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What is Your Push-Pull Strategy in CSSD?

Updated: Mar 10, 2022


Light bulb - Thought of the Week

I have preferred for years to have a push-pull strategy that leans towards a push workflow in the prep and pack work area. My preference stems from always wanting to be prepared in the case of an emergency. You can not always have every instrument in the Central Sterile Supply Department (CSSD) in a sterile state, but you can have more of them in a clean state if the decontamination area is set up properly and staffed accordingly. In an emergency, this allows instruments to be prepared faster and given to the end-user sooner.


To simplify, in a push environment in CSSD, the decontamination area is overproducing compared to the prep/pack area. This does create at least one issue; you will need extra storage in prep/pack. I still believe this is a better scenario than having prep/pack in a pull workflow where they are waiting for instrumentation to arrive from the decontamination area.


Setting up your workflow design, you will need to consider several key aspects. First, what volume of instruments/sets do you need to produce on at least an average day. Taking that statistic, you then can plan for staffing and equipment needs. Based on the size of your workspace, it will also determine where you will need storage space. For example, if you only have enough space in the decontamination for two sinks and your output from the OR will exceed the staff's volume, you will need storage space. Generally, we are looking at production outputs based on hourly increments.


To determine the workflow in decontamination, average the number of sets the staff can produce and compare it to the number of sets your washer/disinfectors can produce in a standard cycle time frame. For example, if the staff can produce 12 trays per hour and the washer/disinfectors can produce the same, you have balance. Again, if the OR is sending more than 12 trays per hour, you will need storage in the decontamination area or add more sinks and staff in a better case scenario. If the staff is producing more than the washer/disinfectors can produce, you need more washers. Balance your staffing based on OR instrument/tray utilization using hourly outputs. If you don't have a tracking system utilize case end times and the average number of sets per case.

To determine workflow in your prep/pack area, you will again look at how much work is being produced by the staff in decontamination and your decontamination equipment's output. If your staffing and equipment are balanced in decontamination, at least to the point where the staff is not under producing the equipment output; you can just use the equipment output per cycle. Utilizing the washer/disinfectors' output will allow you to devise your staffing in prep/pack. For example, if the washer/disinfector produces 12 trays on a 45 min cycle, you average 15 trays per hour. You will need to set up your staffing to have enough staff to produce 15 trays per hour, utilizing the average amount of time a staff member can produce a tray-based on your sets. Staffing for peak periods is critical. Obviously, work stations are a key component. To balance staffing, you have to have enough places for staff to work, or again you will need to have additional storage for overflow. Staffing should be set up to meet the hourly output needed based on OR case end times and adding slack time created by the decontamination process.


The sterilization area output is set up utilizing the output of prep/pack. Equipment volume is again key here. You need to match the average volume output of the staff in the prep/pack area to the output of your sterilizers and the number of sterilizer racks available for use. Otherwise, you will need extra storage space if you don't have enough racks for the output. You don't want to forget to factor in the cool-down process. If you only have one sterilizer rack for each sterilizer, it will increase your turnover time because of the instrument cooling process. Redundancy with sterilizer racks is a key concept if you have the storage place for racks with cooling instruments. Staffing is usually on one staff per shift unless you have an unusually large CSSD department, which may require more.

Lastly, equipment redundancy is key. Constantly running equipment at full capacity tends to lead to break downs more often. No matter what, you will have equipment failures. You will want to have additional equipment that can keep you afloat when repairs are needed, and the added bonus is that when you have an overflow, the redundant equipment will be your go-to.



At Evolved Sterile Processing, our consultants have a greater focus on sterile processing. With our decades of experience, we will help you develop better processes and educational resources for your staff.

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