المملكة العربية السعودية وزارة الصحة القطاع الصحي بمحافظة ينبع مستشفى ينبع النخل العام Kingdom of Saudi Arabia Ministry of Health HEALTH BRANCH YANBU SECTOR Yanbu AL-Nakhal Hospital Central Sterile Supply Department Policy Title: Reference Number: 1st Issue Date: JUN 2011 Creation / Revision Date: SEPT 2014 Checking and Processing Items from Units/Departments Effective Date: OCT 2014 Next Revision Date: OCT 2017 Page 1 of 4 1.APPLICABILITYAll used equipment’s/instruments returned to CSSD for Reprocessing will be checked for correct amount and damage before being processed. 2. PURPOSE: To define the method in which items for CSSD are checked and processed Upon receipt 3. POLICY: the CSSD staff and individuals looking after medical instrumentation and devices in the hospitals and medical centers are those who will implement the plan according management compliance and approval.. 3. SCOPE: This policy is applied to all CSSD personnel. 4.RESPONSIBILITIES:The following functions are performed by the CSSD staff. 5. PROCEDURE: 5.1 Checking procedures: 5.1.1 All items and equipment collected or received from units /department must. Be treated as contaminated and will be cleaned /disinfected manually then by the instrument washer /disinfector as per the CSSD policy& procedure no.ST-07 .All trolley received in the decontamination area must be cleaned /disinfected manually with disinfectant or automatic cart washer /disinfector before being put to further use. 5.1.2 CSSD used bag must be carefully emptied, one item at a time and checked to ensure that instruments are not remaining inside the bag. Department Heads Initial and Date Signed: _______AISHAH AL-THUBIANI _____________________ This Document is the property of Yanbu AL-Nakhal Hospital, any copying of this document without prior approval from the appropriate party will be considered as a violation. المملكة العربية السعودية وزارة الصحة القطاع الصحي بمحافظة ينبع مستشفى ينبع النخل العام Kingdom of Saudi Arabia Ministry of Health HEALTH BRANCH YANBU SECTOR Yanbu AL-Nakhal Hospital Central Sterile Supply Department Policy Title: Reference Number: 1st Issue Date: JUN 2011 Creation / Revision Date: SEPT 2014 Checking and Processing Items from Units/Departments Effective Date: OCT 2014 Next Revision Date: OCT 2017 Page 2 of 4 5.1.3 instruments trays/sets should be checked against itemized instrument list 5.1.4 All instruments/equipment brought to CSSD will be checked at the front desk and the receiving CSSD technicians will check for the correct amount and any damage, before issuing receipt. 5.1.5 Any missing/broken instruments from CSSD collected sets e.g.OR/Day surgery should be reported at once to the CSSD manager who will notify the concerned departments head immediately .CSSD staff must follow the instrument tray check protocol procedures. 5.1.6 Items missing/broken will be replaced by the unit concerned if damage/loss occurred prior to CSSD processing, i.e. discovered on receipt. 5.1.7 CSSD must replace or substitute the items lost or brokenwhile in the custody of CSSD. 5.1.8 All gauges, cotton, disposable needle, rubber tubes and other single use items are to be discarded on the departments / unit and not to be forwarded to CSSD. 5.1.9 If blades, needles, etc. are found, they must be removed and placed in the contamination sharp box. Report immediately to the CSSD manager who will notify the unit manager concerned. 5.2 Plastic Goods:5.2.1 All single used items not allowed to be reprocessed as per policy and procedure issued by the MOH infection control. Department Heads Initial and Date Signed: _______AISHAH AL-THUBIANI _____________________ This Document is the property of Yanbu AL-Nakhal Hospital, any copying of this document without prior approval from the appropriate party will be considered as a violation. المملكة العربية السعودية وزارة الصحة القطاع الصحي بمحافظة ينبع مستشفى ينبع النخل العام Kingdom of Saudi Arabia Ministry of Health HEALTH BRANCH YANBU SECTOR Yanbu AL-Nakhal Hospital Central Sterile Supply Department Reference Number: Policy Title: 1st Issue Date: JUN 2011 Creation / Revision Date: SEPT 2014 Checking and Processing Items from Units/Departments Effective Date: OCT 2014 Next Revision Date: OCT 2017 Page 3 of 4 5.2.2 All plastic with silicon based tubes are to be flushed to be free of any gross soil immediately after returning to CSSD. 5.2.3 Fiber optic items are always hand washed using a soft cloth, and mild detergent then dried with cloth. When packaging, coil is not less than 30 cm in diameter, never place any heavy items on the top of the fiber to avoid damage. 5.3 Reprocessing:5.3.1 Reprocessing of any sterile tray or supplies must be done when one or more of the following conditions exist:5.3.1.1 The packaging of the item has become damage or opened. 5.3.1.2 If paper or plastic outside wrappers were used. 5.3.2 All the linen on the tray is to be laundered and driesprior to sterilization .Sterilization breaks down the fibers in linen. 5.3.3 All reusable items (e.g. instruments, bowls, and glassware) are processed as any other items according policy and procedure. 5.3.4 No. items may be re-autoclaved without re-packaging. 5.4 When loaner instrumentation and implants are delivered to CSSD, the delivery person should request the Processing Supervisor or Lead for receipt ofthe delivery.Following receipt, those items requiring site sterilization will be transported toDecontamination and processed appropriately. The processing staff will use the supplier provided inventory Department Heads Initial and Date Signed: _______AISHAH AL-THUBIANI _____________________ This Document is the property of Yanbu AL-Nakhal Hospital, any copying of this document without prior approval from the appropriate party will be considered as a violation. المملكة العربية السعودية وزارة الصحة القطاع الصحي بمحافظة ينبع مستشفى ينبع النخل العام Kingdom of Saudi Arabia Ministry of Health HEALTH BRANCH YANBU SECTOR Yanbu AL-Nakhal Hospital Central Sterile Supply Department Policy Title: Reference Number: 1st Issue Date: JUN 2011 Creation / Revision Date: SEPT 2014 Checking and Processing Items from Units/Departments Effective Date: OCT 2014 Next Revision Date: OCT 2017 Page 4 of 4 (count) sheet to ensure completeness of instrument/implant sets; all variances will be communicated to the supplier representative for resolution. 6. REFERENCES: Association for the Advancement of Medical Instrumentation Advanced AA MI2011, The International Association of Healthcare Central Service Materiel Management IAHCSMM 7th Edition, CDC Disinfection and sterilization Guide lines 2009, APIC Guidelines 2009 Chapter 55. 7. REVISION AND AUDIT: This Policy will be reviewed every two years or when necessary. Department Heads Initial and Date Signed: _______AISHAH AL-THUBIANI _____________________ This Document is the property of Yanbu AL-Nakhal Hospital, any copying of this document without prior approval from the appropriate party will be considered as a violation.
