction | |  |
A central sterilisation service department (CSSD) serves all hospital areas, including the operation theatres (OT). CSSD works in collaboration with the Infection Control Committee and other hospital programmes to develop and monitor policies on the cleaning and sterilisation of hospital equipment. Defects in sterilisation can lead to catastrophic consequences and economic burdens.[1],[2] The quality of sterilised products must be assessed by certain quality indicators such as the products, the structure and the work process in CSSD.[3] The study was carried out in tertiary care 1000-bedded hospital in Sikkim. This study is done to assess the knowledge of the hospital staff regarding the sterilisation process and functioning of the CSSD.
| Materials and Methods | | |
This is a cross-sectional, questionnaire-based study designed to evaluate the knowledge, attitude and practice of medical professionals regarding the sterilisation process carried out in CSSD of a Government Tertiary Hospital in Sikkim.
A predesigned questionnaires were given to all the concerned healthcare staff, based on the procedure used in the instruments reprocessing in CSSD. Data entry and analysis were done using the IBM Corp. SPSS 2020Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp.
| Results | | |
The total staff who participated in the study were 120; among them, 39% were doctors and the rest were other staff, which included infection control nurses, OT staff, etc., In the study group, 93% were dealing with materials from CSSD, whereas 6% were not.
In this study, 82% of participants felt that reprocessing should be it should be done in CSSD, whereas 16.40% felt it should not be done in CSSD [Table 1]. | Table 1: Knowledge assessment of healthcare staff regarding the cleaning of instruments in CSSD
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The staff were asked what is the role of CSSD in the Infection Control Committee and other hospital programmes. More than 90% of staff knew that the CSSD develops/monitors policies in cleaning and decontamination of contaminated equipment's in collaboration with Infection Control Committee [Figure 1] [Table 2]. | Figure 1: CSSD in collaboration with the Infection Control Committee and other hospital programmes develop and monitor policies. CSSD: Central sterilisation service department
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Regarding the cleaning of the instruments before sending it to CSSD for sterilisation, 34% of staff used to wash with detergent and dried; another 19% of staff washed with plain water and dried, and 16% of staff used to soak in 1% hypochlorite solution, wash and dried than the items were sent to CSSD for sterilisation. All the participants agreed that items should be cleaned at the source. The reason given was as infection control (61%), preventing deposition of blood and other body fluids and infection control (23%), reducing infected load, easy for carriage and handling by staff (5%), removing biological contaminants and preventing the damage of instruments (2%) and infection control and prevent damage to instruments (5%).
About 82% of participants felt that reprocessing should be done in CSSD, whereas 16% felt it should not be done in CSSD. Among the ones who felt it should be reprocessed in CSSD, the reason given was: for infection control (21%), for cleaning of rusted instruments (5%), to make sure it is clean (24%), trained staff are there for sterilisation in CSSD (16%) and do not know (15%).
The functions of CSSD were asked, and most of the participants were aware of the tasks carried out in CSSD such as washing, disassemble, decontamination, drying, packing, apply chemical indicators, sterilising and storage in the sterile zone [Table 2].
Next, the participants were asked, 'Is there a delay in receiving items from CSSD?', 37% said Yes, there is a delay in receiving items from CSSD, whereas 45% of participants said No, (P = 0.006) On asking how often does the delay happen? The response was once a week (18.0%), once in a fortnight (11.5%), once a month (11.5%) and never (47.5%) (P = 0.013). There were various reasons given by the hospital staff for a reason for the delay in receiving items from CSSD [Figure 2]. | Figure 2: Reasons given by the hospital staff for the reason for the delay in receiving items from cssd. Cssd: central sterilisation service department
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Problems faced on receiving the pack when asked, 75% responded as no problem faced in receiving the packs, 4.9% said packs were damaged/broken, 3.3% said inadequate material was provided and 1.5% said there were no indicator tapes on the pack. Regarding the identification labels on the sets, they were asked what all identification labels are there while handling/receiving items from CSSD, it was noticed that 'description of the package' was mentioned in all the packs (67.20%), followed by 'expiry date' (49.20%) and the less mentioned labels were 'washer and steriliser cycle number' (11.50% and 16.40%).
Staff were asked 'How do you know whether the items received by CSSD are sterilized?' 66% of staff responded was that the autoclave tape colour is black, which means the items are sterilised; 23% of staff said that the internal chemical indicator inside the sets shows 'PASS', 11% of staff did not know the answer.
They were also asked whether they have received any set unsterile (without change in the indicator strip on the pack)? All the staff responded saying they have not yet received any items unsterile.
Further, they were asked what would be their next step if they received any items unsterile? The answers given were reporting to their in-charge, informing CSSD and sending back the items for re-sterilisation to CSSD. The next question was asked 'what is recall?' none of the staff had heard about this term.
They were asked about the equipment available in the CSSD. Most of them (77%) knew that steam steriliser is available, but very few (23%) knew that ultrasonic cleaner is available in the CSSD. Participants were asked about the zones in CSSD, 30% did not know and 70% of participants knew about the zones in CSSD [Table 3]. | Table 3: Knowledge assessment of the Healthcare staff on Quality indicators and transport of instruments in CSSD
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Finally, they were asked about the documentation done in their respective departments for the CSSD items. The receiving/issue register for instrument's sterilization were maintained in the wards, ICUs and OTs. In addition to that OTs were also maintaining records for the sterile gauzes and internal chemical indicators. CSSD was keeping the standard operating procedures, equipment's maintenance registers, records of all physical/chemical/biological indicators, stock registers and issue/receiving registers.
| Discussion | | |
The Asia Pacific Society of Infection Control (APSIC) launched its revised Guidelines for Disinfection and Sterilisation of Instruments in HealthCare Facilities in February 2017. It aims to highlight practical recommendations in a concise format designed to assist healthcare facilities in the Asia Pacific region in achieving high standards in sterilisation and disinfection. It recommends the centralisation of reprocessing, training of all staff with annual competency assessment, verification of cleaning, continual monitoring of reprocessing procedures to ensure their quality and a corporate strategy for dealing with single-use and single-patient use medical equipment/devices.[4]
This study is an eye-opener for the institution since it highlighted the areas where more planning and training are required. This investigation determined the knowledge and extent of the practice of sterile techniques among the hospital staff. Findings indicated that hospital staffs hold knowledge on the principles of sterile technique necessary to provide safe and effective nursing to their surgical client during the intraoperative period, but there is a room for a lot of improvement. This result is worth noting since; one of the factors impacting compliance with the standard precautions in any hospital setting is a sound knowledge of its concepts and principles.
A study among a selected group of healthcare providers was carried at A. J. Institute of Medical Sciences and Research Centre, Kuntikana, Mangalore. Seventy-eight percent of the nurses believed that after instrument use, the cleaning of the instruments was entirely the responsibility of the staff appointed in CSSD. Thus, only 22% of the nursing staff felt the need for cleaning instruments at the source is mandatory. A few reasons mentioned were the removal of blood clots and debris, which will get dried up and may be difficult to remove later. Only 30% of the nursing staff were aware of the reasons for cleaning the instruments at source could contribute to hospital-acquired infection.[5]
In the present study, it was noticed that there were different practices adopted by a different group of staff regarding the washing at source, which highlights the fact that the staff should be trained regarding the uniform practice in all the units in the hospital. As per APSIC Guidelines, the gross soil should be removed immediately at the point of use. If it cannot be done immediately, the instruments must be kept moist with pre-treatment product or by placing a moist towel over the used items to prevent the organic matter from drying on it.[4]
Decisions related to reprocessing medical equipment/devices should be made by a multi-disciplinary Infection Prevention and Control Committee. It is strongly recommended that, wherever possible, reprocessing should be performed in a centralised area that complies with the physical and human resource requirements for reprocessing.[4]
According to 8% of the staff, it is not necessary to specify which instruments were used on HIV/HBV/HCV infected patients. APSIC recommends that appropriate personal protective equipment be worn for all reprocessing activities, whether or not the patient is seropositive. Unless they have documented immunity to hepatitis B, all reprocessing staff must be offered hepatitis B immunisation. SOPs must be in place for accidental injuries caused by sharp objects. Measures and procedures shall be in place for immediate response to worker exposure to blood and body fluids.[4]
Delay in receiving packs, 37% of staff said there was a delay in receiving packs. The major reason for the delay in receiving instruments stated by the staff was the machine broke down. Preventative maintenance should be carried out for all the equipment at least annually following the equipment manufacturer's instructions for use. A schedule for maintenance and the work carried out should be maintained for each piece of equipment. The process should be fully documented; all test results should be documented and the documentation reviewed.
Surgical infections are a major cause of morbidity and mortality in low-and middle-income countries (LMICs). Inadequately reprocessed surgical instruments can be a vector for pathogens. Little has been published on the current state of surgical instrument reprocessing in LMICs. A study was conducted where qualitative analysis of all studies to categorize existing practices, and barriers to successful surgical instrument reprocessing were done. Large gaps were found between instrument reprocessing practices in LMICs and recommended policies/procedures. Identified areas for improvement include instrument cleaning and decontamination, sterilisation aspects of instrument reprocessing and verification of sterilisation.[6]
This is very important for the end-users to know about the indicators used in CSSD since this is going to help them to monitor the sterility of instruments and for the better care of the patients. One of the criteria for the release of instruments is the colour change in the process indicator. Information collected as part of the release of sterilised devices should form part of the traceability records so that the patient can be traced back to the process.
| Conclusion | | |
Sterilisation and decontamination of instruments and medical devices play a very important role in the prevention of healthcare-associated infections. The processes of sterilisation and decontamination are complex, require specific infrastructure and equipment and involve several steps that need to be correct, from device collection, receipt by the unit, processing, storage and distribution them throughout the facility. Of utmost importance are also quality control procedures to assess the correct functioning of the equipment.[7]
Regardless of the person managing the CSSD, each level of staff must be competent in delivering against a defined job description. For this reason, a strong training and education programme is essential. The curriculum should contain certain essential concepts and the performance of the operators and supervisor should be checked against these standards. Regular updates, not only in practices but also related to new developments in equipment and technology, should be introduced for CSSD staff. This study focuses on a small number of respondents; thus, further study utilising a bigger population may be done.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 3. | Donabedian A. Exploration in Quality Assessment and Monitoring. Michigan: Health Administration; 1980. |
| 4. | Available from: http://apsic-apac.org/wp-content/uploads/2017/01/APSIC-Sterilization-guidelines-2017.pdf. [Last accessed on 2021.Sep 08]. |
| 5. | Shriyan A, Shriyan A. A study on the efficiency of CSSD at a health care Center. J Nurs Patient Saf Care (TJPRC: JNPSC) 2015;1:7-16. |
| 6. | Forrester JA, Powell BL, Forrester JD, Fast C, Weiser TG. Surgical instrument reprocessing in resource-constrained countries: A scoping review of existing methods, policies, and barriers. Surg Infect (Larchmt) 2018;19:593-602. |
| 7. | Available from: https://apps.who.int/iris/bitstream/handle/10665/250232/9789241549851-eng.pdf; sequence=1. [Last accessed on 2021 Nov 17]. |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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