Analytical Evaluation of Cleaning Agents and Disinfectants in use for Housekeeping Practices at a Tertiary Care Hospital
Author(s): Aarti Vij*, Sunil Kant**, Shakti Gupta***
Vol. 13, No. 1 (2001-01 - 2001-06)
Abstract : Cleaning agents and disinfectants are essential requisites for attaining effectiveness in housekeeping services in health care institutions. The present study critically evaluates the utilisation of these in a multispeciality tertiary care Government hospital. Focused information of cleaning agents and disinfectants for housekeeping activities in use by some of the Corporate Hospitals in Delhi was also obtained. The present study suggests that scientific evaluation of housekeeping detergent-germicides is a must for attaining cost effectiveness and Quality Assurance in health care institutions.
Keywords : Cleaning Agents, Disinfectants, Housekeeping.
Intorduction
The housekeeping services had its origin in the hotel industry. Later the concept of housekeeping got incorporated as a hospital service. There are, however, differences in concept and practice of housekeeping activities in hospital and hotels. Control and prevention of hospital infection is one of the most vital functions of hospital housekeeping, whereas, in a hotel, the aesthetics receive the maximum emphasis. The hospital housekeeping services comprise of activities related to cleanliness, maintenance of hospital environment and good sanitation services for keeping the premises free from pollution1.
Inadequate cleaning and disinfection will result in health care institutions becoming reservoirs of large number of microorganisms. Cleaning must not only be effective in removing dirt but also in maintaining low levels of microorganisms. Cleaning materials and disinfectants are essential components in ensuring Quality Assurance in housekeeping services. Materials of the right quality, quantity and used in the appropriate specified frequency will not only augment the quality of housekeeping services but also ensure optimum utilisation of resources. It will also enhance patient satisfaction.
Present Scanario
In India cleanliness and disinfection practices vary drastically in different health care institutions viz. Corporate/public sector, primary/secondary/tertiary care hospitals. Even in the same category of health care institutions practices and end results of housekeeping may significantly differ. As has been rightly commented by Wright and Greece Medical interest in hygiene and cleaning tends to be biomodally distributed with peaks in the zones corresponding to obsession and apathy but little in the central zone of practical commonsense2.
In India majority of the health care institutions activities related to the housekeeping services including use of cleaning materials and disinfectants are done by personnel with little or no formal education. They carry on their jobs without much training, scientific supervision or direction, they seem to learn everything on the job. In a number of instances housekeeping activity is a purposeless ritual. Inappropriate dilution and adhoc formulation is generally resorted to in housekeeping activities. Generally there is indiscriminate mixing of detergents with disinfectants and the efficacy of it is determined by the odour and colour of the cleaning mixture. The outdated mob and one bucket-system of cleaning is the most prevalent in Indian health care institutions.
Disinfectants are often misused and rationalization of their use in hospitals in desirable for control both of infection and costs. Surprisingly infection maybe caused by microorganisms which contaminate disinfectants during use specially when objects such as mops are stored in disinfectants. Unnecessary use of disinfectants is not only wasteful but may increase the microbiological hazard to the hospital environment and subsequently to patients, visitors, and staff. A study of analytical evaluation of consumption and cost of cleaning and disinfectant materials in use at a tertiary care hospital was carried out.
Materials and Methods
Consumption and utilisation of cleaning agents and disinfectants at 860 bedded superspeciality, tertiary care hospital was undertaken for 3 months. Visits and interaction with administrative housekeeping staff of some of the corporate hospitals in Delhi were undertaken. Following this a market survey was conducted to know the availability of the detergents and disinfectants. Finally a cost benefit analysis was carried out.
For studying the consumption and utilisation, a representative sample of different wards in the hospital catering to different specialities and acuteness of illness, were selected for the study :
- Medical Wards - I and II
- Surgical Wards - I and II
- Multi disciplinary Wards - I
- Emergency Wads - I and II
- ICU
However, the study had following limitations:
- The study is mainly retrospective in nature. To enunciate operative procedures and practices will require further prospective studies.
- The focussed study of cleaning agents and detergent-germicides in use in the Corporate Hospitals was limited to the extent of the product and its cost. Other parameters in housekeeping activities e.g. cleaning practices, staffing including manpower scheduling have not been included in the present study.
- Cleaning agents used for linen services, mattresses and furniture have not been included in the present study.
Observations and Discussion
The various cleaning materials for housekeeping activities used at the hospital are liquid soap, soft soap, soda ash, cleanzo and nitric acid. Liquid soap is used for housekeeping, mechanised cleaning, cleaning floors in special areas eg. ICU. Cleanzo in dilution of 1:15 is used daily for cleaning of wards floors. A mixture of soft soap (15kg), soda ash (71/2 kg) and water (30 liters) is used once a week for periodic cleaning of floors of wards and corridors. Nitric acid is utilised for cleaning tiles and toilet seats. The main disinfectant in use for housekeeping activity is phenyl. The chemical composition, usage, preparation, consumption quantities alongwith the specified area of use is shown in Table. 1
Table-1, Characteristics, monthly consumption of cleaning agents and disinfectants
Items
Characteristic
Preparation
Area Utilised
Monthly Consumption
Cleanzo
Deodorant Proprietary preparation
200ml in mopping cloth
Floors, Toilets
1900 litres
Nitric Acid
5%
Toilets/tiles
150 litres
Liquid Soap
Antiseptic anhydrous soap
200 ml in mopping cloth
Floors/toilets
1900 litres
Soft Soap
Transparent jelly soap With vegetable oils
Soft soap and soda ash mixture (1:2)
Floors of wards, corridors
1300 litres
Phenyl
Carbolic Acid
Dilution with water 1:10
Toilets
1300 litres
The cleaning agents and disinfectants in use in some of the corporate hospitals in Delhi and available in market alongwith the manufacturers are listed in Table 2
Table-2, Available cleaning agents and detergent disinfectants
Cleaning Agent
Manufacturer
Sapona
Inter national Hygiene Products
Teepol - 300
Reckett and Coleman
Spiral
Hindustan Lever
Ajax
Colgate Palmolive
Fesca
Metropole
Wizard
Quartz Home Care
Brisk
Modi Industries
Spick and Span
Etoshapan
Detergent Disinfectants
Polysan - (Akyl phenoxy poly active ingredient ethoxy - ethanol, iodine)
Polyphan Pvt. Ltd
Germinol
Etosha pan
Lamp phenyl
Bengal chemicals
Trishul phenyl
Ampey Lean
Phoenix
Metro pole
Dettol-H - (Ben 2 alkonim chlorid sol. 1. P40 1v/v disodeim edeati)
Rickett and Colman
Bacilloid Special _ ( D. hydroxy - 2,5, Dioxyhexene glutaaldehydi,
de n 201 konuim chloride, caxosguanidiam ehlondi)
Raman Pvt. Ltd
It was observed that most of the above products did not have the composition contents listed on the containers or in the product literature as those as listed.
Cost of Cleaning Materials
The average cost of cleaning materials at the hospital per month is Rs. 61488. The per bed per day cost is Rs. 2.37. The high cost of cleaning materials for the SCF ward (Special Care Facilities for HIV positive cases) is due to the fact that there are only two beds in the wards along with an independent nursing station hence there is a larger surface area per bed in the ward. Further since it is a wards for the management of HIV positive cases, the staff attending to them wash their hands more frequently and even the floor is cleaned more frequently. The details of the cost in Rupees in different wards under study is shown in Table-3.
Table-3 Cost of cleaning materials per bed per day
Wards
No. of beds
Monthly cost/ward
Cost/bed/day
Apportioned cost bed/day
Total cost/ bed/day
Medical-I
42
1683.47
1.34
0.53
1.87
Medical-II
42
981.28
0.78
0.53
1.31
Multidisciplinary
35
916.72
0.87
0.53
1.40
Emergency-I
43
728.49
0.56
0.53
1.09
Emergency-II
44
683.57
0.52
0.53
1.05
SCF
2
217.61
3.63
0.53
4.16
ICU
12
1033.12
2.87
0.53
3.16
Surgical-I
42
612.85
0.49
0.53
1.02
Surgical-II
36
717.02
0.66
0.53
1.19
Sanitation Deptt.
13780.53
0.53
(*) The consumption of the Sanitation Department has been apportioned equally amongst all hospital beds.
As is observed in Table - 3 the cost per bed per day of the different wards varied significantly and no rational correlation could be established between the variables viz. Cost/quality of services.
Disinfectants
The average cost of disinfectant in use at the hospital is Rs. 31890.53 per month and Rs. 1.29 per bed per day. The low cost of disinfectant in SCF ward was due to the fact that it does not have an independent toilet hence phenyl consumption was nil. The cost incurred per bed per day in Medical - II ward observed to be Rs. 48. The main reason for the high cost as compared to other wards was the high level of consumption of phenyl. Though the maximum consumption of phenyl was in Medical-II ward, it was not being scientifically utilised. Concentrated phenyl without dilution was being used by the Sanitary Attendant. The Sanitary Attendant was not utilising adequate water for cleaning and was using the phenyl for masking the odour. The resultant higher consumption of the material was thus due to misutilisation.
Table-4. Cost of disinfectants per bed per day
Wards
No. of beds
Monthly cost/ward
Cost/bed/day
Apportioned cost bed/day
Total cost/ bed/day
Medical-I
42
1830.35
1.44
0.04
1.48
Medical-II
42
660.26
0.52
0.04
0.56
Multidisciplinary
35
863.63
0.82
0.04
0.86
Emergency-I
43
890.28
0.69
0.04
0.73
Emergency-II
44
641.58
0.49
0.04
0.53
SCF
2
21.30
0.36
0.04
0.40
ICU
12
1033.12
1.27
0.04
1.31
Surgical-I
42
456.12
0.49
0.04
0.53
Surgical-II
36
796.65
0.04
0.75
Sanitation Deptt.
988.20 (*)
0.04
(*) The consumption of the sanitation department has been apportioned equally amongst all hospital beds. As is observed from table 4 The cost per bed day of the different wards varied significantly and no rational correlation could be established between the variables viz. Cost/quality of services.
A summary of the cleaning agents and disinfectants used in housekeeping services at hospital along with the cost, dilution for use, alternatives available are depicted in Table 5 and Table 6.
Table5: Cleaning agents for housekeeping in use at the hospital and available alternatives
Nomenclature
Cost
Recommend Dilution
Nomenclature
Rate?
Dilution For use
Relative Rate
after Dilution
Soft Soap
Rs 10/L
1:4
SAPONA
Rs 80/kg
1:20
Rs 16/kg
Soda Ash
Rs 9/kg
1:4
TEEPOL-300
Rs 36/kg
1:16
Rs 9/kg
Clenzo
Rs 9/kg
1:20
SPIRAL
Rs 35/kg
1:16
Rs 9/kg
AZAX
Rs 35/kg
1:20
Rs 7/kg
FRESCA
Rs 35/kg
1:20
Rs 7/kg
WIZARD
Rs 35/kg
1:20
Rs 7/kg
BRISK
Rs 35/kg
1:20
Rs 7/kg
SPIC AND SPAN
Rs 40/kg
1:40
Rs 6/kg
Table-6 Disinfectant for housekeeping in use at hospital and available alternatives
Deodrants and disinfetants in use
Rate/ ltr.
Dilution for use
Alternatives available
Rate/ltr?
Dilution For use
Relative Rate with Dilution factor
Phenyl
Rs 16
1:100
POLYSAN
Rs. 100
1:20
Rs.50/-
GERMINOL
Rs. 60
1:20
Rs.30/-
LAMP BRAND
Rs. 50
?
?
*TRISHUL
Rs. 40
?
Rs.40/-
*PHOENIX
Rs. 32
?
Rs.32/-
*GANDA
Rs. 45
?
Rs.45/-
*TIGER
Rs.50
?
Rs.50/-
*DIAMOND (SUPER)
Rs.40
?
Rs.40/-
* Recommended dilution of there are not available in the literature.
Table:7 Cost benefit analysis of cleaning materials
In use at the Hospital
Alternatives Available
Nomenclature
Quantity use per month
Cost per month
Nomenclature
Cost per month
Cost benefit/ cost-loss per month
SOFT SOAP
1300 L @ Rs. 10/L
13,000/-
TEEPOL-300
11,700/-
+ 13,000/-
SODA ASH .
1300 KG. @ Rs. 9/Kg
11,700/-
SPIRAL
11,700/-
+13,000/-
AZAX
9,100/-
+15,600/-
BRISK
9,100/-
+15,600/-
SPICAND SPAN
7,800/-
+16,900/-
SAPONA
20,800/-
+4,700/-
WIZARD
9,100/-
+15,600/-
FRESCA
9,100/-
+15,600/-
Table:8 Cost benefit analysis of deodorants and disinfectants
In use at the Hospital
Alternatives Available
Nomenclature
Quantity use per month
Cost per month
Nomenclature
Cost per month
Cost benefit/ cost-loss per month
PHENYL-ISMARK
1300 L
20,800/-
POLYSAN
65,000/-
-44,200/-
GD-1
@Rs. 16/L
?
?
?
?
GERMINOL
39,000/-
-18,200/-
LAMP BRAND
65,000/-
-44,200/-
TRISHUL
42,000/-
-21,200/-
GANDA
53,500/-
-32,700/-
TIGER
65,800/-
-44,200/-
PHOENIX
39,000/-
-18,200/-
DIAMOND
42,000/-
-21,200/-
If the presently used cleaning agents which is a combination of soft soap and soda ash is replaced by any of the available alternating viz Teepol, Spiral, Azax, Fresca, Wizard, or Brisk it wouldlead to substantial amount of cost savings in the range of Rs. 13,000 to Rs. 15,000 per month. The final decision should be made after conducting standard bacteriological tests.
It was observed that at places the Sanitary Attendant does not use the recommended two bucket system i.e. the one in which one bucket contains clean water for cleaning the mop head and the other contains the diluted disinfectant for mopping. The mop head is repeatedly wetted from the bucket containing the disinfectant. This may lead to microbiological contamination being spread to the areas where mopping is done. It was also observed that the mop head rather than being changed daily is done so only once in 10-14 days.
It is observed from the consumption pattern of the various wards that there is a wide fluctuation among average monthly consumption, quantities between wards and also consumption of the same ward during different time periods. For example it was observed that consumption of Clenzo in Medical ward-1 was three times that of Medical ward-II whereas the consumption of Phenyl was 2.7 times higher. Further analysis showed that the high consumption levels of Phenyl and clinzo was due to improper dilution done by the Sanitary Attendent. Concenterated Phenyl was being used in conjuction with clenzo in varying dilution both in the toilets and ward floors, though the recommended use of phenyl is for toilets and Clenzo for ward floors. There was absence of standards and procedures in the procurement and use of cleaning material in the hospital. The specific type of the materials and its usage was not being implemented in the different areas of the hospital.
It was also observed that though the cleaning was being carried out frequently, use of cleaning agents and disinfectants was based more on traditional ways and decision of house keeping staff rather than on scientific evaluation, Biological testing and valuation of cleaning agent/disinfectants was not being carried out.
Water is the simplest cleaning agent but normally unless it is used in conjunction with some other agent eg. a detergent, it is not an effective cleanser.
The basic ingredient of any detergent are surface active agents or surfactants. These are primarily the wetting agents which lower the surface tension of water and varying degrees emulsify the grease. Each molecule of surfactant has one end which is attracted to water (hydrophilic) and the other which is repelled by water (hydrophobic).
Surfactants are classified on the basis that when dissolved in water some dissociate in to positively and negatively charged particles or ions while others do not. Anionc surfactants carry a negative charge, have good wetting power but limited power to dispel and suspend soiling, examples are soap, alkyl benezene sulphonate. Quats' or quaternary ammonim compounds are cationic surfactants, and have good germicidal properties. Non ionic surfactants are non soapy and have excellent wetting and emulsifying power. They are used mainly in liquid synthetic detergents eg. polyoxyethylene ethers and esters. Alkaline builders such as soda, borates, silicates and complex phosphates improve the emulsifying power of the detergent by increasing the pH of the solution. Sodium sulphate is added as a filler. Sodium carboxy-methyl-cellulose assists the suspending power of the surfactant and this aids in preventing dirt resettling on the cleaned articles.
Criteria for a good disinfectant The main criteria for a good disinfectant are3
- Has good bacteriocidal properties and a wide microbiological spectrum
- Has good cleaning properties
- Must not be toxic or irritating to the users
- Has some degree of odour control (not simply mask control)
- Must not be corrosive to floor
The properties of the various types of detergent-germicides is given in Table-9
Table-9 Comparative properties of detergents
Properties
Phenolic
Quaternary
Iodophor
Effectiveness against S. aureus
Fair to good
Good
Good
M tuberculosis
Fair to good
Good
Good
Effect on organic matter
Good
Good
Fair
Skin irritation properites
Harsh
Mild
Mild
Odour
Strong to mild
Mild
Mild
pH of use soulution
Alkaline(pH9.10)
Neutral or alkaline(pH7.10)
Acidic(pH3.6)
Soil removal property
Poor to good
Good
Fair
Corrosion to floor Surface
Safe at correct dilutions
Safe
Safe
As seen from the above table quaternary detergent-germicides are the ideal.
Nursing and Housekeeping - Is a Divorce Feasible?
The primary role of the housekeeping department is to keep the hospital clean. To undertake this onerous task, assistance must be given by other departments, particularly the departments of nursing. Housekeeping personnel must also have same understanding of the why as well as the how of their job. Nurses have been quite willing to delegate many of their former housekeeping tasks. In many instances this has been a relegation, rather than a delegation of functions, with an abandonment of responsibility as well. While it is conceded that nurses no longer have the time to do the ward housekeeping them selves, they should still retain over all responsibility for the cleanliness of patients physical environment. It is thus not a practicable solution to completely divorce housekeeping from nursing.
Conclusion
Housekeeping is a complex activity requiring constant attention to many varied details, Scientific housekeeping is still in its infancy in India, however its identity and importance has begun to be recognised. Cleaning agents are perhaps the most critical for effective housekeeping4. Cleaning agents, detergent disinfectants utilised for housekeeping activities must be constantly reviewed in light of new scientific findings. Tradition should not be the only criteria on which to base current procedures and practices. The cleaning and disinfectant properties must be evaluated scientifically. Cost effectiveness should be an essential criteria in the selection of cleaning agents and disinfectants for use in housekeeping activities in health care institutions.
In order to augment the existing housekeeping services and enhance effectivity the main recommendations related to cleaning agents and detergents-germicides forwarded are
1. Mechanised Cleaning
Mechanised cleaning should be carried in areas where it is feasible. An automatic combine machine is recommended which performs the four processes of laying the germicidal-detergent, scrubbing, rinsing the floor and vaccuming back the water.
2. Two Bucket System
In areas where mopping is being practised the two bucket system is one containing clean water for washing mop heads and the other containing diluted disinfectant must be taught practised for mopping. Mop heads must be changed every day to minimise the likelihood of microbial contamination being spread from it.
3. Bacteriocidal Evaluation
Bacteriocidal evaluation of the disinfectant in use in the hospital must be carried out. Detergent-germicide are evaluated for hospital use by tests such as Phenol Coefficient test, Use. Dilution Confirmation Test. The cleaning properties of a disinfectant cleaner are evaluated by tests such as Gardner Straight Line Washability Test3.
4. Operative Procedures
The frequency of cleaning and dilution of germicidal solutions should be based on scientific methods. The operative procedures and practices must be standardised and followed.
5. Cost-Evaluation
The availability and use of the cleaning agents and detergents-germicides in other health care institutions must also be evaluated for their cost-effectiveness.
References
- Manual of Hospital Housekeeping. Chicago, American Hospital Association, 1959.
- Eugence J. Good Housekeeping Hospitals, 1983, 70-72.<
- Mizuno W. G Pryor A. K. Evaluating Detergent Germicides for Hospital Use Hospitals vol. 40, Jan 16. 1966,88-90
- Franchettd T/M, Juzwish DW Integrating Quality Assurance in Dimensionﾁfs Health Services : Feb, 1989 17-19.
* Assistant Professor, Hospital Administration AIIMS, New Delhi.
** JAD (Med.), DGAR, Shillong.
*** Additional Prof. Hosp.Admn, AIIMS, New Delhi. For correspondence Dr. Shakti Gupta, Addl. Prof. Deptt. Hosp. Admn. AIIMS, New Delhi.
Abstract : Cleaning agents and disinfectants are essential requisites for attaining effectiveness in housekeeping services in health care institutions. The present study critically evaluates the utilisation of these in a multispeciality tertiary care Government hospital. Focused information of cleaning agents and disinfectants for housekeeping activities in use by some of the Corporate Hospitals in Delhi was also obtained. The present study suggests that scientific evaluation of housekeeping detergent-germicides is a must for attaining cost effectiveness and Quality Assurance in health care institutions.
Keywords : Cleaning Agents, Disinfectants, Housekeeping.
Intorduction
The housekeeping services had its origin in the hotel industry. Later the concept of housekeeping got incorporated as a hospital service. There are, however, differences in concept and practice of housekeeping activities in hospital and hotels. Control and prevention of hospital infection is one of the most vital functions of hospital housekeeping, whereas, in a hotel, the aesthetics receive the maximum emphasis. The hospital housekeeping services comprise of activities related to cleanliness, maintenance of hospital environment and good sanitation services for keeping the premises free from pollution1.
Inadequate cleaning and disinfection will result in health care institutions becoming reservoirs of large number of microorganisms. Cleaning must not only be effective in removing dirt but also in maintaining low levels of microorganisms. Cleaning materials and disinfectants are essential components in ensuring Quality Assurance in housekeeping services. Materials of the right quality, quantity and used in the appropriate specified frequency will not only augment the quality of housekeeping services but also ensure optimum utilisation of resources. It will also enhance patient satisfaction.
Present Scanario
In India cleanliness and disinfection practices vary drastically in different health care institutions viz. Corporate/public sector, primary/secondary/tertiary care hospitals. Even in the same category of health care institutions practices and end results of housekeeping may significantly differ. As has been rightly commented by Wright and Greece Medical interest in hygiene and cleaning tends to be biomodally distributed with peaks in the zones corresponding to obsession and apathy but little in the central zone of practical commonsense2.
In India majority of the health care institutions activities related to the housekeeping services including use of cleaning materials and disinfectants are done by personnel with little or no formal education. They carry on their jobs without much training, scientific supervision or direction, they seem to learn everything on the job. In a number of instances housekeeping activity is a purposeless ritual. Inappropriate dilution and adhoc formulation is generally resorted to in housekeeping activities. Generally there is indiscriminate mixing of detergents with disinfectants and the efficacy of it is determined by the odour and colour of the cleaning mixture. The outdated mob and one bucket-system of cleaning is the most prevalent in Indian health care institutions.
Disinfectants are often misused and rationalization of their use in hospitals in desirable for control both of infection and costs. Surprisingly infection maybe caused by microorganisms which contaminate disinfectants during use specially when objects such as mops are stored in disinfectants. Unnecessary use of disinfectants is not only wasteful but may increase the microbiological hazard to the hospital environment and subsequently to patients, visitors, and staff. A study of analytical evaluation of consumption and cost of cleaning and disinfectant materials in use at a tertiary care hospital was carried out.
Materials and Methods
Consumption and utilisation of cleaning agents and disinfectants at 860 bedded superspeciality, tertiary care hospital was undertaken for 3 months. Visits and interaction with administrative housekeeping staff of some of the corporate hospitals in Delhi were undertaken. Following this a market survey was conducted to know the availability of the detergents and disinfectants. Finally a cost benefit analysis was carried out.
For studying the consumption and utilisation, a representative sample of different wards in the hospital catering to different specialities and acuteness of illness, were selected for the study :
- Medical Wards - I and II
- Surgical Wards - I and II
- Multi disciplinary Wards - I
- Emergency Wads - I and II
- ICU
However, the study had following limitations:
- The study is mainly retrospective in nature. To enunciate operative procedures and practices will require further prospective studies.
- The focussed study of cleaning agents and detergent-germicides in use in the Corporate Hospitals was limited to the extent of the product and its cost. Other parameters in housekeeping activities e.g. cleaning practices, staffing including manpower scheduling have not been included in the present study.
- Cleaning agents used for linen services, mattresses and furniture have not been included in the present study.
Observations and Discussion
The various cleaning materials for housekeeping activities used at the hospital are liquid soap, soft soap, soda ash, cleanzo and nitric acid. Liquid soap is used for housekeeping, mechanised cleaning, cleaning floors in special areas eg. ICU. Cleanzo in dilution of 1:15 is used daily for cleaning of wards floors. A mixture of soft soap (15kg), soda ash (71/2 kg) and water (30 liters) is used once a week for periodic cleaning of floors of wards and corridors. Nitric acid is utilised for cleaning tiles and toilet seats. The main disinfectant in use for housekeeping activity is phenyl. The chemical composition, usage, preparation, consumption quantities alongwith the specified area of use is shown in Table. 1
Table-1, Characteristics, monthly consumption of cleaning agents and disinfectants
| Items | Characteristic | Preparation | Area Utilised | Monthly Consumption |
| Cleanzo | Deodorant Proprietary preparation | 200ml in mopping cloth | Floors, Toilets | 1900 litres |
| Nitric Acid | 5% | Toilets/tiles | 150 litres | |
| Liquid Soap | Antiseptic anhydrous soap | 200 ml in mopping cloth | Floors/toilets | 1900 litres |
| Soft Soap | Transparent jelly soap With vegetable oils | Soft soap and soda ash mixture (1:2) | Floors of wards, corridors | 1300 litres |
| Phenyl | Carbolic Acid | Dilution with water 1:10 | Toilets | 1300 litres |
The cleaning agents and disinfectants in use in some of the corporate hospitals in Delhi and available in market alongwith the manufacturers are listed in Table 2
Table-2, Available cleaning agents and detergent disinfectants
| Cleaning Agent | Manufacturer |
| Sapona | Inter national Hygiene Products |
| Teepol - 300 | Reckett and Coleman |
| Spiral | Hindustan Lever |
| Ajax | Colgate Palmolive |
| Fesca | Metropole |
| Wizard | Quartz Home Care |
| Brisk | Modi Industries |
| Spick and Span | Etoshapan |
| Detergent Disinfectants | |
| Polysan - (Akyl phenoxy poly active ingredient ethoxy - ethanol, iodine) | Polyphan Pvt. Ltd |
| Germinol | Etosha pan |
| Lamp phenyl | Bengal chemicals |
| Trishul phenyl | Ampey Lean |
| Phoenix | Metro pole |
| Dettol-H - (Ben 2 alkonim chlorid sol. 1. P40 1v/v disodeim edeati) | Rickett and Colman |
| Bacilloid Special _ ( D. hydroxy - 2,5, Dioxyhexene glutaaldehydi, de n 201 konuim chloride, caxosguanidiam ehlondi) |
Raman Pvt. Ltd |
It was observed that most of the above products did not have the composition contents listed on the containers or in the product literature as those as listed.
Cost of Cleaning Materials
The average cost of cleaning materials at the hospital per month is Rs. 61488. The per bed per day cost is Rs. 2.37. The high cost of cleaning materials for the SCF ward (Special Care Facilities for HIV positive cases) is due to the fact that there are only two beds in the wards along with an independent nursing station hence there is a larger surface area per bed in the ward. Further since it is a wards for the management of HIV positive cases, the staff attending to them wash their hands more frequently and even the floor is cleaned more frequently. The details of the cost in Rupees in different wards under study is shown in Table-3.
Table-3 Cost of cleaning materials per bed per day
| Wards | No. of beds | Monthly cost/ward | Cost/bed/day | Apportioned cost bed/day | Total cost/ bed/day |
| Medical-I | 42 | 1683.47 | 1.34 | 0.53 | 1.87 |
| Medical-II | 42 | 981.28 | 0.78 | 0.53 | 1.31 |
| Multidisciplinary | 35 | 916.72 | 0.87 | 0.53 | 1.40 |
| Emergency-I | 43 | 728.49 | 0.56 | 0.53 | 1.09 |
| Emergency-II | 44 | 683.57 | 0.52 | 0.53 | 1.05 |
| SCF | 2 | 217.61 | 3.63 | 0.53 | 4.16 |
| ICU | 12 | 1033.12 | 2.87 | 0.53 | 3.16 |
| Surgical-I | 42 | 612.85 | 0.49 | 0.53 | 1.02 |
| Surgical-II | 36 | 717.02 | 0.66 | 0.53 | 1.19 |
| Sanitation Deptt. | 13780.53 | 0.53 |
(*) The consumption of the Sanitation Department has been apportioned equally amongst all hospital beds.
As is observed in Table - 3 the cost per bed per day of the different wards varied significantly and no rational correlation could be established between the variables viz. Cost/quality of services.
Disinfectants
The average cost of disinfectant in use at the hospital is Rs. 31890.53 per month and Rs. 1.29 per bed per day. The low cost of disinfectant in SCF ward was due to the fact that it does not have an independent toilet hence phenyl consumption was nil. The cost incurred per bed per day in Medical - II ward observed to be Rs. 48. The main reason for the high cost as compared to other wards was the high level of consumption of phenyl. Though the maximum consumption of phenyl was in Medical-II ward, it was not being scientifically utilised. Concentrated phenyl without dilution was being used by the Sanitary Attendant. The Sanitary Attendant was not utilising adequate water for cleaning and was using the phenyl for masking the odour. The resultant higher consumption of the material was thus due to misutilisation.
Table-4. Cost of disinfectants per bed per day
| Wards | No. of beds | Monthly cost/ward | Cost/bed/day | Apportioned cost bed/day | Total cost/ bed/day |
| Medical-I | 42 | 1830.35 | 1.44 | 0.04 | 1.48 |
| Medical-II | 42 | 660.26 | 0.52 | 0.04 | 0.56 |
| Multidisciplinary | 35 | 863.63 | 0.82 | 0.04 | 0.86 |
| Emergency-I | 43 | 890.28 | 0.69 | 0.04 | 0.73 |
| Emergency-II | 44 | 641.58 | 0.49 | 0.04 | 0.53 |
| SCF | 2 | 21.30 | 0.36 | 0.04 | 0.40 |
| ICU | 12 | 1033.12 | 1.27 | 0.04 | 1.31 |
| Surgical-I | 42 | 456.12 | 0.49 | 0.04 | 0.53 |
| Surgical-II | 36 | 796.65 | 0.04 | 0.75 | |
| Sanitation Deptt. | 988.20 (*) | 0.04 |
(*) The consumption of the sanitation department has been apportioned equally amongst all hospital beds. As is observed from table 4 The cost per bed day of the different wards varied significantly and no rational correlation could be established between the variables viz. Cost/quality of services.
A summary of the cleaning agents and disinfectants used in housekeeping services at hospital along with the cost, dilution for use, alternatives available are depicted in Table 5 and Table 6.
Table5: Cleaning agents for housekeeping in use at the hospital and available alternatives
| Nomenclature | Cost | Recommend Dilution | Nomenclature | Rate? | Dilution For use | Relative Rate after Dilution |
| Soft Soap | Rs 10/L | 1:4 | SAPONA | Rs 80/kg | 1:20 | Rs 16/kg |
| Soda Ash | Rs 9/kg | 1:4 | TEEPOL-300 | Rs 36/kg | 1:16 | Rs 9/kg |
| Clenzo | Rs 9/kg | 1:20 | SPIRAL | Rs 35/kg | 1:16 | Rs 9/kg |
| AZAX | Rs 35/kg | 1:20 | Rs 7/kg | |||
| FRESCA | Rs 35/kg | 1:20 | Rs 7/kg | |||
| WIZARD | Rs 35/kg | 1:20 | Rs 7/kg | |||
| BRISK | Rs 35/kg | 1:20 | Rs 7/kg | |||
| SPIC AND SPAN | Rs 40/kg | 1:40 | Rs 6/kg | |||
Table-6 Disinfectant for housekeeping in use at hospital and available alternatives
| Deodrants and disinfetants in use | Rate/ ltr. | Dilution for use | Alternatives available | Rate/ltr? | Dilution For use | Relative Rate with Dilution factor |
| Phenyl | Rs 16 | 1:100 | POLYSAN | Rs. 100 | 1:20 | Rs.50/- |
| GERMINOL | Rs. 60 | 1:20 | Rs.30/- | |||
| LAMP BRAND | Rs. 50 | ? | ? | |||
| *TRISHUL | Rs. 40 | ? | Rs.40/- | |||
| *PHOENIX | Rs. 32 | ? | Rs.32/- | |||
| *GANDA | Rs. 45 | ? | Rs.45/- | |||
| *TIGER | Rs.50 | ? | Rs.50/- | |||
| *DIAMOND (SUPER) | Rs.40 | ? | Rs.40/- | |||
* Recommended dilution of there are not available in the literature.
Table:7 Cost benefit analysis of cleaning materials
| In use at the Hospital | Alternatives Available | ||||
| Nomenclature | Quantity use per month | Cost per month | Nomenclature | Cost per month | Cost benefit/ cost-loss per month |
| SOFT SOAP | 1300 L @ Rs. 10/L | 13,000/- | TEEPOL-300 | 11,700/- | + 13,000/- |
| SODA ASH . | 1300 KG. @ Rs. 9/Kg | 11,700/- | SPIRAL | 11,700/- | +13,000/- |
| AZAX | 9,100/- | +15,600/- | |||
| BRISK | 9,100/- | +15,600/- | |||
| SPICAND SPAN | 7,800/- | +16,900/- | |||
| SAPONA | 20,800/- | +4,700/- | |||
| WIZARD | 9,100/- | +15,600/- | |||
| FRESCA | 9,100/- | +15,600/- | |||
Table:8 Cost benefit analysis of deodorants and disinfectants
| In use at the Hospital | Alternatives Available | ||||
| Nomenclature | Quantity use per month | Cost per month | Nomenclature | Cost per month | Cost benefit/ cost-loss per month |
| PHENYL-ISMARK | 1300 L | 20,800/- | POLYSAN | 65,000/- | -44,200/- |
| GD-1 | @Rs. 16/L | ? | ? | ? | ? |
| GERMINOL | 39,000/- | -18,200/- | |||
| LAMP BRAND | 65,000/- | -44,200/- | |||
| TRISHUL | 42,000/- | -21,200/- | |||
| GANDA | 53,500/- | -32,700/- | |||
| TIGER | 65,800/- | -44,200/- | |||
| PHOENIX | 39,000/- | -18,200/- | |||
| DIAMOND | 42,000/- | -21,200/- | |||
If the presently used cleaning agents which is a combination of soft soap and soda ash is replaced by any of the available alternating viz Teepol, Spiral, Azax, Fresca, Wizard, or Brisk it wouldlead to substantial amount of cost savings in the range of Rs. 13,000 to Rs. 15,000 per month. The final decision should be made after conducting standard bacteriological tests.
It was observed that at places the Sanitary Attendant does not use the recommended two bucket system i.e. the one in which one bucket contains clean water for cleaning the mop head and the other contains the diluted disinfectant for mopping. The mop head is repeatedly wetted from the bucket containing the disinfectant. This may lead to microbiological contamination being spread to the areas where mopping is done. It was also observed that the mop head rather than being changed daily is done so only once in 10-14 days.
It is observed from the consumption pattern of the various wards that there is a wide fluctuation among average monthly consumption, quantities between wards and also consumption of the same ward during different time periods. For example it was observed that consumption of Clenzo in Medical ward-1 was three times that of Medical ward-II whereas the consumption of Phenyl was 2.7 times higher. Further analysis showed that the high consumption levels of Phenyl and clinzo was due to improper dilution done by the Sanitary Attendent. Concenterated Phenyl was being used in conjuction with clenzo in varying dilution both in the toilets and ward floors, though the recommended use of phenyl is for toilets and Clenzo for ward floors. There was absence of standards and procedures in the procurement and use of cleaning material in the hospital. The specific type of the materials and its usage was not being implemented in the different areas of the hospital.
It was also observed that though the cleaning was being carried out frequently, use of cleaning agents and disinfectants was based more on traditional ways and decision of house keeping staff rather than on scientific evaluation, Biological testing and valuation of cleaning agent/disinfectants was not being carried out.
Water is the simplest cleaning agent but normally unless it is used in conjunction with some other agent eg. a detergent, it is not an effective cleanser.
The basic ingredient of any detergent are surface active agents or surfactants. These are primarily the wetting agents which lower the surface tension of water and varying degrees emulsify the grease. Each molecule of surfactant has one end which is attracted to water (hydrophilic) and the other which is repelled by water (hydrophobic).
Surfactants are classified on the basis that when dissolved in water some dissociate in to positively and negatively charged particles or ions while others do not. Anionc surfactants carry a negative charge, have good wetting power but limited power to dispel and suspend soiling, examples are soap, alkyl benezene sulphonate. Quats' or quaternary ammonim compounds are cationic surfactants, and have good germicidal properties. Non ionic surfactants are non soapy and have excellent wetting and emulsifying power. They are used mainly in liquid synthetic detergents eg. polyoxyethylene ethers and esters. Alkaline builders such as soda, borates, silicates and complex phosphates improve the emulsifying power of the detergent by increasing the pH of the solution. Sodium sulphate is added as a filler. Sodium carboxy-methyl-cellulose assists the suspending power of the surfactant and this aids in preventing dirt resettling on the cleaned articles.
Criteria for a good disinfectant The main criteria for a good disinfectant are3
- Has good bacteriocidal properties and a wide microbiological spectrum
- Has good cleaning properties
- Must not be toxic or irritating to the users
- Has some degree of odour control (not simply mask control)
- Must not be corrosive to floor
The properties of the various types of detergent-germicides is given in Table-9
Table-9 Comparative properties of detergents
| Properties | Phenolic | Quaternary | Iodophor |
| Effectiveness against S. aureus | Fair to good | Good | Good |
| M tuberculosis | Fair to good | Good | Good |
| Effect on organic matter | Good | Good | Fair |
| Skin irritation properites | Harsh | Mild | Mild |
| Odour | Strong to mild | Mild | Mild |
| pH of use soulution | Alkaline(pH9.10) | Neutral or alkaline(pH7.10) | Acidic(pH3.6) |
| Soil removal property | Poor to good | Good | Fair |
| Corrosion to floor Surface | Safe at correct dilutions | Safe | Safe |
As seen from the above table quaternary detergent-germicides are the ideal.
Nursing and Housekeeping - Is a Divorce Feasible?
The primary role of the housekeeping department is to keep the hospital clean. To undertake this onerous task, assistance must be given by other departments, particularly the departments of nursing. Housekeeping personnel must also have same understanding of the why as well as the how of their job. Nurses have been quite willing to delegate many of their former housekeeping tasks. In many instances this has been a relegation, rather than a delegation of functions, with an abandonment of responsibility as well. While it is conceded that nurses no longer have the time to do the ward housekeeping them selves, they should still retain over all responsibility for the cleanliness of patients physical environment. It is thus not a practicable solution to completely divorce housekeeping from nursing.
Conclusion
Housekeeping is a complex activity requiring constant attention to many varied details, Scientific housekeeping is still in its infancy in India, however its identity and importance has begun to be recognised. Cleaning agents are perhaps the most critical for effective housekeeping4. Cleaning agents, detergent disinfectants utilised for housekeeping activities must be constantly reviewed in light of new scientific findings. Tradition should not be the only criteria on which to base current procedures and practices. The cleaning and disinfectant properties must be evaluated scientifically. Cost effectiveness should be an essential criteria in the selection of cleaning agents and disinfectants for use in housekeeping activities in health care institutions.
In order to augment the existing housekeeping services and enhance effectivity the main recommendations related to cleaning agents and detergents-germicides forwarded are
1. Mechanised Cleaning
Mechanised cleaning should be carried in areas where it is feasible. An automatic combine machine is recommended which performs the four processes of laying the germicidal-detergent, scrubbing, rinsing the floor and vaccuming back the water.
2. Two Bucket System
In areas where mopping is being practised the two bucket system is one containing clean water for washing mop heads and the other containing diluted disinfectant must be taught practised for mopping. Mop heads must be changed every day to minimise the likelihood of microbial contamination being spread from it.
3. Bacteriocidal Evaluation
Bacteriocidal evaluation of the disinfectant in use in the hospital must be carried out. Detergent-germicide are evaluated for hospital use by tests such as Phenol Coefficient test, Use. Dilution Confirmation Test. The cleaning properties of a disinfectant cleaner are evaluated by tests such as Gardner Straight Line Washability Test3.
4. Operative Procedures
The frequency of cleaning and dilution of germicidal solutions should be based on scientific methods. The operative procedures and practices must be standardised and followed.
5. Cost-Evaluation
The availability and use of the cleaning agents and detergents-germicides in other health care institutions must also be evaluated for their cost-effectiveness.
References
- Manual of Hospital Housekeeping. Chicago, American Hospital Association, 1959.
- Eugence J. Good Housekeeping Hospitals, 1983, 70-72.<
- Mizuno W. G Pryor A. K. Evaluating Detergent Germicides for Hospital Use Hospitals vol. 40, Jan 16. 1966,88-90
- Franchettd T/M, Juzwish DW Integrating Quality Assurance in Dimensionﾁfs Health Services : Feb, 1989 17-19.
* Assistant Professor, Hospital Administration AIIMS, New Delhi.
** JAD (Med.), DGAR, Shillong.
*** Additional Prof. Hosp.Admn, AIIMS, New Delhi. For correspondence Dr. Shakti Gupta, Addl. Prof. Deptt. Hosp. Admn. AIIMS, New Delhi.
