OBM752 - HOSPITAL MANAGEMENT

UNIT IV - SUPPORTIVE SERVICES

Medical Records Department - Central Sterilization and
Supply Department - Pharmacy - Food Services - Laundry
Services.
 Hospital Services

The hospitals also provide services related to research, development and training of
healthcare professionals. According to the service type they provide, the hospitals can be
divided into three groups : general hospitals, specialized branch hospitals and training
hospitals. General hospitals provide interventions for all cases of emergency, employ
specialist medical staff and conduct surgical operations when necessary. Specialized
hospitals like chest and cardiovascular diseases hospital and kidney hospitals focus on
specific diseases, certain age groups or organs and organ transplantation. Training and
research hospitals like medical faculty hospitals are hospitals that have inpatient bed
capacity, provide emergency services and surgical operations when necessary in addition to
their duties related to the medical training and research.
The aspects of hospital services include three main services such as
1) Line Services
2) Supportive Services //Staff services
3) Auxiliary Services
1) Line services
Line service in the hospital is the care which is directly related to the patient treatment.
Line Services include
Emergency services
Out-Patient services
In-patient services (Wards)
Intensive Care Unit (ICU)
Operation Theatre (OT)
2) Support services
Support services are the services which are not directly related to patient care but,
indirectly contribute in patient management. Support services include.
Central Sterile Supply Department (CSSD)
Diet Management
Pharmacy Services
Laundry
Laboratory
Radiology
Nursing Services

Medical Records Department

The Medical Records department maintains records and document relating to patient care.
• The importance of the Medical Records department was always these, but now it has
become a more important department because of increasing
 Medico legal cases such as assaults, attempted suicides, deaths from criminal acts,
 industrial
accidents, poisoning, and road accidents
 Consumer cases

 Teaching in hospitals to postgraduate students

 Research work

• The main functions are filing, indexing and retrieving medical records by
 Developing a procedure for the proper flow or records
 Developing a statistical reporting systems that includes ward census, daily census,
out- patient census, etc.
 Preparing births, deaths and communicable diseases reports which are mandatory
 Preparing statistical reports in relation to admission, discharge, coding all diagnosis
and operations according to the international classification of diseases.

• The primary purpose of establishing a Medical Records department is

 To render service to patients, staff and hospital administration by keeping every thing
handy pertaining to patients, their sex, religion, age, area where they belong to,
disease, operation, whether discharged after satisfactory recovery or left against
medical advice or died.
 Used as primary tools to evaluate the quality of patient care rendered by the medical
staff.
 Widely used for teaching and research purposes.
 Inthe context of increasing medico legal cases and consumer cases against hospitals
and
treating doctors, well documented medical records are a good legal protection.
 In such circumstances, every hospital should formulate policies, rules and regulations
for the completion and maintenance of medical records.

The primary responsibility of each and every treating doctor to review,

• Correct and countersign records that are written by resident doctors working under
him.
• Each entry in the medical records must be signed by the person making the entry
and his/her signature must be identifiable so that responsibility for authenticity can be
fixed.
• The language used in preparing medical record should be clear, concise,
conspicuous and should not lend itself to misinterpretation.
• Abbreviations and symbols used should be of acceptable standard.
 Roles and responsibility
• The Medical Records department is generally headed by a Medical Records officer.
• He should be a graduate with a diploma or degree in Medical Record Technology.
• Should have 10-15 years experience to his credit as it is a post of responsibility where
he is required to maintain confidentiality and at the same time, to discharge
mandatory responsibility by notifying deaths, births, number of communicable cases
reported in the hospital, etc.
• Reports to the Medical Superintendent and convenes the meeting of the Tissue
Committee monthly.

Location and Service

 Locate the Medical Records department near the Admission Office, Out-Patient
department, and
emergency room.
 It should also be close to the Senior and Junior doctors' coffee room so that the medical
staff may conveniently drop in and complete the charts of the discharged patients.
 In order to provide a fast Medical Record service to all concerned and to foster a close
working
relationship and good communication among the related departments.
 The location of the Medical Records department becomes more important in small hospitals
where this department is closed at night and the emergency department may need the
previous record of the patient who has been brought in emergency and the Casualty
Medical Officer may prefer to
review the record of his last admission.
 Itis a matter of policy of a hospital to keep the emergency record of a patient in the
emergency department, outdoor patients' records in the OPD and indoor patients
records in the Medical Records department.
 But it has been experienced that most of the hospitals retain only emergency record

of the patients and indoor record of the patients in the Medical Records department.
 In those hospitals where OPD records of the patients is not retained in the OPD, it
becomes very difficult to defend a complaint filed by a patient in the consumer court.

Space Requirements

• The Medical Records department requires lots of space as it is required to keep record of
all inpatients, deaths, births, medico legal cases, etc.
• As per the notification issued by the government from time to time and it requires
• Reception area
• Work area for record processing, assembling, numbering, indexing, correspondence, etc.,
• Record storage area
• Area for completion of medical record by the medical staff
• Area for the medical records staff
• sPhotocopier is provided to the Medical Records department, it also requires some area for
keeping the photo copying machine

MRD (medical record department):

The Medical Records Department is responsible for maintaining medical records in a
standardized and professional manner in order to protect patient confidentiality while
allowing adequate access to providers in order to promote quality patient care.

Duties of MRD:

 Transcription, diagnosis coding, and release of information are some of the

 other major duties performed in the Medical Records Department.
 Also information is gathered and sent to state agencies concerning
 Traumas, Births, and Deaths.

Purpose of MRD:

The information contained in the medical record allows health care providers to determine
the patient's medical history and provide informed care.
 The medical record serves as the central repository for planning patient care and
documenting communication among patient and health care provider and
professionals contributing to the patient's care.
 An increasing purpose of the medical record is to ensure documentation of
compliance with institutional, professional or governmental regulation. The traditional
medical record for inpatient care can include
 Admission notes, b. on-service notes, c. progress notes (SOAP notes), d. preoperative
notes, e. operative notes, f. postoperative notes, g. Notes. Delivery notes, postpartum
notes, and discharge notes.

SOAP notes:

 The SOAP note (an acronym for subjective, objective, assessment, and plan) is a
method of documentation employed by health care providers to write out notes in a
patient's chart, along with other common formats, such as the admission note.
 Documenting patient encounters in the medical record is an integral part of practice
workflow starting with patient appointment scheduling, to writing out notes, to
medical billing.
Components of SOAP:

A. Subjective component

 Initially is the patient's Chief Complaint, or CC.

 This is a very brief statement of the patient (quoted) as to the purpose of the office
visit or hospitalization.
 If this is the first time a physician is seeing a patient, the physician will take a History
of Present Illness, or HPI. This describes the patient's current condition in narrative
form.
 It will include all pertinent and negative symptoms under review of body systems.
Pertinent medical history, surgical history, family history, and social history, along
with current medications, smoking status, drug/alcohol/caffeine use, level of physical
activity and allergies, are also recorded.

B. Objective component:

 The objective section of the SOAP includes information that the healthcare provider
observes or measures from the patient's current presentation.
 The objective component includes:
 Vital signs and measurements, such as weight.
 Findings from physical examinations, including basic systems of cardiac and
respiratory, the affected systems, possible involvement of other systems, pertinent
normal findings and abnormalities.
 Results from laboratory and other diagnostic tests already completed.
 Medication list obtained from pharmacy or medical records.

C.Assessment:

 A medical diagnosis for the purpose of the medical visit on the given date of the note
written is a quick summary of the patient with main symptoms /diagnosis including a
differential diagnosis, a list of other possible diagnoses usually in order of most likely
to least likely.
 This will include risk factors, assessments of the need for therapy, current therapy,
and therapy options.

D. Plan:

 The plan is what the health care provider will do to treat the patient's concerns - such
as ordering further labs, radiological work up, referrals given, procedures performed,
medications given and education provided.
 The plan will also include goals of therapy and patient-specific drug and disease-state
monitoring parameters. This should address each item of the differential diagnosis.
  For patients who have multiple health problems that are addressed in the SOAP note,
a plan is developed for each problem and is numbered accordingly based on severity
and urgency for therapy.

EMR (electronic medical / health record):

 An electronic health record (EHR), or electronic medical record (EMR), refers to the
systematized collection of patient and population electronically-stored health
information in a digital format.
 These records can be shared across different health care settings.
 Records are shared through network-connected, enterprise-wide information systems
or other information networks and exchanges.
 EHRs may include a range of data, including demographics, medical history,
medication and allergies, immunization status, laboratory test results, radiology
images, vital signs, personal statistics like age and weight, and billing information.
Comparison with paper-based records:
 Handwritten paper medical records may be poorly legible, which can contribute to
medical errors.
 Pre-printed forms, standardization of abbreviations and standards for penmanship
were encouraged to improve reliability of paper medical records.
 Electronic records may help with the standardization of forms, terminology and data
input. Digitization of forms facilitates the collection of data for epidemiology and
clinical studies.
 In ambulances:
 Ambulance services in Australia have introduced the use of EMR systems.
 The benefits of EMR in ambulances include the following: better training for
paramedics, review of clinical standards, better research options for pre- hospital care
and design of future treatment options.
 The advent of electronic medical records has not only changed the format of medical
records but has increased accessibility of files.
 The use of an individual dossier style medical record, where records are kept on each
patient by name and illness. Factors must in medical records:
 The listed data must be in medical records either in digital or manual format, but
digital format is more preferable than the manual format, because of poor quality in
manual written formats.

Medical history:

 The medical history is a longitudinal record of what has happened to the patient since
birth. It chronicles diseases, major and minor illnesses, as well as growth landmarks.
 It gives the clinician a feel for what has happened before to the patient. As a result, it
may often give clues to current disease states. It includes several subsets detailed
below.
Surgical history:

The surgical history is a chronicle of surgery performed for the patient. It may have dates of
operations, operative reports, and/or the detailed narrative of what the surgeon did.

Obstetric history:

The obstetric history lists prior pregnancies and their outcomes. It also includes any
complications of these pregnancies.

Medications and medical allergies:

The medical record may contain a summary of the patient's current and previous medications
as well as any medical allergies.

Family history:

The family history lists the health status of immediate family members as well as their causes
of death (if known).It may also list diseases common in the family or found only in one sex
or the other. It may also include a pedigree chart. It is a valuable asset in predicting some
outcomes for the patient.

Social history:

 The social history is a chronicle of human interactions. It tells of the relationships of

the patient, his/her careers and trainings, and religious training.
 It is helpful for the physician to know what sorts of community support the patient
might expect during a major illness.
 It may explain the behaviour of the patient in relation to illness or loss. It may also
give clues as to the cause of an illness (e.g. occupational exposure to asbestos).

Levels of Medical Care

It is customary to describe healthcare service at 4 levels, viz., primary, secondary, tertiary and
quaternary care levels. These levels represent different types of care involving varying degree
of complexity.

1. Primary Care Level :

Primary care providers may be doctors, nurses or physician assistants. Primary healthcare is
the first level of contact with individuals, the family and community, where “primary health
care” (essential healthcare) is provided.
Sector : Healthcare
2. Secondary Care Level :

The next higher level of care is the secondary (intermediate) healthcare level. At thislevel
more complex problems are dealt with. In India, this kind of care is generally provided in
district hospitals and community healthcare centres which also serve as the first referral level.
Secondary care simply means you will be taken care of by someone who has more specific
expertise. Specialists focus either on a specific body system or on a specific disease or
condition. For example, if there is problem with heart and its pumping system, then the client
need to consult a Cardiologist.

3. Tertiary Care level :

The tertiary level is a more specialized level than secondary care level and requires specific
facilities and attention of highly specialized health workers. This care is provided by the
regional or central level institutions. For example, highly specialized equipment and
expertise is required for coronary artery bypass surgery.

4. Quaternary Care :

Quaternary care is an extension of tertiary care and is more specialized and highly unusual,
therefore every hospital or medical center cannot offer quaternary care. It includes
experimental medicine and procedures.

Central Sterilization and Supply Department

The method basically involves cleaning, disinfecting and sterilizing before use all
instruments, materials, etc. utilized in patient care.
• From different departments of the hospital like
• OPD clinics
• Treatment rooms
• Casualty
• Wards
• Labour room
• Operation theatre and other departments
• All soiled items are collected in the central sterilization and supply department for packing,
sterilizing and finally, transporting back to the user departments.
• The central sterilization and supply department plays a crucial role in the functioning of a
hospital.
• It not only reduces infection but also prevents it to a great extent.

• The infection rate is higher in India than in the advanced countries like, the UK,
 the USA, Australia, and Canada.
• Because the equipment used in the central sterilization and supply
department in India is not of very high quality.
• The personnel working in the department also do not take the work of
sterilizing the
equipment seriously.
• The method basically involves
• Cleaning
• Disinfecting
• sterilizing before use all instruments, materials, etc
• From different departments of the hospital like OPD clinics, treatment rooms, casualty,
wards, labour room, operation theatre and other departments, all soiled items are
collected in the central sterilization and supply department for packing, sterilizing and
finally, transporting back to the
user departments.
• Indian hospitals, the central sterilization and supply department is a part of the Nursing
Service department.
• The CSSD in-charge is directly responsible to the Nursing Superintendent because this
department mostly serves nursing units, operation theatre, ICU, PICU, labour room,
radiology, pharmacy and laboratory of the hospital.
• The primary activities of the department are
• Sterilizing
• Storing and distributing the dressings
• Instrument packs
• Gloves
• Catheters
• Sterile linen packs
Treatment trays, etc.
•

Main objectives
• To prevent infection by sterilizing equipment and materials
• To sterilize equipment and materials so that reuse of these items can be possible
• To achieve higher efficiency in the areas where sterilized equipment and materials are
used
• To reduce the length of stay of patients by providing proper sterilized equipment and
materials
• To reduce the cost of maintenance of the hospital by sterilizing the equipment and
materials
Functions
• Receiving the used equipment and materials
• Sorting out the equipment and materials
• Deciding whether any of the equipment and materials are required to be discarded
• To disinfect prior to sterilization
• Assembling equipment sets, linen packs and treatment trays
• Packing equipment sets, linen packs and treatment trays
• Sterilizing
• Labelling and dating
• Storing equipment packs, linen packs and treatment trays
• Issuing
Locations
• Soiled area
 Used equipment, linen and treatment trays are brought to the soiled area in the
central sterilization and supply department.
 Here the used equipments, linen and treatment trays are washed either in steam or
hot water.
 All these things are sorted, inspected and packed, after packing, they are kept in the
autoclave for sterilization.
• Clean area
 The storage area should not be damp and at the same time, it should be dust free
so that the sterilized materials do not get disinfected.
• Sterile area
 The sterilization room is located next to the operating rooms so that sterile packs
can be carried easily.
 The advantage of this system is that there is direct communication between the
CSSD staff and the OT staff.
 Secondly, the transportation of linen and OT equipment from the operation theatre
to the central sterilization and supply department
is eliminated.
Functions of Central Sterile Services Department (CSSD)
Sterile Processing Departments are typically divided into four major areas to
accomplish the functions of decontamination, assembly and sterile processing, sterile storage,
and distribution.
 In the decontamination area, reusable equipment, instruments, and supplies are
cleaned and decontaminated by means of manual or mechanical cleaning processes
and chemical disinfection.
  Clean items are received in the assembly and packaging area from the
decontamination area and are then assembled and prepared for issue, storage, or
further processing (like sterilization).
 After assembly or sterilization, items are transferred to the sterile storage area until its
time for them to be issued.
 Several major functions are carried out in the distribution area: case cart preparation
and delivery; exchange cart inventory, replenishment and delivery; telephone-order
and requisition-order filling; and, sometimes, patient care equipment delivery.

i) Decontamination Process

Decontamination is the physical or chemical process that renders an inanimate object that
may be contaminated with harmful microbial life safe for further handling. The objective of
decontamination is to protect the preparation and package workers who come in contact with
medical devices after the decontamination process from contracting diseases caused by
microorganisms on those devices.

Steps in the Decontamination Process

1. Transport – Used supplies and equipment should be collected and taken to the
Decontamination Area in the Sterile Processing Department in a way that avoids
contamination of personnel or any area of the hospital. Equipment should be covered and
supplies should be moved in covered carts, closed totes or containers, or closed plastic bags.

2. Attire – Personnel working in the decontamination area should wear protective clothing,
which includes a scrub uniform covered by a moisture-resistant barrier, shoe covers, rubber
or plastic gloves, and a hair covering. During manual cleaning processes, when splashing can
occur, safety goggles and a face mask should be worn.

3. Sorting – Sorting begins at the point of use. Handling of contaminated items should be
minimized unless the user of the device is already wearing full personal protective attire, such
as following care in the operating room. In areas where workers are wearing no or minimal
protective attire, sorting should consist only of removing disposable sharps and discarding
other single-use items.

4. Soaking – This is necessary only if you have lumens or other complex designs that are
filled with debris or if the devices are very bloody and cannot be rinsed or wiped at the point
of use.

5. Washing

Detergent – Should be compatible with the materials in the device and suited for the type of
soil. Consult the recommendations from the device manufacturer.
Equipment – Many types of cleaning equipment are available, the most commonly used are :

Washer/decontaminator – The washer/decontaminator is used to clean heat-tolerant items.

The cycle consists of several washes and rinses, followed by a steam sterilization cycle
appropriate for the types of items contained in the load. Although subjected to a cycle
designed to sterilize clean items, items processed in a washer/decontaminator should not be
assumed to be sterile at
the end of the process. The reason for this is that items enter the washer/decontaminator with
an unknown, but probably very high, level of microbial contamination, which the sterilization
cycle may not be able to completely destroy.

Ultrasonic – The ultrasonic washer is used to remove fine soil from surgical instruments
after manual cleaning and before sterilization. The equipment works by converting high-
frequency sound waves into mechanical vibrations that free soil from the surface of
instruments. The high-frequency energy causes microscopic bubbles to form on the surface of
the instruments and as the bubbles implode, minute vacuum areas are created, drawing out
the tiniest particles of debris from the crevices of the instruments. This process is called
cavitation.

Inspection – After cleaning, all instruments should undergo inspection before being
packaged for reuse or storage. Box locks, serrations, and crevices should be critically
inspected for cleanliness. Instruments with cutting edges such as scissors, rongeurs, chisels,
curettes, etc., should be checked for sharpness. There should be no dull spots, chips, or dents.
Hinged instruments such as clamps and forceps should be checked for stiffness and alignment
of jaws and teeth.Tips should be properly aligned, jaws should meet perfectly, and joints
should
move easily. Ratchets should close easily and hold firmly. Any instruments with pins or
screws should be inspected to make sure they are intact. Plated instruments should be
checked to make sure there are no chips, worn spots, or sharp edges. Worn spots can rust
during autoclaving. Chipped plating can harbor soil and damage tissue and rubber gloves. If
any problems are noticed during the inspection process, these instruments should be either
cleaned again, or sent for repair depending on the problem observed.

ii) Assembly & Packaging Process

After the instruments have been cleaned and inspected, they are typically assembled into sets
or trays according to recipe cards that detail instructions for assembling each set or tray.
Instruments and other items that are prepared for sterilization must be packaged so that their
sterility can be maintained to the point of use. The materials and techniques used for
packaging must allow the sterilant to contact the device during the sterilization process as
well as to protect the device from contamination during storage and handling before it is
used. The time between sterilization and use may range from a few minutes to several weeks
to many months. The packaging material selected must also permit the device to be removed
aseptically.
Types of Packaging
 Textiles
 Nonwovens
 Pouch packaging
 Rigid container systems

iii) Sterilization Process

Bacterial spores are the most resistant of all living organisms because of their capacity to
withstand external destructive agents. Although the physical or chemical process by which all
pathogenic and nonpathogenic microorganisms, including spores, are destroyed is not
absolute, supplies and equipment are considered sterile when necessary conditions have been
met during a sterilization process.

Methods

Reliable sterilization depends on contact of the sterilizing agent with all surfaces of the item
to be sterilized. Selection of the agent to achieve sterility depends primarily upon the nature
of the item to be sterilized. Time required to kill spores in the equipment available for the
process then becomes critical.

Steam

Heat destroys microorganisms, but this process is hastened by the addition of moisture.
Steam in itself is inadequate for sterilization. Pressure, greater than atmospheric, is necessary
to increase the temperature of steam for thermal destruction of microbial life. Death by moist
heat in the form of steam under pressure is caused by the denaturation and coagulation of
protein or the enzyme-protein system within the cells. These reactions are catalyzed by the
presence of water. Steam is water vapor; it is saturated when it contains a maximum amount
of water vapor. Direct saturated steam contact is the basis of the steam process. Steam, for a
specified time at required temperature, must penetrate every fiber and reach every surface of
items to be sterilized. When steam enters the sterilizer chamber under pressure, it condenses
upon contact with cold items. This condensation liberates heat, simultaneously heating and
wetting all items in the load, thereby providing the two requisites: moisture and heat. Non
living thing can survive direct exposure to saturated steam at 250 F (120 C) longer than 15
minutes. And 134c longer than 4 to 7 mint as temperature is increased, time may be
decreased. A minimum temperature-time relationship must be maintained throughout all
portions of load to accomplish effective sterilization. Exposure time depends upon size and
contents of load, and temperature within the sterilizer. At the end of the cycle, re-evaporation
of water condensate must effectively dry contents of the load to maintain sterility.
Ethylene Oxide

Ethylene oxide is used to sterilize items that are heat or moisture sensitive. Ethylene
oxide (EO) is a chemical agent that kills microorganisms, including spores, by interfering
with the normal metabolism of protein and reproductive, processes, (alkylation) resulting in
death of cells. Used in the gaseous state, EO gas must have direct contact with
microorganisms on or in items to be sterilized. Because EO is highly flammable and
explosive in air, it must be used in an explosion-proof sterilizing chamber in a controlled
environment. When handled properly, EO is a reliable and safe agent for sterilization, but
toxic emissions and residues of EO present hazards to personnel and patients. Also, it takes
longer than steam sterilization, typically, 16-18 hrs. for a complete cycle.
EO gas sterilization is dependent upon four parameters : EO gas concentration,
temperature, humidity, and exposure time. Each parameter may be varied. Consequently, EO
sterilization is a complex multi-parameter process. Each parameter affects the other
dependent parameters.

Others

Dry heat : Dry heat in the form of hot air is used primarily to sterilize anhydrous
oils,petroleum products, and bulk powders that steam and ethylene oxide gas cannotpenetrate.
Death of microbial life by dry heat is a physical oxidation or slow burning process of
coagulating the protein in cells. In the absence of moisture, higher temperatures are required
than when moisture is present because microorganisms are destroyed through a very slow
process of heat absorption by conduction.

Quality Assurance

To ensure that instruments and supplies are sterile when used, monitoring of the sterilization
process is essential.

iv) Administrative Monitoring

Work practices must be supervised. Written policies and procedures must be strictly followed
by all personnel responsible and accountable for sterilizing and disinfecting items, and for
handling sterile supplies. If sterility cannot be achieved or maintained, the system has failed.
Policies and procedures pertain to:

Decontaminating, terminally sterilizing, and cleaning all reusable items; disposing

of disposable items.
 Packaging and labeling of items.
 Loading and unloading the sterilizer.
 Operating the sterilizer.
 Monitoring and maintaining records of each cycle.
  Adhering to safety precautions and preventive maintenance protocol.
 Storing of sterile items.
 Handling sterile items ready for use.
 Making sterile transfer to a sterile field.

Mechanical Indicators

Sterilizers have gauges, thermometers, timers, recorders, and/or other devices that monitor
their functions. Most sterilizers have automatic controls and locking devices. Some have
alarm systems that are activated if the sterilizer fails to operate correctly. Records are
maintained and review for each cycle. Test packs (Bowie-Dick test) are run at least daily to
monitor functions of each sterilizer, as appropriate. These can identify process errors in
packing or loading.

Chemical Indicators

A chemical indicator on a package verifies exposure to a sterilization process. An indicator

should be clearly visible on the outside of every on-site sterilized package. This helps
differentiate sterilized from unsterilized items. More importantly, it helps monitor physical
conditions within the sterilizer to alert personnel if the process has been inadequate. An
indicator may be placed inside a package in a position most likely to be difficult for the
sterility to penetrate. A chemical indicator can detect sterilizer malfunction or human error in
packaging or loading the sterilizer. If a chemical reactionon the indicator does not show
expected results, the item should not be used. Severaltypes of chemical indicators are
available :
Tape, labels, and paper strips printed with an ink that changes color when exposed to one or
more process parameters.
Glass tube with pellets that melts when a specific temperature is attained in sterilizer.
Integrating or wicking paper with an ink or chemical tablet at one end that melts and wicks
along paper over time under desired process parameters. The color bar reaches the “accept”
area if parameters are met.

Biological Indicators

Positive assurance that sterilization conditions have been achieved can be obtained
only through a biologic control test. The biologic indicator detects no sterilizing conditions in
the sterilizer. A biologic indicator is a preparation of living spores resistant to the sterilizing
agent. These may be supplied in a self-contained system, in dry spore strips or discs in
envelopes, or sealed vials or ampoules of spores to be sterilized and a control that is not
sterilized. Some incorporate a chemical indicator also. The sterilized units and the control are
incubated for 24 hours for Bacillus stear other mophil is at 131 to 141°F (55 to 66°C) to test
steam under pressure, for 48 hours for Bacillus subtilis at 95 to 98.6°F (35 to 37°C) to test
ethylene oxide.
 A biologic indicator must conform to USP testing standards. A control test must be
performed at least weekly in each sterilizer. Many hospitals monitor on a daily basis; thers
test each cycle. Very load of implantable devices must be monitored and the implant should
not be used until negative test results are known. Biological indicators also are used as a
challenge test before introducing new products or packaging materials, after major repairs on
the sterilizer, or after a sterilization failure. All test results are filled as a permanent record for
each sterilizer.

Example : Hydrogen peroxide plasma sterilizer

Hydrogen peroxide is activated to create a reactive plasma or vapor. Plasma is a state of
matter distinguishable from solid, liquid, or gas. It can be produced through the action of
either a strong electric or magnetic field, somewhat like a neon light. The cloud of plasma
created consists of ions, electrons, and neutral atomic particles that produce a visible glow.
Free radicals of the hydrogen peroxide in the cloud interact with the cell membranes,
enzymes, or nucleic acids to disrupt life functions of microorganisms. The plasma and vapor
phases of hydrogen peroxide are highly spermicidal even at low concentrations and
temperature

Pharmacy

• Pharmacy is a specialized area and it is one of the most extensively used therapeutic
facilities of the hospital, from where fairly high revenue can be generated to meet its
expenditure.
• Each and every hospital administrator is required to plan, organize, staff, control and
evaluate the pharmacy department scientifically and professionally by employing
qualified and experienced pharmacists.
• To run the pharmacy of a hospital, the head of the hospital requires qualified
pharmacists, sound
organization structure, cooperation of the medical and nursing staff of the hospital.
• He should also keep in mind the modem trend, automation, prepacking, drug
distribution, etc.
• Hospitals based in the metropolitan cities are using computer based ordering system,
computerized pricing, billing, cash collection, stock position, etc.

• Working Time
Functions from 7 am to 7 pm without any break round the year
In large size hospitals, pharmacies functions round the clock throughout the year
• Should properly plan, organize staff and control the pharmacy department of the
hospital to avoid
drug theft.
 The chief pharmacist is also responsible for
• Discarding expired medicines
• Issuing guidelines
• Ensuring labeling of medicine containers
• Recommending drugs to be stocked in the nursing stations
• Checking registration of the pharmacists working
• Developing a formulary
• Indenting medicines
• Receiving supplies
• Stocking medicines
• Dispensing

• All purchases are done as per the formulary prepared by the therapeutic committee of
the hospitals, which makes the job of the chief pharmacist easy and he is not blamed
for not keeping all brands of medicines.
• Each hospital should design its own pharmacy and follow norms and legal

requirements of keeping narcotics and preparing I.V.(Intravenous) solutions.

• Mostly pharmacies keep the essential list of drugs, have their own formulary, set up
policies and procedures, and purchase, receive, store and dispense drugs to outdoor
and indoor patients.
• And their chief pharmacist acts as a PRO of the hospital and meets medical

representatives and the government officials such as drug inspectors.

• The number of pharmacists to be employed in a hospital depends upon the policy of

the hospital.
• It has been observed that one pharmacist can dispense medicines to 150 patients per
day.
• One pharmacist can dispose of one prescription of a patient, whether an out- or an in-
patient in approximately 2 minutes.
• One pharmacist who works 8 hours a day can take care of 100 out-patients as well as
50 in- patients.
• Every two pharmacists, one pharmacy aid will have to be provided to assist them.
• If the number of pharmacists in a hospital exceeds 7, the Chief Pharmacist should
employ one senior pharmacist to assist him in supervision so that the efficiency of the
department may be maintained.

Role of Clinical Pharmacist

1. Medicine Assessment
 • Patients’ medicines requirements are regularly assessed and responded to, in order to
keep them safe and optimise their outcomes from medicines. On admission or at first
contact patients’ medicines are reviewed to ensure an accurate medication history, for
clinical appropriateness and to identify patients in need of further
• pharmacy support. The pharmacy team provides the leadership, systems support and
expertise that
• enables a multidisciplinary team to :
• Reconcile patients’ medicines as soon as possible, ideally within 24 hours of
• hospital admission to avoid unintentional changes to medication.
• Effectively document patients’ medication histories as part of the admission process.
• Give patients access to the medicines that they need from the time that their next dose
is needed.
• Identify patients in need of pharmacy support and pharmaceutical care planning.
• Identify potential medicines problems affecting discharge (or transfer to another care
setting) so that they can be accommodated to avoid extending patients’ stays in
hospital.
•
2. Care as an inpatient

• Patients have their medicines reviewed by a clinical pharmacist to ensure that their
medicines are clinically appropriate, and to optimise their outcomes from their
medicines.
• a. Pharmacists regularly clinically review patients and their prescriptions to optimize
outcomes from medicines (timing and level of reviews adjusted according to patient
need and should include newly prescribed medicines out of hours) and take steps to
minimise omitted and delayed medicine doses in hospitals.
• b. Patients targeted for clinical pharmacy support have their medicines’ needs assessed
and documented in a care plan that forms part of the patient record.
• c. Pharmacists attend relevant multidisciplinary ward rounds, case reviews and/or
clinics.
• d. Patients, medical and nursing teams have access to pharmacy expertise when
needed.
• e. The pharmacy team provides the leadership, systems support and expertise that
enables patients to :
• Bring their own medicines into hospital with them and self-administer one or more
• of these wherever possible.
• Have their own medicines returned at discharge where appropriate.

3. Monitoring patients’ outcomes

• Patients’ outcomes from, and experiences of, treatment with medicines are
documented, monitored and reviewed.
• As part of a multidisciplinary team, pharmacy team members monitor:
• Patients’ responses to their medicines
 • Unwanted effects of medicines.
• b. Appropriate action is taken where problems (potential and actual) are
identified.
• c. The pharmacy team provides the leadership, systems support and expertise
that enables healthcare professionals to:
• Help patients to avoid adverse events resulting from their medicines
• Document, report and manage any adverse events that do arise.

4. Continuity of care for patients not admitted

• Patients who are taking medicines at home or in non-acute care settings have access
tocontinuing supplies of medicines and to pharmacy services and support appropriate
to their care.
• a. Systems are in place to ensure patients whose care does not involve admission can
access medicines when they need them.
• b. Patients (and/or their healthcare professionals) have access to the pharmacy
expertise that they need to optimize their medicines.

Responsibility of Pharmacist in Hospital Pharmacy

1. Drug Distribution Standard

2. Interpretation
3. Procurement of Drugs
4. Receiving/Storage of Drugs
5. Inventory Control
6. Medication Profiles
7. Unit-Dose Medication System
8. Individual Patient Prescription
9. Controlled Dosage System Medications
10. Delivery Medication
11. Returned Medications
12. Ward Stock Medications
13. Investigational Drugs
14. Administration of Medication
15. Patient's Own Medication
16. Alcoholic Substances

Food Services

• It is desirable to locate the food service department on the ground floor of the
hospital as this department in the basement is likely to be dingy, dark and poorly
ventilated.
• Secondly locating the Food Service department will not violate the Municipal by-laws
also.
• The employees' cafeteria is concerned, it is generally close to the Food Service
department.
• The patient's meals are carried by the diet aides in the electrically heated food
service trolleys to
the wards and served to them on their bed side only.
• While designing the food service department, it should be kept in mind that receiving
supplies, storing, preparing, serving and washing areas, Food service manager's and
Dietician's offices should be as close as possible so that scientific management and
logical flow can be ensured.

• The food-service department of any hospital caters meals to the patients and plays a
significant role.
• Meals prepared hygienically under the guidance of qualified dieticians, according to
the
instructions of the doctors and attractively served to the patients help in their speedy
recovery.
• Today the food-service department ranks as one of the major departments of a
modern hospital.
• It is responsible for planning, organizing and directing all phases of the dietetic
operations which include
• Visiting patient
• Consulting their charts
• Menu planning
• Food preparation
• Serving
• Budgeting
• Record keeping
• Performance appraisal of its personnel
• Safety
• Sanitation & etc.,
• Once in a while, the dietician should also be present while supplies are being received
by the storekeeper.
• The receiving area should be equipped with weighing scales so that the storekeeper
and the dietician can check supplies according to the specifications.
• Once the supplies are received, they are stored in dry and refrigerated areas. For non-
perishable items like tea, sugar, spices, etc. wooden/teel racks are used and for
perishable items like meat, eggs, vegetables, foods, etc. refrigerators with varying
degrees of temperature are used.
• The storage area which is meant for perishable(fresh) and non-perishable items should
be close to the receiving area. Special attention should be given to the size of the
kitchen of the Food Service department.
• Some hospitals serve only vegetarian food while others non-vegetarian food also. In
 some hospitals, the employee's food is also prepared in the same kitchen. Though the
chief cook is responsible for cooking the dietician has the overall responsibility for in-
patient food.
• Food prepared for the employees is sent to the hospital cafeteria and the food prepared
for the in-patient is sent to the serving room where patient food trays are assembled
according to the menu of each and every patient separately by the diet aides under the
supervision of the dietician.
• After the trays are assembled, they are loaded on food trolleys and sent to patient
floors. These food trolleys have in-built electrical heating arrangement so that the food
remains hot.
Food Service department types
1. Supply receiving area
2. Dry storage area
3. Refrigerated storage area
4. Cooking area:
• for vegetarian cooking
• for non-vegetarian cooking
• for western cooking
• for special diet cooking
5. For employees cooking
6. Patients serving rooms where patients food trays are assembled
7. Food service manager office
8. Dietician office
9. Dishwashing area
10. Peeling of vegetables area
11. Visitors' canteen
12. Pot washing area.
• The hospitals employ qualified Food Service managers with a diploma or degree in hotel
and catering management and a dietician with a degree in Dietetics after B.Sc. in Home
Science or M.Sc. in Nutrition Science.
• Some hospitals engage the workers of the Food Service department through the contractor.
It depends upon the policy of the management, but the Food Service manager and the
Dietician are the employees of the hospital.
• One dietary staff member (excluding supervisory staff) is required for approximately 15 to
20 patients.
• In the food-service department of a hospital, the dietician, food storekeeper, cook, cook
helpers, bearer and dish washer work in close co-ordination.
• One dietician can look after up to 200 beds. If the bed strength exceeds 200 beds, another
dietician should be appointed.
• One cook, one cook helper, one bearer and one dishwasher are sufficient to prepare and
 serve meals for 20 patients/staff members.
• A thirty per cent leave reserve should be appointed, because the food service
department functions round the
year.

Food Chain

The nutritional status of the patient depends on a chain of interacting links. A failure in any one of these

links leads to failure of the whole chain.

The length of time a patient spends in hospital and the cost of that stay is linked to the patient’s nutritional
status.1 Under-nutrition in sick patients is associated with :
Impairment of every system in the body: muscle weakness, particularly in respiratory
muscles; reduction of the ability of the immune system to function; and alterations in the
structure and function of the gut.
Delayed wound healing.
Apathy and depression.
Reduction of appetite and the ability to eat.
Higher rates of mortality.

Obstacle to Avoid in Food Service

Several actions must take place to ensure a patient has adequate food intake while in
hospital. These include :
Screening the patient for nutritional risk.
Monitoring dietary intake.
Modifying the hospital menu according to patient preferences.
Ensuring that the service and ambience of mealtimes are focused on the patient
with reduced appetite
Proper food preparation and distribution.
 Laundry Services

Laundry and linen services play a major role in hospital functioning. A great deal of space
and money is allocated to this department, which is a major consideration in planning,
designing and constructing a hospital.
• The laundry should be located on the ground floor in the open area so that the washed
linen can be dried in the sun as the sun is a very good disinfectant.
• The laundry should also be close to the linen department as well as elevators.
• Some hospitals have chutes through which the dirty linen is dropped on the ground floor
from where the laundry personnel pick up and take to the laundry for washing, drying and
ironing.
Standards adopted United States of America, United Kingdom and India
• American standard
• An average of 15 pounds per bed per day plus 25 pounds for each
operation/delivery.
• British standard
• 60 articles per bed per week at 0.40 kilogram per article.
• Indian standard
• 3-5 kilogram per bed per day.
Space required in a hospital laundry
To open the bundles of the linen
• For sorting linen
• Sluicing and disinfecting area
• Clean linen processing area
• Drying area
• Folding area
• Pressing area
• Material storage area
• Clean linen storage area
• Laundry supervisor's office
• Laundry personnel's rest room
• Toilets
• Water softening plant area, if required
• Cart storage area
• Solution preparation and storage room
• Boiler area

Manpower
• One laundry operator can wash the linen of 25 to 30 beds and one laundry orderly can
assist in washing the linen of 50 to 60 beds.
• Thirty per cent of laundry operators and laundry orderlies should be kept as the
leave reserve.
• The appointment of laundry supervisor, mechanic and clerk, and the number employed
depend upon the size of the hospital.

Equipment required in a hospital laundry

 Washing machines
 Hydro extractors
 Iron for pressing clothes
 Dryers if open space is not available
 Dry linen trolleys
 Wet linen trolleys
 Sewing machines
 Weighing machines
 Boiler
An efficient and effective Linen and Laundry services can enhance patient experience
and reduce the risk of cross contamination. Laundry and its products should preserve
the patients’ dignity, promote the patient care and be appropriate to patient group,
gender, clinical status, religion and beliefs.
 1. The laundry services can be in house or outsourced. As a rule only following
items
may be cleaned in the laundry.
i. Hospital patients linen.
ii. Hospital curtains.
iii. Hospital Kitchen linen.
iv. Hospital staff uniforms.
v. Other authorized items like blankets, mattresses and pillows Staff personal
clothing is not cleaned in the hospital laundry.
2. Segregation and Collection of soiled linen.
3. All linen after use will be collected in each department / ward and segregated into
potentially infective and not potentially infected. The former will include all linen
which has been soiled with body fluids and will be kept separately.
4. Personnel working in the receiving and sorting area are required to wear a long
gown, mask and gloves. He should keep his hands away from his or her mouth and eyes
and thoroughly wash his or her hands when leaving the receiving and sorting area. No
eating and drinking is allowed in this area.
5. Sluicing / Treatment of soiled / infected linen.
i. All infected linen / linen soiled with body fluids will be soaked in 0.5 %
bleaching solution for 30 minutes then washed with water & detergent to
Remove bleach before handing over for washing.
ii. Handing taking over of linen with the laundry staff. The soiled linen is tied into
bundles and an entry made. The infected linen is accounted and handed over separately.
If possible all linen is inspected for tears and damage at this point to avoid dispute.
6. The linen is washed, dried and ironed by the laundry staff. Infected linen is washed
separately. The linen is returned to the health facility where it is properly taken over
and a record made of the same. Repairs will be carried out on torn linen.
7. Clean linen should be stored in a dry place on racks. Clean linen is transported on a
clean trolley.
8. Laundered linen is issued to the patient at the time of admission and taken back at the
time of discharge. Linen if soiled by body fluids is frequently changed.
9. Blankets can be dry cleaned or hand washed. Hand-washing can be done by first
soaking for 15 minutes in lukewarm water. The soap suds are squeezed through the
blanket and then rinsed in cold water at least twice. The blanket should not be twisted
or wrung. It should be dried by spreading it on a clean surface.
10. Pillows and mattresses can be washed with soap and water and left to dry in the sun.
11. Blankets pillows and mattresses can be fumigated if required by keeping them in a
closed room and the room is then fumigated.