Hospital housekeeping

by Charlotte A. Aikens

CHAPTER XIII.

The Problem of Waste

Next in importance to the three vital questions which daily confront the hospital housekeeper, in common with other mortals—“What shall we eat, what shall we drink and wherewithal shall we be clothed?” comes the question of how to prevent waste of the money and materials supplied for carrying on the work of the hospital. Few institutions afford such abundant opportunities for waste, along so many different lines. The sources of leaks seem to be endless. The individuals who are responsible for waste may be found in all departments, and represent all degrees of intelligence. The varied composition of the hospital household, the emergencies of the life and the fact that of necessity in a hospital of even moderate size the work is divided into departments with separate heads, renders the problem of the prevention of waste exceedingly complicated. Then the lack of any thorough system of inspection, the loose method of keeping accounts, and rendering reports of expenditure and income, the absence of uniformity of methods, makes intelligent comparison with other institutions difficult, if not impossible. Because of these conditions, waste may constantly go on in an institution where apparently everyone is trying to be economical.

Main Causes

There are usually three or four main causes existing where habitual waste goes on:

Lack of an accurate system of accounting for supplies.

Lack of careful supervision in the use of supplies.

Lack of a general knowledge as to the average amounts of supplies necessary for each department for a given time.

Unwise purchasing and ignorant or careless handling.

(Employing people who “do not know how” is also a frequent source of waste.)

First Steps

It has been well said that the first step toward thrift is taking account of the items. A proper system of accounting for the daily supplies sent to each department will go a long way toward checking extravagance. This system of accounting secures facts about the consumption of supplies, that are absolutely necessary for the detection of extravagance or waste, and it should be adhered to as an important part of the work of every department. The surgical department is one which needs special supervision. While perhaps it would not technically come under the head of housekeeping, it often is in charge of the hospital housekeeper, and in considering the sources of waste it cannot be well omitted. In measures for the prevention of waste, the departments of a hospital should be a unit. Only thus can the problem be handled successfully. Referring to the excessive use of surgical supplies, Dr. John W. Brannan, president of the board of trustees of Bellevue and allied hospitals, New York, in an open letter to Charities has said:

Surgical Department

“I wish to lay especial stress upon the possibility of effecting a very material saving in the use of surgical appliances and expensive drugs in all the hospitals. In order to accomplish this it is necessary to have the goodwill and co-operation and constant thought, not only of the superintendent and his staff, but also of the surgeons and physicians, both attending and house. If the visiting physicians and surgeons were to exercise the same consideration in the use of surgical dressings and expensive drugs as they do in their private practice among people of moderate means, and exact the same of the house staff; there would be, in my opinion, a marked reduction in the amount of the supply account.

“The following is an example of what can be done in the way of saving in surgical supplies: The attention of the visiting surgeon of one of the divisions of Bellevue Hospital was called about a month ago to the large consumption of gauze in his wards, some 2,100 yards having been used in the previous week. He at once made an investigation, with the result that the next week the amount of gauze consumed was only 1,100 yards, and during the week following that only 610 yards, although the service continued just as active and the patients were cared for fully as well as before.”

The author of “The Commissariat” stated that in the hospitals of London, where the surgical department is diligently supervised, it has been found possible to effect an annual saving amounting to five pounds for each bed, and that without in any way lowering the standard of nursing or treatment.

Utilizing Hospital Waste

At the Boston meeting of the Association of Hospital Superintendents, Dr. F. A. Washburn, Jr., of the Massachusetts General Hospital, in a paper on “Methods of Utilizing Hospital Waste” described the methods used in that hospital to reduce the consumption of gauze and soap. The paper contains so much that is valuable by way of illustrating what might be accomplished and how, that we have requested permission to insert it in this connection.

“Two main principles are involved in reducing hospital expenditures:

“1st. Using less new material.

“2nd. Utilizing waste material.

“In this paper I will dwell principally upon some of the methods which may be employed in carrying out the second of these two principles, namely, utilizing material which has formerly gone to waste.

“The item of absorbent gauze is a large one in every general hospital. At the Massachusetts General Hospital, in 1902, it amounted to $6,079.81, in 1903, to $5,959.37.

“Up to one year ago, at this hospital, it had been customary to destroy all gauze which had been soiled by blood or pus, and I believe that this was the rule at all hospitals, although some had made an attempt to recover the gauze from their clean cases. In October, 1904, with the consent of the visiting staff, a process of washing and sterilizing all gauze was adopted, and its success has exceeded our expectations.

“In the first eight months of 1904 we used over one hundred and forty miles of new gauze three feet wide. In the first eight months of 1905, we used fifty-one miles. The new gauze used in the first eight months of 1904 would have stretched from Boston nearly to New Haven, Conn., while in a corresponding period of 1905 it would have reached only five miles beyond Providence, R. I. Money actually expended for gauze during the first eight months of 1900 was: 1900, $3,774.01; 1901, $4,275.91; 1902, $3,872.61; 1903, $4,029.22; 1904, $4,366.52; 1905, $1,253.40.

“That shows a saving of about $3,000 in eight months over the cost in 1903 and 1904.

“The method employed is as follows:

“All gauze and bandages from ward dressings, amphitheater and out-patient department and operating rooms is collected in paper bags and taken to the laundry. It is transferred from these paper bags to open work bags made of cord, these bags being only half filled. The gauze is kept in these bags throughout the rest of the process of washing and the laundry sterilization.

“It is put in soak over night in cold water which is changed several times. The following morning it is put in an iron washer capable of resisting steam pressure up to ten pounds. It is then washed in cold water until the water runs perfectly clear. The gauze is then washed with warm water, soap,and sal soda. After this washing it is rinsed in hot water. After the rinsing, enough hot water is turned into the washer to cover the bags of gauze as they lie on the bottom of the washer. Steam is then turned on to a pressure of ten pounds. A self-registering thermometer placed in the gauze twice showed a temperature of 239° and 240°. The thermometer, which registers on the outside of the washer, showed a temperature of 236° at pressure of ten pounds. This temperature is maintained for one-half hour. During all this process, the washer is moving with a to-and-fro motion, which continually agitates the gauze and presents all parts of it to the action of the water and steam.

“The gauze is then put in the extractor and when dry is sent to the out-patient department, where it is overhauled under the direction of an intelligent maid. It is untangled and straightened, and the maid is instructed to throw out any piece of gauze which is stained or has anything adherent to it. The gauze is again handled by nurses or maids when it is cut and placed in packages for the last sterilization. These women, also, have instruction to look the gauze over carefully for any stained piece or any piece with foreign matter adherent. The final sterilization is then done at a temperature of 250° F., with a pressure of fifteen pounds in the sterilizing room.

“It is found that the washed gauze is softer and more absorbent than the new gauze. Repeated tests conducted in the pathological laboratory have shown the safety of the process. The overhauling and straightening of the washed gauze involves a very considerable amount of labor, and if it were necessary to hire additional people to do the work the saving would be much less. At the Massachusetts General Hospital we utilize labor that would otherwise go to waste. In our large out-patient department we must have a certain force of messenger boys and maids when the clinic is at its largest and at the busiest hours of the day. Much of the time all this force is not required for running the clinics or cleaning the buildings, and their time is utilized on the gauze.

“So much for the gauze which is recovered and utilized again as gauze. There is a part which is in too small pieces or is too badly tangled to be worth straightening. This material is run through a rag picker and becomes a very light and absorbent lint, which is sterilized and used in dressings where absorbent cotton or oakum is ordinarily used. It is also used in the boiler house in the place of waste for wiping around the engines. Another part of the gauze is thrown out because it is stained with chemicals. These pieces are utilized by the housecleaning force. This process, therefore, means not only less gauze bought, but less absorbent cotton, less oakum, less waste for the engine room. All pieces of compress cloth, many of which have been thrown away in the past, are washed and sterilized by this same process, used over again if large enough, run through the picker if small.

“Packages which are sent to the boiler house to be burned are overhauled and inspected at frequent and irregular intervals, and if it is found that material which should be saved is being wasted, the responsible head nurse is called to account. Safety pins, rubber dam, knives, forks and spoons are recovered from this inspection. I believe that it will pay to have a systematic inspection by a careful employee of everything brought from any part of the hospital to be destroyed or thrown away. Such a man cannot fail to more than earn his pay and board, nor would his inspection work take the whole of his time.

Soap Making

“About one year ago the Massachusetts General Hospital started to make its own soap. I have endeavored to make a comparison of the cost to the hospital of buying soap for the seven months, February to August, 1904, and making it for the seven months, February to August, 1905.

“We formerly used in the laundry a soap chip for which we paid about 4¾ cents a pound. We used a common yellow bar soap for which we paid 5 to 5½ cents per pound. Savogran for the floors, etc., at 6 cents a pound, and soft soap for ward use at 3½ cents. All these have been nearly or quite replaced by our homemade soft soap, which we find answers all these purposes in a satisfactory manner. We still use a small amount of Savogran on the white tile floors of our surgical building, and a little bar of yellow soap here and there. This latter we shall make ourselves as soon as our stock on hand is used up. But soft soap practically replaces everything except sand soap, toilet soap, soap polish, etc., which we buy as before.

“In the seven months of 1904 under consideration, we paid $535.26 more for Savogran than in the seven months of 1905; $108.48 more for yellow bar soap; $24.99 more for soft soap, and $300.65 more for soap chips, a total of $969.38 more paid for soap effected by our home soap making in seven months of 1904 than in the seven months of 1905.

“To counterbalance this we received in the seven months of 1905, $255.15 less for grease. Soap making takes about a third of the time of one man, estimated at $177.25 for seven months. Potash cost $293.91. Steam used in cooking soap estimated at $5 per month, $35. A total saving of $268.07 in seven months.

“We have less trouble with our washers in the laundry because of the larger amount of free alkali in the soap made by our recipe, which is practically the same as that used at the McLean Hospital and the State Hospital. It is as follows:

“Dissolve twenty-two pounds of potash in six nine-quart pails of water, add thirty-four pounds of grease and boil very slowly six hours. Then fill a 100-gallon tank half full of water and let it come to a boil again. When it becomes stringy turn off the steam and fill the tank with water.

“The soap has been tested by the hospital apothecary and is found to correspond to the maximum of free alkali allowed by the 1900 United States Pharmacopia. Various fabrics have been allowed to soak in this soap for several days and have shown no detriment. The practical test of a year’s use shows no injury to clothing.”

Drugs

Dr. W. E. Dreyfus, chemist of Bellevue and Allied Hospitals, calls attention to another leak that formerly existed in those establishments and the same kind of leak may be found in the majority of hospitals of the country. In commenting on the hospital deficit question Dr. Dreyfus says: “You know that all chartered charitable institutions are entitled to tax-free alcohol, but very few take advantage of it. The saving for our city institutions on tax-free alcohol during 1903 amounted to about $21,000, the indirect benefit therefrom being about $9,000 more. To give a specific instance: Before the King’s County Hospitals were supplied from this department, they spent the sum of $17,771.12 for drugs, liquors, etc. After they were consolidated with this department we furnished them the same amount at a saving of nearly $4,000 per annum.” These figures are large, because the institutions concerned are large, but when smaller institutions buy and continue to buy alcohol and pay the tax, which amounts to $2.07 a gallon, it is easy to see that a proportionate sum is being wasted in the majority of the hospitals of this country through this one channel. There is no question that hundreds of thousands of dollars in the aggregate every year are taken from the hospital treasuries of the country and poured into local liquor dealers’ pockets and various other pockets that ought to be expended in supplying legitimate needs.

Wasteful Physicians

Just what to do with physicians who are habitually wasteful is a question. It has been a noticeable fact in some hospitals that physicians who owned hospitals of their own were always more economical in the use of surgical supplies than others, whose only hospital experience was gained in institutions supported by the public. They knew the cost of supplies. They were footing the bills and wasted material meant money taken directly out of their pockets. Therefore they had formed habits of economy and were quick to check nurses who showed a tendency to wastefulness. If the spirit of economy, the spirit of personal ownership could take possession of the doctors connected with hospitals it would mean an enormous saving in the course of a year.

Teach Economy

Abuse of Appliances

The lack of careful instruction in the use and abuse of hospital supplies and the absence of conscientious, competent supervision may always be expected to result in general waste. If in the very beginning of an interne’s or nurse’s course in a hospital, some pointed, practical and definite instruction could be given as to the cost of supplies, and the avoidance of common methods of waste, much might be accomplished. If a sense of individual responsibility can be cultivated at all, efforts in that direction cannot be begun too soon. It is lamentably true that there is perhaps no class of employees who carelessly destroy so much that is useful as those whose names appear as students and employees of our institutions. Usually what is common property is no concern of theirs. A loss to the institution is no loss to them. Whether or not a feeling of responsibility can be aroused in all hospital workers is an open question, but it is worthy of diligent and constant effort. One thing specially needs frequent emphasis, and that is regarding the misappropriation of appliances. “Use an article for the purpose for which it is intended and for no other.” This cannot be too thoroughly drilled into them. How many valuable hospital instruments are broken annually because nurses persist in using them to take corks out of bottles because no corkscrew is in sight. This is only one common illustration out of hundreds that might be cited on this point. A rigid rule requiring a money return or a replacing of the article and a careful account of the articles in each department is the only way to force a study of economy. The abuse of appliances which renders them unfit for use, in an unreasonably short time, can be met in the same way, requiring also that every article reported unfit for use be submitted for the inspection of the head of the department, before being condemned or thrown away as worthless.

Careful Accounting

Watching the Expenditures

By careful accounting (and only in that way) can be ascertained the average amount of supplies that should be required in caring for a given number of patients. If this average amount is generally known or understood by heads of departments, internes, and nurses, it will be found that more care will be exercised to keep at least within ordinary limits. Very frequently the necessity for economy is never brought to the attention of the workers. Heads of departments too often seem in no way to be concerned with the cost or consumption of supplies. When this condition exists somebody is to blame. The superintendent, if he is the head of the hospital, as his official title would indicate, holds more of the power of checking waste in his hands than any other one or two persons. If he does not keep his financial eye on the expenditures of different departments, if he does not give time and study to the question of how to keep current expenses down to the minimum and at the same time do good work, if he does not, up to a certain point, regulate the purchase and distribution of the enormous quantities of supplies needed in the hospital, and insist on his colleagues in charge of departments doing the same thing, then waste is inevitable. If the father of a family simply pays bills for supplies without having a voice in controlling the consumption or use of those supplies he need not wonder if he finds the figures on accounts creeping higher and higher each month, and that is probably what is occurring in some hospitals, where the expense is excessive as compared with other institutions doing the same amount and same class of work. That economy and efficiency are quite compatible can be easily shown by actual results in hospitals that have never adopted the plan of running the institution on a deficit, that either have to pay their bills promptly or close their doors.

Dietetic Department

No doubt the dietetic department of the hospital can furnish more concrete illustrations of waste than any other. Some of this so-called waste is legitimate and inevitable; much of it represents material that should not be saved, that has been rendered unfit for use by handling, but there is no question that a large proportion of this waste of food comes from a failure to fit the amount and character of the food served to the needs and tastes of the individual patient. A wise discrimination on the part of the one who serves the food would prevent much of it. Another important cause of waste comes from imperfect preparation of the food. Food cooked in bulk, and with no bond of connection between the one who cooks and those who consume the cooked product, is almost sure to be handled carelessly, overdone or under-done or unpalatable. Food that is properly cooked and tastefully served, so that it will appeal to the eye and to the palate as well, is much less likely to be wasted or rendered unfit for use by handling.

Pecuniary economy, a large part of it at least, and also hygienic economy of food and nutrition, depend greatly on the manner of handling of food in the kitchen, in transit, and in the wards. Success in fitting the food to the consumer, then, demands skill and care in cooking and serving. It demands discrimination, a proper sense not only of the physiological demands of the consumer, but of his tastes, and it demands, besides, proper facilities for getting the food to the patient in its most palatable and attractive form. Without these three factors being recognized, waste is inevitable. Then, too, the buyer of food must carry a good deal of responsibility. The quality of food purchased, the place in which it was stored, and various other features enter into the question of waste. Without proper storage facilities “intelligent economy” in purchasing and caring for food is impossible. Buying over the telephone is one of the methods to be discouraged. Careful selection of perishable goods in open market is the only sensible way. Some hospitals have succeeded in reducing the expense from food waste by disposing of the garbage to contractors for a stipulated sum.

In the heating of a hospital there is room for a great waste of money. One small hospital, this last winter, one of the most severe seasons in years, saved two hundred dollars on the cost of fuel as compared with last year, as the result of “the intelligent economy” practiced by the engineer. A very considerable reduction in the expense of machinery, light and repairs is attributed by the board to the same source. Intelligent economy! The term deserves to be popularized, for of all things in hospitals it needs to be studied and cultivated.

This system of daily accounting for supplies is one that can be managed in even the smallest hospital. An inventory book in which is listed all the articles found in a department at a given time, such as hypodermic syringes, feeding cups, drinking glasses, medicine glasses, rectal tubes, catheters, etc., can also be used for requisitions or for noting, as furnished, additional articles of that class.

System

Another book for food supplies should be brought to the kitchen or storeroom each time supplies are replenished. Another book for keeping track of surgical supplies should be brought with each requisition. Some hospitals have also a “linen book,” which tells the amount of each kind of linen sent to the laundry from each department. Clean linen is noted in the book also when given out. These books should be sent to the office each week (Monday morning is usually a good time) and the amounts supplied to each department reckoned up. When this amount in any department is excessive an investigation can be made with facts as a basis. Regarding this system, Sir Henry Burdette in “The Commissariat” says: “No true economy can ever be expected under a system by which the persons who order and use supplies, and the person who is responsible for the bills, both work independently and pull different ways. It is absolutely essential to a well-balanced administration that a spirit of responsibility should permeate the whole establishment, from the manager, on whom the multifarious charges accumulate for payment, down to the youngest probationer charged with serving out the rice pudding in her ward. And this spirit of responsibility must in all cases recognize a double duty. There is the duty towards those for whom each person invested with authority of any kind is called on to provide, and there is the duty toward the institution, represented by the person next in authority. Where this dual sense of responsibility is nicely balanced in every member of the institution, the management may be considered perfect.

To that end, it is, above all things, necessary that there should be one person invested with general control and endowed with a grasp of the whole situation. It cannot be too often repeated that in these matters to know is to control. There is no other road to economy. It cannot be compassed by appeals to conscience, not by nagging, not by a grudging, stingy giving out of necessary articles as though the consumer were guilty in requiring them. Let each housemaid know how many yards of cloth she is expected to use in her cleaning in a given time, let each pound of lint be registered against someone’s name, who shall be accountable; let each article be given out at the right time, on the right day, to the right person, and with the understanding that the transaction, slight though it may be, has been noted down and will duly find its place in the weekly average and in the record of the whole expenditure. Let such a system once take root and then, be the institution large or small, rich or poor, hampered with old traditions or brimming over with untried theories, a spirit of true economy will reign throughout every department, worth far more, indeed, than the trifling secretarial labor expended in its production.”