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Recommendations by the Quality Task Group
[2] Transport from the OR to the CSSD

The CSSD processes the greater part of the reusable medical devices. This includes preparation for cleaning and disinfection, manual or automated cleaning and disinfection, or ultrasonic cleaning, checking, packing and sterilisation. The OPERATOR ORDINANCE of June 1998 states in Section 4 "Maintenance" that all these tasks should be carried out in a reproducible manner such that patients, personnel or third parties suffer no damage. Therefore these tasks must be subjected to a quality management procedure.

CLEANING is a precondition for reliable disinfection and sterilisation. But suitability for cleaning decreases the longer blood, tissue, mucus and other residues are allowed to dry. Therefore it must be ensured that the used medical devices are processed as soon as possible. This calls for corresponding logistical measures, i.e. good organisation of the transportation of the sterile supplies from all points of use to the CSSD.

The greatest drawbacks encountered here reside in the fact that the CSSD as a rule does not dispose OF ITS OWN COLLECTION AND DELIVERY SERVICE, but rather is integrated into the general transportation system. This gives rise to the following problems:

• The used instruments reach the CSSD too late because supplies continue to be collected until the trolley is full. As a result of this, there is little to do in the mornings and the machines are not fully utilised. But by afternoon there is rapid succession of incoming supplies, resulting in overloading of machines due to inadequate machine capacity and hence in cleaning problems.
• Residues will have dried too firmly on delicate instruments. This may call for pre-treatment measures such as spraying, brushing, ultrasonic cleaning. However, manual pre-treatment measures always pose a risk of infection to personnel, because even if instrument disinfectants are used all the pathogenic microorganisms implicated will not be killed immediately.
• Instruments used at the weekend, e.g. from the emergency OR, are left unattended until Monday. If they are placed in a closed container, automated cleaning is possible. But if they are placed in a disinfectant bath they will have started to become rusty.

Since these problems derive from the existing transportation system and from the given structural circumstances, changes cannot be ushered in overnight. But already for reasons relating to the economical implications of complete utilisation of the machine and to personnel deployment within the framework of quality management, the CSSD managers will find willing listeners among those persons responsible for implementation of the Medical Device Act and for costs, if they can, on the basis of flow charts and evidence of any damage to instruments, furnish proof of the aforementioned transportation modalities and attendant problems and request help in improving this situation.

The following measures can bring about IMPROVEMENT:

• The collection and delivery service must be optimised by having a CSSD staff member collect the instruments after receiving a signal (bell, lamp).
• Delicate instruments should be rinsed after long operations and placed in a solution (e.g. Varis needle for prostate operations, immersion in hydrogen peroxide solution after HF surgery). But caution is warranted here: if the Ringer's solution or saline solution remains in contact with stainless-steel instruments over a long period of time pitting will be manifest.
• An emergency service should be organised for the weekend (e.g. 4 hours on Saturday afternoon, but not in the mornings as instruments will not have yet collected).
• Cleaning, disinfection and drying can be carried out in a machine installed at a non-central location and operated by an OR assistant, e.g. in a disposal room adjacent to the emergency OR. The instruments must be dried because instruments stored while damp quickly become rusty.
• If there is no emergency service, the instruments should be stored in a container that is closed with a lid (moist chamber). Yet a better solution would be storage in an alkaline detergent and disinfectant solution with inhibitors, because this prevents corrosion and makes provision already for decontamination.
• MIS instruments should not be dismantled before embarking on a long transportation journey or before a long storage period. Even if the emergency service staff are not familiar with dismantling procedures, it is recommended that minimally invasive instruments be left assembled so that they can be processed by specialist personnel.