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CENTRAL STERILE SUPPLY
830 CENTRAL STERILE SUPPLY
THE evolution of central sterile supply departments (c.s.s.D.s) has been rapid; some have grown from simple syringe services, others have begun in the operatingtheatre suite, while many have been carefully planned new developments. The Central and Scottish Health Services Councils’ joint committee on C.S.S.D.s (the Collingwood committee) has just produced a useful and timely report.! Experience gathered from c.s.s.D.s all over Britain and from many other sources has been examined critically and synthesised into an account of the aims, methods, organisation, management, and possible future of this important hospital department. To those who are about to set up a c.s.s.D. this report will be invaluable; and to those already shouldering this responsibility its firm statements will be an encouragement. The declared aim of the c.s.s.D. is to provide all hospital departments with reliably sterilised articles (with the possible exception of operating-theatre instruments, but including disposables) as economically as possible under conditions which are controlled. The report deals firmly with methods of sterilisation: we hope that never again will this or any other committee be forced to state that they were disturbed to hear that water-boilers were still in use, despite repeated warnings. Attention is also drawn to guidance from the Ministry of Health about purchase, planned maintenance, and testing of autoclaves.23 Economy in c.s.s.n.s depends notably on sufficient working size in terms of beds served and on some standardisation of the articles sterilised. The committee accepts that both large and small c.s.s.D.s have a place: the smallest should serve about 500 beds, but 2000 beds is a more economical proposition; and much larger regional services may function without loss of the essential feedback control between user and c.s.s.D. Standardisation of packs requires cooperation between c.s.s.D. and both nursing and medical staff. To this end, the report advocates a committee of management consisting of the consultant charged with clinical responsibility for the c.s.s.D., the department’s superintendent, medical, surgical, and nursing representatives, and the hospital pharmacist. The hospital engineer and the finance officer might be useful members too. The importance of the C.S.S.D. superintendent in a department that impinges on all other departments is clearly recognised in the report. He or she must have administrative ability, adequate technical knowledge of the engineering and biological aspects of the work, and many other qualities that will promote close liaison with medical and nursing staff. Such qualities need adequate recognition and reward, and a review of salary scales is long overdue. Flexibility and the continuing evolution of c.s.s.D.s are also important. Increased use of disposables (at present often an expensive luxury) and commercial supply of other items must be continually borne in mind. Though industry does not at the moment offer a complete and cheaper alternative solution for the complex demands made on the c.s.s.D., further standardisation may eventually produce great changes. It has been suggested that operating-theatre instruments might be sterilised in a special theatre sterile 1. Central Sterile Supply Departments. Report prepared by Joint Committee of the Central and Scottish Health Services Councils. Issued with H.M. (67) 13 by the Ministry of Health. 2. Ministry of Health Technical Memorandum no. 10. 3. Ministry of Health Technical Memorandum no. 13.
supply unit (T.S.S.U.) or, in certain circumstances, within the C.S.S.D.4 Centralisation must involve some standardisation and duplication of expensive instruments, with possible loss of flexibility in surgical development, quite apart from increased cost. Additional staff in T.S.S.U. or c.s.s.D., although relieving theatre staff of work, might not necessarily lead to a reduction in the number of those employed in the theatre, so that running costs would be higher than in theatres which sterilise their own instruments in high-speed autoclaves. Many people also believe that removal or division of this responsibility from the surgical team has both operational and economic disadvantages. The logistics of centralised sterilisation of theatre instruments is complicated: for instance, will industry be able to provide, on a once-and-for-all basis, the large initial supply of instruments to prime the pipeline if this development comes rapidly in many places at once ? Those who have seen careful plans for a C.S.S.D. frustrated by failure of instrument delivery and performance may be wondering about this question. If, however, the preserve of the C.S.S.D. is taken over by industry, the plant and staff could then be used for the central preparation of theatre instruments-if time shows this to be the better system. VASOPRESSOR DRUGS
TEN years ago the main indication for giving a sympathomimetic drug would have been hypotension. This view did not take into account the interaction between the circulating-blood volume and the capacity of the circulation; and it is now recognised that adequate tissue perfusion is even more important than the maintenance of some arbitrary blood-pressure level. Moreover, each organ has its own circulatory arrangements: for example, the brain’s blood-flow is subject to local adjustments which maintain cerebral oxygenation and carbon-dioxide elimination at as safe a level as possible irrespective of the arterial blood-pressure; and a similar process operates in the myocardium. Vasoconstrictors, it is sometimes said, should never be given at all, and, admittedly, their use in hypovolaemic hypotension, when the body’s vasoconstrictor mechanisms have failed, is illogical 5: they reduce tissue blood-flow and increase acidosis; they often cause shutdown in the renal circulation and increase the risk of severe renal ischaemia, and they may overload a heart which is already doing its best with an inadequate coronary circulation. But a hypotensive patient whose vasoconstrictor mechanism has failed but who has a normal blood-volume may benefit from a vasopressor-for example, when bloodpressure has fallen very low during spinal or epidural anaesthesia.6Indeed, during such anaesthesia, there may be a case for giving vasopressor drugs to tide patients over the period of maximum hypotension, for it is now known that some sympathomimetic agents (e.g., methoxamine, phenylephrine, and noradrenaline) act directly on the smooth muscle of the arterial wall and not solely on that part of the body which is unaffected by sympathetic paralysis. Similarly a small dose of a vasopressor drug would be appropriate for a patient with very low bloodpressure caused by a ganglion-blocking agent, if rapid blood-transfusion had failed to restore blood-pressure to 4. 5. 6.
Ministry of Health Building Bloch, J. H., Dietzman, R. Anœsth. 1966, 38, 234. Vickers, M. D. ibid. p. 728.
Note no. 26. H.. Pierce, C.
H., Lillehei, R. C. Br. J.
THE evolution of central sterile supply departments (c.s.s.D.s) has been rapid; some have grown from simple syringe services, others have begun in the operatingtheatre suite, while many have been carefully planned new developments. The Central and Scottish Health Services Councils’ joint committee on C.S.S.D.s (the Collingwood committee) has just produced a useful and timely report.! Experience gathered from c.s.s.D.s all over Britain and from many other sources has been examined critically and synthesised into an account of the aims, methods, organisation, management, and possible future of this important hospital department. To those who are about to set up a c.s.s.D. this report will be invaluable; and to those already shouldering this responsibility its firm statements will be an encouragement. The declared aim of the c.s.s.D. is to provide all hospital departments with reliably sterilised articles (with the possible exception of operating-theatre instruments, but including disposables) as economically as possible under conditions which are controlled. The report deals firmly with methods of sterilisation: we hope that never again will this or any other committee be forced to state that they were disturbed to hear that water-boilers were still in use, despite repeated warnings. Attention is also drawn to guidance from the Ministry of Health about purchase, planned maintenance, and testing of autoclaves.23 Economy in c.s.s.n.s depends notably on sufficient working size in terms of beds served and on some standardisation of the articles sterilised. The committee accepts that both large and small c.s.s.D.s have a place: the smallest should serve about 500 beds, but 2000 beds is a more economical proposition; and much larger regional services may function without loss of the essential feedback control between user and c.s.s.D. Standardisation of packs requires cooperation between c.s.s.D. and both nursing and medical staff. To this end, the report advocates a committee of management consisting of the consultant charged with clinical responsibility for the c.s.s.D., the department’s superintendent, medical, surgical, and nursing representatives, and the hospital pharmacist. The hospital engineer and the finance officer might be useful members too. The importance of the C.S.S.D. superintendent in a department that impinges on all other departments is clearly recognised in the report. He or she must have administrative ability, adequate technical knowledge of the engineering and biological aspects of the work, and many other qualities that will promote close liaison with medical and nursing staff. Such qualities need adequate recognition and reward, and a review of salary scales is long overdue. Flexibility and the continuing evolution of c.s.s.D.s are also important. Increased use of disposables (at present often an expensive luxury) and commercial supply of other items must be continually borne in mind. Though industry does not at the moment offer a complete and cheaper alternative solution for the complex demands made on the c.s.s.D., further standardisation may eventually produce great changes. It has been suggested that operating-theatre instruments might be sterilised in a special theatre sterile 1. Central Sterile Supply Departments. Report prepared by Joint Committee of the Central and Scottish Health Services Councils. Issued with H.M. (67) 13 by the Ministry of Health. 2. Ministry of Health Technical Memorandum no. 10. 3. Ministry of Health Technical Memorandum no. 13.
supply unit (T.S.S.U.) or, in certain circumstances, within the C.S.S.D.4 Centralisation must involve some standardisation and duplication of expensive instruments, with possible loss of flexibility in surgical development, quite apart from increased cost. Additional staff in T.S.S.U. or c.s.s.D., although relieving theatre staff of work, might not necessarily lead to a reduction in the number of those employed in the theatre, so that running costs would be higher than in theatres which sterilise their own instruments in high-speed autoclaves. Many people also believe that removal or division of this responsibility from the surgical team has both operational and economic disadvantages. The logistics of centralised sterilisation of theatre instruments is complicated: for instance, will industry be able to provide, on a once-and-for-all basis, the large initial supply of instruments to prime the pipeline if this development comes rapidly in many places at once ? Those who have seen careful plans for a C.S.S.D. frustrated by failure of instrument delivery and performance may be wondering about this question. If, however, the preserve of the C.S.S.D. is taken over by industry, the plant and staff could then be used for the central preparation of theatre instruments-if time shows this to be the better system. VASOPRESSOR DRUGS
TEN years ago the main indication for giving a sympathomimetic drug would have been hypotension. This view did not take into account the interaction between the circulating-blood volume and the capacity of the circulation; and it is now recognised that adequate tissue perfusion is even more important than the maintenance of some arbitrary blood-pressure level. Moreover, each organ has its own circulatory arrangements: for example, the brain’s blood-flow is subject to local adjustments which maintain cerebral oxygenation and carbon-dioxide elimination at as safe a level as possible irrespective of the arterial blood-pressure; and a similar process operates in the myocardium. Vasoconstrictors, it is sometimes said, should never be given at all, and, admittedly, their use in hypovolaemic hypotension, when the body’s vasoconstrictor mechanisms have failed, is illogical 5: they reduce tissue blood-flow and increase acidosis; they often cause shutdown in the renal circulation and increase the risk of severe renal ischaemia, and they may overload a heart which is already doing its best with an inadequate coronary circulation. But a hypotensive patient whose vasoconstrictor mechanism has failed but who has a normal blood-volume may benefit from a vasopressor-for example, when bloodpressure has fallen very low during spinal or epidural anaesthesia.6Indeed, during such anaesthesia, there may be a case for giving vasopressor drugs to tide patients over the period of maximum hypotension, for it is now known that some sympathomimetic agents (e.g., methoxamine, phenylephrine, and noradrenaline) act directly on the smooth muscle of the arterial wall and not solely on that part of the body which is unaffected by sympathetic paralysis. Similarly a small dose of a vasopressor drug would be appropriate for a patient with very low bloodpressure caused by a ganglion-blocking agent, if rapid blood-transfusion had failed to restore blood-pressure to 4. 5. 6.
Ministry of Health Building Bloch, J. H., Dietzman, R. Anœsth. 1966, 38, 234. Vickers, M. D. ibid. p. 728.
Note no. 26. H.. Pierce, C.
H., Lillehei, R. C. Br. J.