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Laundry services
1. 2. 3. 4. 5. 6. 7. 8. Introduction Laundry Services Definition Objective Importance Functions Key Planning And Design Parameters Problem Situations 1 1 1 1 1 1 2 4

Catering Unit
9. 10. 11. Functions Key Planning And Design Parameters Other Considerations 5 5 7

Central Sterile Supply Department


12. 13. 14. 15. 16. 17. 18. 19. 20. Definition Objectives Functions And Activities Key Planning And Design Parameters Policies And Procudures CSSD Distribution System Disinfection And Sterilization Conclusion Bibliography 7 7 8 10 14 16 16 22 22

SEMINAR ON

CSSD, LAUNDRY & KITCHEN SERVICES


SUBMITTED TO: Mrs. J.Rukumani, Principal, College of nursing, MTPG&RIHS. SUBMITTED BY: R.Raj Bhanu, II year, M.sc nursing, MTPG&RIHS.

INTRODUCTION 2

Laundry services constitute one of the most important supportive services in a hospital. Globalisation, privatisation, need for quality assurance in health care institutions, increase in knowledge expectations, needs, demands, and requirements of clientele and staff are some of the factors which make laundry services of utmost important in health care institutions. Depending on the policy of the hospital processing of the cleaning of linen may be undertaken in-house or it may be outsourced. A food service department hospital is one of the most important supportive services in hospitals. Patients have varied food habits. They may also require therapeutically tailored diets. The decision to have in house food service department or outsourcing it depends on is a policy decision to be taken by the management of the hospital.

LAUNDRY SERVICES
Definition The word laundry has been derived from launderer/laundress meaning a washerman or washerwomen. The activities or services pertaining to the washing or cleaning of linen come under the ambit of laundry services. Objective The main objective of a laundry service is to provide an adequate quantity of the right quality linen for the indoor patients, OTs, OPD and other areas and for the medical and paramedical personnel engaged in providing health care. Importance An effective laundry services in a hospital has the following advantages: It provides psychological satisfaction to the patient and improves the aesthetics. An efficient laundry service reflects a positive image of the hospital and is an important public relations variable. It reduces the incidence of hospital associated infection by preventing infected laundry from being a source of infection. It facilitates a provision of quality health care services. Functions The main functions of laundry service are as follows: Collection of or receiving infected and soiled linen. Sorting, sluicing, disinfecting, washing and ironing of the linen. Repair of damaged linen. Assembling and packing speciality items and linen packs for sterilisation. Distribution of linen to the user departments.

KEY PLANNING AND DESIGN PARAMETERS

Location The laundry should be so located as to have ample daylight and natural ventilation. Ideally, it should be on the ground floor of an isolated building connected or adjacent to the power plant. This is because laundry is one of the largest users of power, steam and water. A location that allows movement of linen by the shortest route saves steps and time. The department should also be close to the service elevators. Some hospitals have linen through which linen bags are dropped to a designed place from where they are picked up by laundry personnel. However, these are now becoming obsolete. Every time a load of linen is handled, the cost of laundry services goes up. The location and physical plan layout are important in keeping the cost down. One way of doing this is to keep the traffic flow line as short as possible on vertical and horizontal transportation between the laundry and the user departments. Physical Layout A mechanised laundry service is not only convenient but also safe and dependable as compared to other methods. The design of the laundry should facilitate the following laundry process: reception of soiled laundry Sorting Sluicing Washing Hydro extraction Drying Calendering & pressing Package, storage and distribution of clean laundry. A separate room should be provided for receiving and holding soiled linen until it is ready for pickup or processing. As a planning guide, the quantity of linen to be cleaned may be taken as 4Kg per day with 10-20% being infected linen. In addition, 8 Kg of soiled linen for each surgical operation and delivery should be taken into consideration. There should barrier separating the soiled linen and infected linen. The infected linen should be separately handled and washed. Infected linen may be sent for sluicing and disinfecting before being loaded into regular washer extractor machines. There should be a physical separation between the clean and soiled areas. Laundry should have a separate entry and exit. The ceiling height should be approximately 4.5 m to facilitate installation and repair of equipment. The floor should be smooth, washable surface. They should not have any dust collecting projections.

The door should be wide enough (minimum 1500mm) to admit heavy machinery and trolleys. The room should have effective ventilation. The recommended air changes are 10 per hour. The boiler room should be appropriately located and there should be separate exhaust pipes for letting off steam. The recommended water supply is 15 litres of hot water and 10 litres of cold water for every Kg of linen. Utilisation of solar thermal system, in places having good sunlight is recommended. If the water being utilised is excessively hard, a water softening plant should be installed. Provision must make for fire safety including the installation of fire extinguishers. Trolley storage areas with separate storage of clean and soiled linen trolleys should be provided. The equipment installed should be able to process at least a seven days supply within a regularly scheduled workweek. Appropriate place should be available for the equipment in the laundry. The following equipments should also be planned and designed for Sewing room Laundry managers office Toilet facilities, resting room and shower facilities for workers. The drains especially in the sorting and washing area should have sediment and lint trays. Laundry should be planned and designed for the present with adequate capacity for future expansion. From departments or wards Receipt and sorting Soiled linen Storage Classification Washing and extraction Conditioning fouled /infected linen Central disinfection area. Storage Sluicing and washing extraction Conditioning Drying, ironing and calendering 5

Assembling and packing Despatch/issue. SPACE REQUIREMENT

The size and type of hospital determines the space requirement. The average floor area varies from 0.100 to 0.45m. SHEDULE OF ACCOMODATION ROOM/SPACE Reception and sorting Sluicing and disinfection mending Washing machines, driers, hydro extractors, calendering and pressing machines. Mattress sterilisation Clean linen storage and distribution Office Changing room Trolley storage Stores PROBLEM SITUATIONS Theft of linen Theft of linen in hospital is common. Linen is good condition is a very marketable commodity. Theft of linen takes place usually at night on the patient floors and departments. Interestingly, soiled linen is not a significant target of theft. All linen should be kept under lock and key, and linen in stock should be made accessible only to those who need it as part of their duty. The linen closet in the nursing unit should be located directly facing the nurses station. The supply level of linen in the wards should be kept low to correspond with the bed occupancy. Thefts are proportionately higher when a large quantity of linen is accessible to the employees, visitors and patients. Area in m2 14-21 21 10.5 42-84

21 14-21 9 8 8 10

CATERING UNIT
INTRODUCTION 6

A food service department in hospitals is one of the most important supportive services in hospitals. Patients have varied food habits. They may also require therapeutically tailored diets. The decision to have an in house food service department or outsource it is a policy decision to be taken by the management of the hospital. Functions The catering unit in a hospital has the following functions: Provision of diet to inpatients as per requirement considering the nature, type of disease, nutritional requirements and food habits of the clientele. To provide counselling to ambulatory patients. In-service training programmes depending on the type and size of the department and policy of the hospital. Provide the best possible food at a cost consistent with the policy of the hospital. Impart instructions to nurses, medical and dental students, interns and residents about principles of nutrition and diet therapy. KEY PLANNING AND DESIGN PARAMETERS Location The unit should preferably be located on the ground floor. The storage area should be close to the unloading dock. It should be in proximity to the inpatient wards with easy access to the vertical transportation system to facilitate delivery of food to the patients. The cafeteria dining rooms should have convenient access to the preparation room as well as to the patients, attendants, visitors and staff. In case steam is utilised in the unit, the kitchen and boiler facility should have facilitating locations to optimize the steam utilisation. Design 1. Receiving area It should have easy outside access for receiving of supplies, loading and unloading platforms. It should be equipped with scales to weigh materials and supplies. 2. Storage area

Storage for crockery, cutlery utensils, dry storage area for staples and refrigerated storage for perishables should be planned. Large hospitals should have walk-in coolers and refrigerators with varying degrees of temperature for meat products, dairy products, and vegetables. Walk-in coolers and freezers may be lockable from outside but have a release mechanism for exit from inside. An automatically operated lighting should be installed to be switched on when the door is open. 3. Preparation area In this area, sorting, peeling, slicing, chopping, mincing and kneading is done. It should be located between the storage and cooking area. A double sink with draining board, worktops, peelers and grinders are the facilities and equipments required. 4. Production/cooking This area will require cooking ranges, bulk cookers, chapatti puffers, baking ovens and frying equipment. This area is required to be located between the preparation and service area. 5. Service area In this area prepared food is received and assembled into food trays. Refrigerators and table tops and cupboards for storing trays, prepared food, cutlery and other items for assembling trays are some of the equipments or facilities required in this area. 6. Food distribution A cart distribution should be provided with spaces for storage, loading, distribution, receiving and sanitising of the food service carts. Trolley washing areas should also be provided. 7. Dishwashing area Storage racks, stainless steel sinks and drainers should be installed as per workload. The area should provide space for receiving, scraping, rinsing, sorting and stocking of soiled tableware. Floors and Walls Floors should be impervious and non slip, walls and ceiling should be smooth, impervious, and easily cleanable. Garbage Disposal

Provision should be made for regular wet and dry garbage storage, removal and disposal in accordance with waste management guidelines/rules. Offices They are required for mangers, dieticians and supervisors. Other requirements include staff change rooms, lockers for workers, toilets and rest room for staffs. A room is also required for clerks. OTHER CONSIDERATIONS Proper ventilation and lighting LPG cylinder bank should be available. There should be provision for adequate steam supply. Fire protection services should be provided. Air lock should be provided between the kitchen and the outside. All tables, benches and other surfaces on which food is prepared or handled should be covered by smooth impervious material. To prevent accidents all internal door kitchens should have clear glazing on the top half to allow view of other side of the door.

CENTRAL STERILE SUPPLY DEPARTMENT


DEFINITION A central sterile supply department is a hospital support service which is entrusted with processing and issue of supplies including sterile instruments and equipments used in various departments of a hospital. In certain hospitals especially in developed countries this department is called central service department and encompasses many other functions in addition to sterilisation such as purchasing, stocking and distribution of supplies. AIM To provide, efficient, economic, continuous and quality supply of sterile materials to various areas of the hospital with ultimate objective of ensuring high quality patient care. OBJECTIVES The objectives of establishing a CSSD are to: Provide all the departments with an adequate supply of reliably sterilised material for routine and emergency use from a central department.

Bacteriologically safe standardisations are conducted under controlled conditions and at minimum cost, thus helping to reduce the incidence of hospital associated infection. Supervise and provide facilities for the bulk sterilisation of the materials. Pool in the equipment resource of the hospital for economical and effective utilisation under adequate managerial and technica supervision. Provide facilities for in-service teaching and training of nursing and ancillary personnel in the sterilisation practices. To undertake operational research techniques for improving sterilisation practices and to participate in research pertaining to supply and equipment in an effort to provide most suitable material for patient care. Play an effective role in hospital infection control practices.

FUNCTIONS AND ACTIVITIES 1. Receipt This includes receiving of the materials, supplies, equipments, dressings and other specialised surgical items for processing. 2. Cleaning The function entails the cleaning of used equipments/materials, rubber and plastic goods either manually or by machines. Ex: ultrasonic cleaner, jet glove washing machines, anaesthetic tubing washers and dryers. 3. Checking, assembling and packaging

This entails the checking of the glass items for breakages, needles and instruments for sharpness and breakages assembling of the equipment after washing and drying making sets and packaging for sterilisation. 4. Sterilization Sterilisation is defined as the process by which an article, surface or medium is freed of all micro-organisms either in vegetative or spore state.

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Agents used in sterilisation: Physical agents Sunlight Drying Dry heat: flaming, incineration, hot air Moist heat: pasteurisation, Dyes, Halogens Phenols Surface active agents Metallic salts Gases: ethylene oxide Formaldehyde Beta propiolactone. It possesses appreciable bacterial activity and plays an important role in spontaneous sterilisation that occurs under natural conditions. The action is due to its content of ultraviolet rays. DRYING Moisture is essential for growth of bacteria. Four fifths of weight of bacterial cell is due to water. Drying in air is therefore a deleterious effect on ma y bacteria. HEAT Heat is the most reliable method of sterilisation. Materials that may be damaged by heat may be sterilised at lower temperatures for longer periods or by repeated cycles. DRY HEAT Flaming: Inoculating loop or wire the tip of forceps and spectacles are held in a Bunsen flame till they become red hot. Incineration: This is an excellent method for safely destroying the materials such as contaminated cloth, animal carcasses and pathologic materials. chemical agents Alcohol: ethyl alcohol: isopropyl ethyl Trichlorobutanol Aldehydes: formaldehyde, butyraldehyde isopropyl

boiling, steam under pressure Filtration: candles, asbestos, pads, membranes. Radiation Ultrasonic and sonic vibrations. SUNLIGHT:

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Hot air oven: This is widely used method. A holding period of 160degree Celsius for one hour is used to sterilise glassware, forceps, scissors, scalpels, glass syringes and grease. Cutting instruments such as those used in ophthalmic surgery should ideally be sterilised for 2 hours at 150 degree Celsius. Allow to cool slowly for about two hours before door is opened, since glassware may crack. Sterilisation control: The spores of a non toxigenic strain of clostridium thermophilus are used as a microbiological test of dry heat efficiency. Paper strips impregnated with 10^6 spores are placed in envelops and inserted into suitable packs. After sterilisation strips are removed and inoculated into thioglycollated or cooked meat media and incubated for sterility test under strict anaerobic conditions for five days at 37 degree Celsius. FUNCTIONS AND ACTIVITIES Receipt: This includes receiving the materials, supplies and equipment, dressings, and other specialized surgical items for processing. Cleaning: The function entails the cleaning of used equipment/materials; rubber and plastic goods either manually or by machines, e.g. ultrasonic cleaner, jet glove washing machines, washer disinfectors, anesthetic tubing washers and dryers. This function may also include the cleaning of the delivery trolleys. Checking, assembling and packaging: This entails the checking of glass items for breakages, needles and instruments for sharpness and breakages, assembling of the equipment after washing and drying, making sets and packaging for sterilization. Sterilization. Labeling. Storage: This function includes the storage of sterilized packs, drums and disposables, dressing materials, spare parts of machines or sterilizers for routine maintenance and broken/unserviceable items for condemnation. Space should also be provided for storing distribution trolleys. Issue and distribution: This includes the issue of sterilized, packages, dressings, linen, instruments and disposables to various departments of the hospital. Flow diagram, functional relationships and circulation diagrams are shown in respectively. Layout diagram is shown. KEY PLANNING AND DESIGN PARAMETERS There should be no back tracking of sterile goods. Materials/items from contaminated and sterile areas should be separated from each other. There should be separate receipt and dispatch areas. 12

The clean and dirty areas should be separated by a physical barrier. The floor surface should be smooth, impervious, non-skid and robust. Light fittings should be recessed. Relative humidity should be maintained at 45 5 %. The clean area should be provided with air locks and maintained at positive pressures relative to the adjoining spaces. The minimum ventilation rate should be 6 to 10 air changes per hour. Facilities must be planned for at least one high speed autoclave preferably in the OT complex. Flash sterilization is performed in the user departments to sterilize instruments that are required immediately. In order to minimize the spread of lint, the preparation and assembly of gauze packs should be confined to a separate, enclosed ventilated work area wherein gauze cutting machine with table and storage racks of gauze packs should be provided. In order to maintain and control a clean environment, it should be ensured that there should be no exposed light fixtures, pipes, ducts or cables to collect lint and dust. The walls and ceilings should be of a smooth surface to facilitate easy cleaning. The work area should be made of marble/granite/stainless steel. The sterilization must be planned for autoclaving by steam as well as by gas since certain items such as rubber; plastic or delicate instruments cannot be autoclaved. Plasma sterilization system: It is a low temperature hydrogen peroxide gas plasma sterilization system. It sterilizes metal and non-metal instruments, endoscopes, electronic and optical equipment as well as plastic and rubber products. Its main advantages are: o Fast instrument turnaround. Since no aeration is required, cycle time is short. o Safe and easy to use. The process is safe for users, patients and instruments due to its non-toxic hydrogen peroxide plasma process. o Process is gentle on instruments since sterilization is at temperatures below 55C under dry conditions. It eliminates instrument stress related to heat, rapid temperature change and humidity. Location: The location of CSSD should be such that it is as close as possible to the major user areas, such as the accident and emergency department, operation theaters and wards. In a multistory building, the CSSD may be situated in the lowest two dedicated dumb waiters one utilized for transportation of sterile and the other for soiled material. Physical layout: The following areas should be planned: Area for receipt of materials/items. Areas for storing sterilized material/items. Cleaning, washing and decontamination area.

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Assembling area: This requires workstations for assembling medical/surgical treatment packs, sets and trays. Work benches with multiple drawers for instruments and supplies should be provided. In the linen pack area, an inspection table must be provided for detecting holes in the linen. Glove processing area. Gauze cutting area. Area for storage of packed sets waiting for autoclaving. Sterilizers room: This should be equipped with double door passthrough autoclaves which are built into the wall between the clean and sterile areas. Materials are loaded on the clean side and unloaded after sterilization on the sterile side. Sterile store. Supervisors room. Issue counter. Office. Change room. Trolley washing and packing area. Area for storage and supply of steam, hot and cold water. Space A minimum of 7 sq ft on a per bed basis (with 100 sq ft for the smallest hospital) is considered essential for planning a CSSD with scope for future expansion and growth. The following area is recommended. The area will be divided into receiving and cleaning, clean work and processing, sterilization, syringes, glove processing, sterile storage, and issue. Needs for space for each of these differ by availability of mechanical devices and modern facilities. Space required for planning a CSSD. Up to 100 beds Up to 200 beds Up to 300 beds 300 and above 10 sq ft per bed. 9-10 sq ft per bed. 8-9 sq ft per bed. 7-8 sq ft per bed.

These activities comprise of the following 1. 2. 3. 4. 5. 6. Receipt of used supplies Accounting Washing, cleaning and assembling Sorting Gauze cutting and assembling Packing 14

7. Sterilization 8. Sterile storage. 9. Issue. Staffing There should be a properly qualified superintendent in charge of the department. The chief of the department, the CSSD supervisor, has traditionally been a senior nurse. The supervisor can be a person from any other stream of hospital personnel provided he or she has grounding in the basic of patient care, bacteriological, principles of sterilization and mechanical and administrative competence. The routine work in the CSSD is of a repetitive nature. The other staffs required are usually in service trained CSSD attendants, semiskilled workers who can be called CSSD assistants, CSSD technicians and sweeper. For the smallest department, a minimum of four persons will be required apart from the supervisor. A 500 bedded teaching hospital has the following staff. Technologists 5 Technical assistants 4 Nursing aides 4 CSSD attendants 4 EQUIPMENT The main items of equipemnt in the cssd are the autoclave. At least one additional autoclave other than the main one should be provided to cater for failure. Various type of autoclaves are available. Most modern electric autoclaves are designed to achieve a vaccum in the sterilization chamber followed by injection of stream under controlled pressure to achieve desired temperatures varying periods, and have recording devices. Walk in type of autoclaves are available which are suitable for the requirements of large hospitals. Other equipment in the CSSD includes the following Dry oven Gauze cutter Ultrasound washer Needle flushing device Autoclaves Ethylene oxide sterilizer Work benches with marble or stainless steel top Storage cupboard and racks Linen folding table Soaking sinks High pressure water jets.

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POLICIES AND PROCUDURES Central sterile supply is most effective when it provides a limited basic range of articles for the greatest possible number of users. A periodical review should be made of the items processed by the CSSD to assess which ones can be modified to meet a wider range of needs and whether any can be dispensed with altogether. CSSD is one department where policies and procedures must be unambiguous and scrupulously followed in letter and sprit. The smallest mistake or carelessness on part of the staff can have serious repercussions elsewhere in the hospital. The policies should cover the following: Responsibility: The responsibility for supervision on the sterilizing tasks should be clearly understood and vested under on person. Due to repetitive work, workers may be tempted to be careless in sterilization procedures and differentiation between sterilized procedures and differentiation between sterilized and unsterilized packed. It is impossible to differentiate between similar looking contaminated, potentially contaminated or sterile packs packed in linen paper wraps. In case of doubt, it is a safe practice to treat all unused articles as contaminated. Disposables: The advantages and disadvantages of using disposables should be fully taken into account when considering the replacement of traditional materials by their disposable equivalents, remembering that some disposables give more values for money. Segregation of sterile and unsterile supplies: Sterile supplies ands packs and contaminated articles should never be carried on the same trolley or by the same staff. The term sterile supplies covers all articles which have either been sterilized in CSSD or disposable sterile packs distributed through CSSD. Standardizations of packs: Special trays and sets to be processed by CSSD should be standardized by the hospital. Surgical instruments and other related items needed for commonly practiced surgical procedures generally do not vary from surgeon to surgeon. This system has the advantage of having standardized sets ready at hand even for emergency operations, irrespective of special preferences of a particular surgeon. Besides these, the other commonly used sets of sterile instruments and materials in various other procedures that are generally standardized are as follows: Cut down set Lumbar puncture set Sternal puncture set Catheterization set Bladder wash set 16

Liver biopsy set Fine needle aspiration cytology set Paracentesis set Suturing set Thoracic aspiration set Incision and drainage set tracheotomy set.

Packing procedures Step by step packing procedure for each pack should be determined, and should specify: The quantities of materials required and their arrangement on the workbench, and The sequence of the packing operation. Fifteen sq feet of packing space is necessary on each workbench for assembly of simple packs with a high throughput, with some storage space above the bench. Manual of operations: A procedure manual listing all procedures followed in the CSSD for each process and their correct sequence is essential for effective operation of the department. It must be realized that more costly and sophisticated the equipment, more training and precision is required to operate it. Packing material Packing material used as wraps for articles for steril9ization differs with the process of autoclaving or hot air oven. Linie and Kraft paper are commonly used, paper being a better bacterial barrier. In case of paper, it is desirable to have a double paper wrapping. Autoclaving Use of saturated steam under pressure is the safest and dependable method of sterilization, in universal use or destruction of all forms of micro organisms. The higher the temperature the more rapidly is sterilization accomplished. The minim time for sterilization by autoclaving process is 121 degree C at 15 Ibs in 15 mts. If the temperature is raised to 126 degree C, the time can be reduced to 10 minutes. At 134 degree C, it is 3 minutes, and only a minute at 150 degree C. The last process is utilized in Flash sterilizers installed in some operation theaters for urgently required instruments during operation. Quality control: Sterilization checks In spite of the process instrumentation fitted on autoclaves which give a graphic record of temperature and pressure, routine methods of check for sterilization must be incorporated. Color index strips available for this purpose should be kept in each pack being autoclaved. Manufactures instructions must 17

be followed scrupulously regarding loading of autoclaves, temperature and pressure levels and timings. Sterilization process After the sterilizer chamber is sealed and the controls set, sterilization process goes through the following phases: Warming the chamber. Evacuating residual air to partial vacuum Introduction of moisture to ensure that it penetrates wrapping and material Raising the temperature Exposure for the required time Release of chamber pressure Removal of the gas under vacuum Re establishment of atmospheric pressure by introduction of filtered air into chamber.

CSSD DISTRIBUTION SYSTEM


Distribution system for sterile article should also be decided at the planning stage itself. The following four systems are in use. The last two are door deliveries. Clean for dirty exchange: A sterilized articles is issued at the CSSD issue counter on return of a used one at any time. Requisition system: Articles needed are requisitioned by users on a daily or regular basis and collected by them at CSSD counter. Grocery System: Each users requirements for all items fro a specific period are delivered at suitable interval irrespective of whether the contents have been used or not and the previous basket or container withdrawn. Quota system: Pre determined stock levels of various items for each user unit are maintained by delivery personnel from CSSD through regular deliveries. Disinfection and Sterilization Disinfection and sterilization are now the most basic necessities in clinical practice as well as laboratory procedures. Their scientific basis has been developed only during the past century. Some of the important terms related to these are defined hereunder:

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Sterilization It is the destruction or complete removal (by filtration) of all forms of micro-organisms including their spores. Disinfection It is the destruction of many microorganisms but not usually the bacterial spores. Antisepsis It is the destruction or inhibition of microorganisms in living tissues thereby limiting or preventing the harmful effect of infection. A static agent It would only inhibit the growth of microorganisms (bacteriostatic, fungistatic, sporostatic). A cidal agent It would kill the microorganism (bactericidal, virucidal, fungicidal). Sterilants These are the chemicals which under controlled conditions can kill sporing bacteria. The agents which perform the functions to fulfill the above mentioned definitions can be divided into two broad groups: physical agents and chemical agents.

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Physical agents S Heat Moist Dry T E R Ionizing proteins X-rays Beta-rays Gamma rays Ultraviolet rays Filtration I L I Z A T I O N

Chemical agents Agents acting on cell membrane Surface acting agents Phenols Organic solvents Agents that denature Acids and alkalies Agents acting on functional group of proteins Heavy metals Oxidizing agents Dyes Alkylating agents

PHYSICAL AGENTS Physical agents are usually preferred over chemical agents for performing sterilization. Heat occupies the most important place as a physical agent and wherever possible, it is the method of choice. Both moist heat as well as dry heat can be applied. Moist Heat This is heating in the presence of water and can be employed in the following ways: Temperature below 100C Temperature around 100C Temperature above 100C Temperature below 100C This includes holder method of pasteurization where 60C for 30 minutes is employed for sterilization and in its flash modification wherein objects are subjected to a temperature of 71.1C for 15 seconds. This method does not destroy spores.

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Temperatures around 100C Tyndallization is an example of this methodology in which steaming of the object is done for 30 minutes on each of three consecutive days. The principle is that spores which survive the heating process would germinate before the next thermal exposure and would then be killed. However, results obtained by this method have not been very encouraging. Hot water boilers are still a common sight in many hospitals and dentists surgeries. The maximum temperature is 100C and will, therefore, not kill all the spores. However, if it is used carefully and correctly, i.e. if the water is changed regularly, the instruments from one patient are not mixed with those of another and a full 20 minutes exposure is achieved, then all vegetative forms of bacteria and viruses can be destroyed provided instruments were cleaned before putting them in boilers. Temperatures above 100C Dry saturated steam acts as an excellent agent for sterilization. Autoclaves have been designed on the principles of moist heat. The ideal timetemperature relationship in moist heat and dry heat sterilization processes is given in Table 3.1. Table 3.1: Time- temperature relationship in heat sterilization Process Moist heat (autoclaving) Dry heat Temperature 121C 126C 134C >160C >170C >180C Holding period 15 minutes 10 minutes 3 minutes >120 minutes >60 minutes >30 minutes

The autoclaving is in use for the sterilization of many ophthalmic and parental products, surgical dressings, rubber gloves, and bacteriological media as well as for decontamination of laboratory and hospital reusable goods. Dry Heat This is less efficient process as compared to moist heat and bacterial spores are most resistant to it. Spores may require a temperature of 140C for three hours to get killed. Dry heat sterilization is usually carried out by flaming as is done in microbiology laboratory to sterilize the inoculating loop and in hot air ovens in which a number of time-temperature combinations can be used. It is essential that hot air should circulate between the objects to be sterilized. Microbial inactivation by dry heat is primarily an oxidation process. 21

Dry heat is employed for sterilization of glassware, glass syringes, oils and oily injections as well as metal instruments. Ionizing Radiations Ionizing, radiations include X-rays, gamma rays and beta rays kill microbes by damaging the DNA. The ionizing radiations are used for the sterilization of single use disposable medical items. Ultraviolet Radiations The ultraviolet (UV) rays of wave length 240-280 nm have been found to be most efficient in sterilizing. Bacterial spores are more resistant to UV rays than the vegetative forms. Exposure to UV damages DNA. This results into noncoding lesions in DNA and bacterial death. The bactericidal activity of sunlight is due to the presence of UV rays. The practical application of this method is in disinfecting the drinking water, obtaining pyrogen free water, air disinfection (especially in safety laboratories, hospitals, operation theatres) and in places where dangerous microorganisms are being handled. Filtration Filters have been used since long to purify water and sewage. Several types of filters are now available with wide applications. Table 3.2: Applications of filtration Sterilization of thermolabile parenteral and ophthalmic solutions Sterility testing of pharmaceutical products Clarification of water supplies Microbiological evaluations of water purity Viable counting procedures Determination of virus particle size Air sterilization Sera sterilization

Type of Filters Various types of filters that are available are: Unglazed ceramic filters (Chamberland and Doulton filters) Asbestos filters (Seitz, Carlson and Sterimat filters) Sintered glass filters Membrane filters

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Membrane filters are widely used nowadays. These are made up of cellulose ester and are most suitable for preparing sterile solutions. The range of pore size in which these are available is 0.05-12 m whereas the required pore size for sterilization is in range of 0.2-0.22 m. CHEMICAL AGENTS Chemical disinfectants, unlike chemotherapeutic agents, are highly toxic for all types of cells. These can be classified into various groups depending upon their site of action or mechanism of inactivating organisms. Chlorine and iodine These are most useful disinfectants. Iodine as a skin disinfectant and chlorine as a water disinfectant have given consistently magnificent results. Their activity is almost exclusively bactericidal and they are effective against sporulating organisms also. Mixtures of various surface acting agents with iodine are known as iodophores and these are used for the sterilization of dairy products. Apart from chlorine, hypochlorite, inorganic chloramines and organic chloramines are all good disinfectants but they also act by liberating chlorine. Hydrogen peroxide in a 3% solution is a harmless but very weak disinfectant whose primary use is in the cleansing of the wound. Potassium permanganate It is another oxidizing agent which is used in the treatment of urethritis Formaldehyde It is one of the least selective agents acting on proteins. It is a gas that is usually employed as its 37% solution, formalin. When used in sufficiently high concentration it destroys the bacteria and their spores. For some of the equipment which cannot be heat sterilized and which are not common sources of spread of infection, cold sterilization can be achieved by diping the precleaned instrument in 2% solution of glutaraldehyde for 15-20 minutes. This time is sufficient to kill the vegetative form as well as spores of the organisms that are commonly encountered. Ethylene oxide It is an alkylating agent extensively used in gaseous sterilization. It is active against all kinds of bacteria and their spores. It can sterilize almost any object but its greatest utility is in sterilizing those objects which are damaged by heat (e.g. heart lung machine). It is also used to sterilize fragile, heat sensitive equipment, powders as well as components of space crafts. The common uses of some of the chemicals and their in-use dilutions have been presented in Table 3.4. Cystoscopes and endoscopes can be sterilized by glutaraldehyde whereas filtration is the method of choice for the sterilization of heat-sensitive substances such as antibiotics, serum and vaccines.

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For the sterilization of a small and closed chamber, sterilization can be achieved by UV rays whereas for bigger rooms and operation theatres (OTs) fumigation with formalin is the most effective method. Conclusion Despite all advances in medical science, hospital-acquired infection remains a serious problem in health care today. To combat this, hospitals must have a scientific and effective method of disinfection and sterilization. In a scientifically planned and constructed CSSD, the process of cleaning, disinfecting, inspecting, packing, sterilizing, storing and distribution is carried out by trained personnel to ensure better control and reliable results to reduce risk of infection. Hospitals must provide adequate facilities for cleaning, sterilization and storage of equipment and instruments to ensure the care and safety of patients and staff. Bibliography: 1. Shakti Kumar Gupta, Sunit Kant, Chandrasekar R et.al, modern trends in planning and designing of hospital, principles and practice, 1st edition, 2007, Jaypee medical publishers, New delhi. 2. Goel.SL, Kumar R Management of Hospital, Hospital Administration in 21 century, Vol.2, Deep and Deep Publications, New Delhi.

3. Francis CM, Hospital administration, 2nd, 1995, Lordan Publishers, New Delhi. 4. Basavanthappa BT, Nursing Administration, 1st Edition, 2000, Jaypee Medical Publishers, New Delhi.

5. Syed Amin Tabish, Hospital and health care service administration, principles and practice, 2005, 2nd ed, Oxford University press, New Delhi. 6. Kundlers GD, Kopinath S, Katakn A, Hospitals planning design and management, 1998, 1st ed, Tata Mc Grow Hill publidhers company , new Delhi.

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