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Journal of the Academy of Hospital Administration

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

5%

Toilets/tiles

150 litres

Nitric
Acid
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

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

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

PHENYLISMARK

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 are 3
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 Dimensionfs 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.