Madinah Cardiac Center

We Care From Heart

We Care From Heart
Policy & Procedure
DEPARTMENT
DOCUMENT
NUMBER
IPC-1.67-3E
INFECTION PREVENTION AND CONTROL

TITLE ORIGINATED AT 1 NOV 2013

CENTRAL STERILIZATION AND SUPPLY DEPARTMENT (CSSD) HEALTH REVISED DATE 1 JULY 2016
CHALLENGES
EFFECTIVE DATE 1 AUG 2016
DATE
REVIEW DUE 31 JULY 2018

APPLIES TO - All CSSD Staff

1. Purpose(s):
1.1. To protect the Central Supplies and Sterilization Department (CSSD) staff from any
occupational and environmental risks exposure.

2. Definition(s): - N/A -

3. Policy:
3.1 The CSSD has a special role in Environmental Health And Occupational Health Safety
(EHOHS) as CSSD is exposed to cleaning and disinfecting agents which control infection
from spreading in the hospital environment.
3.2 Responsibilities:
3.2.1 IPC conducts regular Multidisciplinary Environmental Rounds (MDER) to monitor
CSSD practices. CSSD-related occupational hazards should be immediately
investigated including microbiological water testing done on a monthly basis or
when specific need arises. The table below provides MDER indicators for
monitoring:

Items Indicator MDER Schedule In-Charge

1. Water Quality Hardness Weekly U&M
2. Air Quality a. Air changes Monthly or when U&M
required
b. Air Pressure Quarterly or when U&M
required
c. Toxic gases When alarm is on or IPC EHOHS
o Ethylene oxide when necessary
o Hydrogen Quarterly/when IPC - EHOHS
peroxide necessary

Document No. IPC-1.67-3E Page 1 of 4

 Madinah Cardiac Center
We Care From Heart
Items Indicator
We Care From Heart
MDER Schedule In-Charge
3. PPE Uses and availability On regular basis IPC - EHOHS
4. Chemical Hygiene On regular basis IPC - EHOHS

4. Procedure(s):
4.1. Chemical Use:
4.1.1. IPC should evaluate and approve any chemicals being used in CSSD. Materials
and Safety Data Sheets (MSDS) of chemicals must be regularly reviewed and
updated. CSSD policies and procedures should be in sync with the Infection
Prevention and Control Department (IPC) regulations and standards.

4.2. Burns/Cuts:
4.2.1. CSSD employees are exposed to possible burns or cuts that can occur from
handling or sorting hot sterilized items or sharp instruments when removing
those from autoclaves/sterilizers or from steam liners. Possible solutions to avoid
these risks are:

4.2.1.1. Establish work practices to prevent hazards such as:

4.2.1.1.1. Do not remove items from sterilizers until cooled.
4.2.1.1.2. Avoid handling sharp ends of instruments.
4.2.1.1.3. Use forceps or other devices to remove sharp instruments
from baskets and autoclaves.

4.2.1.2. Use appropriate Personal Protective Equipment (PPE), especially, hand

protection gears such as oven mitts to protect the hands when handling
hot items, and steel meshor Kevlar gloves when handling or sorting
sharp instruments.

4.3. Hazardous Chemicals:

4.3.1. Unlabeled chemicals used in the initial washing process of dirty instruments as
well as untrained employees on hazardous chemicals pose as occupational
risks. Training on work practices that comply with the Hazard Communication
Standards should be provided to all employees. Warning labels and easy access
to MSDS should be inplace. Other ways to avoid workplace hazard are:
4.3.1.1. Provide appropriate PPE such as gloves, goggles, and splash aprons
when handling hazardous dish washing detergents and chemicals.
4.3.1.2. Where the eyes or body of any person may be exposed to injurious
corrosive materials, medical services and first aid should be readily
provided and suitable facilities for quick drenching or flushing the eyes
and body should be available within the work area for immediate
emergency use.
4.3.1.3. Use automatic dishwashing machines that automate the dispensing of
chemicals used for washing to minimize employee exposure to
chemicals. Workers must be cautious and must use appropriate PPE
(e.g., goggles, and/or gloves) when changing detergent and other
chemical containers.

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We Care From Heart
4.4. Slips, Trips, and Falls: We Care From Heart
4.4.1. CSSD employees are exposed to slippery floors due to steam and washing
processes.
4.4.1.1. Keep floors clean and dry to avoid slips. Wet surfaces enhance the
growth of molds, fungi, and bacteria, which can cause infections.
4.4.1.2. Keep aisles and passage ways clear and properly maintained with no
unnecessary obstruction that can create hazards. Provide sufficient and
accessible floor or ceiling electrical outlets for equipment to avoid trips
due to criss crossing power cords.

4.5. Bloodborne Pathogens:

4.5.1. CSSD employees are exposed to blood borne pathogens and other potentially
infectious materials such as bloody, contaminated surgical instruments and
sharps (e.g., needles, scalpels). Employees must safely discard disposable
sharp items and reprocess reusable instruments/equipment.

5. Attachment(s):- N/A -

6. Reference(s):
6.1. Gulf Cooperation Council Center for Infection Control (GCC CIC), Infection
Prevention and Control Manual, 2nd Edition. Copyright, 2013.

Document No. IPC-1.67-3E Page 3 of 4

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We Care From Heart
7. Approvals: We Care From Heart
SIGNATURE
NAME & DATE

Dr. Khaled M. Sayed

Prepared and
Infection Prevention and
Reviewed By:
Control (IPC) Specialist
17 July 2016

Dr. Ahmad Tharwt Ibraheem

Reviewed By: Accreditation Supervisor,
Quality Management and
Patient Safety
18 July 2016

Coordinated & Maintained By:

Dr. Abdul Hameed Al-Najjar
Reviewed By: Document Control Coordinator
Medical Director Quality Management and
Patient Safety Department

19 July 2016

Approved By:

20 July 2016
Dr. Osama Ahmed Amoudi
MCC General Director

Document No. IPC-1.67-3E Page 4 of 4