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 Table of Contents  
SHORT COMMUNICATION
Year : 2019  |  Volume : 21  |  Issue : 1  |  Page : 50-53

The cost of keeping a hospital clean: Insights from a cancer hospital in East India


1 Department of Mechanical Engineering, Fitzwilliam College, University of Cambridge, Cambridge, UK
2 Department of Housekeeping, Medical Administration, Tata Medical Center, Kolkata, West Bengal, India
3 Department of Microbiology, Medical Administration, Tata Medical Center, Kolkata, West Bengal, India
4 Department of Nursing, Medical Administration, Tata Medical Center, Kolkata, West Bengal, India

Date of Web Publication12-Aug-2019

Correspondence Address:
Dr. Sanjay Bhattacharya
Tata Medical Center, 14 Major Arterial Road (E-W), New Town, Rajarhat, Kolkata - 700 156, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacm.jacm_10_18

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  Abstract 


CONTEXT: Assessment of cleaning cost of hospitals is important for hospital administrators, infection control experts and housekeeping managers. Such data are lacking in the medical literature.
AIMS: The aim of this study was to determine the cleaning cost of a tertiary care not-for-profit private cancer hospital.
SETTINGS: This study was conducted in Tata Medical Center, Kolkata, India, which has 183 inpatient beds.
DESIGN: This was a retrospective observational study.
MATERIALS AND METHODS: Cleaning cost assessment was done from financial records over one financial year (April 2015–March 2016). The methodology involved taking into account the cost of various types of wastes (general, biomedical and microbiological), human resource cost (housekeeping staff salary), laundry cost, costs of cleaning equipment, cost of consumables (personal protective equipment, soap solutions, disinfectants, cleaning mops etc.) and the cost of water consumption.
STATISTICAL ANALYSIS: No special statistical tests were used.
RESULTS: The cost of keeping the hospital clean was INR Rs. 49,206,015 ($745,546 USD/€668,854). This comprised 4% of the total operational expenditure of the hospital. The maximum proportion of cost for cleaning hospitals was due to housekeeping staff salaries (66%), followed by cost of laundry (17%) and cost of cleaning consumables (13%). The trend analysis of the multidrug-resistant organism (MDRO)-related bacteraemia rate during the study period (calendar year of 2015 and 2016) showed a slight reduction of Methicillin- resistant Staphylococcus aureus, Vancomycin- resistant Enterococci and extended-spectrum beta-lactamase and AmpC beta-lactamase bacteraemia rates.
CONCLUSION: Keeping hospital clean is resource intensive. This is an essential strategy to keep MDRO infection rates under control.

Keywords: Biomedical waste, cleaning equipment, hospital cleaning cost, microbiological waste, staff salary


How to cite this article:
Lister J, Rakshit S, Bose S, Dhar K, Sarkar De M, Bhattacharya S, Ramanan VR, Mahajan AY, Chandy M. The cost of keeping a hospital clean: Insights from a cancer hospital in East India. J Acad Clin Microbiol 2019;21:50-3

How to cite this URL:
Lister J, Rakshit S, Bose S, Dhar K, Sarkar De M, Bhattacharya S, Ramanan VR, Mahajan AY, Chandy M. The cost of keeping a hospital clean: Insights from a cancer hospital in East India. J Acad Clin Microbiol [serial online] 2019 [cited 2019 Oct 23];21:50-3. Available from: http://www.jacmjournal.org/text.asp?2019/21/1/50/264244




  Introduction Top


The processes involved in keeping a hospital clean are both complex and expensive. Hospital cleaning is taken seriously because evidence suggests that cleaning the environment is linked to reduction in the risk of hospital-acquired infections.[1] Unclean hospital environments have been associated with outbreak of various infections, especially like those related to Methicillin- resistant Staphylococcus aureus (MRSA), multidrug-resistant (MDR)Gram-negative bacilli and fungal infections.[1],[2] The current study, done in a 183-bed oncology hospital in East India, involved determination of the cleaning cost of the hospital during one financial year (April 2015–March 2016).


  Materials and Methods Top


The methodology involved taking into account the cost of various types of wastes (general, biomedical and microbiological), human resource cost (housekeeping staff salary), laundry cost, costs of cleaning equipment, cost of consumables (personal protective equipment [PPE], soap solutions, disinfectants, cleaning mops, etc.) and the cost of water consumption. Chemical waste, radiological wastes and pest control activities were excluded from the current analysis. The cleaning agents used in our hospital included cleaning solutions such as R1 (anhydrous citric acid; Diversey, India) for toilet cleaning (at a dilution of 1:20 in water), R2 (alkyl alcohol ethoxylate, 2-aminoethanol and propan-2-ol; Diversey, India) for cleaning hard surfaces (at a dilution of 1:20 in water), R3 (1-methoxy-2-propanol and ethanol; Diversey, India) used for cleaning glass surfaces (at a dilution of 1:20 in water), R4 (mineral oil; Diversey, India) for wooden furniture maintenance, R5 room freshener, R6 (hydrochloric acid, quaternary ammonium compounds, trimethyl tallow alkyl and chlorides; Diversey, India) for bedpan and urinal cleaning and D7 (isoparaffinic hydrocarbon solvent; Diversey, India) for polishing steel surfaces. Disinfectants used included Linosafe (didecyldimethylammonium chloride; BioShields, India) for linen disinfection; EcoShield (11% w/v hydrogen peroxide and 0.015% w/v silver nitrate) for fumigation (used rarely for this application) and metallic surface disinfection; Bacillol 25 (ethanol, isopropanol and propan-1-ol; Raman and Weil, India) for medical equipment and steel surface disinfection and Suma tab (sodium dichloroisocyanurate dihydrate; Diversey, India) for hypochlorite-based surface disinfection (floors and laboratory benches). Appropriate PPE was used based on risk involved and the material safety data sheet of the various cleaning or disinfection chemicals.

General waste included all waste products that were not biomedical or hazardous or radiochemical wastes (e.g., food and paper wastes). Biomedical waste included hospital wastes which were generated during diagnosis, treatment and infection prevention activities including immunisation of the patients and staff. Furthermore, included within these categories were waste generated in diagnostic and research laboratories including clinical samples from patients. Microbiological wastes included culture plates, discarded culture stocks and infectious clinical samples. The hospital follows the statutory regulations of the local pollution control board (West Bengal Pollution Control Board, India), and all wastes were segregated at source using color-coded bags.[3] Bacteraemia rates of MRSA, Vancomycin- resistantEnterococci (VRE) and extended-spectrum beta-lactamase and AmpC beta-lactamase (ESBL/AmpC) were calculated during the calendar years of 2015 and 2016.


  Results Top


During cost analysis [Table 1] and [Figure 1], it was noted that the maximum proportion of cost for keeping the hospital clean was due to housekeeping staff salaries (66%), followed by cost of laundry (17%) and the cost of cleaning consumables (13%). The cost of cleaning equipment (capital and maintenance costs) and the cost of microbiological waste management using the waste autoclave were 1% of the total cost each. We also noted that the cost of microbiological waste management was the maximum among the waste categories and exceeded that of other biomedical waste and general waste. Finally, cleaning activities used a lot of water (7361 l/day), and the cost of this hospital water (purified through reverse osmosis and chlorination) was not negligible (1% of total cost).
Table 1: Analysis of the cost involved in keeping a cancer hospital clean

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Figure 1: Analysis of the cost involved in keeping a cancer hospital clean

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The current study shows that the cost of keeping the hospital clean was Rs. 49,206,015 INR ($745,546 USD/€668,854) and it comprised 4% of the total operational expenditure of the hospital for the same period (Rs. 1.15 billion/$ 17,454,545 USD/€15,314,056). The hospital cleaning cost accounted for about 62% of the total infection control-related expenditure of the hospital (which included cleaning cost, disinfectant cost, microbiology diagnostic test consumable cost, cost of central sterile supply department operations, cost of immunisation of staff, cost of managing sharps injury or splash exposure in staff and the cost of water) but excluding the heating, ventilation and air conditioning cost. The trend analysis of the MDR organism (MDRO)-related bacteraemia rate during the study period (2015 and 2016) showed a slight reduction of MRSA, VRE and ESBL/AmpC bacteraemia rates [Table 2].
Table 2: Trend analysis of the multidrug-resistant bacteraemia rates during the study period

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  Discussion Top


The hospital cleaning cost data as determined through this study are important for hospital administrators, housekeeping managers and infection control specialists and hygiene experts. A study comparing unit costs in different categories of hospitals in India has reported the laundry and cleaning costs to be 9.2%, 14.8% and 25.4% among private hospital, charitable hospital and tertiary care hospital, respectively.[4] Another study from England has shown hospital cleaning cost to be £236 ($ 302 USD/€265) per bed per year, whereas similar kind of study from the United States reported the hospital cleaning cost to be $ 232USD (€204) per bed per year.[5],[6] In our study, we found the cost of cleaning to be higher [$ 4074 (Rs. 268,885/€3,656) per bed per year]. It may be because we have included staff salaries and other infrastructure costs into consideration (such as laundry) and not just looked at cleaning consumables.

It is likely that as cleaning and disinfection technologies change and evolve, the hospital cleaning cost is also likely to change. The cost is also dependent to large extent on the cost of recruiting and maintaining a large pool of human resources. In our case, the salaries of the housekeeping staff (including benefits) were more than the gross domestic product (GDP) per capita (World Bank, India data, 2015) or the average salaries of domestic workers in India.[7],[8] Therefore, as the salaries of the individuals increase with socio-economic development, the overall cost of cleaning will change significantly. What needs to be explored is the role of new technology and engineering solutions such as automation and robotics in hospital cleaning processes.[9],[10],[11] New hospital cleaning technology options being pursued include (a) creation of 'self-disinfecting' surfaces by coating medical equipment with metals such as copper or silver; (b) 'no-touch' (automated) decontamination technologies such as vaporised hydrogen peroxide, (c) mobile devices that emit continuous ultraviolet (UV-C) light, (d) a pulsed-xenon UV light system and (e) use of high-intensity narrow-spectrum (405 nm) light. These 'no-touch' technologies have been reported to reduce bacterial contamination of surfaces.[10] The control of MDR infections requires a multimodal strategy as described by the World Health Organization. Environmental cleaning and disinfection is a part of that multimodal strategy which also includes the components of standard precautions such as hand hygiene, appropriate use of PPE, appropriate disposal of biomedical wastes and safe injection practices.[12] The challenge for hospital cleaning in future would be to balance technology with cost, safety and human resource commitments (especially in developing countries). A more detailed analysis may be needed to actually correlate environmental cleaning with reduction in MDRO infections. However, this study is an indication that such a study is necessary to show the hospital management, the need for better cleaning methods in hospitals and its efficacy in terms of money saved through in reduction of antibiotic use.

Acknowledgement

We would like to express our gratitude to housekeeping staff of Tata Medical Center, Kolkata, India, for keeping the hospital clean.

Financial support and sponsorship

The work by Jonathan Lister was supported by the Tata Social Internship Program.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kleypas Y, McCubbin D, Curnow ES. The role of environmental cleaning in health care-associated infections. Crit Care Nurs Q 2011;34:11-7.  Back to cited text no. 1
    
2.
Hebert C, Weber SG. Common approaches to the control of multidrug-resistant organisms other than methicillin-resistant Staphylococcus aureus (MRSA). Infect Dis Clin North Am 2011;25:181-200.  Back to cited text no. 2
    
3.
West Bengal Pollution Control Board. Available from: https:// www.wbpcb.gov.in/. [Last accessed on 2019 May 17].  Back to cited text no. 3
    
4.
Chatterjee S, Levin C, Laxminarayan R. Unit cost of medical services at different hospitals in India. PLoS One 2013;8:e69728.  Back to cited text no. 4
    
5.
Toffolutti V, Reeves A, McKee M, Stuckler D. Outsourcing cleaning services increases MRSA incidence: Evidence from 126 English acute trusts. Soc Sci Med 2017;174:64-9.  Back to cited text no. 5
    
6.
Nelson RE, Jones M, Leecaster M, Samore MH, Ray W, Huttner A, et al. An economic analysis of strategies to control clostridium difficile transmission and infection using an agent-based simulation model. PLoS One 2016;11:e0152248.  Back to cited text no. 6
    
7.
The World Bank. GDP Per Capita. World Bank National Accounts Data, and OECD National Accounts Data Files. Available from: http://data.worldbank.org/indicator/NY.GDP.PCAP.CD. [Last accessed on 2017 Jun 02].  Back to cited text no. 7
    
8.
How Much Do Indians Pay Their Many Domestic Helpers? The Wall Street Jounal. Available from: https://blogs.wsj.com/indiarealtime/2016/05/03/how-much-do-indians-pay-their-many-domestic-helpers/. [Last accessed on 2017 Jun 02].  Back to cited text no. 8
    
9.
Gronquist R. Robotic carpet cleaning at Stanford hospital delivers time and labor savings. Exec Housekeep Today 1998;19:31-2.  Back to cited text no. 9
    
10.
Griffin WR. Where are the robots? Good and bad news for automated cleaning. Health Facil Manage 2001;14:42-5.  Back to cited text no. 10
    
11.
Boyce JM. Modern technologies for improving cleaning and disinfection of environmental surfaces in hospitals. Antimicrob Resist Infect Control 2016;5:10.  Back to cited text no. 11
    
12.
World Health Organization. Standard Precautions in Health Care. Available from: https://www.who.int/csr/resources/publications/EPR_AM2_E7.pdf. [Last accessed on 2019 May 18].  Back to cited text no. 12
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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