CSSD

Infection Prevention & Control

Precautions

GDIP&C - MOH
 Introduction
o Infection prevention & control is a critical mission
of CSSD staff as they receive, prepare, process,
store and distribute medical & surgical equipment,
instruments and supplies.
o CSSD is considered as an integral part of every
hospital. The quality assurance given in CSSD can
be considered as one of the significant hospital
infection control indicators.
o Scope of CSSD has expanded from a department
similar to an autoclave sterilization unit to include
hospital infection control and stand for a dedicated
workflow of sterile supplies and goods.
 Introduction
o Infection prevention & control goals of the
CSSD are to:
- Eliminate and/or destroy all potentially infectious
contaminants present on reusable instruments to
break the chain of infectionin hospital.
- Safely distribute reusable (and sometimes single-
use) items required for the delivery of patient care.
- Establish approved standards for decontamination,
disinfection, and sterilization in healthcare facility.
 Introduction
During carrying out decontamination processes,
CSSD staff may be at risk of different injuries
and disorders. The following are examples of
hazards that CSSD staff could face:
o Biological Hazards.
o Chemical Hazards.
o Physical Hazards: fire incidents, burns …etc.
o Ergonomic Hazards: musculoskeletal disorders
(low back pain, carpal tunnel syndrome …etc.),
slips and falls.
 Biological Hazards
o Biological hazards in health care facilities include
transmission of Blood-borne Pathogens (HBV,
HCV & HIV) mainly from needle stick injuries.
o Needle Stick Injuries are the most prevalent, least
reported, and largely preventable serious risk in
the CSSD from sharp instruments including
broken metal instruments.
o Disposable sharp needles and blades should not be
received in CSSD; If incidentally have been sent,
they need to be discarded in sharps container.
 Biological Hazards
o This presentation advises on how to manage the
risks of infection at CSSD, by applying the
principles of Standard Infection Control
Precautions (SICPs).
 Standard Precautions
o Standard IC Precautions (SICPs) were developed
to manage the risks of infection from patients in
healthcare settings, but they are also applicable as
a means of controlling the risks of infection from
contaminated instruments and equipment.
o Standard Precautions are the basic IC measures
that should be used at all times, whether infection
is known to be present or not, to ensure the safety
of workers and visitors.
 Standard Precautions
o Standard Precautions are combination of
organizational arrangements, use of PPE,
application of safe working practices, and
appropriate behaviors ... etc.
- Treat all items used with all patients as
contaminated.
- Prevent exposure to infectious materials by the
use of gloves, gowns, masks, goggles, … etc.
- Prevent exposure to Blood-borne Pathogens by
the careful handling of needles and other sharps.
 Standard Precautions
9 categories are applicable inside CSSD:
o CSSD location, design and assessment for infection
risks
o Hand hygiene
o PPE
o Safe management of soiled patient care equipment
o Safe management of the environment
o Safe management of blood and body fluid spillages
o Safe disposal of waste (including sharps)
o Safe management of linen (uniforms & work clothing)
o Occupational safety: prevention and management of
exposures (including sharps)
 CSSD Infrastructures
Planning and Designing of Hospital CSSD:
o The Central Sterilization Service Department
(CSSD) should be located with direct or close
access to the Operating Theatre and Day Surgery
Units. This may be achieved with the use of lifts.
o For minimizing distance for transportation & also
for saving time, CSSD should be located as near
main user areas as possible like OR
o Therefore, CSSD should be on the same floor or
the floor immediately above or below.
 CSSD Infrastructures
Design Layout:
o CSSD must have physical separation with clear
demarcation between “Dirty” and “Clean” areas.
o There is a separation between “Dirty” and
“Clean” areas with access controlled entries and
no back-flow (Unidirectional Flow).
o Airlocks may be required to maintain the air
pressurization of different zones.
 CSSD Infrastructures
Work Flow (Specific pathway for surgical instruments):
o Unidirectional Flow of processed instrument from
contaminated dirty areas to clean and sterile areas is
critical to prevent spread of microorganisms and
infection in the unit
 CSSD Infrastructures
Heating, Ventilation, and Air Conditioning
System (HVAC):
o Heating, ventilation, & air conditioning systems
(HVAC) in health-care facilities are designed to:
- Maintain the indoor air temperature and humidity
at appropriate comfortable levels
- Control odours
- Remove contaminated air
- Minimize the risk for transmission of airborne
pathogens.
 CSSD Infrastructures
Work Flow (Specific pathway for surgical instruments):

Decontamination Area – Negative Pressure (-)

Versus adjoining areas
Inspection, Assembly & Packaging Area – Positive Pressure
(++)
Versus to all adjoining areas
 CSSD Infrastructures
Traffic Control Protocols:
o CSSD staff should protect the integrity of the

controlled environment of CSSD by applying

traffic control guidelines.
o These traffic control protocols include
educating visitors about:
- Controlled access to the department
- Dress code
 Traffic Control Protocols
Traffic control protocols for CSSD staff :
o CSSD staff access through a separate entry via
staff locker rooms to enter the “Dirty” zone or the
“Clean” zone.
o CSSD technicians change their street clothes into
basic clean attire:
- A facility-issued scrub uniform.
- Head and facial hair coverings.
- Non-skid dedicated shoes.
o Also, they remove watches, jewelry and other
accessories.
 Traffic Control Protocols
Traffic control protocols for CSSD staff :
o Basic semi-critical dress code in the “Clean” areas
(Surgical scrub, hair covering & dedicated shoes)
o Biohazard dress code for the “Decontamination
Area” (Full PPE)
o Staff leaving the “Dirty” zone via changing rooms
to remove contaminated PPE
These protocols are required to maintain controlled
environment inside CSSD (i.e., reduces the amount of
microorganisms introduced into CSSD) + prevent
transmission of microorganisms outside CSSD.
 Traffic Control Protocols
Traffic control protocols for CSSD visitors:
o Authorized CSSD visitors access through a
separate entry via changing rooms to enter the
“Dirty” zone or the “Clean” zone
o In the “Clean” areas
(yellow-gown, hair covering & dedicated shoes)
o In the “Decontamination Area” (Full PPE).
 Hand Hygiene

o Hand hygiene is a
general term that
involves:
1) Hand Washing with
soap and water.
2) Hand Rubbing with
alcohol-based products.
Hand Washing

Cleaning hands with

soap and warm water
to remove soil, dirt,
and microorganisms.
Hand Washing
o Hand washing facilities
and supplies should be
available.
Hand washing station:
o Easily accessible sinks

that are DEDICATED

only for hand washing /
plain soap dispensers /
paper towels.
 Hand Washing
o Hand washing station(s) should be located in
or near the Decontamination Area
o Hand washing station(s) should be located in
or near the entrance of the “Clean Zone” but
never inside the Inspection, Assembly,
Packaging & Sterilization Area or inside the
Sterile Storage Area. This will protect the
packaging materials and packages from
splashes that may occur.
22
Hand Washing
To effectively reduce the
growth of germs on
hands, handwashing
must last 40-60 secs
and should be performed
by following all steps
illustrated on the left.
 Hand Rubbing

Moistening the hands with

an alcohol-containing
preparation (liquid, gel or
foam) and rubbing hands
together until dry.
Hand Rubbing
Unless hands are visibly
soiled, an alcohol-based
hand rub is preferred over
hand washing with soap
and water:
o Better compliance.
o Less irritating to hands.
o Effective method in the
absence of HW sinks).
 Hand Rubbing
o Alcohol-based hand rub
dispensers should be
available in adequate
numbers
(i.e., at least ONE
alcohol-based hand rub
gel dispenser – either wall
mounted dispenser or
desk top dispenser –
within each working area
or very close to it).
To effectively reduce the
growth of germs on
hands, handrubbing
must be performed by
following all steps
illustrated on the
left.This takes only 20-
30 secs!
Hand Hygiene
 Hand Hygiene
Hand Washing Moments in CSSD
CSSD staff should wash their hands upon:
o Entering & leaving from the “Decontamination
Area”
o Before entering “Clean” areas or planning to
touch a sterile packs
o Whenever hands become soiled or contaminated
o Before donning and after doffing of PPE
o Whenever gloves become torn or compromised
o Before and after using the toilet
o Before and after touching food in the staff lounge
 Hand Hygiene
Hand Rubbing Moments in CSSD
CSSD staff should perform the hand rubbing:
o After each set inspection, assembly
o Before loading or unloading packages and sets in
or from the sterilizers
o Before & after dispatching the instruments
o After touching your eyes, nose, or mouth
o When touching an item or surface that may be
frequently touched by others (e.g., door handles,
tables, telephone, racks handles …etc.)
Personal Protective Equipment
 Personal Protective Equipment - PPE

o Personal protective equipment (PPE) involves use

of protective barriers such as gloves, gowns,
aprons, masks, protective eyewear and full-length
face shield, which can reduce the risk of exposure
of health care personnel to potentially infective
materials and harmful microorganisms.
 Personal Protective Equipment - PPE

o Employees should select appropriate Personal

Protective Equipment (PPE) and must receive
training on PPE:
- Which PPE required to be used.
- When to use it
- How to use it
o Failure to wear the appropriate PPE and/or
improper use of PPE increase the employee's risk
of acquiring infection.
 Personal Protective Equipment - PPE

o CSSD staff must understand the importance of

wearing the proper PPE in each area to:
- Protect themselves from the potential hazards
present in the contaminated devices.
- Reduces the amount of microorganisms
introduced into CSSD & maintain controlled
environment inside CSSD
- Minimize the amount of contamination by dead
skin cells & hair they can bring to the surgical
devices.
 Personal Protective Equipment - PPE

o CSSD personnel should choose the appropriate

PPE based on the CSSD area’s requirement and
activities involved in reprocessing of instruments.
o When selecting PPE, CSSD personnel should
make sure it is approved by MOH and that it suits
the user in terms of size, fit, … etc.
o PPE should be available at all times and located
close to its point of use.
o Don and doff PPE in proper order.
o Limit surfaces and items touched while wearing
the PPE
 Personal Protective Equipment - PPE

o Dispose of single-use PPE after use in the correct

waste stream
e.g., place disposable heavy duty gloves used
during decontamination in general waste
containers.
o For reusable PPE (e.g., face shields, goggles and
aprons) you should specify the arrangements for
decontamination before reuse.
e.g., cleaning & disinfection of reusable goggles.
 Personal Protective Equipment – PPE
Sequence for Donning PPE
o Perform hand hygiene
o Gown first
o Mask or respirator
o Goggles or face shield
o Gloves

* Combination of PPE will affect sequence “Be Practical”

Donning
Steps
 Personal Protective Equipment – PPE
Sequence for Removing PPE
o Remove gloves
- Perform hand hygiene
o Remove gown
o Remove eye protection
o Remove mask or respirator
- Perform hand hygiene
Doffing
Steps
Safe Handling of Sharps
Use Care When:
o Handling used sharp
devices or instruments.
o Cleaning used sharp
devices or instruments.
o Handling & disposing of
incidentally received
needles, scalpels, and
other used disposable
sharp instruments.
 Safe Handling of Sharps

o Any contaminated
item must be
transported in covered,
rigid, puncture-proof
containers that are
properly labeled and
color-coded.
Safe Handling of Sharps

o Dispose all sharp items

in rigid, puncture-proof,
biohazard-labeled, sharps
containers that can be
sealed.
o Sharps containers should
not be over-filled (i.e.,
less than ¾ full).
 Safe Disposal of Waste
)Including Sharps(
o Wide range of waste may be generated during
reprocessing of instruments, which should to
be disposed of safely:
- Contaminated PPE
- Received disposable medical devices
- Used biological indicator (BI) vials
- Chemical solutions
o Handling CSSD wastes should align with the
hospital’s policies on waste disposal.
 Safe Disposal of Waste
)Including Sharps(

Non-hazardous Medical Waste:

o All used PPE should be disposed of inside regular
black waste containers.
Hazardous Medical Waste:
o Biological Indicator (BI) vials should be disposed of
inside hazardous waste container.
o Accidentally received used disposable non-sharp
instruments should be disposed of inside hazardous
waste container.
 Safe Disposal of Waste
)Including Sharps(

Hazardous Medical Waste:

o Incidentally received used disposable sharp objects
(e.g., needles, blades) must be disposed of in the sharp
containers
 Safe Management of Environment
o CSSD should have a clear schedule for
housekeeping activities (cleaning & disinfection)
with clear roles & responsibility of relevant staff
(whether CSSD technicians or housekeeping staff).
o CSSD housekeeping checklists should be practical,
compatible with the approved hospital's policy and
cover all environmental surfaces in different
working areas.
o Also, it should include responsible staff / dates &
times / cleaning ingredients and disinfectants to be
used (types – concentrations – contact times) … etc.
 Safe Management of Blood & Body
Fluid Spillages
o Spillages of blood and other body fluids may
present a risk of infection or cross-contamination
between different working areas.
o Spillages should be decontaminated immediately
by staff trained to undertake this safely.
o Adequate supplies of cleaning and disinfection
equipment and materials should be available.
Safe management of Linen & Textiles
Handling of Uniforms & Work Clothing

Handle and transport

used work clothing in a
manner which:
o Prevents skin and mucous
membrane exposures and
contamination of clothing.
o Avoids transfer of
pathogens to other people
and/or the environment.
Safe management of Linen & Textiles
Handling of Uniforms & Work Clothing

o Standard precautions must be applied when

handling soiled linen.
o Use minimal agitation when handling.
o Textiles that are heavily soiled with blood and/or
body fluids must be placed into leak-proof laundry
bags.
 Occupational Safety
Immunization & Personnel Health:
o According to the Occupational Safety & Health
Administration - OSHA regulations, all employees
who are dealing with potentially contaminated
items should receive all recommended Vaccines /
Screening & Post Exposure Serological Tests
based on MOH policies to maintain immunity and
protect HCWs from infection, thereby helping to
safeguard patients from becoming infected.
 Occupational Safety
Pre-employment Counseling & Screening:
Blood Borne Pathogens (HBV, HCV & HIV) Serology:
o Baseline Serological Testing when hiring.
o Post Exposure Serological Testing: Exposures to

BBPs e.g., sharp/needle-stick injuries.

PPD-based TST Screening ( ± X-ray):
o When hiring (for all HCWs without documented

positive reaction).
o Annually for PPD non-reactive HCWs
o Known exposure (close contacts)
 Occupational Safety
Routine Vaccination & Immunization:
o HBV vaccine.
o Influenza vaccine (annually).
o Td (tetanus and diphtheria) / Tdap (tetanus,
diphtheria, and pertussis).
o Varicella (Chickenpox) vaccine if not immune.
o MMR (Measles, Mumps & Rubella) vaccine if not
immune.
o Meningococcal meningitis vaccine.
o Other vaccines according to instructions of public
health authorities (e.g., COVID-19 vaccine).
 Occupational Safety
Reporting & Management of Exposures:
o Needle-stick or sharp injuries.
o Blood or body fluid exposures.
o Exposures to open pulmonary TB.
o Exposures to chicken pox, measles, mumps, and
rubella.
o Exposures to MERS-CoV.
o Exposures to COVID-19.
Thank You