The CSSD Simply a Source of Costs?
At the heart of the congress, which this year focused mainly on the subject "Equipping a CSSD", was right away the issue of costs. P. Weber, Winterthur, outlined how to make provision in the budget for equipping a CSSD. Increasing costs in healthcare, and hence in the CSSD, are presently pitted against massive budget restrictions. Who can we counter this? Weber pointed to ways of reducing costs, but also drew attention to their inherent disadvantages. For example, rash personnel reduction could quickly backfire if at a later date qualified staff have to be engaged again at short notice and often at a higher price. One should bear in mind at the planning stage that even small things cost money and must be earmarked in the budget.
Looking ahead, he outlined the changes awaiting us should all individual hospital departments act as independent enterprises. This would surely entail a change in consumption behaviour, also of sterile supplies, if each item for the "surgery enterprise" were to be invoiced separately.
For the CSSD this ultimately means the final separation from the OR domain and the necessity for an independent business account with full responsibility for its budget, which would cover all areas including personnel.
R. Aids, Tübingen, in his lecture "Equipping the CSSD from the manager's viewpoint" elaborated in particular on the reputation of the CSSD as an independent department within the hospital. To lend momentum to the subject of the CSSD, "self-publicity" is needed. A good management and dedicated staff can make an important contribution to having the CSSD perceived as a vital department within the hospital. Hence, to cite Herr Aids, successful establishments engage in intelligent planning which apart from adequate fittings, which naturally are essential, is to a large extent tailored to the needs of the staff. It is not cost reduction that must be placed in the foreground but rather a more efficient performance with an unchanging budget.
Room Climate and Hygiene
R. Machmerth, Mainz, highlighted the room fitttings of the CSSD in respect of hospital hygiene. He pointed out that myriad interrelationships exist between medical devices, instruments, operating materials (e.g. steam) and personnel. He later elaborated on some of these factors and described the repercussions generated by the steam quality or by the quality of cleaning and disinfection on the validation processes. Not least, the effects of temperature, moisture and air velocity on staff comfort must also be taken into consideration when constructing a CSSD. It is particularly difficult to set these parameters in optimal fashion because different conditions prevail in respect of the onerous nature of the work carried out in different workplaces. Moreover, the requirements for protective clothing allow little latitude for climate adaptation since protective clothing contributes to reduction of the microbial count released per minute and must be commensurate with the respective task. This discussion highlighted the fact that especially in older departments it is hardly possible to create comfortable environmental conditions for all staff members.
Clear Routing - Basis for Quality
The structural and spatial preconditions were outlined by R. Frey, Bad Friedrichshall, based on a new CSSD design. Frey stated that to assure hygiene above all clear routing is needed which must be planned while bearing in mind aspects of hygiene, work efficiency, quality assurance and not least staff motivation and made possible by the structural preconditions. Furthermore, stipulations for personnel must be clearly formulated. But these can only be implemented if for example separation of the clean and unclean sides is not rendered more difficult by problems of space. Legal provisions such as the Ordinance on Workplaces must be taken into account, something that precludes the much dreaded "banishment" to basement rooms without visual contact with the outside.
M. Held, Bad Mergentheim, in his paper also identified the route that the instruments and devices to be sterilised must embark upon from the OR through the CSSD and back again as the basis for designing the department. Held stated that points of intersection must be ruled out. Based on the example of his own CSSD, which was newly designed in 1997, he demonstrated what aspects must additionally be borne in mind so that there are no ergonomic shortcomings while nonetheless being able to implement space-saving solutions.
Reconstruction During Ongoing Operations
Reconstruction is rendered especially difficult if it has to be carried out during ongoing operations. Claudia Neubauer, Regensburg, reported on her own experiences of this as head of a CSSD. Since in most cases operations cannot be interrupted when reconstruction has to be carried out, her lecture provided practical suggestions for this realistic scenario. Good planning, to quote Neubauer, is the very essence of the matter. Of special importance is that the CSSD specialists should play a major role here - this is something of a "privilege" which is often obtained only with persistence. Only constant and open communication with those responsible (business management, architects, etc.) enable input of one's own practical experience and desires. In addition to smooth progression of the actual move, planning should also be aimed at standardisation of work flow patterns in the new department, because this is ultimately the basis for reproducibility and only then is the CSSD in line with the state of the art.
Storage Time - An End to the Expiry Date?
Josy Holdener, Zurich, in her talk described a special aspect of sterile supply, namely storage. Industrial sterile supplies without an expiry date are deemed sterile so long as the packaging has not been opened or damaged. Conversely, in the hospital sterile supplies continue to still show an expiry date. Since the requirements addressed to the packaging are the same in both domains, there is no reason for this divergent approach. What is more, Holdener stated, provision with expiry dates is a waste of time and money because it calls for cumbersome sorting and reprocessing. Holdener pointed out that the event-related storage time in the USA is supported by all prominent organisations and to conclude she explained how the change of system can be brought about.
Equipment: Tips for Decision-Making
H. J. Drouin, Planegg, in his presentation gave the audience some tips on the subject "Equipping with decontamination systems". He pointed out that cleaning/disinfection has now occupied centre stage in discussions, not least because increasingly more complex instruments have to be processed. Apart from functional criteria, the operating costs, which must be ascertained individually, have to be taken into consideration when deciding to purchase a either a tunnel washer or a washer-disinfector. Furthermore, individual provisions (such as type and quantity of articles) and once again the structural preconditions play a vital role.
M. Franke, Cologne, highlighted the factors that have to be borne in mind when it comes to organisational optimisation of a new facility. Cost developments for sterilisers make it imperative to engage in long-term planning. Citing the aphorism "nothing is as enduring as change", Franke stated that future developments should also be taken into account at the planning stage. It is recommended that above all long-term installed modules of a steriliser, which are expensive and/or difficult to replace, be used as a basis for decision-making. Conversely, computer systems for example can be adapted in the short term.
To conclude, Franke pointed to the changes in apportioning of liability emanating from EU legislation: accordingly, the manufacturer is responsible only for supplying a proper device, but liability for operating materials, load, documentation and maintenance is borne by the operator. Validated processes and uninterrupted documentation are especially important in this context.
In addition to appliances, surgical instruments are a major investment item. L. Giovanettoni, St. Gallen, presented an electronic information system for management purposes. This management system covers three areas which like the pieces of a jigsaw have to fit together. For example, a complete inventory permits direct assignment to certain cost centres. Being able to unambiguously identify each instrument is furthermore an important tool for quality assurance. Key features such as surgeon, patient, date of use and sterilisation are automatically registered and serve to effect an audit trail and reconstruction of each intervention. Not least the work flow patterns and their documentation in the OR and CSSD are also rendered essentially easier, such as e.g. packing of trays and placement of orders. Identification of instruments with a data matrix code which can be scanned with a camera system is a precondition for implementation.
DGKH Guest Performance: the Sterilisation Section Introduces Itself
The early afternoon of the first day of the congress was availed of to take a look beyond the DGSV horizon. Members of the Sterilisation Section of the German Society for Hospital Hygiene (DGKH) spoke on the subject "Old and new requirements for sterilisation". This guest performance is intended as a starting point for closer cooperation in the future between the DGSV and the Sterilisation Section of the DGKH.
To begin with, R. Machmerth, Mainz, reported on the requirements for sterile supply which have undergone major changes in the past few years. Due to the demand for quicker release of sterilised devices based on the sterility assurance level (SAL <= 106) there is no longer practically any means of circumventing the validation of sterilisation processes - the time needed for evaluation of biological methods would be too long. Machmerth also emphasised when using packaging as per the pertinent standards long storage times do not compromise sterility.
H.-P. Werner, Schwerin, dealt with the processing of medical devices and emphasised that in line with current legislation the quality of processed items must be as high as that of industrially sterilised devices. He called upon the members of the audience to impress upon themselves that each individual in his daily work as operator and user of medical devices is personally responsible for this quality. The management and industry cannot be held responsible. The organisational structure plays an important role in quality assurance. Quality of the required level can be achieved only by means of decentralised checks, to cite Werner.
The talk given by D. Achterberg, Planegg, dealt with steam as the "most important operating material" in the CSSD. He outlined the characteristics of wet steam, saturated steam and overheated steam and demonstrated how the ideal state, namely saturated steam, is encountered in practice only in exceptional cases, because temperature and pressure are difficult to set such that the liquid and gaseous phase are exactly at equilibrium. DIN EN 285 therefore contains corresponding tolerances.
Achterberg stated that when checking sterilisation, one cannot therefore rely only on measurement of pressure and temperature because due to an unsatisfactory steam quality the requisite sterilisation effect may not have been achieved. Continuing his talk, Achterberg outlined other requirements for pure steam and stressed that the possibilities available for detecting faults in any load should be urgently made use of.
In the final lecture of this Section, P. Kober, Neustrelitz, focused on validation of sterilisation processes. Validation of sterilisation processes in the CSSD is being more readily accepted but, to cite Kober, it is not a substitute for routine checks. Much more so, the two types of control act as complementary systems. The Sterilisation Section of the DGKH published recommendations for validation and routine monitoring of sterilisation processes in the spring of 2000. These also include practical instructions for preparing and carrying out validation. Preparation for validation is ultimately to be viewed as the process that most enhances quality.
T. von dem Hagen, Bad Schwartau, described the special requirements governing the sterilisation of heat-sensitive materials. He outlined the special features of the process on the basis of partial processes for the low-temperature procedures:
- Conditioning during which the active agent is transported to the surface of the items to be sterilised
- Exposure to the sterilisant
- Removal of the active agent
Von dem Hagen emphasised that in the last instance each of these partial processes, if it has not been performed according to a validated method, can lead to lack of sterility of items and hence to diminished sterilisation safety and finally to endangerment of patients and users.
The first day was rounded off by a colourful evening programme during which the industry prizes were once again awarded. For the umpteenth time the firm Brömeda was awarded the prize for the most original stall, which with its decoration proved that draping materials need not have only a boring and sterile appearance. The prize for the most innovative product was awarded to the ET-System of the firm 3M Medica, and the prize for the best presentation went to Aesculap.
The audience prize drawn among those voting on the industry prizes was not for once given this year to Frau Strack, but to Herr Kapaun who was able to take home the mini-stereo system.
Day 2 in the Service of the Personnel
The delegates, who had sufficiently reinvigorated themselves during the evening event, listened on the second and last day of the congress to lectures completely dedicated to personnel planning.
How many staff members are needed to operate a CSSD? Sabine Premer, Marburg, put forward a concept based on her own department for calculation of requirements which takes account of daily routine tasks of fixed time input as well as flexible working times. The latter must first of all be ascertained over a long period of time on the basis of the average times needed by staff to carry out certain tasks. After around 6 months the mean times per day can then be taken for further planning.
This cumbersome procedure is by all means justified when one sees the deviations that occur from the actual requirement if one uses only rough formulae for personnel planning.
To conclude, Premer pointed out that for example permission must be obtained from the staff council to record the packing times for each employee.
W. Boerman, Kootwijkerbroek (Netherlands) also spoke in favour of business analysis as the basis for personnel planning. Less complex calculation models that for instance are based on the number of sterile units processed are too inexact. Too many tasks and individual factors that cannot be recorded as sterilisation units would not be taken into consideration. What is important above all according to Boerman is the individual abilities of staff to make judgements and incorporate them, and this is sufficiently possible only within the framework of the business analysis.
Motivation is the Boss's Job
Only motivated staff members are good staff members. In the last two lectures it became clear that motivation is the boss’s job. To begin with Cornelia Hugo described how qualification talks with staff can be used for motivation. The aims and results should be defined and documented - but the atmosphere is also important. Hence this type of talk should begin and end on a friendly note, so that the staff member becomes more self-confident and no bitter aftertaste lingers on. Carefully conducted talks with personnel can lead to a collegial relationship and ultimately also enhance production quality in the CSSD.
That management must not be restrictive was outlined by J. Graf, Regensburg, on the basis of a report from his department. Rosters and holidays are planned there essentially by the staff themselves. "The staff do the work better than the boss" is the tenor of Graf’s talk. He pointed to the large number of administrative tasks which the CSSD management has to perform. If one permits it, the staff are apparently also well able to "manage" themselves - a system that reinforces self-responsibility and motivation. This is noticeable above all when shortcomings, e.g. due to illness or holiday, call for flexible reactions on the part of staff.
Conclusion from a Successful Congress
Conclusion: The lectures delivered a lot of practical insights. That some points are controversial was borne out by the often lively discussions. The contributions to discussions from the foreign delegates were especially interesting, showing what approaches are adopted in other European countries and thus opening up vistas beyond the horizon.
Motivation - this was exactly the correct slogan on closing the congress. Motivation grows when one sees that there is still much to be done, but that on the other hand with a certain amount of initiative much can also be accomplished in a short time. And the congress has certainly demonstrated this.
Dr. Gudrun Droop