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NUTRITION AND FOOD SERVICE IN HOSPITAL

Hospitals being what they are – where patients of almost all kinds visit or stay – are very potent sources of infection. Infection can arise from any part of the hospital. They can spread from patients to patients, from caregivers to patients, from patients to caregivers, from patients to support or administrative staff and vice versa, and so on. An often overlooked source of infection and contamination is the food that comes into hospitals.

Food safety in hospitals is described as the scientific way by which food is prepared, handled and stored in hospital settings. Any food that is prepared in hospital kitchens is, like food made in other places such as canteens, hotels and restaurants and even homes, sourced from outside. This food comes from suppliers whose hygiene has to be ensured. Food hazards can come in many forms, including, but not limited to Biological, Chemical, Physical and Allergenic Hazards.

The Hospital needs to have a procedure to ensure food safety in the hospital. Some of these include:

Personnel

  1. Food service personnel are required to report to their supervisor information about their health as it relates to diseases that are transmissible person-to-person, especially through food. Reportable symptoms include vomiting, diarrhea, jaundice, sore throat with fever or lesions containing pus such as a boil or infected wound that is open or draining. Reportable diagnoses include Norovirus, Hepatitis A virus, Shigella spp., Shiga toxin-producing E.coli, Cryptosporidium, and Salmonella. Food service employees must be free of communicable diseases such as hepatitis A, skin lesions, boils, respiratory infections or diarrhea. Personnel with a suspected infectious disease should report to their supervisor and be cleared by Occupational Health and Safety before returning to work. It is the Supervisor’s responsibility to observe personnel daily to ensure compliance with this policy and to ensure staff is knowledgeable about reporting to by Occupational Health and Safety for known/suspected communicable disease.
  2. Proper attire for food handlers should include hair-covering (hair net or cap, beard restraints), freshly laundered uniforms, and safety shoes. Fingernails are to be short and clean. Mustaches, beards, and sideburns must be kept trimmed. Artificial nails and nail polish are not to be worn in the Nutrition and Food Services Department.
  3. The use of any form of tobacco products is not permitted.
  4. Hand hygiene will be performed with soap and water before work, after using the toilet, before and after eating, after contact with contaminated equipment, work surfaces, soiled clothing, washcloths, etc., and after handling raw food. In patient care areas, alcohol-based hand rubs may be used if hands are not visibly soiled. Adequate numbers of handwashing sinks with soap dispensers and single use towels are provided. Food personnel may not clean their hands in a sink used for food preparation or ware washing.
  5. Restrooms should be conveniently located near the department and should not open directly into food service areas.
  6. Annual in-service education should include personal hygiene, sanitation, and hand hygiene. Education on infection control practices is presented by department educators or Infection Control and Prevention staff as needed and documented. Basic orientation for all new Nutrition and Food Services personnel should include personal hygiene, sanitation, hand hygiene, and isolation precautions and when to notify their supervisor and Occupational Health and Safety of illness with an infectious disease.
  7. Nutrition and Food Services personnel in direct contact with food will wear plastic or vinyl disposable gloves. Gloves should be removed upon leaving the work area and hand hygiene performed. When returning to the work area, hand hygiene should be conducted and new gloves worn. Gloves should be changed, and hand hygiene performed whenever the gloves are contaminated by touching potentially soiled surfaces such as floors, waste cans, cardboard boxes, etc.

 

Food Supplies

  1. All food and food supplies should be obtained from an approved source. An approved source is one that is inspected based on regulation, state, and local laws and has appropriate procedures in place. In all cases, the source should be identifiable from labeling or bills of sale.
  2. Products should be delivered in appropriate vehicles (refrigerated, enclosed vehicles).
  3. Suppliers should be selected by the facility that offers quality products derived in safe and sanitary conditions.
  4. Raw eggs or undercooked eggs should not be served to patients. Poached or fried eggs will NOT be prepared for patients. Only pasteurized eggs are to be used in making foods such as meringues.
  5. All shellfish and crustacean meat shall be obtained from sources according to law and the requirements specified in the Department of Health and Human Services, Public Health Service, Food, and Drug Administration. If the source of clams, oysters, or mussels is outside the state, the shipper’s name shall be on the Interstate Certified Shellfish Shippers List. If the source of cooked crustacean meat is outside the state, the establishment in which the crab meat was packed must be approved by the state or territory of origin, attested by the appearance of an official permit number on the container.
  6. Only “Grade A” pasteurized milk and dairy products will be used. These are to be served in the individual, original containers in which they were received from the distributor, so that the consumer may readily observe the name and grade of the contents and the name of the milk distributor. Exceptions are those patients on fluid restriction. These patients will be served limited amounts in a cup. Milk and dairy products should be stored in a sanitary manner and kept refrigerated except when being served.
  7. Only pasteurized juices should be served.
  8. The Food Safety and Inspection notifies the public of a recall. Suppliers may also notify the facility. Items for recall should be separated in the storeroom from products that may be used. Ensure that the product is not used. Follow the recall procedure of discarding or returning the product to the supplier.

Food Products and Storage

  1. Upon arrival, all food should be inspected for damage, rodent or insect infestation and spoilage. Anything in a damaged container should be rejected.
  2. Store food only in designated areas, never in locker rooms, toilet areas, garbage rooms, mechanical rooms, under sewer lines (that are not adequately shielded), under open stairwells, or near any other source of contamination.
  3. All food should be stored in clean wrappers or containers with covers.
  4. If products are removed from the original container that has the lot number, it is important to maintain lot numbers to be able to track and recall in the event of an identified problem.
  5. Store eggs in the original container in the refrigerator at 33°F-41°F.
  6. Keep storage areas and vehicles to transport food clean. The area must have variable lighting, ventilation and air circulation.
  7. Food must be stored 6 inches above the floor on clean racks.
  8. Shelving must allow for cleaning under the bottom shelf (6 inches above the floor) or be flush with the floor and away from walls to facilitate cleaning and reduce places for pests to find refuge. Floor drains that may allow for contamination by sewerage backflow are prohibited.
  9. All stock should be rotated and goods used in the order in which they are received.
  10. All products should be checked on a periodic basis for expiration dates.
  11. All non-food items and chemicals should be properly labeled and stored away from food products. Toxic cleaning material should be appropriately labeled, stored and used in such a manner as not to contaminate food.
  12. Refrigerate cut leafy vegetables because of outbreaks of Salmonella and enterohemorrhagic E.coli. These foods are now considered hazardous.
  13. Whole tomatoes may still be stored and ripened at room temperature, but they must be refrigerated once cut or sliced. Recipes using sliced tomatoes must be refrigerated. Processed foods containing cut tomatoes must be refrigerated unless the manufacturer does not require refrigeration.
  14. Leaves from leafy green vegetables should be removed from the head and cut, shredded, sliced, chopped or torn. This standard does not include whole heads from which leaves are removed and discarded or fresh herbs such as cilantro or parsley. Handle fresh cut leafy greens with care, including washing. When washing, use running potable water. If soaked or “crisped,” clean running water rinse must follow. Keep refrigerated, as cut leafy greens are potentially dangerous foods.
  15. Low-temperature storage maintenance
  16. Fruits and vegetables (except those in dry storage): 33°F to 41°F
  17. Dairy products, eggs, meats and poultry, fish and shellfish: 33°F to 41°F
  18. Stored frozen foods shall be maintained frozen.
  19. Refrigerator and freezer temperatures must be monitored and recorded on a daily basis to assure that appropriate temperature are kept. The refrigerator and freezer daily temperature logs will be held for 90 days. The Maintenance Department should be notified immediately if the temperature is above or below the acceptable range.
  20. Home-canned foods may not be used.
  21. Food should be protected from rodents and insects.
  22. Lighting, ventilation, and humidity should be controlled to prevent both condensation and the growth of microorganisms. Implement cleaning schedules and monitor for cleanliness, temperature, ventilation and pest infestation.

 

Food Preparation and Service

  1. Raw, unprocessed fruits and vegetables should be thoroughly washed under running water before use.
  2. Frozen foods are thawed at refrigeration temperatures of 41°F or below, quick-thawed as part of the cooking process, or completely submerged under running water at a water temperature of 21°C or below per Food Code. Thawed food should not be refrozen.
  3. Food coming from broken packages, swollen cans, and food with an abnormal appearance or odor, should be discarded.
  4. Personnel may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, gloves or dispensing equipment. Prepared food should be transported to other areas in covered containers. Hot held foods will be kept above 140°F. Cold held foods will be maintained at 41°F or below.
  5. Unwrapped foods should be protected from contamination by sneeze guards.
  6. When food scoops used for food service are kept in the product served, the handle should be held out of the product.
  7. Food should be served as soon as possible, but no longer than four hours after the final product is presented for service.
  8. All unwrapped or unenclosed food for customer self-service shall be protected by a glass or similar shield to prevent public handling or other contamination except for a hand opening on the counter-front.

Equipment

  1. Separate cutting boards for raw and uncooked foods/meats are necessary and are color coded according to the food prepared. Prepared foods should not be cut on the same boards as fresh foods. Cutting boards used in food preparation should be made of plastic and cleaned in the pot washer.
  2. All equipment and utensils should be designed as to be smooth, easily cleanable, and durable and kept in good repair. Any plastic-ware, china and glassware that have lost their glaze or are chipped or cracked are to be discarded.
  3. All reusable eating and drinking utensils should be thoroughly cleaned and sanitized after each use.
  4. All food grinders, choppers, and mixers should be cleaned, sanitized, dried and reassembled after each use per manufacturer’s recommendations
  5. All kitchenware and food-contact surfaces of equipment used in the preparation or serving of food or drink, and all food storage utensils should be thoroughly cleaned after each use. Cooking surfaces should be cleaned once a day with an approved germicide. Non-food contact surfaces should be cleaned at such intervals to keep them in clean and sanitary conditions.
  6. All utensils and equipment should be stored so as to drain, dry and be protected from splash, dust or contamination.
  7. Disposable containers and utensils should be discarded after one use.
  8. Dishwashers should be drained and flushed after each meal period. The machine should be maintained and operated according to manufacturer’s instructions. The dishwasher should maintain a final sanitizing rinse off at least 180°F and wash cycle of 160°F. Contact time shall be consistent with those on EPA-registered label use instructions. Stacking and emptying of the dishwasher should be done by separate personnel to prevent recontamination of dishes. In exceptional circumstances with only one person available, he or she must perform hand hygiene and put on a clean apron before handling clean dishes. Clean utensils and pans will be stored on clean surfaces at all times. All items stacked for storage will be allowed to air dry before stacking or cross-stacked completely.
  9. Steam tables must maintain hot foods at temperatures of 140°F or above and must not contaminate food held therein through splashing or condensation. Steam tables are not for warming food; they are for holding hot foods hot.
  10. Cold tables must keep cold foods below 41°F and are not used to refrigerate foods; they are for keeping cold foods cold.
  11. Ice machines should be of a type that eliminates contamination during ice manufacture, storage and dispensing. Ideally, ice should be dispensed by an ice machine. The outside of ice machines should be cleaned and sanitized daily. The inside of ice machines should be cleaned and preventive maintenance performed at a frequency specified by the manufacturer. If an ice scoop is necessary, hand hygiene should be conducted before, and gloves must be worn during the procedure. The scoop used with the ice storage chest should be held by the handle only. Unused ice should not be returned to the ice storage chest. The access door should remain closed except when removing ice. The ice scoop should be washed daily with detergent and hot water or run through a dishwasher. Alternatively, the scoop may be disinfected by immersing in a 1:100 dilution of bleach and water. The ice scoop should be stored in a tray or holder when not in use. The ice chest should be cleaned after use and when visibly soiled with detergent and hot water.
  12. Knives should be cleaned, sanitized, and dried before storing in fabric knife bags. The real knife bags should be cleaned and disinfected once weekly and when soiled.
  13. The blades and shafts of the non-electric can openers are sanitized daily in the dishwasher. The electric can openers are wiped daily with a sanitizing solution.

Daily Cleaning

  1. Ranges and grills should be cleaned daily with grease-release cleaner.
  2. All work surfaces and counters are cleaned and sanitized daily and more frequently as needed. Utensils and equipment should be cleaned and sanitized after each use.
  3. Holding refrigerators and hot holding units will be cleaned daily.
  4. All floor surfaces must be wet-mopped daily and as needed with an EPA-registered germicidal detergent. Mops and brooms should not be left in food preparation areas when not in immediate use.
  5. All agents used for cleaning equipment and utensils must be approved for that use.
  6. All garbage is removed and handled safely for sanitation purposes. Garbage cans should be stored away from food preparation areas.

 

Patient

Regular Patient Service

  1. Individual portions of food not consumed by the patient will be discarded.
  2. Nutrition and Food Services personnel are responsible for clearing the bedside table, serving the food tray to the patient and removing the plate at the completion of the meal. Hand hygiene should be performed before entering and after leaving each patient room. Gloves should not be worn except to deliver and pick up trays for patients on Contact Precautions/Enteric Contact Precautions. If gloves are worn, they must be changed and hand hygiene performed between each patient room.

 

Isolation Patient Service

  1. After appropriate training, dietary personnel may enter the rooms of patients on Airborne Precautions (requires medical clearance and fit-testing), Droplet Precautions, Contact Precautions, Enteric Contact Precautions or Protective Precautions. A sign will be posted outside the patient’s door stating the type of isolation precautions required.
  2. Contact Isolation/Enteric Contact Precautions: Clean exam gloves are worn to deliver and pick up the tray for patients on Contact and Enteric Contact Precautions. Gowns should be worn if there will be direct patient contact or whenever clothing may contact surfaces in the room. Gloves/gown should be removed and hand hygiene performed upon leaving the patient’s room and before handling the food tray for the next patient. For patients on Enteric Precautions, hand hygiene must be carried out with soap and water.

 

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