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Journal of the Academy of Hospital Administration

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 :

  1. Medical Wards - I and II
  2. Surgical Wards - I and II
  3. Multi disciplinary Wards - I
  4. Emergency Wads - I and II
  5. ICU

However, the study had following limitations:

  1. The study is mainly retrospective in nature. To enunciate operative procedures and practices will require further prospective studies.
  2. 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.
  3. 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

  1. Manual of Hospital Housekeeping. Chicago, American Hospital Association, 1959.
  2. Eugence J. Good Housekeeping Hospitals, 1983, 70-72.<
  3. Mizuno W. G Pryor A. K. Evaluating Detergent Germicides for Hospital Use Hospitals vol. 40, Jan 16. 1966,88-90
  4. 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.

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