(A handbook for the health staff)

Our Health Centre

How to keep it

Clean and Beautiful

First edition : 2006

Number of copies : 500

Graphic Design : Lajja Communications, Vallabh Vidyanagar

Cover Page : Prakash Parmar

Printing : King Image, Ahmedabad

Published by

Department of Health and Family Welfare,

Gandhinagar, Gujarat

in partnership with

The European Commission Technical Assistance

(ECTA), Gujarat

(A handbook for the health staff)

O r H a h Ce t eu e lt n r

How to keep it

Clean and Beautiful

PREFACE

This handbook is the first attempt to give

comprehensive and simple guidelines to the health staff to

keep their health facilities clean and beautiful, while they

provide invaluable services to the community in the

remotest areas of the State.

It may be noted that the majority of the statements in

the booklet address the smaller health facilities. The

guidelines in this booklet may be slightly different from the

national and international guidelines for disposal of bio-

medical waste, but they seemed practical and appropriate

for our rural health facilities.

We would greatly appreciate receiving feedback on

experiences, problems encountered and suggestions for

improvements in the next edition of this booklet.

- Shri Kiran Mukerji

Team Leader,

ECTA Gujarat

-

-

- Dr. Uma Vyas

Programme Advisor,

ECTA Gujarat

Gandhinagar, January 2006

-

-

-

FOREWORD

Dr. Amarjit Singh, I.A.S.

Secretary Family Welfare

and Commissioner Health,

Government of Gujarat

∆MfiI≤Ë ©fio≤We are proud to present this booklet on the very

important issue of cleanliness and health. We have all been

working for many years for the health and welfare of the people,

but the areas of cleanliness and prevention of infection have

been neglected for long. A study by the WHO has proved that

10% of the patients admitted to the health centres and hospitals

get cross infection from the health facility itself.

This is one of the most important reasons why the

maternal and infant mortality rates are not being reduced. This is

a matter of serious concern. The guidelines printed in this

booklet are simple and practical, and I am confident that they will

be very useful and easy to follow. It is our responsibility to

implement the measures for cleanliness immediately.

Let us all resolve to carry forward the campaign of service

with cleanliness.

• Attributes of the best health facility 5• Important points to remember 6• Who are at risk? 9• Diseases transmitted by bio-medical waste 10• How do germs enter the body from a dirty environment? 11• Properties of bio-medical waste 12• Did you know? 13• Disposal of waste 14• Storage of waste in big facilities 15• Transportation of bio-medical waste 16• In case of injury by sharps… 17• Yellow bag/bin (Infectious materials) 18• Blue bag/bin (Sharps, injurious materials) 19• Black bag/bin (Organic materials, wet food waste) 20• Red bag/bin (Synthetic materials) 21• Washing of hands 22• How to wash hands 23• Self protective gear 24• Gloves 25• Mask and cap 26• Slippers/shoes/boots 27• Guidelines for the nursing staff 28• Guidelines for the cleaning staff 30• Guidelines for the laboratory staff 32• Guidelines for the patients' relatives 34• It is in our hands… 36• Acknowledgments 37

CONTENTS

5

ATTRIBUTES OF THE BEST

HEALTH CENTRE

• Sensitive, efficient and affectionate staff

• Clean and green surroundings

- Having plantations

- Free from dirty water puddles

- Free from garbage

• Patients and visitors should feel welcome

• Clean building with health slogans on the walls

• Facility for clean drinking water

• Clean toilets

• Proper disposal of garbage

• Proper disposal of wastewater

6

IMPORTANT POINTS TO REMEMBER

Surroundings

• The surroundings of the health facility should be kept clean-

there should be easily accessible garbage bins and

spittoons (for pan spitting) at entrances and waiting areas.

• If there is no compound wall, the staff can themselves make

a protective boundary with thorny shrubs or wire fencing.

This can be done economically.

• The surroundings of the health centre should be turned into a

pleasant garden by growing flowers, bushes and trees.

Clean interiors

• The walls of the health centre should be protected from

spitting - messages to this effect should be painted on the

walls and spittoons provided at various places, including

staircases.

• The health centre should be mopped at least twice a day with

a clean mop and disinfectant solution. The floors should not

be swept in the traditional way, as it throws up dust, which

can transmit diseases.

• Careful dusting with a clean cloth should be carried out every

day. This should be done without distributing the dust into

the air.

• Cobwebs should be removed once a week from the walls and

ceilings, behind and under furniture, in cupboards and lofts.

• Messages on the walls should constantly remind the staff,

patients and visitors about the way to keep the health centre

clean.

7

Wards

• Used bed sheets and pillow covers should be replaced by

clean ones after a patient is discharged.

• The used bed sheets must be washed, ironed, disinfected

and stored in a clean place.

• Mattresses should be exposed to direct sunlight periodically,

because the sun acts as a disinfectant.

• Beds should be periodically washed, de-rusted and

re-painted.

Bathrooms, water supply and drainage

• The bathrooms and toilets of the health centre should be

cleaned with disinfectants twice a day. Appropriate cleaning

kits (buckets, clean wiping cloth, toilet brushes) should be

provided to the cleaning staff. The cleaning kits must be

stored in clean places.

• The cleaning staff must be instructed and trained in the

correct methods of cleaning and use of cleaning utensils.

Their work must be checked regularly by the health staff.

• Water tanks must be inspected regularly and cleaned at

least every 6 months to remove dirt, algae, dead creatures,

insect larvae, etc.

• Defective water and drainage pipes must be repaired

immediately.

• Puddles of waste water must be dried up immediately to

avoid insect breeding.

• Septic tanks must be checked regularly for proper

functioning.

8

• Broken or missing covers to septic tanks, soak pits,

inspection chambers must be replaced quickly to avoid

accidents.

Walls, ceilings and terraces

• Moist walls and ceilings result in growth of mill dew, which

can cause serious diseases. They can also cause steel

reinforcements to rust and weaken the building. Therefore,

the causes of moist walls and ceilings (usually water-logging

on roofs and damages in the waterproofing) have to be

detected and rectified immediately.

• Wet walls can encourage the growth of plants with fast

growing roots, which penetrate and seriously damage the

building. Therefore, all plants growing out of walls and roofs

must be removed immediately and the causes of wet walls

and ceilings have to be eliminated quickly.

• Drainage outlets on terraces must be inspected regularly to

avoid clogging, which results in water-logging.

Electrical installations

• All electrical fittings and appliances must be checked

regularly to ensure correct and safe functioning.

• Defective appliances can cause short circuits, which can

cause injuries or even fires. These appliances should be

removed or repaired immediately.

• Live wires hanging loosely, switches without protective

covers and other dangerous items must be avoided at

all costs.

9

WHO ARE AT RISK?

• Doctors

• Nurses

• Patients and their relatives

• Cleaning staff, sweepers

• Rag pickers, who pick garbage

10

• Intestinal diseases : Diarrhoea, vomiting, cholera,

typhoid etc

• Pulmonary (lung) diseases : tuberculosis (TB),

pneumonia, etc

• Skin diseases : abscess, eczema, etc

• Liver diseases : jaundice, hepatitis A, B and C, etc

• AIDS

• Tetanus

DISEASES TRANSMITTED BY BIO-MEDICAL WASTE

lungs

large intestine

liver stomach

small

intestine

HOW DO GERMS ENTER THE BODY

FROM A DIRTY ENVIRONMENT?

• Orally

• By inhalation

• Injuries to the body - injury by sharps not only causes a

painful wound, but the germs on the sharp object enter the

body and cause infection.

11

By the wind pipe

(Trachea)By the food pipe

(Oesophagus)Injury by sharps

(needles, blades,

knives, broken glass)

PROPERTIES OF BIO-MEDICAL WASTE

• Infectious - through infected cotton, bandages, gauze piece,

body parts, tissues etc. (causing infection by germs - bacteria,

viruses, etc)

• Injurious - through syringe needles, scalpels, blades and

broken glass

• Toxic - by bacteria, virus

• Radioactive - by X-ray radiation

• Chemical - old medicines, laboratory chemicals

These properties render the waste dangerous. On the one hand

the health centres are responsible for curing people of the diseases,

whereas on the other hand improper waste disposal can lead to

spreading serious illnesses.

The patient admitted for the treatment of one disease

inadvertently becomes a victim of some other disease, because of

infection by some other bacteria or virus.

12

DID YOU KNOW?

It has been reported that 66% of the rag pickers dealing

with the waste get injured or become victims of deadly

diseases while picking the garbage of the health centres.

• The maximum injuries are caused by broken syringes

and needles

• According to a survey, 17% of the injuries are caused

while using the needles and syringes by the health

staff, whereas 83% of the injuries are caused after their

use and disposal.

13

DISPOSAL OF WASTE

14

• The mouth of the disposal bag should be tied properly and the

bag should not have any leakage.

• The bag should be held from the tied end.

• The bag should be held away from the body.

• The bag should not be supported by the hand at the bottom.

• Not more than one bag should be carried by hand.

• The bag should not be hitting against the body while carrying.

• The bag should not be thrown or banged on the floor.

• A cart should be used to transfer it from one place to another.

• While transferring, the bags should not be taken in the vicinity of

the patients.

• The bins should be clean.

• The health staff handling the waste should be vaccinated

against hepatitis B, tetanus, etc.

STORAGE OF WASTE IN BIG FACILITIES

The collected waste should be kept in a room

• where there is good ventilation and sunlight,

• where there is a concrete floor,

• where animals and insects cannot enter,

• which can be closed,

• which can be under surveillance round the clock,

• which should be cleaned and washed regularly,

• which should have drainage facility,

• which has a capacity to store waste accumulated for two

days.

Protective gear, like gloves, boots, masks, etc., should be

available readily.

15

TRANSPORTATION OF BIO-MEDICAL WASTE

• Fully isolated from general waste

• Completely closed, covered and safe

• The vehicle must be clearly labelled as a bio-medical waste

carrier

• It should be a metal carrier and easy to clean

• The driver should have a completely separate cabin

• The driver should have protective gear (e.g. gloves, boots,

masks etc) and knowledge about them

• The driver should be vaccinated against diseases like

hepatitis B, tetanus etc.

16

NGERDA

IN CASE OF INJURY BY SHARPS….

• Inform the doctor immediately

• The wound should be cleaned with soap and water

immediately, and then with antiseptic lotion, following which it

should be treated appropriately

• The incident should be reported to the Medical Officer and

should be recorded by the responsible staff

• Sharps should not be handled with bare hands

17

• Infected cotton, bandages,

gauze pieces (dressing

materials)

• Human body parts, soft

tissues

• Human waste

• Tablets, pills, capsules,

powdered chemicals

18

Each type of bio-medical waste should be segregated according to its property

Final disposal

Incineration (special burning furnace) or

Deep burial (such that they cannot be dug out by animals,

playing children or the like)

YELLOW BAG/BIN

(Infectious materials)

• Needles, broken syringes

• Broken glass bottles, vials

• Ampoules

• Scalpels

• Blades

19

Final disposal

These items must be rendered aseptic by chemical methods,

and broken, mutilated or destroyed to prevent inappropriate use.

Subsequently, they must be buried in deep pits.

BLUE BAG/BIN

(Sharps, injurious materials)

• Peels of fruits

• Food leftovers

• Thermocol or cardboard

may also be disposed in

this bin

20

(Organic materials, wet food waste)

Final disposal

Deep burial

BLACK BAG/BIN

Note : thAccording to the definition in the gazette published on 30 July 1998 by

the Central Pollution Control Board under the Ministry of Environment

and Forests, the black bag/bin should also be used for incinerator ash,

old pills, tablets and dry chemicals, but that is not practical for our rural

health facilities.

21

Final disposal

Initially, it should be rendered non-infectious with antiseptic

solution and then autoclaved.

Prior to final disposal it should be mutilated or cut into smaller

pieces and then buried into a deep pit.

(Synthetic materials)

RED BAG/BIN

Waste that cannot be burnt but needs to

be disinfected

• Rubber pipes

• Catheters

• Intra venous injection/infusion sets

• Infectious waste plastics, rubber

WASHING OF HANDS

22

When ?

• On returning from outside • After using the toilet

• Before cooking • Before serving food

• Before eating

Advantages

• The simplest method • The most effective

• The most helpful • The most important step

towards prevention

It is important to form the habit

to wash hands with appropriate

detergent, soap or antiseptic

solution.

HOW TO WASH HANDS

• Always use soap

• Keep the soap dish dry, as far as possible

• Wash the hands under running water

• Rub your hands on both sides and between the fingers

• Rub your hands with soap for a minimum of 30 seconds

• Wash your hands under running water for a minimum of

30 seconds

• Let the water trickle down keeping the elbows towards

the floor

• Washing hands and using gloves - should not be either/or,

but should be both together for proper protection against

infection

23

SELF PROTECTIVE GEAR

• Gloves

• Mask

• Apron

• Gown

• Eye protective glasses

• Long gloves and

• Knee long gum boots

24

GLOVES

• It is essential to use the gloves at every stage where

infection is a risk and direct or indirect contact with infectious

material is a possibility.

• The gloves should fit the hand properly.

• One should be careful about touching any objects on

wearing the gloves, and the general rules of asepsis should

be followed.

• Before removing the infected gloves, the hands should be

washed with the gloves on using soap and water, and again

with soap and water after removing the gloves.

25

MASK AND CAP

While wearing the mask it is important to ensure that

• nose and mouth are covered

• the mask is not very tight or loose

• the mask is not touched anywhere except at its tying threads

• on removing the mask, it is to be kept at its allocated place, so

that it can be sent along with other masks for cleaning and

disinfecting

• a cap is worn on the head - this is of utmost importance

26

SLIPPERS / SHOES / BOOTS

• Slippers/shoes/boots are for protection of the feet.

• One should not walk around in the health centre bare foot,

till the last stage of disposal of waste.

• There is always a danger of sharps, like broken glass,

injuring the feet, while walking bare foot. It is not advisable

for human skin to come in contact with waste.

• Sharps like needles and other metallic objects can also

injure the skin.

• Injured skin can spread infection.

• Any contact with infectious material can lead to serious

infection.

27

GUIDELINES FOR THE NURSING STAFF

28

3. The needle and syringe should be

disposed of in the blue bag/bin, so that

the person handling the injurious waste

can handle it carefully.

2. The cotton swabs used to clean the

skin should be disposed of in the

yellow bag/bin.

1. After giving an injection the

disposable syringe and needle

should be mutilated and dipped in a

bleaching solution for at least 30

minutes.

for the proper disposal of waste

How to make the bleaching solution

• Dissolve 10 grams of bleaching powder into one litre of water to

make a 1% bleaching solution.

• The bleaching powder container should be air tight, so that the

chlorine powder does not get moist.

29

6. Plastic transfusion bags/bottles, intra

venous sets, catheters, etc., which

cannot be burnt, should be mutilated,

disinfected in bleaching solution and

then sent for deep burial.

5. Infected waste should be covered

properly.

4. Dressing material, cotton, bandages,

gauze pieces, sanitary napkins and

other destroyable waste, which may

be incinerated, should be put into the

yellow bag/bin.

GUIDELINES FOR THE CLEANING STAFF

• The used dressing material like cotton, bandages,

gauze pieces etc collected from the ward or operation

theatre should be handled only while wearing gloves

and mask.

• The used dressing waste, such as cotton, bandages,

gauze pieces, infected dirty cloth, sanitary pads, etc

should be disposed of in the yellow bag/bin.

• The yellow bag/bin should always be kept covered.

• Sharps, such as needles, syringes, scalpels, blades,

broken glass, etc., which can cause injury, should be

dipped in disinfectant solution and mutilated, and then

30

(ward boy, sweeper and others)

31

disposed of in the blue bin, so that the person handling

this waste can dispose of it properly.

• Needles, syringes, plastic infusion bags/bottles, intra

venous sets, gloves, etc., should be mutilated or cut into

small pieces with scissors and then dipped in bleaching

solution before taking them out of the ward.

• The infectious and vegetable waste, or leftover food

generated in the ward should be kept separately. Under

no circumstances should it be thrown out of the

window.

GUIDELINES FOR THE LABORATORY STAFF

• The cleaning staff should be instructed about the

covering and safe transfer of samples to be examined

in the laboratory, like patients' blood, urine, body fluids,

etc.

• The disposal of liquid samples should not be straight

into the drainage, but should be disinfected in 1%

bleaching powder before its disposal into the sewer.

• Used glass equipments should be disinfected and

autoclaved before being re-used.

• The laboratory staff must make sure that the cleaning

staff working in the laboratory uses protective gear,

such as gloves, masks, etc.

32

33

• Disposable sharps should be stored in the blue bin, so

that the staff handling this waste is able to handle it

carefully.

• The laboratory medium used for bacterial culture

should be autoclaved before disposal. For this, a

separate autoclave should be used. In case that is not

possible, the media/culture should be disposed of in

the yellow bag/bin and sent for incineration.

• Laboratory waste containing cotton, bandages, body

parts or other human waste should be disposed of in

the yellow bag/bin and finally sent for incineration. The

yellow bag/bin should be covered safely.

GUIDELINES FOR THE PATIENTS' RELATIVES

• Different wastes produced by various activities should be

put in the respective dustbins designated for each waste.

• Do not throw the garbage out of the window, and never in

the drainage.

• The used dressing material, like cotton, bandages, dirty

cloth, pads, spirit swabs, etc., should be put into the

yellow bag/bin.

• Food waste, such as the peels of fruits, leftover food, etc.,

should be kept in the black bin/bag and not thrown out of

the window.

34

35

• Young healthy infants and

children should not be taken

to the health centre or

allowed to play in the

compound, as a child's

resistance to infection is

limited and it can get

seriously ill.

• The toilets and bathrooms

should be kept absolutely

clean.

• The walls should be kept

clean from spitting. Spittoons

must be used for spitting pan.

• The cleanliness of the

surrounding area of the

health centre is essential for

the people living around and

visiting the centre.

• Neither glass nor plastic infusion

bott les, nor needles and

syringes should be carried

home, as they can be highly

infectious and dangerous.

THIS IS IN OUR HANDS…

• It is important to give the right information to the patients and

their relatives on cleanliness.

• Appropriate waste disposal will reduce the amount of waste

and save unnecessary labour.

• Appropriate waste disposal will give mental peace and

increase efficiency.

• Making an example of a clean health centre will increase

people's faith in the health services and also increase the

clientele.

• The people's cooperation will be easy to get, and it will also

be easier to make the health facility better equipped, if it is nice

and clean.

• Cleanliness will lead to prevention of illness and thus

epidemics and emergencies will be less frequent.

• A green environment of the health centre will lead to mental

and physical well being.

• These health centres belong to us, are made for us and are

because of us. 36

WE ARE GRATEFUL TO:

- Dr. S B Saxena

Medical Superintendent

SSG Hospital

Vadodara

- Dr. Rajesh Mehta

Secretary

Peoples Health and Development Trust

Ahmedabad

- Dr. N D Ghasura

Additional Director (Retd)

Department of Health and Family Welfare

Gandhinagar

- Shri S R Rao, IAS

Principal Secretary (Health)

Ministry of Health

Gandhinagar

This handbook is the first attempt

to give comprehensive and

simple guidelines to the health

staff to keep their health facilities

clean and beautiful, while they

provide invaluable services to the

community in the remotest areas

of the State.

Department of Health and Family WelfareCommissionerate of Health, Medical Services, Medical Education and Research,Block No. 5, Dr. Jivraj Mehta Bhavan,Old Sachivalaya, Gandhinagar, Gujarat

Delegation of the European Commission to India, Bhutan and Nepal65 Golf Links, New Delhi 110003 European Commission Technical Assistance (ECTA)Gujarat OfficePlot No. 95/1, Sector 2A,Near 'CH' Zero Circle,Gandhinagar 382 007Phone No. : 079 23238851/52/54/56Fax No.: 079 23225742E-mail : ectaguj@ectagujarat.com