Recordkeeping system for Central Sterile Supply Department

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Record keeping systeminCentral Sterile Supply
Department

• Created by Debabrata Basu
• Associate Scientific Officer
• Central Sterile Supply Department
• Tata Medical Center
• Kolkata, India

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Daily equipment quality monitoring system
http//www.cdc.gov/hicpac/Disinfection_Sterilizati
on/13_11sterilizingPractices.html
PHYSICAL (Frequency) CHEMICAL (Frequency) BIOLOGICAL (Frequency) PCD/ OTHERS (Frequency)
Ultrasonic Cleaner N/A Aluminum Foil Testing
Washer Disinfector Manual System/ Automatic Printouts (Each Cycle) One indicator in every cycle N/A N/A
Steam Sterilization Printouts (Every Cycle) Leak test Every week Class I Every Pack Class II Once a Day Class IV Each Pack Class V Each Pack Geo bacillus stearothermophilus Once in a day. (For implant every cycle) Every Cycle
EO Sterilization Automatic Printouts (Every Cycle) Class I Every Pack Class IV Each Pack Bacillus atrophaeus Every Cycle Every Cycle
Plasma Sterilization Automatic Printouts (Every Cycle) Class I Every Pack Class III Each Pack Geo bacillus stearothermophilus Once in a day. N/A
Sealing Automatic Printouts (Every Packs) Seal Check (weekly) N/A N/A
Equipments
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Audit for CSSD quality monitoringhttp//www.infec
tioncontrol.co.nz/uploaded/file/downloads/CSSD20a
udit.pdf
Main Points Area Frequency Status Responsible Person
Water TDS Pressure Monitoring Decontamination room Daily  
Temperature Humidity Monitoring Packing/Sterile store Daily  
Compressed air quality pressure Monitoring Decontamination room Daily  
Wearing PPE appropriately Soil and sterile zone Routinely  
Routine hand wash practice Scrub sink Routinely  
Changing enzymatic solution Soil zone Twice a day  
Condition of cleaning brushes Decontamination room Daily  
Wet pack incident Sterile Store If any  
Needle stick injury Soil and packing zone If any  
Proper waste segregation Soil and Packing room Daily  
Safety stock maintaining Consumable/Sterile Store Daily  
Equipment register maintaining Packing zone Daily  
Status of equipment with printer roll Soil Packing zone Daily  
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Cleaning audit for CSSD http//www.hse.ie/eng/ser
vices/publications/Hospitals/HSE_National_Cleaning
_Standards_Manual_Appendices.pdf
Main Points Area Frequency Status Responsible Person
Machine Dusting Soil and Packing room Daily  
Trolley Washing Trolley wash zone Daily  
Computer cleaning Packing/Sterile store Weekly  
Furniture dusting Soil/Packing/Sterile Weekly  
Wall/Ceiling cleaning Packing/Sterile store Once a week  
Door/ Pass box cleaning All area Once a week  
Cleaning air flow ventilator duct grill Sterile store Alternative months  
Shoe cleaning C.S.S.D Daily  
Floors/ Corridor cleaning All area Daily  
Remove /clean garbage Soil and Packing room Daily  
Condition of cleaning mops Area wise Daily
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CSSD various waste and disposal system
Types of waste materials Colored bin Area of waste generate
ETO gas cartridge BLACK Packing zone
Plasma cassettes BLACK Packing zone
Biological Indicator BLUE Not disposed from CSSD
Plastic wrapper BLACK/BLUE Packing / Soil zone
Non woven fabric wrapper BLACK Packing zone
Chemical indicator (If any) BLACK Packing zone
Any sharp items, Broken glass SHARP CONTAINER Soil zone
Any bloody cotton items YELLOW Soil zone
Food particles BLACK Soil zone
Rubber tube, catheters BLUE Soil zone
Cartoons BLACK Packing zone
Tissues YELLOW Soil zone
Solution container BLACK Soil zone
Oil spray container BLACK Packing zone
Cap/ Mask BLUE Soil zone
Gloves/ Apron BLUE Soil zone
Tissue paper BLACK Soil zone
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Sample copy of a ward requisition
SL.NO. INSTRUMENTS DESCRIPTION QUANTIITY CSSD RECEIVED CSSD ISSUED DUES EXPIRED SIGNATURE






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Sample copy of a re-usable linen receiving
register
DATE LINEN DESCRIPTION RECEIVING QUANTITY CSSD SIGNATURE RETURN FOR REWASH RETURN FOR STITCHING LAUNDRY SIGNATURE







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Sample copy of a sterilizer register
DATE DEPARTMENT NAME OF ITEMS QTY PARAMETER BATCH LABEL BIOLOGICAL INDICATOR RESULT AFFIX CHEMICAL INDICATOR REMARKS OR RECALL







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Sample copy of a sterilized materials dispatch
register
DATE DEPARTMENT INSTRUMENTS DESCRIPTION QTY SIGNATURE OF ISSUED PERSON SIGNATURE OF RECEIVING PERSON







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Sample copy of a re-call register
Sl.No. Date Department Re-called Items Recall Batch Reason for Re-sterilization Re-sterilization Date Signature







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CSSD records retention policy
https//www.distance.purdue.edu/training/cssp/less
ons/pdf/lesson113.pdf
Name of the Record Books Duration in CSSD Duration in MRD
Autoclave register with print out Six months 10 years
ETO register Six Months 10 years
Plasma register Six months 10 years
Dispatch register Six months 10 years
Bowie-Dick PCD records Six months 10 years
Biological indicator report (Steam/ETO/Plasma) Six months 10 years
Washer disinfector records Three months N/A
Seal check indicator records Three months N/A
Eto printout Six months 10 years
Plasma printout Six months 10 years
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Some electronic record keeping system
https//www.distance.purdue.edu/training/cssp/less
ons/pdf/lesson113.pdf

• Number of sterilizers run per day
• Numbers of materials sterilized per day
• Numbers of dressing materials issued per day
• Numbers of wet pack occurrences in every month
• Water quality testing (chlorine and
  microbiological test)
• Air quality testing (particle count and air
  microbiology)
• Temperature Humidity monitoring in sterile
  store
• Result of sterility test from Microbiology
• List of patients with documented infections (HIV,
  HepB)

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CSSD quality indicators www.ncbi.nlm.nih.gov/pubm
ed/16850657

• Infrastructure of CSSD with location and
  unidirectional workflow systems
• Monitoring air flow air exchange rate in
  sterile storage area
• Air quality monitoring (Air particle and Air
  microbiology testing)
• Water quality monitoring (TDS, Chlorine
  Microbiology)
• Sterility assurance testing in Microbiology
• Temperature and humidity monitoring in sterile
  store and sterilizer room
• pH level monitoring in washer disinfector for
  monitoring chemical dosing system
• Equipment registers and batch label monitoring
  system
• Daily equipment monitoring system (Physical,
  Chemical, Biological)
• Bar-coding for surgical set tracking system
• Audit for wet pack occurrences
• Audit for no of load re-calls
• Audit for daily cleaning and maintenance
• Audit for broken or damage surgical instruments
• Valid product quality certificates and Material
  safety data sheet
• Standard Operating Procedures (CSSD manual)
• Staff training and evaluation
• Turn around time, feed back from users, Infection
  control surveillance report

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