Various aspects determine health and hygiene in hospitals which ultimately have a bearing on patient care. Hygiene can therefore be considered as those conditions and practices which are conducive to health or can be defined as a science for the establishment and maintenance of health. This indicates broadly as what hygiene is but does not quite tell us what hygiene implies for different areas in hospitals.
When we look at hospitals and what the determinants of hygiene in hospitals are, we have to begin with the surroundings, the buildings and then the services, interiors, occupants, activities, visitors and the output. Each of these impact hygiene.
An ideal surrounding in such a case can be considered as open areas, green spaces, no crowd and no vehicular traffic. When we have hospitals situated in the middle of the town, what is required then is that every civic utility should be at the arms reach.
The building of the hospital does not generate any pollutant or conditions that impact hygiene inside. Occupants of the hospital, patients, doctors, nurses, technicians, paramedical staff, kitchen staff, housekeeping staff - each one of them play a dual role in hygiene conditions. One as a recipient of good hygiene and at the same time being also responsible for the poor hygiene in one way or the other.
In general, the quantum of visitors impacts hospital hygiene. These are factors like the movement of people across wards from the interior to the exterior and from one service area to another. The other factor is personal hygiene of patients and healthcare providers - clothes and footwear that they wear and the way they groom themselves and come to the hospital.
Hygiene determinants
Workload is another important determinant. There are people who work in air conditioned OT, OPD and clinics and go away whereas housekeeping, engineering and the kitchen staff have to work in hot humid environments and travel through dusty cellars and basements to carry out work and also visit patient care areas in the hospital. Work environment consists of tables, curtains, floors and walls - which is an entire gamut of factors dependent on the occupants of the hospital.
Hygiene in different areas of the hospital
Many people including administrators don’t see Out Patient Clinic as an integral part of the hospital and would like to do as little as possible in these areas because they feel that patients who visit these areas soil it. So it is cleaned only twice a day. There are in patients belonging to different department which again go through various departments in the hospital.
People coming in for deliveries and labour rooms tend to have more body fluids and dirt than in any other area of the hospital. It is difficult to clean this area because of the large volume of patients in this area. There are interventions and operations which could lead to spillage of blood and body fluids and overflowing of bio medical waste. This leads to the exposure of a variety of disinfectants and cleaning agents on patients and surroundings.
There are Intensive Care Units (ICUs) and other areas where patients are on life support. There are monitors on the shelf, machines on the floor, tubes running and curtains all around which can accumulate dust and can be the potential source of bacteria, fungi, spores and micro-organisms. This can impact hygiene because of the very continuous nature of care in the ICU. It cannot be vacated. There is a need to devise certain strategies to take care of this department.
In government hospitals, depending on the number of the patients influx, the load on the mortuaries can be tremendous. This is an integral part of the hospital. NABH has a standard on mortuary upkeep.
Usually government general hospitals have large number of cots and big volume of patients in one room as a government hospital cannot turn patients away. The day care centre of the All India Institute of Medical Sciences (AIIMS), New Delhi has over 400 patients everyday for day care surgery, transfusions and chemotherapy.
External factors impacting hygiene
Visitors can also impact general hygiene by intervening with the housekeeping activity. Visitors are also likely to harm themselves by coming in contact with physical and electrical objects or body fluids, disinfectants, chemicals and other hazardous material that are used in the hospital.
Bed bugs are another problem plaguing Indian hospitals. Bed bugs are very difficult to eliminate. Fumigation is not a solution as they do not live on the surface. They get into corners, crevices, mattresses, pillows, clothes etc. where no cleaning agent or disinfectant can reach.
Patients going outside the hospital carry their illnesses and bugs away with them but leave behind bio - medical waste, which is the most hazardous source of poor hygiene.
Many a time material comes to the hospital for the pharmacies, general store and engineering store through cardboard cartons. After the material is used, cartons are thrown in some corner of the corridor which soon becomes a breeding ground for cockroaches. Similar is the case with construction material, paint and a spectrum of engineering residue which are also left behind.
Futher more we have no control over the structural or architectural aspects of buildings. Many a time age of a building is a cause for concern. We have structures as old as 80 to 100 years which have developed engineering deficiencies having nook and crannies which cannot be cleaned.
Infection control
Pest Control is a problem because there is no unique solution for all pests. Each pest would require a different solution. Some solutions are as hazardous to the human beings as they are to the pests themselves.
Antibiotic abuse is causing lot of drug resistant micro-organisms which are responsible for Hospital Acquired Infections (HAIs). To control the HAIs, hospital hygiene is important. Cleanliness of a hospital is a major quality indicator. Unfortunately hospital infection programme has taken a back-seat in India.
Indian hospitals need to learn from Centre for Disease Control (CDC), Atlanta which started the hospital infection control programme, management of bio medical waste and hospital health hygiene in the 1960s.
There is a need for proper use of appropriate disinfectants and antiseptics, cleaning agents and sterilizing methods. Isopropyl alcohol hand rub should be used to prevent infections. Continuous education programme should be promoted for the housekeeping and nursing staff.
Challenges and solutions
House surgeons are not much aware about hospital hygiene and cleanliness because at present in MBBS courses there is no topic on hospital infection control programme. Hence it is essential to include the same in the curriculum.
Hospital hygiene also includes waste segregation and management. Waste has to be segregated at the source of generation, which many hospitals fail to follow. Around 85 per cent of the hospital is non-hazardous and non infectious. Infection control policy and procedures therefore should be followed.
Hand hygiene and cleanliness should be strictly followed. Compliance of various categories of people with the disinfectant and sanitizers should be practiced. Use of alcohol - based hand rubs with chlorhexadine helps in reducing the incidence of infections.
Administrators generally have the tendency to go for the lowest quoted disinfectant and sanitizer, which may not work. There should be a clinical microbiologist, infection control doctor and infection control nurse for every 250 bed hospital. This will go a long way in monitoring hygienic practices in a hospital.