A journey to improvement: The reality of tackling a CSSD - IHI Africa, Durban, 2018

 
A journey to improvement: The reality of tackling a CSSD - IHI Africa, Durban, 2018
A journey to improvement:
            The reality of tackling a CSSD

                    IHI Africa, Durban, 2018

Dr Anthony Reed
Chief Specialist Anaesthesiologist, New Somerset Hospital
Head General Specialist Services, Metro West
A journey to improvement: The reality of tackling a CSSD - IHI Africa, Durban, 2018
A journey to improvement: The reality of tackling a CSSD - IHI Africa, Durban, 2018
Declarations

• Anaesthesiologist with minimal schooling in matters CSSD
• May be frightening for those expert in sterilisation
• Buckle up, this may be a wild ride…..
A journey to improvement: The reality of tackling a CSSD - IHI Africa, Durban, 2018
Why an anaesthesiologist?

•   Oldest hospital in the country
•   Regional hospital
•   700-800 cases per month
•   4 OR’s

• Theatre flow/efficiency hiccups

• Three 160 litre autoclaves in 3 OR theatre
  complex

• Quality of the work
A journey to improvement: The reality of tackling a CSSD - IHI Africa, Durban, 2018
The setting

•    3 autoclaves in OR, 3 in CSSD
•    Reprocessing in theatre
•    Couldn’t do consecutive cases
•    Delays due to “autoclave issues”
•    Always blaming “CSSD”

1.    Sluice machine

2.    Asked IPC RN for sterilisation policy

3.    EO gassing to GSH
A journey to improvement: The reality of tackling a CSSD - IHI Africa, Durban, 2018
The setting

• Acting Theatre OM at hospital since a
  student nurse
• Current Area Manager previously
  Theatre and CSSD OM
• IPC manager, previously CSSD OM
  until OSD
• DD nursing about to retire after
  career at the hospital

                                   “We cannot solve our problems with the same
                                    thinking that we used to create them”
A journey to improvement: The reality of tackling a CSSD - IHI Africa, Durban, 2018
The setting - Infrastructure
A journey to improvement: The reality of tackling a CSSD - IHI Africa, Durban, 2018
The setting - Infrastructure
A journey to improvement: The reality of tackling a CSSD - IHI Africa, Durban, 2018
The setting - Infrastructure
A journey to improvement: The reality of tackling a CSSD - IHI Africa, Durban, 2018
The setting - Infrastructure
The setting - Infrastructure
The setting - Equipment
The setting - Equipment
The setting - Equipment
The setting - Equipment
The setting - Process
The setting - Process
My assessment

• No management
• No appreciation of the importance
• Need external help
Independent assessment

• General overview
   – Light and airy, but large poorly designed and needs urgent
     maintenance
   – Artificial lighting is totally ineffective
   – Housekeeping is good but walls and ceiling are marked and crumbling
   – Floors are tiled but clean and in good condition
• Access
   –   Can be accessed through two doors, both of which are open
   –   No air conditioning
   –   Should have controlled, restricted access
   –   There is a receiving hatch but not used as too heavy
   –   Clean and dirty laundry intermingled
   –   Surfaces over-stacked
Independent assessment

• Automated cleaning
   – Washer is inadequate for the workload – should have 2 x 10 tray
   – Instrument trays changed through the process
       • Time
       • Instruments
       • Staff health
   – Instrument trays old and buckled
       • Semi-solid makes sterilisation unlikely
   – Wet green towels used to dry instruments as instrument washer unable to cycle
   – Poor work practices not opening instruments
   – Baskets in washer are overloaded
Independent assessment

• Autoclaves
   – Area is old with open windows and solid surface
   – Autoclaves small with inadequate racks
       •   Racks single shelf
       •   Incorrect loading – hence unsterile items
       •   The newest autoclave was not “fitted”
       •   Autoclave heat is entering the CSSD

• Storage area
   – Has windows and direct sunlight
   – Shelving solid and rusted
Independent assessment

• Containers not being washed as sinks too small
• Single use filters being used repeatedly, filter holders jammed
•   IAP area
     – Wooden surfaces totally unacceptable
     – Chipped and gouged
     – Items stored on floor as lack of storage space
     – Insufficient tables
     – Work-flow is criss-crossing, and needs re-ordering
     – Shelves and racks solid, old and rusted

• Linen area
     –   Stored on floor
     –   Linen preparation is occurring in packing area
     –   Needs separate room with extractor to stop linting
     –   Explore non-linting textiles
Our goals

1. Minimise processing in theatre
     –   More surgical packs/trays
     –   More washer ability in CSSD
     –   More autoclaves in CSSD
     –   Close autoclaves in OR
2.   Separate clean and dirty pathways
3.   Separate wet and dry areas in CSSD
4.   Move laundry out of packing area
5.   Minimise workload of CSSD even with processing shift
     – Minimise washing workload (machines, tray size and type)
     – Containers, reusable filters, minimise wrapping
     – Stickers or stamps
Improvement steps

• Steps                                        • Driven by:
   – Equipment and infrastructure in tandem       – “Uneducated” enthusiast together with
   – Process improvement through these              TMC
     changes                                      – Supported by Theatre OM
   – Standard operating procedures for every      – Created support of hospital management
     small part of the process                    – IPC RN only joining the journey now
Our roadmap

• Infrastructure                          • Equipment
   –   Tiles                                –   Washer
   –   Painting                             –   Ultrasonic washer
   –   Linen room                           –   New autoclaves
   –   Wet/dry area - move washer           –   Containerise
Our roadmap

• Infrastructure
Working in CSSD whilst upgrading
Our roadmap

• Process- theatre                       • Process CSSD
   – Move from 3 autoclaves to 1            – Wet/Dry area
   – More surgical packs                    – Containerise
   – Automated ultrasonic washer
Our roadmap

• Process- between OR and CSSD                 • Process Laundry
   –   New carts for clean                        –   Clean laundry in via different door
   –   Old carts for soiled                       –   Door to linen room bypassing packing area
   –   Clean side and dirty side lifts            –   Large sliding window in linen room
   –   Close doors                                –   Doors closed in linen room
   –   Limit access                               –   Linen stored off the floor
Improvement initiatives

• CSSD staff
   – Visit to central hospital and Medi-clinic CSSD’s
   – Staff to Cape CSSD Forum and Africa Health
   – Management and surgeons taken and introduced to CSSD multiple
     times
   – Make hospital value the CSSD

                                         CSSD
Improvement initiatives

• Pack revision week June 2016
   –   No elective surgery for a week
   –   Department by department review of packs
   –   CSSD staff, nursing, surgeons and anaesthesia staff side by side
   –   Reviewed content lists, discarded up to 30%, identified replacement
   –   New tray lists, many with pictures (especially laparoscopic sets)
Changes and challenges

• Receiving
Changes and challenges

• Wet/dry areas
Changes and challenges

• Washers
  – Bought a 2nd one
      • Same size (10 tray) a mistake
      • “DINN” not same for all manufacturers
  – Placed a plinth
      • Pipes/cables were lying on floor surface
  – Bought quality baskets with finer size
      • Still needing to move transfer instruments
Plinth
Changes and challenges

• Autoclaves
   – CSSD replaced 3 x 400 litre machines
   – Theatre went from 3 x 160 litre to 1 x 160
     litre
Changes and challenges

• Autoclaves
   – CSSD replaced 3 x 400 litre machines
Changes and challenges

• Autoclaves
   – 2 weeks after commisioning
     won’release vaccum
Changes and challenges

• Autoclaves correctly used
Changes and challenges

• Autoclaves incorrectly used
Changes and challenges

• Autoclaves
   – The water returns
Changes and challenges

• EO gas unit
Changes and challenges

• Containerisation
   – Colour coded for each discipline
   – About 30% containerised now
• Benefits
   1.   Workload of wrapping
   2.   Cost of wrapping
   3.   Sterility in transit
   4.   Re-usable 1200-use filters to save work
Tags and lids since
Changes and challenges

• Instrument marking
   – Good intentions
   – Not aware that not ideal
   – Institutional decision to proceed
Changes and challenges

• Linen management
   –   Removed from main IAP area
   –   Linen room - window into main area
   –   New door – separate clean pathway
   –   New packing tables
   –   Not stored on floor
Changes and challenges

• CSSD sterile pack storage
   – R750 000 racking
   – R8 000 label holders and labels
Changes and challenges

• Theatre sterile pack storage
   – R750 000 racking
   – R8 000 label holders and labels

                            Old theatre            New theatre
Changes and challenges

• Sterile pack storage
   – R750 000 racking
   – R8 000 label holders and labels
Changes and challenges

• Sterile pack storage
   – R750 000 racking
   – R8 000 label holders and labels
Changes and challenges

• Sterile pack carts
   –   R48 000 a piece
   –   Staged replacement
   –   Kept old “buses” for dirty trays
   –   Obstetric FBU has not taken delivery
   –   Confusing having two systems

                                Dirty packs              Sterile packs
Changes and challenges

• Sterile pack carts
   –   R48 000 a piece
   –   Staged replacement
   –   Kept old “buses” for dirty trays
   –   Obstetric FBU had not taken delivery
   –   Confusing having two systems
Changes and challenges

• Leaking roof above CSSD
   – Related to chiller plant room
   – Compounded by rain
   – Huge impact on condition of unit
Fire 29/11/2016
Fire
Fire
Fire
Service impact

• Day 1
   – Obstetrics only
   – Processed packs with trips to GSH to autoclave
   – Used all packs that were in theatre
• Day 2
   – Prioritised sterile pack area, EO and autoclaves
   – Moth-balled 5th floor theatre = ad-hoc CSSD
   – Hand washing extras rather than transporting

   – Day 3 almost full service ~ standards ?
Fire
Fire
Fire
Fire
Fire –Soot everywhere
Fire- 10 days and back
Second review by Denise

•   Doors left open
•   Container cleaning
•   Barrier between wet/dry
•   Instrument tape not ideal
•   Room cleaning whilst packing
•   Autoclave packed touching sides
•   Racking incorrectly spaced………
What we had no idea about

• Thinking of case load and case mix = work
   – Consider hours you have staffed
   – Work out what is required within the hours
   – BUT we did set out to minimise workload
• Automated instrument washers
   –   Size
   –   Number
   –   Fast cycle etc & requirements
   –   Plinth
• Container/tray/basket choice
   – Size not standard, but matters enormously
   – Determines so much
What we struggle with….
Processes

• Clean and dirty pathways
Processes

• Clean and dirty pack carts
• May 2017 obstetric unit sterile
  packs on old “bus”
Processes

• Clean and dirty pack carts
• February 2018
• Clean carts x 3 being pushed
  into wet/dirty side of CSSD
• Not sure CSSD staff would have
  required them to be directed to
  another floor to approach from
  the clean side.
Infrastructure

• Maintenance by workshops
• Water ingress
• Drains/plumbing
Outstanding issues

• Processes
   – Autoclave packing
   – Pack integrity
   – Instrument and container washing

• Measure
   – Throughput
   – Outcomes

• Develop detailed SOP’s

• Etc……
What we learnt

• We started this the wrong way
   – Failed to realise the magnitude of the problem
   – Failed to consider the change management needed
   – Never going to fly with an anaesthesiologist leading the change

• CSSD’s fall between the cracks
   – Certainly in government hospitals
   – Where does responsibility lie?
   – Where should responsibility lie?

• Our experience suggests that nursing cannot implement this
   – Never spent more than R100 000 on equipment
   – Needs to involve whole hospital/medical staff in the change
Lessons for those embarking on this journey

• This is a project
   – Approach it as you would a project
   – Mandate and clear
     outcome/deliverable
   – Budget
   – Time limit
   – Responsibility/accountability
• Change management
   – Major part of the project
   – Consider sustainability

• Look at the published assistance
   – Freely available
Result
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