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The Central Sterile Supply Department
Inr. J. A’urs. Snd. Vol. 3, pp. S-80,
Pergamon Press, 1966.
Printed in Great Britam
The Central Sterile Sup&
Department
The Central Sterile Supply Department
TIIE function of the C.S.S.D. is to supply sterile equipment, so that it may be used immediately, without the need for any further sterilising being necessary by the ward or departmental staff. If working in conjunction with a sterile syringe service, it should be possible to dispense with the ward sterilisers completely. In the operating theatre, however, where the instruments are required quickly, and on the spot, it is best if these are sterilised by the theatre staff in the theatrc suite. Thus, it can be seen how much work, noise, and. wastage is removecl when a C.S.S.D. is introduced into a hospital. Facts in favour
of the C.3’S.l).
1. Immediate
use of sterile equipment.
2. Using disposable
towels makes a large saving in laundering
3. As the packs are used on one patient lessened.
only, the incidence
costs.
of cross infection
is
4. Less room is required in which to store the packs. Special pack dispensers are manufactured which allow only the lowermost pack to be removed at a time. thus ensuring that the packs are used in strict date rotation. 5. There is a drastic removal of noise, especially as regards stainless steel items. This has been replaced by foil or polypropylene ware. 6. Removal of the ward sterilisers would entail less work, leave more room in the clinical rooms, and make a large saving in electricity costs. Requirements for the smooth running of the department
1. There must be close liaison between the ward staff, C.S.S.D. staff, pharmacist, and the bacteriologist. 2. A good system of delivery
of bulk stores.
3. An agreement
to have equipment
or contract
4. A good system of delivery of collection of used items.
regularly
overhauled.
of packs to the wards and departments, 5Y
and also
A.JOHNSON
60
The C.S.S.D. as a Department Basic accommodation The Mowing rooms are considered essential in the C.S.S.D. being newly built. Hospitals converting existing facilities would find great difficulty in providing all these rooms, and have to compromise. 1. Clean-up room, 2. packing and work room, 3. autoclave room, 4. sterile store, 5. bulk store, 6. supervisors’ office, 7. staff locker room and toilets. Additional These building, 1. 2.
accommodation will have to be provided in a department or where such facilities do not exist. Staff rest room, showers.
Clean-up room The following
equipment
is used in the clean-up
not
included
in a hospital
room:
a. High pressure taps for the washing and rinsing of rubber tubing, etc.; b. facilities for the rinsing and pre-soaking of articles; c. a high-pressure jet washing machine, for washing syringes, stainless steel items, etc. ; d. if the above washer does not incorporate a drying element, then drying cabinets must be provided ; e. plenty of work-top space is essential, and of the easily cleaned and nonabsorbable type, i.e. Formica ; f. ultrasonic cleaning apparatus may have to be provided if many instruments are to be processed. I do not think that facilities for the processing of surgeons’ gloves or hypodermic needles arc necessary, as it has been proved that using the disposable types is more economical, and safer. A strict daily cleaning of the work surfaces is essential, to prevent the build up of bacteria. Packing room Plenty of work-top space is required on which the packs are assembled. A direct access to the bulk store is necessary, to enable stores to be withdrawn quickly as required. Adjustable shelving may be required, on which packs may be stored, A capping machine would be necessary if syringes and awaiting sterilisation. instruments are to be supplied in aluminium tubes. A heat-seal machine for the sealing of the sterilisation bags is of prime importance. Special illuminated tables are manufactured for the folding and checking of linen. These would be required if the department was supplying an operating theatre.
FK. 1. Pack dispenser.
(By courtesy of Cuxon-Gerrmd
Ltd.)
Nurs.
f.p. 60-I
FIG. 2. The ideal autoclave for the C.S.S.D.
(By courtesy of British Sterilizers Ltd.)
FIG. 4. Foil articles
in use in the C.S.S.D.
(By courtesy
of Bowater-Scott
Corporation
Ltd.)
(153) The contents of the pack-gauze, cotton wool, cellulose wadding, etc.-are placed in a which acts as the sterile area when the pack is receiver in the centre of the INNER WRAPPER opened for use. Underneath is the OUTER PROTECTIVE wrapper. is folded over in the manner shown so as to cover the contents. (Cenlre) The INNER WRAPPER (Right) The paper is again folded over so as to enclose the contents.
(Left) Both ends are neatly folded over the contents so that the wrapper can easily be opened when required. (Gxtre) The forceps in a paper bag or wrapper which will be used for opening the inner wrapper are then put on top. (Ri+t) A paper towel is put on top. This is for use as a sterile towel by the doctor or nurse who will be using the pack.
(12)) One corner of the OUTER WRAPPER is now folded over so as to cover the top of the contents and the corner folded back on top. (Centre) In a similar manner the paper is folded over to the centre of the pack and the corner turned back. (Rig/d) Fold the third corner over in a similar manner.
(I.&) Then turn pack round and remaining flap of paper is folded over and tucked undrr the two top folds. (Cenlre) Leave the corner projecting out. (Right) When the pack is ready to be used pull the corner out and open. The OUTER WRAPPER is opened by a person who need not be ‘scrubbed up’. FIG. 5. How to make up a sterile dressing pack. Ltd.)
(By courtesy of Bowater-Scott
Corporation
,td.)
&IG. 8. A typical dressing station using pack dispensers. Ltd.)
(Photograph
FIG. 9. Contents of Basic Trolley Pack.
by courtesy of Capecraft
Ftc.
IO. Catheterisation.
FIG. 1 I. Intravenous
infusion.
FIG. 12. Rrmoval
of suture
FIG. 13. Bladder washout
FIG.
14.
Contents
FIG.
of injection
15.
Introduction
pack,
plus
s)-ringe
of Rylcs
and
needle.
tub?. Nurs.
f.p. 60-2
FIG. 16. Trolley
for dressing.
FIG. 17. Lumbar
F1c:. 18.
punctuw
c:ut chvn
wt.
set.
THE CEATRAL
STERILE
SL’PPLY DEP.dRT,I tE_hT-
Autoclave room
A separate room in which the autoclaves are situated makes it much easier to autoclaves control the temperature of the room. Two high pressure pre-vacuum are recommended. The sterilisation chamber is best rectangular in shape, as this gives a larger load, and enables the packs to be placed in cartons before sterilisation, thus saving undue handling of the packs. Having two autoclaves gives cover against breakdowns, and enables one to carry on working whilst the other is being overhauled. The autoclaves must be of the double ended type, the sterile end opening into the sterile store. This would eliminate the need for staff to carry sterile packs from an otherwise “unsterile” area. For sterilising the syringes and instruments in the aluminium tubes hot air ovens or conveyor sterilisers would be required. The conveyor types are to be preferred, as they give a larger turnover. Also, the conveyor can be run through the wall into the sterile store. Sterile store
Adjustable shelving, of the easily cleaned Formica types, are preferred to cupboards, as they give easy access, and enable staff to check the contents. The need for cleanliness andoperating theatre conditions in the sterile store cannot be over-stressed. There must certainly not be any direct access to any of the other rooms, especially the clean-up room. Trolleys carrying dirty items to the clean-up room must not be used for delivering sterile packs, and vice-versa. Bulk store
Again, plenty of adjustable shelving is necessary. Easy access to the work room is necessary. There should not be much need to provide much space for the storage of linen, as disposable towels are mostly used in the packs, except in the operating theatre. Supervisors’ o&e
This should be so situated as to give a clear view of the clean-up rooms. This can be accomplished by having half glass walls.
and packing
Locker room and toilets
A room large enough to take a locker for each member required. Two W.C.s would be necessary.
of the department
is
Staff rest room and showers
The rest room would be necessary if the department was not in a hospital building, or if these facilities were not provided. Experience has proved these to be totally inadequate, to say the least. The equipment required would be table and chairs, facilities for drinking water, and facilities for the making of hot drinks. A vending machine would be excellent. Showers
In the interests of hygiene and health of the staff, I think these are essential, especially as the conditions would be warm and humid. Two showers should suffice, if possible, sited next to the locker room,
62
A.JOH.MWh'
For ease of showing staff the type of room they are about to enter, doors are painted different colours, i.e. red for the clean-up room, denoting the area contaminated; blue for the packing room and bulk store, denoting the articles are clean, but unsterile; and green for the sterile store, denoting the packs are sterile.
Clean-up room (Red area1
Staff
Bulk store (Blue area)
rooms and toilets
b. ---_i
Autoclave room (Blue orco)
1
’
Sterile store (Green area)
I
(I. Infro-red steriliscr b. Conveyor c. Autoclaves
FIG. 3. Plan of the C.S.S.D.
Materials
I
(This is not necessarily the plan of all C.S.S.D.s ideal arrangement of the rooms.)
but shows the
used in the C.S.S.D.
Stainless steel. Instruments constitute the highest proportion of stainless steel ware used. Bowls, receivers and gallipots are being replaced by foil items, or polypropylene ware. Ward stocks of the stainless steel ware are usually used when starting the department, but are bulky, noisy, heavy, and very expensive to replace.
patterns of bowls, receivers and gallipots Po&ropylene ware. The conventional are manufactured. They are light, quiet to use, nest easily, and are comparatively cheap to buy. Care must be taken when packing, however, to see that heavy articles are not placed on top of packs containing this material. When heated, the material becomes softened, easily pressed out of shape. It hardens again when returning to room temperature. Metal foil. This is a more recent introduction to the range of materials used. It is very cheap to buy, quiet to use, and, is disposable. This material is becoming the more popular material used in the packs.
THE CENTRAL
STERILE
63
SUPPLY DEPARTMENT
Aluminium tubes. Syringes and small instruments are sterilised in these. They are comparatively cheap to buy, and virtually everlasting. The tubes may be The metal foil is to be preferred, as once sealed by metal foil, or by screw caps. the seal is broken it cannot be replaced.
Nylon jilm. This material has been used to wrap the inner packs. It has an excellent bacterial barrier effect, but can only be used once, as it becomes brittle when resterilised. It is quite dear to buy. It has the advantage in that the contents of the pack can be seen. Paper. This has been proved to be an excellent bacterial barrier, and allows It is very cheap to buy, the cost of a the easy entry of steam in the autoclave. dressing towel being Id., as against the cost of laundering a linen towel being an average of 3d. Some papers are plasticised, enabling them to be used as mackintoshes. The papers are usually expressed in pounds D.C., the weight of 480 sheets of Double Crown paper, 20” x30”. Outer wraps are of the 26 to 28 lb type, whilst the inner wraps are of the 20 lb type. Cardboard cartons. These are used to contain items, or when the pack is a bulky one.
Starting IN PLANNING
the C.S.S.D.,
and protect
packs containing
glass
a C.S.S.D.
one has to consider the following facts very thoroughly:
1. The pack system which is to be used has to be worked out. Frequent procedure meetings will have to be attended, with the Matron, ward sisters, tutors, pharmacist, and C.S.S.D. supervisor present. Every perceivable procedure carried out at the hospital has to be discussed, so that the pack contents can be agreed upon. Are the packs to be of the composite type, or are they to be basic packs, supplemented by special packs ? Are disposable syringes to be used, What type of forceps are going to be used in the packs, Are stitch cutters going to be used instead of stitch scissors? There are so many such facts to be agreed upon. Of course the type of hospital will play a large part, whether it is a teaching hospital or not. 2. Many samples from firms will have to be tested before one is satisfied. If one firm’s products can be used in toto, then the ordering and delivery of the articles will be made easier. 3. The numbers of packs required by the wards will have to be worked out. This can be arrived at by searching through the ward report books, injection charts, etc., and getting a six-monthly average figure. I found that if one uses less than six months for an average, one is apt to arrive at a seasonal figure, i.e. I found that at least 40 more injection packs were required per 24 hours in the winter months, because of cases of bronchitis, asthma, etc., than in the summer months. Similarly, more suture packs were required by the casualty department during the months of July and August, because of the holiday periods. I think if one finds the average number for a six-monthly period, and adds half again, this should
.4. JOHNSON
64
except in the case of a major disaster. Because of this chance, and also to give coverage for two days, one should try and carry 24 times the ward issues in the sterile store. suffice,
4. The method of delivery of the packs must be decided upon. Also, the way that packs are to be stored on the wards. Are existing cupboards going to be converted, or are pack dispensers going to be ordered? Are the instruments to be placed in detergent solution after use, or are they to be left dry? Experience has found that the prolonged soaking in the wards has resulted in the instruments being rusted. A ten minute soak in Pyroneg on arrival at the C.S.S.D. is enough to loosen any proteinous substances on the instruments. 5. The method of collecting used articles from the wards must be decided. Are panniers, buckets, baskets, or cartons to be used ? One must also work out the number of times a day one is going to deliver and collect to and from the wards. This will depend on the type of hospital being supplied. 6. Finally, but by no means least, the layout of the department itself must be This depends on the facilities available, or whether a new carefully planned. department is being built. If so, then there must be frequent consultations with the Hospital Secretary, engineers, builders, etc. One is well advised to read the various reports by Working Parties on the C.S.S.D., and, before ordering any equipment study all the information available on the different types, as such equipment is expensive. If the chance arises to visit another C.S.S.D., do not hesitate to take it, as the experience is invaluable. If existing facilities are to be converted, then one will have to be prepared to compromise to some extent. Two rooms are required, but one room can be used with some excellent results. The layout of the room must be very carefully planned. The sterile packs must be kept separate from the unsterile ones, and labelled so. There will be some trouble with the storage of bulk stores, so it is best if these are ordered every three months, stored by the pharmacist, and drawn on a weekly basis. Methods
of the Distribution
of Packs
Methods of deliver_y of packs
A daily or twice daily delivery of packs is essential in the acute hospital, but may only be necessary every two days in the geriatric unit. Every precaution must be taken to prevent the packs becoming damp or wet, and also to protect them from damage to the outer wrap, and the contents. Special trolleys are now being manufactured for the purpose of delivering the packs. Most of these trolleys are some being in in the experimental stage. Fibre panniers are also manufactured, the form of pack dispensers. This form of delivery has great advantages for the District Nurse, and for the geriatric unit. One method used by some hospitals is to use the otherwise obsolete dressing drums. These are heavy, bulky, and do not carry many packs. Cartons may also be used, but care must be taken not to get these wet. Lids have to be replaced often, due to the wear and tear caused by the staff having to remove them so often. Finally, it has been known for redundant dinner trolleys to be converted into pack delivery trolleys. The following methods of distribution have been tried in various hospitals:
THE CEJVTR,4L STERILE Shelves
SUI’PLT- L’EP.4RTMEflT Worktop surfaces on top of shelves
for unsterile pocks
Shelves
for sterale
65
packs.
FIG. 6. Work-flow
adapted
to room.
1. The one-for-one exchange system. A used pack is exchanged for a sterile one, thus keeping the number of packs on the wards at a predetermined number. A trial period is required to find out the number of packs required by the wards. 2. Topping up method. I find that this method is the best. The wards are issued with a set number of packs, after reference to ward reports, treatment cards, etc., for a period of one month. The average number of procedures is then applied to the types of packs issued. The method soon works out its own numbers required. After this number has been reached, it is easy for staff collecting used articles in the mornings to note down packs used, these being delivered later by the C.S.S.D. staff. The only other alternative is to take round a large number of packs, topping up the numbers as one visits each ward. It has been found, however, that this method would require a very large trolley to carry the packs required. 3. Pannier method. The C.S.S.D. load specially designed panniers or trolleys with enough packs for the 24 hours. This is left in the ward clinical room, being exchanged for a similar trolley next morning, whether all the packs have been used or not. 4. Requisition method. The ward sister orders her daily requirements in advance. This method has the disadvantage that the wards are apt to over stock, packs may be hoarded, and one of the aims of the C.S.S.D, is to remove as much paper work as possible. Syringes. Special boxes exchanged on a one-for-one left in the box. Of course, actually been used, one can
containing a predetermined number of syringes are basis, irrespective of the number of unused syringes if one does wish to check how many syringes have count the empty containers.
Collection of items. Trolleys used for the collection of used items should not be used for the delivery of sterile packs, and vice-versa. In fact, the two trolleys should be of entirely different design.
A.JOHNSON
66
If panniers are used, then those containing used instruments and foil should have red lids, those containing unused items blue lids, and sterile items green lids. Syringes should be placed in polythene buckets having red lids. Empty syringe containers may be placed in a carton, or in string bags. It is strongly recommended that one person should be responsible for the collection service, and one for the delivery service. Packs issued by other C.S.S.D.8.
THESE packs are mentioned to give an idea of how packs can vary, and to show how different types of hospital require more special packs. One can, however, vary the contents to suit one’s needs. Soft packs 1. Large dressing packs 2 pieces wool, 9” X6”,
1 foil gallipot, 3 gauze squares, 4”X4”, 3 gauze squares, 3”X3”, 8 cotton wool balls, 1 disposable dressing towel. Wrapped in Sterifield, in paper bag. 2. Small 3 3 8
dressing pack
gauze squares, 4” X4”, gauze squares, 3”X3”, cotton wool balls, 1 foil gallipot, 1 disposable dressing towel. Wrapped in Sterifield, in paper bag.
Supplementary packs 1. 2 pieces 9”X6” wool, in bag,
2. Gauze squares, 4”~ 4” 3 in each bag, Gauze squares, 3” x “3 > 3. Cotton wool balls, 8 in bag, 4. Maternity pads, 1 in bag, 5. Ribbon gauze, rX6 yd, in bag, 6. Ribbon gauze, 1” X 6 yd, in bag, 7. Ribbon gauze, 2” x6 yd, in bag. Casualty packs Toilet and suture pack 12 gauze squares,
3”X3”, 8 cotton wool balls, 1 foil gallipot, 1 disposable dressing towel. Wrapped in dressing towel, in bag.
THE CE.NIRAL
Incision puck 12 gauze squares,
STERILE
SlJppty
l3EPARTMENT
67
3” X 3”,
1 piece wool, 9” X 6”, 8 cotton wool balls, 1 foil gallipot, 1 disposable dressing towel. Wrapped in dressing towel, in bag. Miscellaneous
Receivers, graduated jugs, funnel and tubing, douche can, catheter introducers, are all placed in bags, after being wrapped in disposable dressing towels. Catheters are wrapped in Sterifield paper before being placed in the bags. Special packs Bone marrow
1 foil tray, 2 foil gallipots, 6 cotton wool balls, 6 gauze squares, 3”~ 3”, 1 bone marrow needle, 1 pair dressing forceps, 2 disposable dressing towels. Wrapped in linen dressing towel and CSS paper. Carotid aortogram
1 receiver, 2 gallipots, 2 carotid needles, 3 aspiration needles, 20 cc. Luer lock syringe, 10 cc. Luer lock syringe, 1 pair large artery forceps, 2 three-way taps, 2 hypodermic needles, 1, 2, 12, 17, and 20, 8 gauze squares, 3” x 3”, 8 cotton wool balls, 1 30 cc. glass and metal syringe, 3 linen towels. Wrapped in two linen towels and CSS paper. Chest aspiration
1 foil tray, 2 foil gallipots, 1 pair dressing forceps, 6 aspiration needles, assorted sizes, 1 B.P. handle, 1 50 cc. syringe,
68
d. JOHjVSON 1 two-way tap with rubber tubing, 6 gauze squares, 3” x 3”, 6 cotton wool balls, 2 linen dressing towels, 1 hand towel, 1 P-pint jug. Liver biopv 1 foil tray, 2 foil gallipots, 8 cotton wool balls, 6 gauze squares, 3”x3”, 1 liver biopsy needle, short, 1 stillete, 1 sharp pointed probe, 1 small needle valve, 2 linen dressing towels, 1 B.P. handle, 1 hand towel, Wrapped in linen dressing towel and CSS paper. Male catheterisation set 1 boat, 1 foil bowl, 2 foil gallipots, 12 cotton wool balls, 6 gauze squares, 3” x 3”, 2 pairs dressing forceps, 1 linen dressing towel, 1 Sterifield paper. Wrapped in linen towel, in bag. Renal and femoral arteriogram 1 large receiver, 2 stainless steel gallipots, 2 renal needles, 2 hypodermic needles, size 1, 2, 12, 17, and 20, 2 two-way taps, 2 aspiration needles, 1 large artery forcep, 1 B.P. handle, gauze swabs, 3” X 3”, 8 cotton wool balls, 1 30-cc. glass and metal syringe, 1 30-cc. metal syringe, 20- and IO-cc. Luer lock syringes, 4 linen towels, 1 abdominal sheet. Wrapped in 2 linen towels and large CSS paper.
THE CENTRAL
Translumbar
STERILE
SUPPLI^ DEPi4RTME.NT
aortogram
1 receiver, 2 gallipots, 2 translumbar needles, 2 three-way taps, 2 aspiration needles, 1 pair large artery forceps, 1 B.P. handle, 6 gauze squares, 3” X 3”, 8 cotton wool balls, 1 30-cc. glass and metal syringe, 3 linen towels, 1 abdominal sheet. Wrapped in two linen towels and CSS papers. Separate packs containing gowns, gloves and towels are given with each aortogram pack.
Dressing packs are as those above, gauze squares and cotton wool balls.
with slight variations
The special packs issued are as follows: Skin packs 2 stainless steel receivers,
2 stainless steel medium porringers, 2 stainless steel gallipots, 5 gauze dressings, 10” ~6” (2 layers), 10 cotton wool balls, 4 clinical swabs, 3 pairs disposable forceps wrapped in Sterifield paper. Biopsy packs 4 disposable
foil trays, 1 disposable bowl, 3 foil gallipots, 10 gauze swabs, 10 cotton wool balls, 2 clinical sheets, 2 linen dressing towels, 1 sheet Sterifield paper, 4 pairs disposable forceps, 1 biopsy towel.
Biopsy instruments
1 pair eye scissors, 1 No. 3 scalpel handle, 2 Ghillies hooks, 1 needle holder,
in the numbers
of
A.3OHNSON
70
1 pair artery forceps, 1 pair non-toothed forceps, 1 pair toothed forceps, 1 pair epilating forceps, 3 B.P. blades, 3 curved cutting needles, and Mersilk. EL. 7: anaesthetic pack 2 foil trays, 2 gallipots, 2 bowls, 2 dressing towels. Two packs per box. Supplementary pack to above flack
10 gauze swabs, in bag, 10 cotton wool balls, in bag, 8 Fillin needles, 4 per bag. Burns dressing pack
12 clinical sheets, 4 rolls wool, Q wool roll size, 4 Kling bandages, 3 rolls gauze, 6 masks, 6 wooden spatulae, 20 gauze swabs, 20 cotton wool balls, 2 gowns, 4 pairs disposable forceps. Burns linen, bed 2 sheets, 3 draw sheets,
Burns linen, cot 3 cot sheets,
2 draw sheets, 2 pillow cases, 4 napkins, 1 small coat.
3 pillow cases.
Mouth tray
1 clinical sheet, 1 tray, 3 gallipots, 1 pair disposable forceps, old linen, 2 wool squares, 2”~2”, in bag. Head tray
1 foil tray, 2 clinical sheets, 2 stainless steel gallipots, 10 cotton wool balls.
4” dia.,
THE CENTRAL
STERILE
71
SUPPLY DEPARTME.NT
Aspiration tray
Enema pack
1 funnel, length rubber tubing, connexion, rubber catheter.
1 stainless steel gallipot, 1 stainless steel receiver, 1 4-0~. glass measure, 1 clinical sheet.
Buttock tray, baby
1 small stainless steel tray, 1 stainless steel gallipot, 10 cotton wool balls. Those described above are packs supplied by hospital C.S.S.D.s. are a few of the packs that may be purchased from firms. These packs are sold either unsterilised or sterilised: Luxan Hospital
The following
Supplies Co.
Vaginal dressing pack
1 sheet CSS sterile field paper, 8 large cotton wool balls, 1 maternity pad, 1 gauze swab, 4” x4”, 1 sheet CSS sterile field paper used as wrap.
7/w
813
Ward dressing pack, large
1 sheet CSS sterile field paper, 10 large cotton wool balls, 4 gauze swabs, 4”~4”, 1 gallipot. Wrapped in sterile field paper.
lO/ll,
11/4
Ward dressing pack, small
1 sheet CSS sterile field paper, 5 large cotton wool balls, 2 gauze swabs, 4” x4-“, 1 gallipot. Wrapped in sterile field paper.
81%
815
5/l 4
612
12/g,
13/3
Abortion pack
1 sheet CSS sterile field paper, 6 large cotton wool balls, 1 maternity pad. Wrapped in CSS sterile field paper. Post operative dressing pack
1 sheet CSS sterile field paper, 10 large cotton wool balls, 4 gauze swabs, 2 absorbent dressing pads, 1 gallipot. Wrapped in CSS sterile field paper.
72
A. JOHNSON
Maternity
pads, individually
wrapped.
17/- gr,
19/S gr
2O”X20” CSS sterile field paper, folded, in 10s.
124/- per 840
20” X 18” 2-ply dressing towels, folded, in 10s.
107/- per 840
Packs supplied by Vernon and Co. Ltd. Minor injury pack 4 cotton wool balls,
Post operative pack 6 large cotton wool balls,
2 gauze swabs, 3” x 3”. Single tye pack 4 small cotton
wool balls,
Delivery pack 24 large cotton
2
4 2
Swabbing pack, maternity 6 large cotton wool balls,
1 maternity
1 eye pad.
3 8
4 gauze swabs, 4” x4”, 1 dressing sheet, 18” x 24”.
wool balls, dressing sheets, gauze swabs, 4” x 4”, maternity pads, cord ligatures, 12” lengths, gauze tissue pads, 8” x 11”.
pad.
Swabbing pack 6 large cotton
wool balls, 2 gauze swabs, 4” x4”.
The above are just a few of the very large range of packs supplied There is also a large range of supplementary packs.
by this firm.
It can be seen that the packs supplied by firms are particularly suitable for use in casualty stations in industry, and for use by the district nurses and midwives. The costs are not much higher when buying presterilised packs, as can be seen from the prices of the packs by Luxan Hospital Supplies Co., being within the range of threepence to fivepence per dozen more than the unsterilised costs. If the cartons containing the packs could be used as a dispenser, then the packs would be very cheap for the price.
The
WITH
C.S.S.D. and the Operating
Theatre
the introduction of a C.S.S.D. into a hospital, it becomes immediately apparent that the pack system would save much time in the operating theatre. For instance, one pack would be required per trolley, instead of the present system of using approximately six dressing drums, i.e. for towels, mackintoshes, abdominal sheets, surgeons’ gowns, gloves, swabs, etc. All these dressing drums take up a large amount of the rather limited space in the theatre, not to mention the hazards caused when setting.up a trolley whilst an operation is in progress. The “communal drum” constitutes the greatest danger I have actually seen surgeons taking gowns out to surgical asepsis in the theatre. of a drum with their hands after scrubbing up, thus contaminating not only the gown they put on, but also the remaining gowns left in the drum. Cheatles forceps are also a source of contamination, as the, tips can so easily become contaminated.
THE CE.NTRAL STERILE
SUPPLY DEPARTMENT
As in the wards, basic trolley packs are supplemented by special packs. following packs are issued to the theatre from the C.S.S.D. at our hospital:
73
The
Abdominal pack
This is the pack in most constant hospital. 1 abdominal
demand,
the hospital
being an acute general
sheet,
3 dressing towels,
1 dressing towel and CSS paper folded together, 1 mackintosh bag and linen cover for Mayos’ stand, 1 foil tray, 2 gallipots, 3 bundles Raytec swabs, tied in fives, 1 dressing towel to cover trolley. The whole contents are wrapped in a dressing towel and CSS paper, this being the sterile field on the trolley when the pack is opened. The whole contents are then placed in a sterilisation bag. For most operations, this pack need only be supplemented by the general set, lotions and ligatures.
E.N. ‘I: packs Tonsil pack
1 dressing towel and CSS paper folded together, 1 E.N.T. towel (towel with square hole in centre), 2 bundles E.N.T. swabs, tied in fives, 2 spools l/O linen thread. Two such sets are wrapped in a dressing towel and CSS paper, and placed in a sterilisation bag. Subsequent follow-on packs need only be wrapped in CSS paper, as they will be opened on the empty sterile field of the previous pack. This pack need only be supplemented by the tonsillectomy instruments. Nasalpack
1 dressing towel, 1 E.N.T. sheet, 1 bundle E.N.T. swabs, tied in fives, 2 gallipots, 2 lengths r and 1” ribbon gauze, 1 CSS paper and towel folded together. The whole contents are placed in a sterilisation bag after being wrapped in a dressing towel and CSS paper. This pack may also be used for aural operations, circumcisions, and minor operations. Anaesthetic pack
1 foil tray, 2 gallipots, 12 green swabs, 1 serum needle, 1 dressing towel to cover trolley. B
74
A. JOHNSON
The whole contents wrapped in towel and CSS paper, in sterilisation bag. This pack is supplemented with disposable syringes and needles, or by presterilised syringes and needles from the C.S.S.D. It may also be used as a stimulant tray, when supplemented with the drugs. Gown and towel pack 3 surgeons’ gowns, 3 hand towels, 1 towel to cover trolley. Two packs are supplied, Pack 1 being wrapped in a dressing towel and CSS paper, and containing two caps and masks. Pack 2, the follow-on pack, does not contain caps and masks, and is wrapped in CSS paper only. It is opened on the sterile field of Pack 1 after all have gowned up. The pack is supplemented by the appropriate sizes of gloves. These are packed in single pairs, except size seven, this being packed in threes, as it is the most commonly used size. Other sizes are SQ, 74, and size 8. Lithotomy pack This pack is used for operations calling for the lithotomy position. It is used mainly for haemorrhoidectomy and cystoscopy operations, and for dilatation and curettage. 1 lithotomy sheet, 3 dressing towels, 2 bundles Raytec swabs, tied in fives, 1 dressing towel and CSS paper folded together, 2 gallipots, 1 foil tray, 1 dressing towel to cover trolley. The whole contents wrapped in a towel and CSS paper, and placed in a sterilisation bag. To enable these packs to be used to their fullest advantage, they are supplemented by smaller packs, mainly extra dressings, towels, drainage tubes, instruments, etc. Some hospitals, especially in the United States, supply packs containing all the dressings, linen and instruments in one pack, the pack being supplied for a specific operation. This method, however, is very costly, and a very large range of packs is required. So far our method has worked very well. There has been no adverse effects using the CSS paper in the place of mackintoshes. It would be a great help if manufacturers would look into the matter of the antistatic properties of such papers. Up to now, no firm will guarantee their papers antistatic, although many are plasticised. The Application
of the C.S.S.D. to the Teaching Hospital
THE differences in techniques used when a Central Sterile Supply Department is introduced into a hospital are so great, that if the hospital happens to be a teaching
THE CENTRAL
STERILE
SUPPLY DEPARTAfENT
75
hospital, then the whole curriculum of the teaching aspects have to be completely changed. The nurse is not required to sterilise any articles, or wash any articles used. She is not required to make up the trolleys or trays from scratch, as it were, as the packs contain the basic necessities required, or, as in the United States, where composite packs are supplied for each procedure. In a teaching hospital, the pack contents must be so planned that the nurse has to add the necessary instruments or articles to a basic dressing pack, thus being able to learn the procedure, and what is required to carry it out. The system I have devised at our hospital, which is a teaching hospital for the State Enrolled Nurse, is such that the nurse is supplied with all the articles sterilised, but she has to make up the trolley from supplementary packs. Packs supplied to the wards
There are two main packs, namely, The contents are as follows:
a dressing
pack and an injection
pack.
Basic trollg pack 1 foil tray, 2 pairs dressing forceps, 2 foil gallipots, 10 gauze swabs, 5 cotton wool balls, 2 disposable towels, 1 disposable hand towel. (wrapped in sterile field paper) 2 pairs disposable forceps, 1 disposable hand towel. The whole contents are placed in a heat-seal bag.
This pack may be used for all ward procedures, when supplemented by the special articles required, as can be seen in Figs. 10 and Il. A second dressing pack, designed for use in a stainless steel tray, where the procedure is a minor one, or where a trolley is not required, is also issued, as follows: Minor dressing pack 1 foil tray, 2 foil gallipots, 5 gauze swabs, 5 cotton wool balls, 2 pairs disposable forceps, 2 disposable dressing towels, 1 disposable hand towel. (wrapped in sterile field paper) Placed in heat-seal bag.
This pack has been found very suitable for use by the night staff. As can be seen from Figs. 12 and 13, this pack can be readily adapted for any minor procedure.
76
A. 30HJGON
Injection pack 1 foil tray, 1 foil gallipot, 3 cotton wool balls, 1 disposable hand towel, Placed in heat-seal bag. Although meant for injections, this small pack may also be utilised for taking blood specimens, for instilling eye drops or ointments, for taking mid-stream specimens of urine, and for introducing Ryles’ tubes (see Fig. 15). Supplementary packs consist of presterilised catheters, syringes and needles, these being the disposable types, sterilised by Gamma radiation. The supplementary packs supplied by the C.S.S.D. are as follows: Gauze swabs, 5 in bag, Cotton wool balls, 5 in bag, Cotton wool rolls, wrapped in sterile field .paper, in bag, Maternity pads, in bag, Ribbon gauze, 4” and I”, two lengths of each in bag, 3”, 1 in bag, Bladder drainage tube and connexion, 1 in bag (this may also be used to make up an enema tray), Bladder syringes, 1 in sterile field paper, in bag, Ryles tubes, 1 per bag, Rectal catheters, flatus tubes, 1 per bag, Syringes for giving paraldehyde injections, wrapped in nylon foil, Instruments, 1 per bag, Graduated jugs 1 all wrapped
in clinical
Basic dressing technique using packs The basic aseptic dressing technique sequence of events is as follows :
sheet,
1 per bag.
has had to be adapted
to the packs.
The
1. Swab top of trolley with Hibitane 1: 2000 in spirit, using a disposable tissue. Leave the surface wetted for at least four minutes, whilst preparing the trolley. 2. Place the appropriate packs, lotions, bandages, etc., on the bottom shelf of the trolley. Clip a paper bag on the left hand side of the trolley to receive soiled dressings. Clip a similar bag in position on the back of the trolley to receive unused A third bag, the outer bag of the pack, will be clipped items after the procedure. in position when the pack is opened, to receive used instruments. 3. Wipe shelf dry with disposable
tissue.
Cut open outer pack, sliding the 4. Don mask, and wheel trolley to bedside. Hang bag on the right hand side of inner pack onto the top shelf of the trolley. the trolley. Loosen bandages, or strapping, leaving dressing only in position. 5. Wash hands, and dry on disposable tissue. Using the disposable forceps found on the top of the inner pack, open out the sterile field paper. Hold gallipot
THE
CE.YTRAL
STERILE
S(‘PPLY
77
DEP:iRTAfE,~VT
in forceps and pour out the appropriate lotion. Take care not to spill any lotion on the sterile field. 6. Place the disposable forceps on the edge of the sterile field, point innermost. 7. Scrub up. Dry hands on the disposable hand towel found in the pack contents. 8. Remove the soiled dressing, using one pair of the disposable forceps previously used to open the pack. Discard the dressing into the soiled dressing bag, and the forceps, points uppermost, into the used instrument bag. 9. Using the second pair of disposable forceps, and one pair from the foil tray, open out a disposable dressing towel and place below the wound, making a second sterile field. 10. Using the same forceps, wring out a cotton wool ball in the lotion, and place one pair of the forceps on the second sterile field. 11. Hold the cotton wool ball in the second pair of forceps, and clean the wound, swabbing from the wound outwards. Use each wool ball once only. Discard each swab after use into the soiled dressing bag. Discard the forceps into the used instrument bag. 12. Using third pair of forceps, and scissors or clip removers, remove sutures Discard the scissors into the used instrument bag. or clips if required. 13. Swab wound dry, holding swab in the forceps. 14. Using third and fourth pairs of forceps, place clean dressing in position. Fix dressing in position, and make the patient comfortable. 15. Screw up the sterile field papers, together with the soiled dressing bag. Place these in the ward incinerator on return to the clinical room, or into the refuse bag. Tip out the used instruments into the bucket provided by the C.S.S.D. Place the unused dressings into the pannier provided. Special packs issued to the wards
For speed in setting up for the more specialised issued, containing all the articles required.
procedures,
special packs are
Lumbar puncture set
1 foil tray, 2 gallipots, 5 gauze swabs, 3 cotton wool balls, 3 disposable dressing towels, 1 manometer, complete with rubber tube and adaptor, 2 spinal needles, 2 lumbar puncture needles (1 with 2-way tap), 2 specimen bottles, 1 disposable hand towel. Wrapped in CSS paper, in Permapak box. Cut down set
This set may department.
be also used for the suturing
of lacerations
in the casualty
A. JOHNSOA'
1 foil tray, 2 gallipots, 10 gauze swabs, 5 cotton wool balls, 2 pairs dissecting forceps, toothed, 4 pairs Mosquito forceps, 1 aneurysm needle, 1 pair small sharp-pointed scissors, 1 pair small needle holders, 1 R.P. handle, No. 3, 2 Hamilton-Bailey cannula, 2 disposable hand towels, 2 disposable dressing towels, 2 atraumatic mersilk sutures, with cutting needles, 2 scalpel blades, No. 15. The whole contents
are wrapped
in CSS paper
and placed in a sterilisation
Paracmt~sis .ret . Southeys’ tubes,
rubber tubing to fit above, gate clip or clamp, guest cannula, 2 pairs dissecting forceps, 1 pair artery forceps, 1 No. 3 scalpel handle, 1 pair stitch scissors, 2 specimen bottles, 5 cotton wool balls, 10 gauze swabs, 1 foil tray, 2 gallipots, 3 disposable dressing towels, 2 disposable hand towels. Wrapped in CSS paper, in Permapak Burns tack,
box.
bedding
1 bed or cot sheet, 1 draw sheet, 4 linen dressing towels. Wrapped in CSS paper.
RCsuzn~L’tbullition ne peut dCtruire Its spores et comme ces derniers reprksentent les organismes chirurgicaux les plus importants, comme le tetanus, la gangrene de gaz, etc., on doit arreter de se servir dc la mkhode de sterilisation par Cbullition. Le contenu des autoclaves B pansemcnts est aistment contamint. Le fait m6me que Ies autoclaves sont ‘communaux’ comportc Ic plus grand risque qui soit pour de materiel pour l’asepsie, &ant donnf que chaque autoclave contient sufiamment 8 k 10 utilisations.
bag.
THE CENTRAL
STERILE
SUPPLY DEPARTMENT
en tliminant le besoin de Comment peut-on Cviter ces risques. 2 Tout d’abord, Ensuite, en fournissant, en un seul sttfrilisation dans les services d’hospitalisation. paquet, tous les pansements, serviettes, petits pots, etc., qui sont requis pour une utilisation. Une methode de ce genre comprend des avantages suppltmentaires immediats. Dans la Salle d’operation, le temps de preparation est jusqu’a six fois moindre et les mouvements y sont rtduits au minimum. Dans l’hopital universitaire, des paquets d’utilisation g&r&ale sont fournis, auxquels l’tleve-infirm&e ajoute le materiel ou les instruments sptciaux dont elle La necessitt de prottger les articles de la contamination reste encore a besoin. present; il est done essentiel d’effectuer la stricte segregation des materiels sterile, non sterile et contamine. 11 est preferable que les chariots de ramassage et de distribution Les boites, pharmacies portatives ou soient de modtles entierement differents. dispensateurs de paquets speciaux serviront a stocker les paquets dans les services d’hospitalisation. Le systtme a paquets reprtsente une methode meilleur marche, plus sure, plus rapide et plus silencieuse pour realiser la sttrilisation.
Resumen-La ebullicion no es capaz de destruir a las esporas, y coma Cstas constituyen 10s organismos quirurgicamente mh importantes, por ejemplo tttanos, gangrena gaseosa, etc., las tentativas de esterilizar por ebullicion deben cesar. El contenido de 10s tambores de aphitos se contamina facilmente. El hecho real de ser “colectivos” 10s tambores es el gran peligro para la asepsia, puesto que cada tambor contiene material suficiente para 8 a 10 curas. por elimination de 2 Coma pueden ser evitados estos peligros ? Primeramente, la necesidad de esterilizar en las salas; en Segundo lugar, suministrando todos 10s apositos, patios, recipientes, etc., necesarios para una cura, en un solo paquete. Este mttodo tiene inmediatas ventajas adicionales. En la zona de intervention se reduce a una sexta parte el tiempo de preparation. En dicha zona 10s movimientos se reducen al minima. En el hospital de ensenanza son suministrados paquetes blsicos, a 10s que la enfermera alumna agrega el equip0 especial 0 materiales necesarios. La conveniencia de protejer al material esttril de toda contamination, es no obstante vilida, por lo tanto 10s materiales esttriles, no esteriles y contaminados deben permanecer rigurosamente separados. Las carretillas de recoleccion y de suministro son preferibles de formas totalmente diferenciadas. Las cajas, cestas o distribuidores de paquetes especiales deben ser usados de manera tal que se almacenen 10s paquetes en las salas. El sistema de1 paquete complete aporta un mttodo barato, seguro, rapid0 y tranquil0 para llevar a cabo curas esteriles.
AHHOTaWiR-&nRW?HueM HeBOiJMOSKHO pa3pyUIuTb CuOpbl u TBK KPK CUOpbl HBJIRIOTCR CaMblMEi l'JIaBHhIMU XupyplW'leCKuMU OpraHu3Ma~lu, T3Kue KaK BO36yAuTenb CTOJI6HRKa, MaCnHHOKHcnbIe 6aKTepuu u T. A., nonbIT~u CTepunn3upoBaTb KAnR~eHMeM AOJI?KH~I 6bITb npeKpau&eeM. CoAep)KaHue 6apa6aHa O'leHb JICrKO 3arpR3HUTb. YTO 6apa6aB RBJlffeTCFI KaK pa3 UOTOMy, GKOMMyHa JIbfibIM)), OH npeACTaBJIfW' OuaCTWOCTb aCeIITRKe,TaK KaK Ka?KAbIti 6apa6aH CoAepRwT AoBonbHo MaTepuaJra Ha e-10 UpoqeAyp. &Ili yCTpaHuTb 3Ty OnaCTHOCTb ? Bo-nepsblx, yCTpaHUTb Hy?KAy CTepunu3upoBaTb B nanaTax, Bo-BTOPUX, CHa6HteHUeM nepesrrsowioro MaTepuana, IlOJIOTeHq YalIleK II T., A., HyiKHbIX AJIH npoqeAyp, B OAHOM naKeTe. TaKol cnoco6 UMeeT HenOCpeACTBeHHO AO6aBOvHOe npeuMy~ecTB0. B OnepaqUOHHOil npUrOTOBJIeHuR 6epyT He MeHbLue 9eM B 6 pa3 MeHblLIe BpeMeIni.~BurtteBAe B onepaquomiol noBuncaeTcn ~0 MUHUMyMa. ~KOJI~I MeAcecTep npu 6OnbHUqax cua6maloT OCHOBHNMU UaKeTamu, fi KOTOpblM yYaWaJWFl MeACeCTpa npU6aBJrneT HyHCHbIe CneqUanLUOe CHapRHteHUe UJIU MaTepUaJI. I~eO6XOAUMOCTb 3allJUTUTb CTepUnbllyIO 9aCTL UpeAMeTOB OT 3al'pl?TaHeHuEleIIJ@ CMIl(eCTBy@T, IIO3TOMy CTepUJILHbIti, KeCTep-
79
80
A. JOHNSON IlJfbHbfiiII 3LWpR3IleIIHblti M~TC~liaJlbl ~OJl?Kltbl 6blTb CTl'Or0 H30JInpOUallbf. TponneM ,wfx cGopa 11 nocTamin maTepnana ~0JfmHar 6bfTb nywe Bcero cosepwemo paannrao# ~o~c~py~qffn. KopoB~a, Kapanffn mn cneqnanbnne ~qnrrn hfory~ 6bfTb npnhfeHeHbf ~nff XpaHeHnR naKeTOB B nanaTax. B uenohf naHeTffarf cncTeMa naeT C,onec ~emesbfti, Ha!4ewfrblfi, 6ncTpbrti of 6emyhi~bfi4 cnoco6 Bbfnomfeffm acenTn9ecwfx nposenyp.
Pergamon Press, 1966.
Printed in Great Britam
The Central Sterile Sup&
Department
The Central Sterile Supply Department
TIIE function of the C.S.S.D. is to supply sterile equipment, so that it may be used immediately, without the need for any further sterilising being necessary by the ward or departmental staff. If working in conjunction with a sterile syringe service, it should be possible to dispense with the ward sterilisers completely. In the operating theatre, however, where the instruments are required quickly, and on the spot, it is best if these are sterilised by the theatre staff in the theatrc suite. Thus, it can be seen how much work, noise, and. wastage is removecl when a C.S.S.D. is introduced into a hospital. Facts in favour
of the C.3’S.l).
1. Immediate
use of sterile equipment.
2. Using disposable
towels makes a large saving in laundering
3. As the packs are used on one patient lessened.
only, the incidence
costs.
of cross infection
is
4. Less room is required in which to store the packs. Special pack dispensers are manufactured which allow only the lowermost pack to be removed at a time. thus ensuring that the packs are used in strict date rotation. 5. There is a drastic removal of noise, especially as regards stainless steel items. This has been replaced by foil or polypropylene ware. 6. Removal of the ward sterilisers would entail less work, leave more room in the clinical rooms, and make a large saving in electricity costs. Requirements for the smooth running of the department
1. There must be close liaison between the ward staff, C.S.S.D. staff, pharmacist, and the bacteriologist. 2. A good system of delivery
of bulk stores.
3. An agreement
to have equipment
or contract
4. A good system of delivery of collection of used items.
regularly
overhauled.
of packs to the wards and departments, 5Y
and also
A.JOHNSON
60
The C.S.S.D. as a Department Basic accommodation The Mowing rooms are considered essential in the C.S.S.D. being newly built. Hospitals converting existing facilities would find great difficulty in providing all these rooms, and have to compromise. 1. Clean-up room, 2. packing and work room, 3. autoclave room, 4. sterile store, 5. bulk store, 6. supervisors’ office, 7. staff locker room and toilets. Additional These building, 1. 2.
accommodation will have to be provided in a department or where such facilities do not exist. Staff rest room, showers.
Clean-up room The following
equipment
is used in the clean-up
not
included
in a hospital
room:
a. High pressure taps for the washing and rinsing of rubber tubing, etc.; b. facilities for the rinsing and pre-soaking of articles; c. a high-pressure jet washing machine, for washing syringes, stainless steel items, etc. ; d. if the above washer does not incorporate a drying element, then drying cabinets must be provided ; e. plenty of work-top space is essential, and of the easily cleaned and nonabsorbable type, i.e. Formica ; f. ultrasonic cleaning apparatus may have to be provided if many instruments are to be processed. I do not think that facilities for the processing of surgeons’ gloves or hypodermic needles arc necessary, as it has been proved that using the disposable types is more economical, and safer. A strict daily cleaning of the work surfaces is essential, to prevent the build up of bacteria. Packing room Plenty of work-top space is required on which the packs are assembled. A direct access to the bulk store is necessary, to enable stores to be withdrawn quickly as required. Adjustable shelving may be required, on which packs may be stored, A capping machine would be necessary if syringes and awaiting sterilisation. instruments are to be supplied in aluminium tubes. A heat-seal machine for the sealing of the sterilisation bags is of prime importance. Special illuminated tables are manufactured for the folding and checking of linen. These would be required if the department was supplying an operating theatre.
FK. 1. Pack dispenser.
(By courtesy of Cuxon-Gerrmd
Ltd.)
Nurs.
f.p. 60-I
FIG. 2. The ideal autoclave for the C.S.S.D.
(By courtesy of British Sterilizers Ltd.)
FIG. 4. Foil articles
in use in the C.S.S.D.
(By courtesy
of Bowater-Scott
Corporation
Ltd.)
(153) The contents of the pack-gauze, cotton wool, cellulose wadding, etc.-are placed in a which acts as the sterile area when the pack is receiver in the centre of the INNER WRAPPER opened for use. Underneath is the OUTER PROTECTIVE wrapper. is folded over in the manner shown so as to cover the contents. (Cenlre) The INNER WRAPPER (Right) The paper is again folded over so as to enclose the contents.
(Left) Both ends are neatly folded over the contents so that the wrapper can easily be opened when required. (Gxtre) The forceps in a paper bag or wrapper which will be used for opening the inner wrapper are then put on top. (Ri+t) A paper towel is put on top. This is for use as a sterile towel by the doctor or nurse who will be using the pack.
(12)) One corner of the OUTER WRAPPER is now folded over so as to cover the top of the contents and the corner folded back on top. (Centre) In a similar manner the paper is folded over to the centre of the pack and the corner turned back. (Rig/d) Fold the third corner over in a similar manner.
(I.&) Then turn pack round and remaining flap of paper is folded over and tucked undrr the two top folds. (Cenlre) Leave the corner projecting out. (Right) When the pack is ready to be used pull the corner out and open. The OUTER WRAPPER is opened by a person who need not be ‘scrubbed up’. FIG. 5. How to make up a sterile dressing pack. Ltd.)
(By courtesy of Bowater-Scott
Corporation
,td.)
&IG. 8. A typical dressing station using pack dispensers. Ltd.)
(Photograph
FIG. 9. Contents of Basic Trolley Pack.
by courtesy of Capecraft
Ftc.
IO. Catheterisation.
FIG. 1 I. Intravenous
infusion.
FIG. 12. Rrmoval
of suture
FIG. 13. Bladder washout
FIG.
14.
Contents
FIG.
of injection
15.
Introduction
pack,
plus
s)-ringe
of Rylcs
and
needle.
tub?. Nurs.
f.p. 60-2
FIG. 16. Trolley
for dressing.
FIG. 17. Lumbar
F1c:. 18.
punctuw
c:ut chvn
wt.
set.
THE CEATRAL
STERILE
SL’PPLY DEP.dRT,I tE_hT-
Autoclave room
A separate room in which the autoclaves are situated makes it much easier to autoclaves control the temperature of the room. Two high pressure pre-vacuum are recommended. The sterilisation chamber is best rectangular in shape, as this gives a larger load, and enables the packs to be placed in cartons before sterilisation, thus saving undue handling of the packs. Having two autoclaves gives cover against breakdowns, and enables one to carry on working whilst the other is being overhauled. The autoclaves must be of the double ended type, the sterile end opening into the sterile store. This would eliminate the need for staff to carry sterile packs from an otherwise “unsterile” area. For sterilising the syringes and instruments in the aluminium tubes hot air ovens or conveyor sterilisers would be required. The conveyor types are to be preferred, as they give a larger turnover. Also, the conveyor can be run through the wall into the sterile store. Sterile store
Adjustable shelving, of the easily cleaned Formica types, are preferred to cupboards, as they give easy access, and enable staff to check the contents. The need for cleanliness andoperating theatre conditions in the sterile store cannot be over-stressed. There must certainly not be any direct access to any of the other rooms, especially the clean-up room. Trolleys carrying dirty items to the clean-up room must not be used for delivering sterile packs, and vice-versa. Bulk store
Again, plenty of adjustable shelving is necessary. Easy access to the work room is necessary. There should not be much need to provide much space for the storage of linen, as disposable towels are mostly used in the packs, except in the operating theatre. Supervisors’ o&e
This should be so situated as to give a clear view of the clean-up rooms. This can be accomplished by having half glass walls.
and packing
Locker room and toilets
A room large enough to take a locker for each member required. Two W.C.s would be necessary.
of the department
is
Staff rest room and showers
The rest room would be necessary if the department was not in a hospital building, or if these facilities were not provided. Experience has proved these to be totally inadequate, to say the least. The equipment required would be table and chairs, facilities for drinking water, and facilities for the making of hot drinks. A vending machine would be excellent. Showers
In the interests of hygiene and health of the staff, I think these are essential, especially as the conditions would be warm and humid. Two showers should suffice, if possible, sited next to the locker room,
62
A.JOH.MWh'
For ease of showing staff the type of room they are about to enter, doors are painted different colours, i.e. red for the clean-up room, denoting the area contaminated; blue for the packing room and bulk store, denoting the articles are clean, but unsterile; and green for the sterile store, denoting the packs are sterile.
Clean-up room (Red area1
Staff
Bulk store (Blue area)
rooms and toilets
b. ---_i
Autoclave room (Blue orco)
1
’
Sterile store (Green area)
I
(I. Infro-red steriliscr b. Conveyor c. Autoclaves
FIG. 3. Plan of the C.S.S.D.
Materials
I
(This is not necessarily the plan of all C.S.S.D.s ideal arrangement of the rooms.)
but shows the
used in the C.S.S.D.
Stainless steel. Instruments constitute the highest proportion of stainless steel ware used. Bowls, receivers and gallipots are being replaced by foil items, or polypropylene ware. Ward stocks of the stainless steel ware are usually used when starting the department, but are bulky, noisy, heavy, and very expensive to replace.
patterns of bowls, receivers and gallipots Po&ropylene ware. The conventional are manufactured. They are light, quiet to use, nest easily, and are comparatively cheap to buy. Care must be taken when packing, however, to see that heavy articles are not placed on top of packs containing this material. When heated, the material becomes softened, easily pressed out of shape. It hardens again when returning to room temperature. Metal foil. This is a more recent introduction to the range of materials used. It is very cheap to buy, quiet to use, and, is disposable. This material is becoming the more popular material used in the packs.
THE CENTRAL
STERILE
63
SUPPLY DEPARTMENT
Aluminium tubes. Syringes and small instruments are sterilised in these. They are comparatively cheap to buy, and virtually everlasting. The tubes may be The metal foil is to be preferred, as once sealed by metal foil, or by screw caps. the seal is broken it cannot be replaced.
Nylon jilm. This material has been used to wrap the inner packs. It has an excellent bacterial barrier effect, but can only be used once, as it becomes brittle when resterilised. It is quite dear to buy. It has the advantage in that the contents of the pack can be seen. Paper. This has been proved to be an excellent bacterial barrier, and allows It is very cheap to buy, the cost of a the easy entry of steam in the autoclave. dressing towel being Id., as against the cost of laundering a linen towel being an average of 3d. Some papers are plasticised, enabling them to be used as mackintoshes. The papers are usually expressed in pounds D.C., the weight of 480 sheets of Double Crown paper, 20” x30”. Outer wraps are of the 26 to 28 lb type, whilst the inner wraps are of the 20 lb type. Cardboard cartons. These are used to contain items, or when the pack is a bulky one.
Starting IN PLANNING
the C.S.S.D.,
and protect
packs containing
glass
a C.S.S.D.
one has to consider the following facts very thoroughly:
1. The pack system which is to be used has to be worked out. Frequent procedure meetings will have to be attended, with the Matron, ward sisters, tutors, pharmacist, and C.S.S.D. supervisor present. Every perceivable procedure carried out at the hospital has to be discussed, so that the pack contents can be agreed upon. Are the packs to be of the composite type, or are they to be basic packs, supplemented by special packs ? Are disposable syringes to be used, What type of forceps are going to be used in the packs, Are stitch cutters going to be used instead of stitch scissors? There are so many such facts to be agreed upon. Of course the type of hospital will play a large part, whether it is a teaching hospital or not. 2. Many samples from firms will have to be tested before one is satisfied. If one firm’s products can be used in toto, then the ordering and delivery of the articles will be made easier. 3. The numbers of packs required by the wards will have to be worked out. This can be arrived at by searching through the ward report books, injection charts, etc., and getting a six-monthly average figure. I found that if one uses less than six months for an average, one is apt to arrive at a seasonal figure, i.e. I found that at least 40 more injection packs were required per 24 hours in the winter months, because of cases of bronchitis, asthma, etc., than in the summer months. Similarly, more suture packs were required by the casualty department during the months of July and August, because of the holiday periods. I think if one finds the average number for a six-monthly period, and adds half again, this should
.4. JOHNSON
64
except in the case of a major disaster. Because of this chance, and also to give coverage for two days, one should try and carry 24 times the ward issues in the sterile store. suffice,
4. The method of delivery of the packs must be decided upon. Also, the way that packs are to be stored on the wards. Are existing cupboards going to be converted, or are pack dispensers going to be ordered? Are the instruments to be placed in detergent solution after use, or are they to be left dry? Experience has found that the prolonged soaking in the wards has resulted in the instruments being rusted. A ten minute soak in Pyroneg on arrival at the C.S.S.D. is enough to loosen any proteinous substances on the instruments. 5. The method of collecting used articles from the wards must be decided. Are panniers, buckets, baskets, or cartons to be used ? One must also work out the number of times a day one is going to deliver and collect to and from the wards. This will depend on the type of hospital being supplied. 6. Finally, but by no means least, the layout of the department itself must be This depends on the facilities available, or whether a new carefully planned. department is being built. If so, then there must be frequent consultations with the Hospital Secretary, engineers, builders, etc. One is well advised to read the various reports by Working Parties on the C.S.S.D., and, before ordering any equipment study all the information available on the different types, as such equipment is expensive. If the chance arises to visit another C.S.S.D., do not hesitate to take it, as the experience is invaluable. If existing facilities are to be converted, then one will have to be prepared to compromise to some extent. Two rooms are required, but one room can be used with some excellent results. The layout of the room must be very carefully planned. The sterile packs must be kept separate from the unsterile ones, and labelled so. There will be some trouble with the storage of bulk stores, so it is best if these are ordered every three months, stored by the pharmacist, and drawn on a weekly basis. Methods
of the Distribution
of Packs
Methods of deliver_y of packs
A daily or twice daily delivery of packs is essential in the acute hospital, but may only be necessary every two days in the geriatric unit. Every precaution must be taken to prevent the packs becoming damp or wet, and also to protect them from damage to the outer wrap, and the contents. Special trolleys are now being manufactured for the purpose of delivering the packs. Most of these trolleys are some being in in the experimental stage. Fibre panniers are also manufactured, the form of pack dispensers. This form of delivery has great advantages for the District Nurse, and for the geriatric unit. One method used by some hospitals is to use the otherwise obsolete dressing drums. These are heavy, bulky, and do not carry many packs. Cartons may also be used, but care must be taken not to get these wet. Lids have to be replaced often, due to the wear and tear caused by the staff having to remove them so often. Finally, it has been known for redundant dinner trolleys to be converted into pack delivery trolleys. The following methods of distribution have been tried in various hospitals:
THE CEJVTR,4L STERILE Shelves
SUI’PLT- L’EP.4RTMEflT Worktop surfaces on top of shelves
for unsterile pocks
Shelves
for sterale
65
packs.
FIG. 6. Work-flow
adapted
to room.
1. The one-for-one exchange system. A used pack is exchanged for a sterile one, thus keeping the number of packs on the wards at a predetermined number. A trial period is required to find out the number of packs required by the wards. 2. Topping up method. I find that this method is the best. The wards are issued with a set number of packs, after reference to ward reports, treatment cards, etc., for a period of one month. The average number of procedures is then applied to the types of packs issued. The method soon works out its own numbers required. After this number has been reached, it is easy for staff collecting used articles in the mornings to note down packs used, these being delivered later by the C.S.S.D. staff. The only other alternative is to take round a large number of packs, topping up the numbers as one visits each ward. It has been found, however, that this method would require a very large trolley to carry the packs required. 3. Pannier method. The C.S.S.D. load specially designed panniers or trolleys with enough packs for the 24 hours. This is left in the ward clinical room, being exchanged for a similar trolley next morning, whether all the packs have been used or not. 4. Requisition method. The ward sister orders her daily requirements in advance. This method has the disadvantage that the wards are apt to over stock, packs may be hoarded, and one of the aims of the C.S.S.D, is to remove as much paper work as possible. Syringes. Special boxes exchanged on a one-for-one left in the box. Of course, actually been used, one can
containing a predetermined number of syringes are basis, irrespective of the number of unused syringes if one does wish to check how many syringes have count the empty containers.
Collection of items. Trolleys used for the collection of used items should not be used for the delivery of sterile packs, and vice-versa. In fact, the two trolleys should be of entirely different design.
A.JOHNSON
66
If panniers are used, then those containing used instruments and foil should have red lids, those containing unused items blue lids, and sterile items green lids. Syringes should be placed in polythene buckets having red lids. Empty syringe containers may be placed in a carton, or in string bags. It is strongly recommended that one person should be responsible for the collection service, and one for the delivery service. Packs issued by other C.S.S.D.8.
THESE packs are mentioned to give an idea of how packs can vary, and to show how different types of hospital require more special packs. One can, however, vary the contents to suit one’s needs. Soft packs 1. Large dressing packs 2 pieces wool, 9” X6”,
1 foil gallipot, 3 gauze squares, 4”X4”, 3 gauze squares, 3”X3”, 8 cotton wool balls, 1 disposable dressing towel. Wrapped in Sterifield, in paper bag. 2. Small 3 3 8
dressing pack
gauze squares, 4” X4”, gauze squares, 3”X3”, cotton wool balls, 1 foil gallipot, 1 disposable dressing towel. Wrapped in Sterifield, in paper bag.
Supplementary packs 1. 2 pieces 9”X6” wool, in bag,
2. Gauze squares, 4”~ 4” 3 in each bag, Gauze squares, 3” x “3 > 3. Cotton wool balls, 8 in bag, 4. Maternity pads, 1 in bag, 5. Ribbon gauze, rX6 yd, in bag, 6. Ribbon gauze, 1” X 6 yd, in bag, 7. Ribbon gauze, 2” x6 yd, in bag. Casualty packs Toilet and suture pack 12 gauze squares,
3”X3”, 8 cotton wool balls, 1 foil gallipot, 1 disposable dressing towel. Wrapped in dressing towel, in bag.
THE CE.NIRAL
Incision puck 12 gauze squares,
STERILE
SlJppty
l3EPARTMENT
67
3” X 3”,
1 piece wool, 9” X 6”, 8 cotton wool balls, 1 foil gallipot, 1 disposable dressing towel. Wrapped in dressing towel, in bag. Miscellaneous
Receivers, graduated jugs, funnel and tubing, douche can, catheter introducers, are all placed in bags, after being wrapped in disposable dressing towels. Catheters are wrapped in Sterifield paper before being placed in the bags. Special packs Bone marrow
1 foil tray, 2 foil gallipots, 6 cotton wool balls, 6 gauze squares, 3”~ 3”, 1 bone marrow needle, 1 pair dressing forceps, 2 disposable dressing towels. Wrapped in linen dressing towel and CSS paper. Carotid aortogram
1 receiver, 2 gallipots, 2 carotid needles, 3 aspiration needles, 20 cc. Luer lock syringe, 10 cc. Luer lock syringe, 1 pair large artery forceps, 2 three-way taps, 2 hypodermic needles, 1, 2, 12, 17, and 20, 8 gauze squares, 3” x 3”, 8 cotton wool balls, 1 30 cc. glass and metal syringe, 3 linen towels. Wrapped in two linen towels and CSS paper. Chest aspiration
1 foil tray, 2 foil gallipots, 1 pair dressing forceps, 6 aspiration needles, assorted sizes, 1 B.P. handle, 1 50 cc. syringe,
68
d. JOHjVSON 1 two-way tap with rubber tubing, 6 gauze squares, 3” x 3”, 6 cotton wool balls, 2 linen dressing towels, 1 hand towel, 1 P-pint jug. Liver biopv 1 foil tray, 2 foil gallipots, 8 cotton wool balls, 6 gauze squares, 3”x3”, 1 liver biopsy needle, short, 1 stillete, 1 sharp pointed probe, 1 small needle valve, 2 linen dressing towels, 1 B.P. handle, 1 hand towel, Wrapped in linen dressing towel and CSS paper. Male catheterisation set 1 boat, 1 foil bowl, 2 foil gallipots, 12 cotton wool balls, 6 gauze squares, 3” x 3”, 2 pairs dressing forceps, 1 linen dressing towel, 1 Sterifield paper. Wrapped in linen towel, in bag. Renal and femoral arteriogram 1 large receiver, 2 stainless steel gallipots, 2 renal needles, 2 hypodermic needles, size 1, 2, 12, 17, and 20, 2 two-way taps, 2 aspiration needles, 1 large artery forcep, 1 B.P. handle, gauze swabs, 3” X 3”, 8 cotton wool balls, 1 30-cc. glass and metal syringe, 1 30-cc. metal syringe, 20- and IO-cc. Luer lock syringes, 4 linen towels, 1 abdominal sheet. Wrapped in 2 linen towels and large CSS paper.
THE CENTRAL
Translumbar
STERILE
SUPPLI^ DEPi4RTME.NT
aortogram
1 receiver, 2 gallipots, 2 translumbar needles, 2 three-way taps, 2 aspiration needles, 1 pair large artery forceps, 1 B.P. handle, 6 gauze squares, 3” X 3”, 8 cotton wool balls, 1 30-cc. glass and metal syringe, 3 linen towels, 1 abdominal sheet. Wrapped in two linen towels and CSS papers. Separate packs containing gowns, gloves and towels are given with each aortogram pack.
Dressing packs are as those above, gauze squares and cotton wool balls.
with slight variations
The special packs issued are as follows: Skin packs 2 stainless steel receivers,
2 stainless steel medium porringers, 2 stainless steel gallipots, 5 gauze dressings, 10” ~6” (2 layers), 10 cotton wool balls, 4 clinical swabs, 3 pairs disposable forceps wrapped in Sterifield paper. Biopsy packs 4 disposable
foil trays, 1 disposable bowl, 3 foil gallipots, 10 gauze swabs, 10 cotton wool balls, 2 clinical sheets, 2 linen dressing towels, 1 sheet Sterifield paper, 4 pairs disposable forceps, 1 biopsy towel.
Biopsy instruments
1 pair eye scissors, 1 No. 3 scalpel handle, 2 Ghillies hooks, 1 needle holder,
in the numbers
of
A.3OHNSON
70
1 pair artery forceps, 1 pair non-toothed forceps, 1 pair toothed forceps, 1 pair epilating forceps, 3 B.P. blades, 3 curved cutting needles, and Mersilk. EL. 7: anaesthetic pack 2 foil trays, 2 gallipots, 2 bowls, 2 dressing towels. Two packs per box. Supplementary pack to above flack
10 gauze swabs, in bag, 10 cotton wool balls, in bag, 8 Fillin needles, 4 per bag. Burns dressing pack
12 clinical sheets, 4 rolls wool, Q wool roll size, 4 Kling bandages, 3 rolls gauze, 6 masks, 6 wooden spatulae, 20 gauze swabs, 20 cotton wool balls, 2 gowns, 4 pairs disposable forceps. Burns linen, bed 2 sheets, 3 draw sheets,
Burns linen, cot 3 cot sheets,
2 draw sheets, 2 pillow cases, 4 napkins, 1 small coat.
3 pillow cases.
Mouth tray
1 clinical sheet, 1 tray, 3 gallipots, 1 pair disposable forceps, old linen, 2 wool squares, 2”~2”, in bag. Head tray
1 foil tray, 2 clinical sheets, 2 stainless steel gallipots, 10 cotton wool balls.
4” dia.,
THE CENTRAL
STERILE
71
SUPPLY DEPARTME.NT
Aspiration tray
Enema pack
1 funnel, length rubber tubing, connexion, rubber catheter.
1 stainless steel gallipot, 1 stainless steel receiver, 1 4-0~. glass measure, 1 clinical sheet.
Buttock tray, baby
1 small stainless steel tray, 1 stainless steel gallipot, 10 cotton wool balls. Those described above are packs supplied by hospital C.S.S.D.s. are a few of the packs that may be purchased from firms. These packs are sold either unsterilised or sterilised: Luxan Hospital
The following
Supplies Co.
Vaginal dressing pack
1 sheet CSS sterile field paper, 8 large cotton wool balls, 1 maternity pad, 1 gauze swab, 4” x4”, 1 sheet CSS sterile field paper used as wrap.
7/w
813
Ward dressing pack, large
1 sheet CSS sterile field paper, 10 large cotton wool balls, 4 gauze swabs, 4”~4”, 1 gallipot. Wrapped in sterile field paper.
lO/ll,
11/4
Ward dressing pack, small
1 sheet CSS sterile field paper, 5 large cotton wool balls, 2 gauze swabs, 4” x4-“, 1 gallipot. Wrapped in sterile field paper.
81%
815
5/l 4
612
12/g,
13/3
Abortion pack
1 sheet CSS sterile field paper, 6 large cotton wool balls, 1 maternity pad. Wrapped in CSS sterile field paper. Post operative dressing pack
1 sheet CSS sterile field paper, 10 large cotton wool balls, 4 gauze swabs, 2 absorbent dressing pads, 1 gallipot. Wrapped in CSS sterile field paper.
72
A. JOHNSON
Maternity
pads, individually
wrapped.
17/- gr,
19/S gr
2O”X20” CSS sterile field paper, folded, in 10s.
124/- per 840
20” X 18” 2-ply dressing towels, folded, in 10s.
107/- per 840
Packs supplied by Vernon and Co. Ltd. Minor injury pack 4 cotton wool balls,
Post operative pack 6 large cotton wool balls,
2 gauze swabs, 3” x 3”. Single tye pack 4 small cotton
wool balls,
Delivery pack 24 large cotton
2
4 2
Swabbing pack, maternity 6 large cotton wool balls,
1 maternity
1 eye pad.
3 8
4 gauze swabs, 4” x4”, 1 dressing sheet, 18” x 24”.
wool balls, dressing sheets, gauze swabs, 4” x 4”, maternity pads, cord ligatures, 12” lengths, gauze tissue pads, 8” x 11”.
pad.
Swabbing pack 6 large cotton
wool balls, 2 gauze swabs, 4” x4”.
The above are just a few of the very large range of packs supplied There is also a large range of supplementary packs.
by this firm.
It can be seen that the packs supplied by firms are particularly suitable for use in casualty stations in industry, and for use by the district nurses and midwives. The costs are not much higher when buying presterilised packs, as can be seen from the prices of the packs by Luxan Hospital Supplies Co., being within the range of threepence to fivepence per dozen more than the unsterilised costs. If the cartons containing the packs could be used as a dispenser, then the packs would be very cheap for the price.
The
WITH
C.S.S.D. and the Operating
Theatre
the introduction of a C.S.S.D. into a hospital, it becomes immediately apparent that the pack system would save much time in the operating theatre. For instance, one pack would be required per trolley, instead of the present system of using approximately six dressing drums, i.e. for towels, mackintoshes, abdominal sheets, surgeons’ gowns, gloves, swabs, etc. All these dressing drums take up a large amount of the rather limited space in the theatre, not to mention the hazards caused when setting.up a trolley whilst an operation is in progress. The “communal drum” constitutes the greatest danger I have actually seen surgeons taking gowns out to surgical asepsis in the theatre. of a drum with their hands after scrubbing up, thus contaminating not only the gown they put on, but also the remaining gowns left in the drum. Cheatles forceps are also a source of contamination, as the, tips can so easily become contaminated.
THE CE.NTRAL STERILE
SUPPLY DEPARTMENT
As in the wards, basic trolley packs are supplemented by special packs. following packs are issued to the theatre from the C.S.S.D. at our hospital:
73
The
Abdominal pack
This is the pack in most constant hospital. 1 abdominal
demand,
the hospital
being an acute general
sheet,
3 dressing towels,
1 dressing towel and CSS paper folded together, 1 mackintosh bag and linen cover for Mayos’ stand, 1 foil tray, 2 gallipots, 3 bundles Raytec swabs, tied in fives, 1 dressing towel to cover trolley. The whole contents are wrapped in a dressing towel and CSS paper, this being the sterile field on the trolley when the pack is opened. The whole contents are then placed in a sterilisation bag. For most operations, this pack need only be supplemented by the general set, lotions and ligatures.
E.N. ‘I: packs Tonsil pack
1 dressing towel and CSS paper folded together, 1 E.N.T. towel (towel with square hole in centre), 2 bundles E.N.T. swabs, tied in fives, 2 spools l/O linen thread. Two such sets are wrapped in a dressing towel and CSS paper, and placed in a sterilisation bag. Subsequent follow-on packs need only be wrapped in CSS paper, as they will be opened on the empty sterile field of the previous pack. This pack need only be supplemented by the tonsillectomy instruments. Nasalpack
1 dressing towel, 1 E.N.T. sheet, 1 bundle E.N.T. swabs, tied in fives, 2 gallipots, 2 lengths r and 1” ribbon gauze, 1 CSS paper and towel folded together. The whole contents are placed in a sterilisation bag after being wrapped in a dressing towel and CSS paper. This pack may also be used for aural operations, circumcisions, and minor operations. Anaesthetic pack
1 foil tray, 2 gallipots, 12 green swabs, 1 serum needle, 1 dressing towel to cover trolley. B
74
A. JOHNSON
The whole contents wrapped in towel and CSS paper, in sterilisation bag. This pack is supplemented with disposable syringes and needles, or by presterilised syringes and needles from the C.S.S.D. It may also be used as a stimulant tray, when supplemented with the drugs. Gown and towel pack 3 surgeons’ gowns, 3 hand towels, 1 towel to cover trolley. Two packs are supplied, Pack 1 being wrapped in a dressing towel and CSS paper, and containing two caps and masks. Pack 2, the follow-on pack, does not contain caps and masks, and is wrapped in CSS paper only. It is opened on the sterile field of Pack 1 after all have gowned up. The pack is supplemented by the appropriate sizes of gloves. These are packed in single pairs, except size seven, this being packed in threes, as it is the most commonly used size. Other sizes are SQ, 74, and size 8. Lithotomy pack This pack is used for operations calling for the lithotomy position. It is used mainly for haemorrhoidectomy and cystoscopy operations, and for dilatation and curettage. 1 lithotomy sheet, 3 dressing towels, 2 bundles Raytec swabs, tied in fives, 1 dressing towel and CSS paper folded together, 2 gallipots, 1 foil tray, 1 dressing towel to cover trolley. The whole contents wrapped in a towel and CSS paper, and placed in a sterilisation bag. To enable these packs to be used to their fullest advantage, they are supplemented by smaller packs, mainly extra dressings, towels, drainage tubes, instruments, etc. Some hospitals, especially in the United States, supply packs containing all the dressings, linen and instruments in one pack, the pack being supplied for a specific operation. This method, however, is very costly, and a very large range of packs is required. So far our method has worked very well. There has been no adverse effects using the CSS paper in the place of mackintoshes. It would be a great help if manufacturers would look into the matter of the antistatic properties of such papers. Up to now, no firm will guarantee their papers antistatic, although many are plasticised. The Application
of the C.S.S.D. to the Teaching Hospital
THE differences in techniques used when a Central Sterile Supply Department is introduced into a hospital are so great, that if the hospital happens to be a teaching
THE CENTRAL
STERILE
SUPPLY DEPARTAfENT
75
hospital, then the whole curriculum of the teaching aspects have to be completely changed. The nurse is not required to sterilise any articles, or wash any articles used. She is not required to make up the trolleys or trays from scratch, as it were, as the packs contain the basic necessities required, or, as in the United States, where composite packs are supplied for each procedure. In a teaching hospital, the pack contents must be so planned that the nurse has to add the necessary instruments or articles to a basic dressing pack, thus being able to learn the procedure, and what is required to carry it out. The system I have devised at our hospital, which is a teaching hospital for the State Enrolled Nurse, is such that the nurse is supplied with all the articles sterilised, but she has to make up the trolley from supplementary packs. Packs supplied to the wards
There are two main packs, namely, The contents are as follows:
a dressing
pack and an injection
pack.
Basic trollg pack 1 foil tray, 2 pairs dressing forceps, 2 foil gallipots, 10 gauze swabs, 5 cotton wool balls, 2 disposable towels, 1 disposable hand towel. (wrapped in sterile field paper) 2 pairs disposable forceps, 1 disposable hand towel. The whole contents are placed in a heat-seal bag.
This pack may be used for all ward procedures, when supplemented by the special articles required, as can be seen in Figs. 10 and Il. A second dressing pack, designed for use in a stainless steel tray, where the procedure is a minor one, or where a trolley is not required, is also issued, as follows: Minor dressing pack 1 foil tray, 2 foil gallipots, 5 gauze swabs, 5 cotton wool balls, 2 pairs disposable forceps, 2 disposable dressing towels, 1 disposable hand towel. (wrapped in sterile field paper) Placed in heat-seal bag.
This pack has been found very suitable for use by the night staff. As can be seen from Figs. 12 and 13, this pack can be readily adapted for any minor procedure.
76
A. 30HJGON
Injection pack 1 foil tray, 1 foil gallipot, 3 cotton wool balls, 1 disposable hand towel, Placed in heat-seal bag. Although meant for injections, this small pack may also be utilised for taking blood specimens, for instilling eye drops or ointments, for taking mid-stream specimens of urine, and for introducing Ryles’ tubes (see Fig. 15). Supplementary packs consist of presterilised catheters, syringes and needles, these being the disposable types, sterilised by Gamma radiation. The supplementary packs supplied by the C.S.S.D. are as follows: Gauze swabs, 5 in bag, Cotton wool balls, 5 in bag, Cotton wool rolls, wrapped in sterile field .paper, in bag, Maternity pads, in bag, Ribbon gauze, 4” and I”, two lengths of each in bag, 3”, 1 in bag, Bladder drainage tube and connexion, 1 in bag (this may also be used to make up an enema tray), Bladder syringes, 1 in sterile field paper, in bag, Ryles tubes, 1 per bag, Rectal catheters, flatus tubes, 1 per bag, Syringes for giving paraldehyde injections, wrapped in nylon foil, Instruments, 1 per bag, Graduated jugs 1 all wrapped
in clinical
Basic dressing technique using packs The basic aseptic dressing technique sequence of events is as follows :
sheet,
1 per bag.
has had to be adapted
to the packs.
The
1. Swab top of trolley with Hibitane 1: 2000 in spirit, using a disposable tissue. Leave the surface wetted for at least four minutes, whilst preparing the trolley. 2. Place the appropriate packs, lotions, bandages, etc., on the bottom shelf of the trolley. Clip a paper bag on the left hand side of the trolley to receive soiled dressings. Clip a similar bag in position on the back of the trolley to receive unused A third bag, the outer bag of the pack, will be clipped items after the procedure. in position when the pack is opened, to receive used instruments. 3. Wipe shelf dry with disposable
tissue.
Cut open outer pack, sliding the 4. Don mask, and wheel trolley to bedside. Hang bag on the right hand side of inner pack onto the top shelf of the trolley. the trolley. Loosen bandages, or strapping, leaving dressing only in position. 5. Wash hands, and dry on disposable tissue. Using the disposable forceps found on the top of the inner pack, open out the sterile field paper. Hold gallipot
THE
CE.YTRAL
STERILE
S(‘PPLY
77
DEP:iRTAfE,~VT
in forceps and pour out the appropriate lotion. Take care not to spill any lotion on the sterile field. 6. Place the disposable forceps on the edge of the sterile field, point innermost. 7. Scrub up. Dry hands on the disposable hand towel found in the pack contents. 8. Remove the soiled dressing, using one pair of the disposable forceps previously used to open the pack. Discard the dressing into the soiled dressing bag, and the forceps, points uppermost, into the used instrument bag. 9. Using the second pair of disposable forceps, and one pair from the foil tray, open out a disposable dressing towel and place below the wound, making a second sterile field. 10. Using the same forceps, wring out a cotton wool ball in the lotion, and place one pair of the forceps on the second sterile field. 11. Hold the cotton wool ball in the second pair of forceps, and clean the wound, swabbing from the wound outwards. Use each wool ball once only. Discard each swab after use into the soiled dressing bag. Discard the forceps into the used instrument bag. 12. Using third pair of forceps, and scissors or clip removers, remove sutures Discard the scissors into the used instrument bag. or clips if required. 13. Swab wound dry, holding swab in the forceps. 14. Using third and fourth pairs of forceps, place clean dressing in position. Fix dressing in position, and make the patient comfortable. 15. Screw up the sterile field papers, together with the soiled dressing bag. Place these in the ward incinerator on return to the clinical room, or into the refuse bag. Tip out the used instruments into the bucket provided by the C.S.S.D. Place the unused dressings into the pannier provided. Special packs issued to the wards
For speed in setting up for the more specialised issued, containing all the articles required.
procedures,
special packs are
Lumbar puncture set
1 foil tray, 2 gallipots, 5 gauze swabs, 3 cotton wool balls, 3 disposable dressing towels, 1 manometer, complete with rubber tube and adaptor, 2 spinal needles, 2 lumbar puncture needles (1 with 2-way tap), 2 specimen bottles, 1 disposable hand towel. Wrapped in CSS paper, in Permapak box. Cut down set
This set may department.
be also used for the suturing
of lacerations
in the casualty
A. JOHNSOA'
1 foil tray, 2 gallipots, 10 gauze swabs, 5 cotton wool balls, 2 pairs dissecting forceps, toothed, 4 pairs Mosquito forceps, 1 aneurysm needle, 1 pair small sharp-pointed scissors, 1 pair small needle holders, 1 R.P. handle, No. 3, 2 Hamilton-Bailey cannula, 2 disposable hand towels, 2 disposable dressing towels, 2 atraumatic mersilk sutures, with cutting needles, 2 scalpel blades, No. 15. The whole contents
are wrapped
in CSS paper
and placed in a sterilisation
Paracmt~sis .ret . Southeys’ tubes,
rubber tubing to fit above, gate clip or clamp, guest cannula, 2 pairs dissecting forceps, 1 pair artery forceps, 1 No. 3 scalpel handle, 1 pair stitch scissors, 2 specimen bottles, 5 cotton wool balls, 10 gauze swabs, 1 foil tray, 2 gallipots, 3 disposable dressing towels, 2 disposable hand towels. Wrapped in CSS paper, in Permapak Burns tack,
box.
bedding
1 bed or cot sheet, 1 draw sheet, 4 linen dressing towels. Wrapped in CSS paper.
RCsuzn~L’tbullition ne peut dCtruire Its spores et comme ces derniers reprksentent les organismes chirurgicaux les plus importants, comme le tetanus, la gangrene de gaz, etc., on doit arreter de se servir dc la mkhode de sterilisation par Cbullition. Le contenu des autoclaves B pansemcnts est aistment contamint. Le fait m6me que Ies autoclaves sont ‘communaux’ comportc Ic plus grand risque qui soit pour de materiel pour l’asepsie, &ant donnf que chaque autoclave contient sufiamment 8 k 10 utilisations.
bag.
THE CENTRAL
STERILE
SUPPLY DEPARTMENT
en tliminant le besoin de Comment peut-on Cviter ces risques. 2 Tout d’abord, Ensuite, en fournissant, en un seul sttfrilisation dans les services d’hospitalisation. paquet, tous les pansements, serviettes, petits pots, etc., qui sont requis pour une utilisation. Une methode de ce genre comprend des avantages suppltmentaires immediats. Dans la Salle d’operation, le temps de preparation est jusqu’a six fois moindre et les mouvements y sont rtduits au minimum. Dans l’hopital universitaire, des paquets d’utilisation g&r&ale sont fournis, auxquels l’tleve-infirm&e ajoute le materiel ou les instruments sptciaux dont elle La necessitt de prottger les articles de la contamination reste encore a besoin. present; il est done essentiel d’effectuer la stricte segregation des materiels sterile, non sterile et contamine. 11 est preferable que les chariots de ramassage et de distribution Les boites, pharmacies portatives ou soient de modtles entierement differents. dispensateurs de paquets speciaux serviront a stocker les paquets dans les services d’hospitalisation. Le systtme a paquets reprtsente une methode meilleur marche, plus sure, plus rapide et plus silencieuse pour realiser la sttrilisation.
Resumen-La ebullicion no es capaz de destruir a las esporas, y coma Cstas constituyen 10s organismos quirurgicamente mh importantes, por ejemplo tttanos, gangrena gaseosa, etc., las tentativas de esterilizar por ebullicion deben cesar. El contenido de 10s tambores de aphitos se contamina facilmente. El hecho real de ser “colectivos” 10s tambores es el gran peligro para la asepsia, puesto que cada tambor contiene material suficiente para 8 a 10 curas. por elimination de 2 Coma pueden ser evitados estos peligros ? Primeramente, la necesidad de esterilizar en las salas; en Segundo lugar, suministrando todos 10s apositos, patios, recipientes, etc., necesarios para una cura, en un solo paquete. Este mttodo tiene inmediatas ventajas adicionales. En la zona de intervention se reduce a una sexta parte el tiempo de preparation. En dicha zona 10s movimientos se reducen al minima. En el hospital de ensenanza son suministrados paquetes blsicos, a 10s que la enfermera alumna agrega el equip0 especial 0 materiales necesarios. La conveniencia de protejer al material esttril de toda contamination, es no obstante vilida, por lo tanto 10s materiales esttriles, no esteriles y contaminados deben permanecer rigurosamente separados. Las carretillas de recoleccion y de suministro son preferibles de formas totalmente diferenciadas. Las cajas, cestas o distribuidores de paquetes especiales deben ser usados de manera tal que se almacenen 10s paquetes en las salas. El sistema de1 paquete complete aporta un mttodo barato, seguro, rapid0 y tranquil0 para llevar a cabo curas esteriles.
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