ANCILLARY

SERVICES

S A N G E E TA B S R
170503009
CSSD SERVICES
OBJECTIVES
• define CSSD
• understand the ideal plan and the organizational
consideration of CSSD.
• Layout of CSSD
• Staffing pattern
• Methods of sterilisation
• Inventory management
 furnishes all supplies

To

nursing units and departments of a hospital, i.e. theatres,

CSSD
wards, out-patient and causality departments

With

complete, sterile equipment

For

immediate treatment of
patients
SUPPLIES

Operating Needles and

Sterile linens room packs syringes

Medical-
Sterile kits Surgical
supplies
PLANNING AND ORGANIZATIONAL
CONSIDERATION OF CSSD
Bed size of the hospital Location of CSSD

Up to 100 beds In operation theatre

100-500 beds located centrally in service

area
Above 500 beds In service area and a separate
unit for OT to be called
Theatre Sterile Supply Unit
(TSSU)
AREAS TO BE PROVIDED IN CSSD
Equipment Receiving counter and
storage room clean up room

Gloves assembling room with

Needles and syringes
rubber goods processing
processing room
room

Clean work area Sterile storage area and

including sterilizers issue counter

Gauze and dressing assembly

area
PROCESS
Counter of receipt of Decontamination and
items cleaning area

Separation of sterilised items by Processing and

packing of items
a partition or corridor

Sterilised items
Distribution point Sterilisation
store
 Physically separated Temperatures should be
from all other work controlled between 18-
areas. 22ºCelsius

Changing area for Wash room, clean

workers including room and sterilizer
toilet facilities and LAYOUT unloading area should
lockers be free from ‘opening’
windows

Unidirectional flow from Contamination of

the ‘dirty’ area to the sterile goods should be
‘clean’ area avoided.
STAFFING PATTERN
• One CSSD worker per 30 beds plus one supervisor is
recommended. In 200-300 beds hospital, 10-15 persons are
needed.
• Staffs for 1000 bedded hospital is
• Supervisor- 1 (senior most and trained technician)
• Asst. supervisor- one of the senior technicians
• Technician -6
• Sweeper-15
• Clerk- 1
REQUIRED EQUIPMENTS AND MATERIALS
• Hot and cold running water
• Cleaning brushes and jet
water gadgets
• Hot air oven for drying
instruments and sterilization
• Instrument sharpener like
needle sharpening machines
Ultrasonic washer
• Steam sterilizes and boiler
for steam
• Autoclaves of various sizes including gas autoclave
• Testing equipment
• Chemicals to clean materials
• Wall fixtures like sinks, taps
• Trolleys for supply of sterilized items and separate trolleys
for collection of used items are needed
METHODS OF STERILIZATION:

Steam sterilization

Autoclaving is the commonest method

ETO STERILISER
Sub atmospheric pressure
sterilisation with formalin
It is meant to disinfect
instruments like endoscopes, the
temperature required is 90-
degree C for 10-30 minutes.

Formaldehyde steam sterilization

Chemical steriliser Gamma irradiation steriliser
 INVENTORY MANAGEMENT
• Stock: To ensure the availability of sterilized items to the
hospital units, five times the average daily requirements, the
replacement and procurement of condemned items should
be laid out so that situation of ‘stock out’ can be avoided.
• Issue of materials: The principle of ‘first in -first out’
ensures proper rotation of supplies in CSSD and prevents
any item from being kept for longer time so that its
sterilisation date expires.
• Distribution of sterile items: The method that can be
used for distribution of sterile items are:
Grocery system: CSSD is open for limited hours
• Clean for dirty exchange system: one clean item is
provided for each item in the ward used.
• Basket system: A basket with daily requirement of ward is
changed everyday irrespective of the sterile items used or
not, and the items of the whole basket is sterilized every
day.
• In case the items are to be stocked in wards, the date of
sterilisation is written on each item so that the unused
items are returned to CSSD for re-sterilization after 72
hours.
Quality control methods:
• Routine temperature/pressure and holding time testing of
each autoclave.
• Steam clox is also very handy and reliable. Changes colour
from brown to green.
• Random samplings of sterilized
items are also tested in laboratory.
• Culture of wall/floor and scrapings.
Laundry services
OBJECTIVES
• Define laundry.
• Functions of laundry
• Types of laundry
• Planning and organizing of laundry services
• Areas
• Laundry management
• Laundry equipments
DEFINITION
It is a business establishment where clothes, linens, etc., are
laundered. (Free dictionary)
FUNCTIONS OF LAUNDRY

Control of cross infection

Patient satisfaction

Public relation
T Y P E S O F L AU N D RY

In-patient or in-house
laundry
In this system, the
hospital has its own
linen and laundry
services. All the activities
of the hospital laundry
services are done in
hospital premises. A
hospital with more than
100 beds can run this
type of laundry services.
Rental system
• In this system, the hospital hires laundered linen from
contractor on rental basis.
• Useful for a hospital with small size where it will not be
economical to have their own laundry.
Contract system
In India most of the hospitals have their own linen, but
has no means of laundering it. It hires a contracter whose
job is to collect the linen and after laundering delivers to
the hospital. In some cases, the hospitals provide water
and washing area within the hospital premises.
Co-operative system
• It is most beneficial to the smaller hospitals than the large
hospitals.
• A single laundry caters to a number of hospitals.
PLANNING AND ORGANIZING OF LAUNDRY
SERVICES
Location:
• Should be in the same building
• Having separate entrance for entrance and exit areas
• Recommended to have a mechanized laundry in the
basement, with proper drainage arrangements.
Space requirements
• The requirement for any laundry services has been worked
out to be approx. 10-15sq.ft/bed.

No. of beds Space

200-300 beds 3750 sq. Ft.
300-500 beds 5670sq. Ft.
500-600 beds 6460 sq. Ft.
>650 beds 8210 sq. Ft.
Physical layout
• The planning of the building and installation of Straight
through flow equipment from the dirty end to the clean
end.
• U- flow: where the dirty and clean ends are in the same
direction.
TWO DISTINCT AREAS
Dirty area:
It comprises of
• Reception of solid linen
• Sorting of soiled linen into
suitable quantities for
processing.
Clean area:
It comprises of
• Drying
• Finishing
DRYING
• Discharge
• A barrier wall between
the clean and dirty area is
desirable

FINISHING
LAUNDRY MANAGEMENT:
• The management of laundry contributes to morale of the
staff and patients with fresh laundered linen
1. Linen distributing system:
• Topping up: In this, ward is given certain number of
stocks of linen based on 24 hours requirement and
shortage of linen due to use is topped up by the laundry
staff every day and used ones are collected.
• Clean for ‘dirty’ exchange: The issue of clean linen to
exchange number of pieces of dirty linen.
• Exchange trolley system: This is expensive and not
used in India. In this, total trolley is supplied which has 24-
hour requirement and next day fresh trolley is supplied
with same number of pieces.
LAUNDRY EQUIPMENTS

Washing machine Washer cum extractor

Hydroextractor Dryers
PRESSING EQUIPMENTS

Calender machine Flat bed press

Hand iron Ironing board
JOURNAL :Quality Control in Linen and Laundry Service at A Tertiary Care Teaching
Hospital in India (International journal of health sciences, vol.3 No.1)
The current study found that in spite of certain deficiencies in the
equipment, manpower and process, the linen and laundry service is
providing a satisfactory service to its users. However the services can
be further improved by removing the present deficiencies both at
structure and process level.
• 20% of pillow covers were positive for aerobic spores.
• Blankets may act as reservoirs from which new patients may be
infected. Regular disinfection of blankets was reported to result in
marked reduction in number of (Staphylococci aureus) setting on
culture media.
• 40% of trolleys positive for pseudomonas, (trolleys and vans used for
the carriage of linen)
Kitchen services
OBJECTIVES
• Introduction to Hospital dietary services
• Functions of dietary services
• Location and space requirements
• Layout of kitchen
• Distribution of diet
• Dietary store management
• Equipment
A hospital dietary service includes most importantly a
production unit that converts raw materials into palatable
food.

Raw food materials to palatable food

FUNCTIONS OF DIETARY SERVICES
• The dietary services cater for the following:
Planning and Diet
management of counselling to
hospital diet patients
Dietary
service

Dietary education
LOCATION AND SPACE REQUIREMENT
• LOCATION: The dietary department should be located
on the ground floor near wards where the diets need to
be taken and also accessible to road as supplies are to be
carried to storage areas.
• SPACE REQUIREMENT: Hospital kitchen is divided
into number of divisions, which has different activities. The
broad areas are supplies receiving area, cooking area, pots
and pan wash, garbage disposal, LPG stove and refrigeration
facilities, housekeeping, dietitian, steward offices and
circulation area.
Space requirements are recommended for different size of
hospitals:
200 beds or less 20 sq. ft per bed
200-400 beds 16-18 sq. ft per bed
500 beds and above 20 sq. ft per bed
Layout of kitchen
DISTRIBUTION OF DIET
C E N TRALIZE D S E RV I CE : D E C E N T R A L I S E D S E RV I C E
The food is set in individual
The food is served to the
tray centrally at dietary
wards and served as per
department including
the need of the patient.
therapeutic diet of patients
and are transferred to
wards in trolleys and
served to the patients.
DIETARY STORE MANAGEMENT:
• Storage of food items: For dry storage, the temperature
should be 70-degree C, with adequate ventilation. The
storing shelves, bins should be placed 10” above the floor.
• Purchase of food products: The items can be purchased
from open market or through calling tenders. The items to
be purchased should have AG MARK. For this, an internal
purchase committee can be constituted
by hospital administration.
Equipment planning: Equipment purchase depends on
the objectives and basic functions of the department,
workload and availability of the personnel, and quality
standards.
Laboratory services
OBJECTIVES
• Introduction to laboratory services
• Functions of laboratory services
• Functional division
• Organisation
• Equipment
Laboratory services include testing of materials, tissues
and fluids obtained from a patient to determine the cause
and nature of disease.
FUNCTIONS OF LABORATORY SERVICES
The basic functions of laboratory service are:
✓ To assist doctors in arriving at or confirm a diagnosis and
to assist in the treatment and follow-up of patients.
✓ The laboratory not only generates prompt and reliable
reports, but also functions as store house of reports for
future references.
✓ It carries out urgent tests at any part of day or night.
FUNCTIONAL DIVISIONS
ORGANIZATION
Location:
• It is preferable to have hospital laboratory planned on the
ground floor and so located that it is accessible to the
wards.
• In large hospitals, the entry of the outpatients to the
laboratory can be done by opening a sample collection
counter in the outpatient service area itself.
Outpatient sample collection:
• It should be located in the outpatient department itself.
• The design of this area should include waiting room for
patients, venipuncture area and specimen toilets separately
for male and female patients.
• Area/Space: In a small hospital, the laboratory facility
consists of a room in which all the routine urinalysis,
hematology and biochemistry investigations are carried out.
As the hospital size increases, the necessity for
departmentalization of the laboratory is also expected.
• Point of care: Tests performed at patient’s bed side.
• Stat laboratory: Located near an emergency to provide
immediate lab values.
• Administrative space: It offers for the pathologists and
others, staff toilets.
• Circulation space: It is the space required for
uncluttered movement of personnel and materials within
the department between various technical work stations,
rooms, stores etc.
• Reception and sample collection: This area should be
well ventilated and lighted, should have the chair where the
patient can sit in comfort and his arms can be stretched
for the phlebotomy.
• Specimen toilet: It is provided for the collection of urine
and stool specimens.
• Bar coding system for samples:
This system is used to trace the samples. The sample is
received, bar coded and then sent to processing area. This
protects patient’s identity.
• Specimen toilet
It is provided for the collection of urine and stool
specimens.
• Pathologist office
It is so placed that the pathologist can have an easy access
to the technical areas especially histopathology unit.
• Report issue
The reports should be issued in printed format. The hospital
lab software can be made as per the requirement of the
hospitals.
• Glass washing and sterilizing unit
Small labs collect blood in bottles that are washed and
reused. This is partitioned into washing and sterilizing area
containing sterilizer, pipette washer and sinks.
Internal design and fitments
a) Work benches
The height of the work bench
on which the technician sit while working
(revolving stools) vary from 75-90cm
depending upon the height of the workers.
b) Lighting
Natural light should be used to the fullest. Each work bench
should be provided with adequate electric points especially
fluorescent fixtures that give uniform illumination and
minimize heat.
c) Storage
Each laboratory bench length should have storage space for
reagents, chemicals, glass wares and other items, provided in
the form of under bench drawers, cupboards etc.
d) Air conditioning
Laboratory should be air conditioned due to accumulation
of formalin vapors or else a powerful exhaust system should
be installed.
e) Working surface/ flooring surface
The surface of the work benches should
be resistant to heat, chemicals, stain
proof and easy to clean. Flexible vinyl
flooring is preferred for laboratory floor
coverings.
EQUIPMENTS
Some of the core instruments that are needed are:

Auto analyser Cell counter Centrifuge

Refrigerators ELISA reader
✓ Pressure sterilizers ✓ Blood gas analyser
✓ Pipette washers  PCR instrument
✓ Analytical balance ✓ Flow cytometer
✓ Semi auto analyser
Journal
Patients Satisfaction on Clinical Laboratory Services at Nekemte Referral
Hospital, Oromia, Ethiopia
Abstract : Satisfaction is the extent to which the clients feel their needs are
fulfilled and their expectations are being met by the service provider.
Furthermore, understanding the level of client satisfaction and identifying the
factors hindering client satisfaction are the most important base lines to
improve the quality of service being delivered.
The overall degree of patient customers’ satisfaction with the laboratory
services at Nekemte Referral Hospital was 60.4% .patients were dissatisfied in
cleanness and location of latrines in the hospital. Therefore; hospital
administration and the laboratory department of Nekemte referral Hospital
should strive more to enhance patients’ satisfaction, particularly in sanitation
and location of the latrine in the hospital.
Cont….
Points identified for dissatisfaction of the laboratory services
• Total waiting time to get results
• Accessibility of sample collector
• Information given before and during specimen collection out
side the laboratory room
• Insufficient sample collection
• Improvement of laboratory service from time to time
• The cost of the laboratory service
Emergency services
OBJECTIVES
• Introduction to emergency department
• Planning and organizational considerations
• Medico-legal aspects of emergency department
Sudden illness or injury
requiring immediate
physicians attention to
prevent the danger and delay
in treatment to save the
precious part or life with
minimum disability and
death.
An emergency department
must be developed as a mini
hospital within a hospital i.e.
independent and self-
sufficient in day to day
working.
PLANNING AND ORGANIZATIONAL
CONSIDERATIONS
Location
There are two essential location requirements:
✓ It must be on ground floor and easily accessible to both
ambulatory and ambulance patients, and there should be
minimal separation between it and radiology department.
✓ Secondly, the emergency department should have ready
access to the acute patient care areas, e.g. operation theatre,
ICU, blood bank etc.
Emergency department must be designed; usually 1000 sq. ft
is required for daily patient load of 100 patients.
Stretcher, trolley, wheelchairs should be located adjacent
to the entrance.
Ambulance attendants, police, mass media room must be
equipped for about 10m square near the entrance hall with
attached toilet serves the need of above personnel.
Work area
It should be spacious with enough room for personnel and
patients.
Waiting area for relatives
Patient relatives should not be allowed in the areas of
emergency department. Waiting room with recreational
facilities may be provided.
 Nurse’s station and administrative office should be next
to the entrance.
It should be provided with multiple telephones, bulletin
board with duty roster of doctors on call.
The workroom must be well stocked with drugs, IV fluids.
Examination room
• Equipment such as
✓ On the wall oxygen unit
✓ On the wall suction unit
✓ BP apparatus, otoscope, Stethoscope, ophthalmoscope, monitors
✓ Spot lights
✓ Utility table
✓ Airways and resuscitation bags
✓ ECG machine
✓ X ray viewing screening
✓ Facility for performing minor operative procedures.
• Isolation rooms
Staffing pattern:
a) Full time emergency physicians, especially trained in emergency
medicine.
b) A well-staffed emergency department needs 8 nurses per shift of 8
hours each per 100 daily patients’ visits. Additional staff nurses are
required, if there is a close monitoring and isolation services of the
patient is required.
c) For registration and records, usually 3 GRE’swork in day and
afternoon shift, and one during night.
d) Security should be available round the clock.
e) Manager On Duty (MOD) and social worker should be available to
take care of the anxious and disturbed patients and their relatives.
MEDICO-LEGAL ASPECTS OF EMERGENCY
DEPARTMENT
a) Negligence
b) Duty to treat all
c) Problem areas in emergency department
i. Consent to treatment
ii. Medical records
JOURNAL [ patient experience journal, volume 2, Issue 2)
Managing patient expectations at emergency department triage
Emergency departments (ED) overcrowding, long wait, and uncomfortable waiting room conditions
may lower perceived quality of the patient experience and satisfaction.This study investigates the
relationship between patient satisfaction and communication of expected wait times, at the point of
triage. A static expected wait time model (i.e., average wait time + one standard deviation) based on
time of the day, day of the week and triage levels was employed to communicating expected wait time
at triage while an in-house survey with five-point Likert-scale patient satisfaction questions (satisfied
with wait time in triage, informed about delays, and overall rating of ED visit) was administrated at the
discharge desk. The communication of delays intervention was significant for only overall rating of ED,
while binary communication status was significantly associated with all three patient satisfaction
questions. The patients who didn’t receive any communication about delays, were between 1.42
to 5.48 times more likely to rate the three satisfaction questions lower than very good. With
communication about delays, the percentage of patients responding very good and very poor/poor
were 14.6% higher and 5.9% lower, respectively, for the satisfied with wait time in triage question.
Although communication of delays intervention was not significant, the patients who received wait
times information were significantly more satisfied. This indicates that patients are more likely
to accept longer wait times provided their expectations are managed via communication.
CONCLUSION
REFERENCES
• A Comprehensive textbook on Nursing Management . (n.d.). In S. C. Deepak K.
• Clement, N. (n.d.). Text Book on Introduction to Nursing Service Administration. EMMESS .
• Joseph, S. (2016). Nursing administration and management. AITBS Publishers, India.
• Robert A. Berenson, E. D. (2013). Doing Better by Doing Less: Approaches to tackle overuse of
services.
• JOURNAL : patient experience journal, volume 2, Issue 2
Managing patient expectations at emergency department triage
• JOURNAL :Quality Control in Linen and Laundry Service at A Tertiary Care Teaching Hospital in
India (International journal of health sciences, vol.3 No.1)
• JOURNAL: Patients Satisfaction on Clinical Laboratory Services at Nekemte Referral Hospital,
Oromia, Ethiopia