FOOD SERVICE SANITATION AND SAFETY IN HEALTHCARE INSTITUTIONS

The production and service of food and beverages, meats and snacks require
constant attention to sanitation and safety especially in healthcare institutions. Proper
delivery and service of safe foods to eat after it has been prepared are major aspects of
the total food service system.

Food Safety and Sanitation

Of all the desirable attributes of food, safety is of prime importance. A delicious

and nutritious meal is useless if it will cause serious illness and untold misery. Food safe
to eat is free from any harmful material or pathogenic organism from one or more of
these sources:

1. Microbiological (e.g. pathogenic microorganisms like bacteria, viruses,

parasites, and harmful fungi).
2. Biological (e.g. household pests like insects and rodents, domestic pets, and
the food handler who harbors the pathogens or transmits them to food, surfaces
of tables and equipment, and to consumer).
3. Physical (e.g. “foreign materials that are ingested and harm the oral cavity
cause choking or injure the GIT)
4. Chemical (e.g. poisonous substances or toxins naturally occurring in the food of
added as contaminant, added intentionally, and food additive that exceeds the
allowed limit).

Sanitation is the hygienic and aesthetic aspect of food safety. Examples are
chipped edge of plate, stained coffee cup, lipstick marks in a glass, and water marks on
the spoon. Sanitation come from a Latin word, sanitas, which means health. Sanitation
means freedom from filth, dust, dirt and other characteristics that are unacceptable to a
consumer.

1. Microbiological Hazards

Microorganisms are unicellular very small living things and are not visible to the
naked eye, unless aided by microscopes. The four groups that can be food-borne are
bacteria, viruses, parasites and fungi. Bacterial contamination is the most common and
is the main focus in training and educating consumers, especially food handlers.

Common Foodborne Pathogens

Etiologic Agent Implicated Foods Preventive Measures

Bacteria Wide variety of foods;
Bacillus cereus vegetables, meat, milk, fish, if
(diarrheal toxin) left uncovered because of soil
and dust contaminates.
Spores survive milk
pasteurization
Campylobacter jejuri Raw poultry, beef, lamb,
unpasteurized milk (foods of
animal origin eaten raw or
undercooked or
Does not grow at
recommended refrigerator
temperature (below 41⁰F),
but it can grow at slightly
higher temperatures.
Therefore, cook food
thoroughly . Cool rapidly and
separate cooked from the
environment by covering
them to reduce their
contamination by airborne
spores.
Cook foods thoroughly; use
pasteurized milk; use safe
food handling methods
 recontaminated after cooking)
Clostridium botulinum Anaerobic environment of low
(children and adults) acidity (canned corn,
peppers, green beans, soups,
beets, asparagus,
mushrooms, ripe olives,
spinach, tuna, chicken liver,
luncheon meats, ham,
sausage, garlic in oil,
lobster0; smoked and salted
fish
Clostridium botulinum Honey: this is the one dietary Do not feed honey to infants;
(infants) vehicle of C. botulinum spores do not prepare infant
linked to infant botulism
Clostridium perfringes Left-over meats and meat
products stored at between
120 ⁰F and 130 ⁰F
E. coli (ETEC) Undercooked ground beef,
unpasteurized milk and milk
products, contaminated
water, and person-to-person
contact
Listeria Raw meat and seafood,
monocytogenes processed meats, raw milk,
and soft cheeses
Salmonella spp. Raw or undercooked eggs,
meats, poultry, milk and
other dairy products, shrimp, milk; cook foods thoroughly;
frog legs, yeast, coconut,
pasta, and chocolate
Shigella spp. Person-to-person contact, raw Use safe food handling
foods, salads, dairy products, methods; cook foods
and contaminated water
Staphylococcus aureus Toxin produced in meats,
poultry, egg products, tuna,
potato, and macaroni salads
and cream-filled pastries
Vibrio cholerae Raw seafood and
contaminated water
Yersinia enterocolitica Undercooked pork,
unpasteurized milk,
contaminated water
Virus Water and ice, shellfish,
Hepatitis A virus salads, deli meats and
sandwiches, fruits and fruit
juices, raw milk and milk
products, vegetables, any
Use proper canning methods
for low-acid foods (e.g.
pressure cooker) refrigerate
homemade garlic and herb
oils; avoid commercially
prepared foods with leaky
seals or with bent, bulging, or
broken cans.
formulas with honey or dip
pacifiers in honey
Use safe food-handling
methods; cook foods
thoroughly; use pasteurized
milk
Cooked ground beef
thoroughly (160 ⁰F); avoid
raw milk and milk products;
use safe food handling
methods; use treated, boiled,
or bottled water
Use safe food handling
methods; cook foods
thoroughly; use pasteurized
milk
Use safe food handling
methods; use pasteurized
refrigerate foods promptly
and properly
thoroughly; refrigerate foods
promptly and properly
Use safe food handling
methods; cook foods
thoroughly; refrigerate foods
promptly and properly
Use safe food handling
methods; cook foods
thoroughly
Use only pasteurized milk and
dairy products; treated water
for drinking and for food
preparation. Cook foods
thoroughly; separate cooked
foods from raw foods. After
handling raw foods, wash
your hands properly.
Prevent cross contamination
from hands; ensure food
handlers practice good
personal hygiene; thoroughly
cook food to require minimum
 food that will nor receive
further heat treatment.
Norwalk-like virus Water, shellfish (especially
raw or insufficiently steamed
clams and oysters), raw
vegetables, fresh fruit and
salads, contaminated water
Parasites Raw, uncooked or improperly Avoid eating raw or partly
Anisakis spp frozen fish, especially cod,
haddock, Pacific salmon,
herring, flounder, monk fish,
and fish used for sashimi and When serving raw or
sushi
Ascaris lumbricoides Contaminated food and
water, Person-to-person
contact.
Cryptosporidium Water, salads, and raw
parvum vegetables; raw milk; raw
food, such as apple, cider;
ready-to-eat food.
Cyclospora Water, marine fish, raw milk, Ensure that food handlers
cayetanensis raw produce
Entamoeba histolytica Sewage contaminated water
or eating fruit, vegetables and is waterborne and foodborne.
other foods contaminated
with this amoeba
Gardia lamblia Contaminated water and ice,
salads, and (possibly) other
raw vegetables
Taenia saginata Beef infected with tapeworm
that is undercooked
Taenia solium Pork infected with tapeworm Thoroughly cooked pork.
that is undercooked
internal temperatures; use
sanitary/safe water sources.
Prevent cross contamination
from hands; ensure food
handlers practice good
personal hygiene; thoroughly
cook food to require minimum
internal temperatures; use
sanitary/safe water sources.
cooked fish and shellfish
unless it has been properly
treated to eliminate parasites.
undercooked fish, only use
sashimi grade fish that has
been properly frozen. Fish
intended to be eaten raw
should be frozen at -4 ⁰F
(-20⁰C) or lower for 7 days in
freezer, or at -31⁰F (-35⁰C)
or lower for 15 hours in a
blast chiller. Sanitary disposal
of feces; cook food
thoroughly.
Ensure that food handlers
practice good personal
hygiene; thoroughly wash
produce; use potable water.
Sanitary disposal of feces,
cook food thoroughly.
Ensure that food handlers
practice good personal
hygiene; thoroughly wash
produce; use potable water.
Sanitary disposal of feces,
cook food thoroughly.
practice good personal
hygiene; thoroughly wash
produce; use potable water.
Sanitary disposal of feces,
cook food thoroughly.
This disease called amebiasis,
Therefore, practice safe food
handling and sanitary
hygiene. Sanitary disposal of
feces, cook food thoroughly.
Use sanitary, chlorinated
water supplies; ensure that
food handlers practice good
personal hygiene; wash raw
produce carefully.
Thoroughly cooked beef.
Practice good personal
hygiene. General sanitation
Practice good personal

Taenia Raw and undercooked fish
diphylobothrium infected with tapeworm.
Trichenella spiralis Undercooked pork or wild
game, pork and other
sausages (ground meat may
be contaminated by meat
grinders).
hygiene. General sanitation
Thoroughly cooked fish.
Practice good personal
hygiene. General sanitation
Cook pork and other meat to
internal cooking
temperatures; wash, rinse,
and sanitize equipment, such
as sausage grinders and
utensils used in the
preparation of raw pork and
other meat.

In general, control of pathogenic bacteria is by depriving them of their

requirements for growth and multiplication, known as FATTOM. The acronym stands
for food, acidity, or optimum pH, time, temperature, oxygen and moisture.
Observe personal hygiene and sanitary practices in food handling from the time food is
received, through storage, preparation, cooking and serving or eating of the meal.

2. Biological Hazards
Other than microorganisms, biological organisms include household pests (e.g.,
mice, rats, flies, cockroaches), farm animals, domestic pets, certain plants and fishes
may transmit infectious diseases to humans through contamination of food and water.
The food handler is considered under this category. Cross-contamination is also another
way of transmitting food borne illnesses.
To control pests, observe sanitation (cleaning schedules and use of disinfectants
when applicable) not only inside the house or building, but also in the surrounding
areas. Do not provide food, water, and shelter that would attract them and promote
their growth and reproduction. Dispose of garbage as often as possible. Trash cans are
provided with tight lids Seal holes, screen any entrance and store food in tightly
covered containers. Once inside the kitchen or building, get rid of them safely by
biological, mechanical or chemical means (traps, pesticides, insecticides, rodenticides)
that will not contaminate food and water. Again frequent washing of hands properly
and observing hygiene practices at all times are emphasized.

3. Physical Hazards

Any foreign object ingested with the food that will injure the oral cavity and GIT
is considered a physical hazard. Examples are metal fragments, wood splinters, pieces
of plastic, sharp fish bone, and tiny pebbles. Of serious concern is choking because it
can be life threatening.
Accidental contamination is prevented by covering food properly, good lighting,
visual inspection of the ingredients, wearing hair nets and no jewelry, (except a plain
wedding band) and getting rid of worn out sponges, rugs, and dish washing tools.
Purchase food from reliable sources that have quality control and check boxes or
packaging for torn out labels, any fragments of wiring of strings, and insect eggs or
other fragments. Wash and insect produce, particularly root crops or those that grow
near the soil for any sand or stone particles.

4. Chemical hazards
Poisonous chemicals ( e.g. heavy metals, sanitizers and disinfectants, radioactive
materials) and toxins inherent in some species of plants and fishes are the most
common chemical contaminants in food and water. Any chemical can be poisonous if
ingested at toxic levels. Food additives and medical drugs are carefully regulated not to
exceed tolerable limits.

Preventive measures for any accidental contamination are as follows:

 Read instructions for proper use of the chemical.

 Note any expiration date
 Store chemicals in a separate closet away from food
 Label clearly and write in big letters POISON as needed
 Never use recycled other containers. Use original if possible.
 Maintain cool temperature of storage, especially for flammable chemical
 Buy only what is reasonable amount within a period of use
 Keep inventory records
 Always wash your hands before and after using chemicals. Wear protective
gloves, clothes, and even eye glasses as required
 If in doubt, get professional help, especially with aerosols or sprays
 Use kitchen equipment made of materials that will not leach to the food or
react with food causing toxic products

HACCP

HACCP stands for Hazard Analysis and Critical Control Point, which is a
prevention-based food safety system. Essentially, HACCP is a system that identifies and
monitors specific foodborne hazards – biological, chemical, or physical properties – that
can adversely affect the safety of the food product. Every operation producing and
serving food needs to have a food safety system in place that is designed specifically to
guarantee the food being served is safe to eat. This system comprised of 7 steps that
are to be applied to a written food safety program focusing on the food in the
operation.

Step 1: Conduct a Hazard Analysis

You must determine the food safety hazards and then identify the preventive
measures the food service establishment can then apply to control these hazards.
Potential hazards associated with a food could be biological, such as microbe, or
chemical, or they could be physical. For example, if a hazard analysis is conducted on
the preparation of hamburgers from frozen beef patties, enteric pathogens on the
incoming raw meat would be identified as a potential hazard. Cooking in the preventive
measure which can be used to eliminate this hazard.

Step 2: Identify the Critical Control Points (CCP)

A CCP is a point, step, or procedure in a food process (from its raw state through
processing and service) that must be controlled to prevent, eliminate or reduce the
hazard to an acceptable level. A CCP is any biological, chemical or physical property
that may cause food to be unsafe. CCPs are essential for product safety, as they are the
points where control is ultimately effected. However, the CCP itself does not implement
control. Instead it is the action which is taken at the CCP which controls the hazard. For
example, cooking that must occur at a specific temperature and for a specified time in
order to destroy the microbiological pathogens is a critical control point. Likewise,
refrigeration o prevent hazardous microorganisms from multiplying or toxins from
forming is a CCP.

Step 3: Establish Critical Limits for Preventive Measures

A critical limit is the maximum or minimum value to which a physical,

biological, or chemical hazard must be controlled at a critical control point to prevent,
eliminate, or reduce it to an acceptable level. Critical limits may be thought of as
boundaries of safety for each CCP and may be set for preventive measures such as
time, temperature, humidity, pH, preservative, salt concentration, viscosity, etc. it may
be derived from sources such as regulatory, standards and guidelines, scientific
literature and consultation with experts. An example of this principle is the cooking of
beef patties. The process should be designed to eliminate the most heat-resistant
vegetative pathogen which can be reasonably expected to be in this product. Criteria
may be required for factors such as temperature, time and meat patty thickness. The
relationship between the CC:P and its critical limits for the meat patty example is shown
below:

Process Step CCP Critical Limits

Cooking YES Minimum internal temperature of Patty : 68⁰C/155⁰F
Broiler temperature:______ ⁰C/: ___________⁰F
Time: rate of heating/cooking

Patty thickness_________cm/____________in.
Patty composition: e.g % fat, % filler
Oven humidity:________________% RH

Step 4: Establish Monitoring Procedures

It is essential to establish a procedure to monitor the control points. Monitoring

activities are necessary to ensure that the process is under control at each critical
control point. Measures for monitoring include: visual observations, temperature, time,
pH, etc. Instrumentation used by the food service establishment for measuring critical
limits must be calibrated for accuracy.
Continuous monitoring is preferred when feasible and when not possible, to
establish a monitoring interval reliable enough to indicate that the hazard is under
control. Most monitoring procedures for CCP’s will need to be done rapidly because the
time frame between food preparation and consumption does not allow for lengthy
analytical testing. Because of the time-consuming nature of microbiological testing, it is
seldom effective for monitoring CCP’s. Use physical and chemical measurements
because they may be done rapidly and can indicate whether microbiological control is
occurring. It is important to assign the responsibility for monitoring to trained
employees associated with the operation, such as the person in charge of the food
establishment, chefs, and departmental supervisors. The person responsible for
monitoring must also record an operation or product that does not meet critical limits
and ensure that immediate corrective action can be taken.

Step 5: Establish Corrective Action

Corrective actions are to be taken when monitoring indicates a deviation from a

critical limit has not been met. It also determines the disposition of any food that was
produced when a deviation was occurring, correct the cause of the deviation, ensure
that the CCP is unde3r control and maintain records of corrective actions. Employees
who have a thorough understanding of the operation, product, and HACCP plan must
be assigned responsibility for taking corrective action. Corrective action procedures
must be documented in the HACCP plan.

Step 6: Establish Record Keeping Procedures

This step requires the preparation and maintenance of a written HACCP plan by
the food service department. The following documents are examples of what to be
included in the HACCP plan:
1. Members of the HACCP team and their responsibilities
2. Description of the product and its intended use
3. Process step or food preparation flow diagram indicating CCP’s
4. Chemical, physical, biological hazards associated with each CCP and
preventive measures
5. Critical limits
6. Monitoring system procedure/person responsible
7. Corrective action plans/person responsible
8. Record keeping protocol
9. Verification procedures/person responsible

Step 7: Establish Verification Procedures

Verification ensures that HACCP plan is adequate. Food service establishments

must rely on frequent reviews of the HACCP plan, verify that the plan is being correctly
followed, review their CCP records and determine that appropriate risk management
decisions and product dispositions are made when deviations occur.

The following are some examples of HACCP plan verification activities:

1. Establishing verification inspection schedules

2. Review of HACCP plan
3. Review CCP record
4. Review deviations and their resolutions
5. Visual inspections of operations to verify if CCP’s are under control
6. Random sample collection and analysis
7. Review critical limits
8. Review written records of verification inspections
9. Validation of HACCP plan, including on-site review and verification of flow
diagrams and CCP’s
10.Review of modifications of the HACCP plan

Golden Rules on Food Safety and Sanitation

A fitting conclusion for food safety and sanitation is the list of the Ten Golden
Rules by the World Health Organization (WHO) for consumers:

1. Buy or choose foods that have been processed for safety.

2. Cook foods thoroughly.
3. Eat cooked foods immediately.
4. Store cooked foods carefully and properly.
5. Reheat foods thoroughly.
6. Wash hands repeatedly and properly.
7. Keep all kitchen surfaces clean and sanitary.
 8. Protect foods from insect, rodents, pests, and animal that may transmit
pathogens.
9. Use potable water for drinking, washing produce and for cooking.
10.Keep hot foods hot and cold foods cold. Remember that the danger zone of
holding foods (i.e., most favorable for most bacteria to multiply) are the
temperatures between 40 to 140⁰F or 4-60⁰C.

Temperature Guide for Control of Bacteria and Food Safety

Do not store raw meats for more than 5 days or poultry, fish or ground meat for more than 2 days in the
refrigerator
Discarding Procedures for Food to be Discarded or Salvaged

Discard Salvage
Any food or service item Frozen foods if stored in sealed walk-in or
that has been cabinet freezer (no water, smoke, fumes or
contaminated or come in chemical) and where ambient temperature
contact with water, has remained below 40⁰F.
sewage, smoke, fumes, or
chemicals.

This includes: Disinfect undamaged cans and bottles that

 Fresh perishables – have no heat or water damage and are
produce, meat, poultry, fish, free from dents, bulging, leaks or rust
dairy products and eggs  Paper label removed
 Opened containers and  Washed with soap and water, then rinsed
packages  Sanitized with sanitizing solution, then air
 Vulnerable containers dried
with peel off, waxed  Relabeled with permanent marker
cardboard, cork or screw
tops or paraffin seals such
as glass or plastic
containers of catsup,
dressing, milk, mayonnaise,
soft drinks, sauces, etc.
 Soft porous packaging –
food in cardboard boxes,
paper, foil, plastic, and
cellophane such as boxes or
bags of food, cereal, flour,
sugar, rice, salt, etc.
 Dry goods – spices,
seasoning and extract, flour,
sugar and other staples in
canisters
 Single service items –
paper, cups, utensils, lids,
etc.
Canned and bottled items If fire, flood or sewage back-up had been
must be discarded if: effectively contained:
 In contact with sewage,  Food in areas unaffected by smoke, fumes,
water, smoke, fumes or water, heat, fire suppression chemicals,
chemical seepage. floodwater or sewage back-up may be
 Above 40⁰F for four or salvaged
more hours  Seek the advice of your local health inspector
 Deteriorates in quality or
has an unusual appearance,
color or odor

Potentially Hazardous Non-PHF may be kept at room

Food (PHF) must be temperature, though quality may
discarded if it has been in deteriorate including:
the “Temperature Danger  Bread, rolls, muffins, dry cakes
Zone” (40⁰F-140⁰F) for  Solid butter or margarine
more than 4 hours. PHF’s  Hard cheese-cheddar, parmesan, etc.
include:  Fresh uncut fruits and vegetables
 Fruit and vegetable juices, dried fruit, fruit
Meat and mixed dishes pies
 Beef, veal, lamb, pork,  Canned goods
poultry, fish, seafood,  Dry foods –flour, pasta, rice, etc.
luncheon meats, hot dogs,  High sugar foods – honey, jellies
hams, etc.  Acid based condiments – ketchup, mustard
 Soups, stews, casseroles or
similar dishes containing
meats, pasta, rice, eggs or
cheeses
Eggs and dairy products
 Eggs or egg products, ice
cream, yogurt

 Milk, cream, cream-based

foods or soups
 Soft cheeses such as cream,
ricotta, brie, etc.
Desserts- pies, cakes and
pastries including custard,
cheese, chiffon, meringue or
pumpkin
Cut melons and cooked
vegetables – Watermelon,
honeydrew melons, cooked
peas, corn, or beans
Partially cooked food Partially cooked food may be quickly
must be discarded if reheated to 165⁰F if without power for less
without power for more than one hour. “When in doubt, throw it
than one hour out!”
Non-Food Items
Discard any exposed materials that cannot be effectively cleaned and
sanitized, including toasters and other equipment, linens, furnishings,
carpets, etc.
Refrigerator Foods
Food still Held above 40⁰F for
cold, held over 2 hours
at 40⁰F or
above
under 2
Dairy/Eggs/Cheese hours
Milk, cream, sour cream, buttermilk, Keep Discard
evaporated milk, yogurt
Butter, margarine Keep Keep
Baby formula, opened Keep Discard
Eggs, egg dishes, custards, puddings Keep Discard
Hard and processed cheeses Keep Keep
Soft cheeses, cottage cheeses Keep Discard
Fruits and vegetables
Fruit juices, opened; canned fruits, Keep Keep
opened: fresh fruits
Vegetables, cooked; vegetable juices Keep Discard after 6 hrs
opened
Baked potatoes Keep Discard
Fresh mushrooms, herbs, spices Keep Keep
Garlic, chopped in oil or butter Keep Discard
Meat, Poultry, Seafood
Fresh or leftover meat poultry, fish, Keep Discard
seafood
Luncheon meats, hot dogs, bacon, Keep Discard
sausage, dried beef
Canned meats NOT labeled “Keep Keep Discard
refrigerated” but refrigerated after
opening
Canned hams labeled “Keep Keep Discard
refrigerated”
Mixed Dishes, Side Dishes
Casseroles, soups, stews, pizza with Keep Discard
meat
Meat, tuna, shrimp, chicken or egg Keep Discard
salad

Cooked pasta. Pasta salads with Keep Discard

mayonnaise or vinegar base
Gravy stuffing Keep Discard
Pies, Breads
Cream or cheese filled pastries and Keep Discard
pies
Fruit pies Keep Keep
Breads, rolls, cakes, muffins, quick Keep Keep
breads
Refrigerated biscuits, rolls, cookie Keep Discard
dough
Sauces, Spread, Jams
Mayonnaise, Tartar sauce, horseradish Keep Discard
Opened salad dressing, jelly, relish, Keep Keep
barbeque sauce, mustard, catsup,
olives
FROZEN FOODS
Still Thawed, Held
Contains <40⁰F or Over 2 hours
Iced
crystals.
Not above
Meat and mixed dishes 40⁰F
Beef, veal, lamb, pork, poultry, ground Refreeze Discard
meat & poultry
Casseroles with meat, pasta, rice, egg Refreeze Discard
or cheese base, stews, soups,
convenience foods, pizza
Fish, shellfish, breaded seafood Refreeze Discard
products
Dairy
Milk Refreeze Discard
Eggs (out of shell), egg products Refreeze Discard
Ice cream, frozen yogurt Discard Discard
Cheese (soft and semi-soft), cream Refreeze Discard
cheese, ricotta
Hard cheese (Cheddar, Swiss, Refreeze Refreeze
parmesan)
Fruits and Vegetables
Fruit juices Refreeze Refreeze. Discard if
mold, yeasty smell or
sliminess develops
Home and commercially packaged Refreeze Refreeze. Discard if
fruits mold, yeasty smell or
sliminess develops
Vegetable juices Refreeze Discard if above 50⁰F for
over 8 hours
Home and commercially packaged Refreeze Discard if above 50⁰F for
blanched vegetables over 8 hours
Baked Goods, Baking Ingredients
Flour, cornmeal nuts Refreeze Refreeze
Pie crusts, breads, rolls, muffins, cakes Refreeze Discard if above 50⁰F for
(no custard filling) over 8 hours
Cakes, pies, pastries with custard or Refreeze Discard
cheese filling, cheesecake
Commercial and homemade bread Refreeze Refreeze
dough

The following chart provides guidelines for how long you can use products
after their Use By and Sell By Dates under proper storage temperature. Food
Marketing Institute, Cornell University and University of Michigan developed
these guidelines.
Food Storage Guidelines

Product types Storage life past the

code dates
Dry Canned Goods
Canned goods, Low Acid (Meat, Fish, Gravy, Stew, 5 years
Beans, Soups, Carrots, Corn, Pasta, Spinach
Canned goods, High Acid (Juices, Fruit, Pickles, 12 months
Tomato Soup)
Condiments (Ketchup, Mustard, Salad Dressing, Salsa) 12 months
Mayonnaise 3 months
Jams, Jellies 12 months
Pasta 2 years
Oils 12 months
Peanut butter 9 months
Bottled water 1 year
Baby Food Consume by code date
Vinegar 2 years
Soda: diet 3 months
Soda: regular 9 months
Cottage cheese 21 days
Milk 7 days
Refrigerated
Cottage cheese 21 days
Milk 7 days
Yogurt 10 days
Whipping cream/Aerosol Whipped cream 30 days
Sour Cream 21 days
Other Fresh juices 14 days
Unpasteurized juices Consume by code date
Tofu 21 days
Deli meats Consume by code date
Margarine 5 months
Butter 3 months
Eggs 5 weeks
 Egg substitute 10 days

Food Service in the Hospital

The client in a health-related institutional foodservice like a large hospital are the
patients and the staff who have shifts around the clock. They expect quality food and
services and the dietary or foodservices department should offer them quality in a cost
effective manner.
Quality refers to the totality of features and characteristics of a product or
service that bears on its quality to satisfy, stated or implied needs. In the foodservice
setting, food is the product. Quality service may be defined as the attributes of the
delivery and service accompanying the product before, while and after it is sold to the
customer.
Quality has many different aspects. For example, the patient customers base
their perception of the quality more on the health and nutrition aspects of the food than
the staff of the hospital. Attentive listening can often provide information about

customer satisfaction. Nurses having direct contact with patients can serve as the eyes
and ears of foodservices unit in evaluating food quality levels and client needs.

Food Distribution Systems

Delivery, sometimes called distribution, refers to the transportation of prepared
foods from the place of production to the place of serving them. Service includes
activities of assembling the foods delivered in bulk to individual trays or covers. There
are two delivery-service systems: centralized and decentralized.
In centralized delivery-service system, prepared foods are portioned and
assembled for individual meals at a designated space in the main kitchen or central
area near the kitchen. They are transported and directly served to the consumers. This
method is popular among hospitals, nursing facilities, fast-food chains, and counter
services. Compared to the decentralized system, the complete meal is served faster and
requires less labor and less equipment temperatures and portion control are better
supervised. However, for a larger number to feed, it may take too long to finish serving
all the consumers or clients. The decentralized delivery-service system can serve a
larger number of consumers, because bulk quantities of food are divided into batches
sufficient or a ward or satellite kitchens close to the point of service. In medical centers
or larger hospitals with many wards spread in the compound, decentralized service is
preferred. Transporting by the use of carts, trucks or some vehicle is required. The food
may require reheating and portioning before assembling on individual trays or dinner
plates. Thus, the ward kitchens need refrigerators, ovens, and counters for work space.
However, serving hot foods hot and cold foods cold may be more likely to happen in
decentralized system.
In any food delivery and service system, there is a kitchen equipped with a
refrigerator-freezer unit which should be stocked with a minimum amount of plain ice
cream, canned juices, skim or low fat milk cartons, gelatin, ginger ale, diet lemonade or
diet juices and bottled water in individual packaging. These are emergency needs for
liquid diets in addition to what are served during meal trays.
The pantry or dry food storage will have supplies of individual packets of salt,
pepper, sugars (regular or sugar substitutes), decaf instant coffee in individual packs,
and tea bags. It is not surprising if such items are sometimes missing on the trays if
allowed for a patient. Instead of calling the main kitchen for any item, they are
available in the ward or unit that a nursing aide can easily serve. Disposable containers
like foam cups, plastic spoon and forks, and napkins are standard supplies in the
pantry.
Other food items may be ordered for the unit kitchen, such as cheese and white
bread crackers (salted and unsalted), butter substitute, low calorie-jelly, graham
crackers, etc. in case of late night admissions and the main kitchen is closed.
Whether it is the dietary or nursing department, who is in charge of ordering the
above supplies and do an inventory before ordering more, should be agreed upon
according to policies of the hospital. What is important is to be sure a refrigerator and a
freezer must have thermometers and a daily reading is documented. Not because
surveyor/food inspectors will look for them but food safety.
Once the diet is prescribed by the physician for a particular patient, the two
departments that work closely in feeding the patient are the dietary and nursing
departments. The responsibilities of dietary department are: the preparation and the
training of dietitians and others involved in diet therapy. The major portion of the work
of the dietary department revolves around the preparation and service of meals
according to acceptable standards of management. Meals should take into account
customer appeal, sanitation, nutrition, the hospital budget and facilities available.

Proper Tray Service

Meals are usually served at the bedside, but some hospitals have cafeterias for
ambulatory patients. Nursing homes generally have a dining room for patients eat in
small groups. Nurses and dietary personnel work together to ensure the patients
receive food at meal times and the trays are collected afterward.
Since most hospital meals are served on a tray, certain standards must be
observed for tray service.

A MODEL FOR PROPER TRAY SERVICE

SALAD SOUP
PLATE DESSERT
BEVE-
RAGE

CUP
CUP &
BREAD
DINNER SAUCER
PLATE
PLATE
 Checklist for Proper Tray Service
1. Is the tray correctly identified with the patient’s name, ward and room number,
and right diet prescription?
2. Is the size of the tray suitable to the amount and kind of diet?
3. Is the cover clean and neat, free from wrinkles and from spoilage?
4. Are the silverware and glassware free from grease marks, chips and crack?
5. Is the arrangement of dishes and cover appointments in proper order?
6. Are the meals served on time?
7. Are the hot food served hot and cold foods served cold?
8. Are the serving portions according to dietary prescription and suitable to the
patient’s appetite?
9. Are the color, texture, and flavor combinations pleasing?
10.Are the seasonings and other food adjuncts correctly included (i.e., restricted
sodium diets should have salt packets and bland diets must not have pepper
shakers)?

In general, client satisfaction depends in large part on the pleasing presentation of

carefully prepared, assembled, and transported food in every type of foodservice
operation. A hospital patient with poor appetite may want his/her meal served
attractively and may refuse to eat if the food is not tasty. The style of service used –
whether self-serve, tray, or waited service – must be appropriate for the type of
operation and for attaining its goals. Training the utility workers to use correct serving
procedures and to present the food to the consumers in a pleasing and courteous
manner is an essential element in achieving a successful foodservice operation.

In the dietary department, informal survey techniques like plate waste and actual
observations in the dining room provide a gauge of customer satisfaction. Exit
interviews prior to patient’s discharge also provide feedback on satisfaction. Questions
like the following are usually asked:

 Are your meals served on time?

 Are the trays attractive and neat?
 Did you get enough variety?
 Are hot foods served hot and cold foods served cold?
 Did a nutritionist-dietitian visit you?
 Were you given instructions regarding special diets before you got
discharged?

Serving Isolation Trays

Reverse isolation means protecting the patient from all possible contamination
of infections. Patients with blood dyscrasias and leukemias or severe burns are the ones
confined in the reverse isolation area. A portion of hospital space is specially designed
to be completely self-contained for patient care, for example the Burn Unit. Persons
who lost a major portion of their skin are high risk to infections. In the isolation units,
all hospital staff, personnel, and guests are required to wear sterile masks, gown, cap,
and slippers. Eating and sleeping are not allowed in the waiting room.

When a patient has a contagious disease, his food tray is set up with disposable
containers, including a disposable tray. After eating, it is picked up in a separate cart
and everything is thrown into a trash bag properly tied. It goes directly to a bin for
disposing biological hazardous waste. Nursing and Dietary personnel are instructed as
part of their orientation program how to handle situations that need special safety
measures, like reverse isolation, washing hands before wearing suitable gloves, gowns,
caps, nose and mouth masks, etc.

Responsibilities of the Nursing Department

The nurse is the first person who observes the patient’s feeding problems such
as inability to chew, and physical handicap to feed himself, complaints about the food,
etc. She has more direct and continuous communications with the patient and must
therefore be well-informed about the principles of the diet, and food items allowed and
prohibited. Any question of the patient regarding his food must be referred to the
dietitian as soon as possible.

The nurse should immediately forward the physician’s diet prescription on the
dietary department. If a patient is going home on a special diet (“discharge” diet or
“take home” diet), the nurse should immediately notify the dietitian. However, for
effective counseling, the dietitian does not wait for the last day’s notice for diet
discharge orders to explain diet therapy for cases that need more time, like a newly
diagnosed patient with diabetes, cancer, failure to thrive, renal disorders and stroke.
Usually, when a patient is discharged, he/she is excited about going home and there
are so many concerns to be instructed about (e.g. medications, injections, nursing a
wound), hence may not be attentive to diet therapy guidelines, food allowed and
avoided, etc. The busy dietitian, with many other tasks for the day, may just give a
ready list for the patient/family to observe at home.

Usually food charting is accomplished by the nursing staff using the form and
illustration shown below. Whoever is in charge of the food recording should be properly
instructed about the form, amounts description, etc.

The nursing aide sees to it that the patient is ready for his food tray. The
bedside table may need sanitizing because sometimes, there may be trash, live flower
vase or plant, or even a bed pan on the table. The patient may need help in washing
her hands, sitting up, cutting his meat, pouring water, etc. She helps in encouraging the
patient to eat, tidying her bedside table and cleaning up. She should removed the tray
promptly and make sure to note down leftovers if food recording is needed.

The small size table near the head board usually has shelves for magazines,
flower vase, and perhaps a telephone. Nursing aides must check that there is bottled
water or a pitcher of water and disposable cups for patients to reach any time they are
thirsty and not wait for someone to come by a ringing bell. For the elderly and other
patients who do not feel they are thirsty, but must be encouraged to drink to avoid
dehydration, nursing aides should offer them a nourishing liquid and water as allowed
by their medical condition.

Sample Form in Recording Daily Food Intake of a Patient

Patient: Ward & Bed No.

Dietary Prescription: Physician:
 Date Time Food & Beverage Intake Amount Recorded by:

Remarks
(examples)
2-15-10 Lunchtime: patient not hungry because of GI tests.
2-16-10 Morning snack not taken. Feels nauseated: no appetite
Note: Daily Food Intake of a patient includes snacks, supplements like high protein milk, vitamin and
mineral capsules, and describe the items adequately. Use standard measures (Tbsp, cups, ml)

GUIDE FOR CHARTING MEAL PATIENT CONSUMPTION

This is a chart intended as a guide for charting meal patient consumption.

Subtract the amount of food items left on tray from 100% to get the percentage of the
consumption (the amount eaten)

Breakfast Meal

15% juice or
Fruit
40% 2o% milk
starch/cereal
25%
Protein Dish
(egg/meat)
0%
hot
Beverage

Noon and/or Evening Meal

10%
Dessert
10%
soup
40% Starch
10%Vegetables
30% Protein 0%
Dish hot
Beverage

For example: If one egg is the only item left on the tray eaten at breakfast,
subtract 25% from 100% and the percentage of consumption for that meal is 75%. If
milk is the only item left on the tray eaten at breakfast, subtract 20% from 100% and
the % of consumption for the meal is 80%

Appetite Considered As:

0-5% = Very Poor

10-30% = Poor
35-65% = Fair
70-85% = Good
90-100% = Excellent

For nutritional evaluation, a more effective charting of food intake is not just by
percentage of food eaten as listed above, but note also the kind of food/beverage left
on the tray. For example, a record of 70 to 85% considered good which is 15-25% not
consumed; is nutritionally inadequate if milk, fish, eggs were left on the tray, compared
to eating them and not finishing a baked dessert or breads.
If patient receives a high protein drink or supplemental drink with meals it is not
figured in the percentage of food eaten. Charting should reflect the percentage and/or
supplement either consumed or refused. If patient’s appetite is poor or very poor,
consult a nurse or Dietetic Service supervisor regarding patient’s intake.

Food Service to Patients with Communicable Diseases

Some hospitals provide a separate ward for patients with communicable

diseases. Others provide isolation rooms observing standard procedures for
communicable diseases. In such cases, the personnel responsible for bringing food
trays leaves the tray at the nurse’s station and the nurse in appropriate garb brings it to
the patient’s room. The food is served in disposable containers including the spoons,
forks and knives. After the meal service, everything is thrown away in tightly covered
garbage cans or plastic bags and immediately incinerated.
Patients who are fed in this manner should be made to understand the reasons
for such standard procedures. The physician and allied groups should give supportive
information to alleviate unnecessary worry about the patient’s condition.

Preventive Measures in the Dietary Department

Food sanitation and hygiene should be given priority and emphasis. Food
handlers must be trained to observe proper personal hygiene and practices such as
wearing of clean working garments and hair restrain, washing of hands and arms
before working, during working hours, and after smoking, visiting the toilet, coughing or
sneezing into hands. No person should be allowed to work in food handling and
preparation while afflicted with a communicable disease or a carrier-of such diseases. In
terms of food sanitation practices, the dietitian in-charge-of the food supply, food
production, and food service section must ensure that all foods used by the hospital for
feeding patients come from sources approved by the local health authority. Adequate
sanitation practices are also expected when transporting food and food materials so
that foods are protected from contamination.

Adherence to PD 856
Pres. Decree No. 856 embodies the Code of Sanitation of the Philippines
enforced by the Department of Health. Chapter III of the Code covering Sections 14 to
33 pertains to sanitation in food establishments.
 Section 17 includes sanitation requirements of food service structures and
facilities. Section 19 describes the requirements for food handlers. Section 20 and 21,
and 22 outline the regulations about toilet and washing facilities, disposal of garbage,
and vermin control. Section 23 to 27 present rules about equipment and utensils
(washing, handling, storage, and bactericidal treatment); section 28 and 29 deals with
dry and cold storage of goods while section 30 describes the food servicing operations.
Before approval is given by local health authorities, the premises where food will
be prepared and served should conform to the following standards (Section 17):
1. The place should be at least 23 meters away from possible sources of
contamination.
2. There should be no direct connection with a sleeping apartment or toilet.
3. No animals should be kept in the premises.
4. The building should be constructed to conform to the requirements of the
local health authority.
5. It should be well maintained and should offer no entrance for rats and mice.
6. The floors, walls, ceiling requirements should be so constructed as to
facilitate cleaning and maintaining sanitation.
7. Lighting should be free from glare; if glass is used it should be so distributed
as to avoid the shadow and permit effective inspection and cleaning.
8. Sufficient ventilation should be provided to maintain comfortable conditions.
9. Locker rooms with toilets and facilities for washing hands and availability of
hot and cold rinsing water, disposal of garbage, and vermin control are also
specified in the code.

A checklist is used by sanitary inspectors during their regular visits to guide them
in determining if the establishment has complied with all provisions.

Personal Sanitation Checklist

In the food service operation, personal sanitation guidelines for employees

should be strictly followed. This includes good health and grooming habits. Section 15
and 19 of the Sanitation Code stipulates that no person shall be employed in any food
establishment without a health certificate issued by the local health authority.
The DOH’s Dietary Service Management Manual also provides some checklists on
personal sanitation.