1. CENTRAL STERILIZATION AND SUPPLIES DIVISION
Infection Control Nursing Officer
Infection Control Unit
Teaching Hospital
Jaffna.

2. Definition of terms
Sterilization – complete elimination or destruction of all forms of microbial life (including spores)
Disinfection – elimination of micro-organisms on inanimate objects with the exception of bacterial spores
Antisepsis – prevention of infection of tissues and body surfaces by application of germicides
Cleaning – the removal of visible soil (eg; inorganic and organic material) from objects and surfaces

3. Disinfection and sterilization practices are essential for ensuring that medical and surgical instruments do not transmit infectious pathogens to patients

4. Instruments and items for patient care are divided into 3 categories based on the degree of risk of infection involved in the use of the items
1. Critical/ high risk items
2. Semicritical/ intermediate risk items
3. Non critical/ low risk items

5. Critical / high risk items
Objects that enter sterile body tissue or vascular system
Any microbial contamination could result in disease transmission
Must be sterile

6. Semi-critical / intermediate risk items
Items that come in contact with intact mucous membranes
Generally resistant to infection by common bacterial spores but susceptible to other micro-organisms
Need not be sterile; disinfection acceptable

7. Non-critical / low risk items
Items that come into contact with intact skin but not mucous membranes
Intact skin is an effective barrier to most micro-organisms, hence low risk of disease transmission
Thorough cleaning is adequate with low level disinfection as necessary

8. Factors influence the sterilization process
The temperature of sterilization
The period of sterilization
Inactivation by organic matter
Whether the article was cleaned before sterilization
 The sterilization cycle can be divided into three periods:
a.Heating up period
b. Holding period
c. Cooling period

9. CENTRAL STERILE SUPPLY DIVISION

10. Objective
To reduce hospital associated infections and protect patients, employees, health care students and visitors.

11. The functional flow of activities in CSSD
RINSING
CLEANING
DRYING
INSPECTION AND ASSEMBLY
PACKAGING
LABELLING
STERILIZATION
STORAGE
DISTRIBUTION

12. RINSING
Rinsing of articles after use should not be permitted in patient care areas unless carried out by a trained member of the staff.

13. CLEANING
All reusable medical devices should be thoroughly cleaned prior to disinfection or sterilization.

14. All articles should be dried appropriately
DRYING
All articles should be dried appropriately

15. INSPECTION AND ASSEMBLY
Each item should be inspected for functionality, defects, breakage and then appropriately assembled.

16. PACKAGING
Articles should preferably be packed in porous material.

17. LABELLING
Each pack should be marked with nomenclature of the article, contents of the pack, initials of the person who packed it, date and initials of the person who carried out the sterilization.

18. STORAGE
Should be properly managed separately for sterile and non-sterile stores. For sterile goods, clean room conditions should be followed.
Sterile pack should be stored cm from the floor, cm from the ceiling, cm on out side of the wall.

19. DISTRIBUTION
Refers to clean and dirty articles exchange system. A program should be established for the collection of used items from patient care areas and distribution of sterilized goods.

20. Moist heat sterilization
Moist heat kills microorganisms by coagulating and denaturing enzymes and structural proteins
Applied in the form of steam
Steam under pressure is used to achieve a higher temperature
4 parameters of steam sterilization
Steam – saturated and dry steam without air
Pressure – 2.4 bar / 15lb
Temperature – 1210C
Time min
Autoclaving at 1210C at 15 lb pressure
for 20 min is acceptable for routine
hospital use

21. Moist heat sterilization…
Advantages
Non toxic
Inexpensive
Rapid action
Good penetration ability

22. Sterilization by dry heat
Dry heat penetrates less well and is less effective than moist heat
Consequently, higher temperatures and longer periods are required for sterilization with dry heat
 Used for sterilization of
-sharp cutting instruments and
-laboratory glass wear
-powder, oil

23. Sterilization by dry heat
Total cycle may be several hours, hence hot air ovens should have
Time lock on the door - items cannot be added or removed during, the cycle
Fan to distribute the heat evenly
Dry heating at 1600C for for 2 hours is acceptable for routine
hospital use

24. Monitoring of sterilization
Mechanical indicators – Observe the machine's dials and gauges - temperature, pressure, time
Chemical indicators – changes colour on exposure to the appropriate sterilization cycle
Autoclave strips Bowie Dick test

25. Monitoring of sterilization…
Biological indicators – bacterial spores which require high temperatures to lose viability – spore strips, self contained vials
Geobacillus stearothermophilus – for steam or chemical vapor sterilization
Bacillus subtilis -for dry-heat or ethylene oxide gas sterilization

27. Storage
Once sterilized, the instruments should be maintained in a sterile state until they are used again
Improper storage would result in a break of the 'chain of Sterility'
The expected 'shelf-life' of a sterile package is depend on the type of area in which it is stored and the material used for packaging
A closed, protected area with a minimal airflow such as a cabinet or drawer that can easily be disinfected is preferable to an open stacking system

28. Disinfection Methods Heat – Physical –
Pasteurization C for 30 min
72 0C for 15 sec. (the flash method)
Boiling - bacterial spores can survive
Physical –
ultrasonic, UV radiation - used for removing debris (cleaning) prior to autoclaving
Chemical
Disinfectant used for one purpose may not be equally effective for another
The antimicrobial activity falls in the presence of organic debris

29. Disinfection & Sterilization
2% Glutaraldehyde (cidex)
- 2% Alkaline solution
- Needs activation
- Sterilization time – 10 hours
- Disinfection time – 20 mins
- Activated solution – 2 weeks/20 times
- Sterilization/HLD of heat sensitive items
- Irritant to skin, eyes & respiratory tract
- Should be handled in a well ventilated area
- Should wear protective clothing
- Fixation of protein

30. Disinfection & Sterilization (cont.)
Para Safe
- Combination of per oxygen compound, activator & stabilizer
- Non-corrosive
- Non-irritant to skin
- Eye irritation
- No toxic residues
- Expensive
- Stable for 24 hours only

31. Disinfection & Sterilization (cont.)
Chlorine releasing agents
- Sodium hypochlorite, Calcium hypochlorite, Chlorine granules
- Active against bacteria, viruses, fungi & some spores
- Less active against mycobacteria
- Contact time mins
- Rapidly inactivated by organic matter
- Corrosive to metal
- Do not add powder to water
- Avoid contact with acid/acidic body fluids e.g.- urine
- Avoid contact with skin, eyes & mucus membrane
- Unstable - daily preparation is necessary
- Blood & body fluid spillages – 1% solution (10000 ppm)
- General environmental cleaning – 0.1% (1000 ppm)

32. Disinfection & Sterilization (cont.)
Alcohol
- 70% - 90% Ethyl alcohol/ Isopropyl alcohol
- Rapidly active against vegetative bacteria & mycobacteria
- Viruses – variable activity
- Not sporicidal
- Only on clean surfaces
- Disinfection of items that cannot be immersed in other disinfectants e.g.- electric equipment
- Skin anti-sepsis

33. Disinfection & Sterilization (cont.)
Chlorhexidine – 4%-5% (Hibiscrub/Hibitane)
- Active against Gram positive organisms & fungi
- Poorly active against Gram negative organisms
- Non toxic
- Good residual activity
- Pre operative skin disinfection/Surgical hand washing
- Savlon – 1.5% Chlorhexidine + 15% Cetrimide
Poor bactericidal activity

34. Disinfection & Sterilization (cont.)
Chlorhexidine – 4%-5% (Hibiscrub/Hibitane)
- Active against Gram positive organisms & fungi
- Poorly active against Gram negative organisms
- Non toxic
- Good residual activity
- Pre operative skin disinfection/Surgical hand washing
- Savlon – 1.5% Chlorhexidine + 15% Cetrimide
Poor bactericidal activity

35. Principles of disinfection
Objects that cannot be heat-treated, should be disinfected by chemicals
Clean the article before disinfection
Dilution of concentrates should be accurately measured
Consider the range of activity, toxicity and cost
Beware of inactivating substances
Use fresh disinfectant solutions
Use clean containers
Never 'Top up' disinfection containers
Item should kept in contact with the disinfectant for the required time period and no longer than that

36. Chemical disinfectants…
Factors affecting the effectiveness/usefulness of chemical disinfection
Range of activity
Satisfactory contact
Concentration
pH- alkaline for gluta. and acid for phenols
Neutralization- organic matter, hard water, soap
Stability
Speed of action- high-hypochlorite
Cost
Potency- high, intermediate, low
Lack of adverse effects

37. Commonly used disinfectants
Antimicrobial activity
Disinfectant
Vegetative bacteria
mycobacteria
virus
spores
Glutaraldehyde +
Hypochlorite
Phenolics
+(poor) _
Alcohol
+(limited)
Chlorexhidine
Povidone-iodine
+(prolong contact)
+/-
QAC

38. Chemical agents used as high-level disinfectants
Advantages
Disadvantages
Glutaraldehyde (2%)
Relatively inexpensive
Excellent material compatibility
Needs activation
Respiratory irritation
Allergic contact dermatitis
Irritating odor
Hydrogen peroxide (3%)
No activation required
Enhance removal of organic matter and organisms
No odor or irritation
Corrosive
Eye damage with contact
Ortho-phthalaldehyde (0.55%)
Fast acting
Good material compatibility
No odor
Stains skin, MM, clothing and environmental surfaces
Expensive
Eye irritation
Peracetic acid ( %)
Fully automated system
Environmental friendly by-products
Effective in the presence of organic matter
Unstable
Small no. of items only per cycle
Serious eye and skin damage on contact

39. Sterilizing medical items
High risk
Surgical instruments, lumber puncture sets, surgical dressings, surgical protective clothes, rubber
gloves, soiled or fouled linen,
Tracheostomy tubes
Autoclave
Cannulae & catheters, Prosthesis
Nasogastric tubes, endothracheal
tubes, syringes and needles
IV Infusions
Radiation
Endoscopes
(1) 2% glutaraldehyde for 20 min.
(2)0.34%peracetic acid-:10min
Thereafter, rinse scope and channels with sterile water

40. Intermediate risk -High level disinfection
Thermometer
Wipe with 70% alcohol swab & store dry
Vaginal speculem 
Tongue depressor 
Proctoscope
Wash with detergent & water and boil for 20 minutes
(In high risk patients - autoclave)
Respiraotry equipment;
Eg: Masks
Wash thoroughly
Dry & wipe over with 70% alcohol
Airways
Ambu bag
Tubing
Disinfect by heat or using 2% glutaraldehyde for 30 min.
After immersing in glutaraldehyde, rinse thoroughly in sterile water
Nebulizer
Use sterile water for nebulization
Clean with detergent and hot water after each patient. Tubing can be immersed in 2% glutaraldehyde for 30 min.

41. Low risk- cleaning and low level disinfection
Floors
 Mop with hot water & detergent
Walls
Clean with hot water & detergent
Cutlery & crockery
Liquid detergent & hot water
Linen
All hospital laundry must be heat disinfected
Bed pans, urinals
Empty the contents into toilet.
Fill the utensil with phenolics, leave for 5min. & wash with water

42. Management of a blood spill
Wear heavy duty gloves
Soak the spill with an absorbent material
Cover with 1% Sodium hypochlorite
Leave for 20 minutes
Clean

43. Take home message In failure of sterilization and disinfection
Increase morbidity and mortality
Longer hospital stay
Expensive antibiotics
Increase work load- doctors, nurses, laboratory
Extra cost to the state!
Apply your knowledge appropriately

44. THANK YOU