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Hospital food hygiene: The application of hazard analysis critical control points to conventional hospital catering
Journal
of Hospital
Infection
(1993) 24, 273-282
Hospital food hygiene: The application of Hazard Analysis Critical Control Points to conventional hospital catering J. Richards*,
E. Parrj-
and P. RiseboroughS
Public Health Laboratory* and Catering Department?, West Norwich Hospital; Environmental Health OficeS, Norwich City Council, Norwich, UK Accepted for publication
30 April
1993
Summary: The Hazard Analysis Critical Control Point (HACCP) concept is a preventive approach to quality control. It is based on a logical, structured exploration of potential hazard points in a food operation and the introduction of control and monitoring measures. HACCP studies have been extensively applied to manufacturing systems. It has been difficult to extend this detailed systematic analysis to conventional catering, partly due to the wide range of foods being processed. We describe here the application of HACCP methods to a hospital department that uses conventional catering methods. Basic principles, based on the work flow and the range of products are established. The guidelines produced can be applied to any kitchen using similar catering methods. Examples of log charts used for monitoring are provided. Keywords:
Hazard
Analysis
Critical
Control
Point;
hospital
catering.
Introduction The concept of Hazard Analysis Critical Control Points (HACCP) has been used and actively promoted by the food industry for over 20 years, and has been accepted nationally and internationally as a powerful tool for ensuring food quality and safety. HACCP is a logical, structured approach to the analysis and control of the potential hazard points in a food operation. This simple and logical system makes it an ideal tool for hospital infection control and food hygiene practices, yet to date only limited work has been done on its application to these areas. ’ Early workers in the field of food hygiene2 applied HACCP principles to catering practices but concentrated mainly on foods and processes already perceived as high risk.3 Some large cook-chill and cook-freeze production units were also able to adopt * Correspondence Norwich Hospital, 0195%6701.‘93r080273+
to: Dr J. Richards, Consultant Microbiologist, Bowthorpe Road, Norwich NR2 3TX.
Public
Health
Laboratory,
c 1993 The Hospml
10 908 ON0
273
lnfectxm
West
Society
274
J. Richards
et al.
HACCP systems.4 To our knowledge few attempts have been made at obtaining a total evaluation of kitchen facilities,5’6 possibly because of the wide range of foods being assessed. We describe here the application of HACCP by a Hospital Food Hygiene Committee to a hospital kitchen employing conventional catering practices. The introduction of the 1990 Food Act,7 with its emphasis on self assessment and self regulation (due diligence defence) provided the impetus for the Norwich Food Hygiene Committee to initiate an evaluation of practices in one of its kitchens. The West Norwich Hospital kitchen already functions at a high quality level in areas such as preparation and delivery of nutritious and palatable food. It was awarded the Heart Beat Award in 1991 and is a catering department with highly motivated staff, whose keenness was seen as an important factor in establishing a team that would not be afraid to examine critically its practices. The agreed aim of the exercise was ‘to promote risk assessment and self evaluation by means of a HACCP exercise’. Methods The team The first in the series of interlocking steps that form the HACCP method is the assembly of the team. It normally entails a multidisciplinary approach, involving key members of all the areas associated with the products under consideration. Selected members of the Norwich District Food Hygiene Committee attended a series of preliminary meetings. It was decided that a team consisting of Catering Manager (l), Senior Chefs (4), Servery and Ward Waitress Supervisors (2), Consultant Microbiologist (l), Environmental Health Officer (EHO) (1) and Hospital Manager (1) would constitute the core group with others, such as representatives of the Works Department, co-opted as required. The product The next step in HACCP is the description of the product, identification of its use, and a careful description of all steps involved in the process. The variety of procedures used in the kitchen and the complexity of the operation made it very difficult to apply strictly conventional HACCP criteria. The team decided instead to divide all the categories of foods purchased and processed into fresh and frozen, meat, poultry, dairy etc, and examine each of them separately under headings representing the flow of work from purchase and delivery through preparation and cooking to serving (Figure 1). The hazards At this stage, potential described. As food
hazards were identified, and preventive measures poisoning was perceived as the main risk,
HACCP in conventional Purchase
hospital
catering
275
and delivery I
Preparation
Defrost
4 * Storage
(2)
cooking I
t Cold hold I
Reheating : Hold
Delivery
I
I
Figure 1. Flow diagram for the steps involved in processing food in the kitchen. microbiological hazards and their preventive measures were listed. Physical hazards such as the presence of foreign bodies were also taken into consideration. To complement the assessment of theoretical microbiological hazards, and to provide a useful database for future audit, environmental and food sampling was carried out. Sampling was performed at stages of the food production where hazards had been identified. Food samples included steak and kidney pie, roast beef, turkey curry, beef stew, vegetable pizza, cottage pie and gravy. Total viable counts (TVC) were obtained by spiral plating on to Plate count agar (Oxoid, Basingstoke, Herts.). Coliforms including Escherichia coli were enumerated by the Most Probable Number (MPN) method as described in the Public Health Laboratory Service (PHLS) Food Method Manual.8 Isolation and enumeration of Salmonella and Listeria spp. in 25 g of food and isolation methods for Staphylococcus aweus and Clostridium perfringens were based on methods published in British Standard (BS) 5763.9 Limits of acceptability were defined in accordance with guidelines recently published by the PHLS.‘” Critical control points (CCPs) The determination of CCPs is The HACCP ‘decision tree’ process. A decision is reached and preventive measures, and the product.
the most crucial step in (Figure 2) is applied about the relevance of how critical they are in
the HACCP analysis. to every step of the all the control points ensuring the safety of
Application of controls Once the critical control points have been established, the exact limits required for each preventive measure to be effective have to be specified.
J. Richards
276
et al.
Hazard
-
This hazard is not a Critical Control Point A m
V
-
Could contamination due to identified hazard occur in excess of an acceptable level or could this fi;;;se to an unacceptable
No
Figure
2. The HACCP
‘decision tree’.
Simple and easily measurable characteristics such as temperature, pH, available chlorine are preferred. Target values, and limits of acceptability, are set. For each of these points a monitoring system is established, and the team agrees on what action to take if these limits are breached. A member of staff is designated both to carry out the monitoring, and to take remedial action if a fault is found. The final step in the whole process is to verify that the controls are in place, and audit the monitoring system. Random bacteriological checks were incorporated to this stage of the exercise as part of the validation exercise. The same methods as described in the previous section were applied. Foods sampled included beef casserole, chicken curry, steak and kidney pies, liver stew, and lasagna. These products were sampled shortly after
HACCP in conventional Table Food
I. Summary
of hazard
Production
type
Fresh vegetables
(salad)
phase
Preparation: cooking Cooking
Meat: beef/lamb/pork/poultry Meat: beef/lamb/pork/poultry
Storage
Meat: beef/lamb/pork/poultry
Slicing
Re-heating
control
points Control
Hazard
during
Cross-contamination; excessive contamination of wash/rinse water Inadequate cooking temperature Inadequate bacterial kill if required cooking temperature not achieved Overgrowth of bacteria/spores/toxins Cross contamination
Inadequate kill
277
catering
and critical
Inappropriate temperature delivery
Preparation: washing and slicing
Fresh vegetables (cooked) Meat: beef/lamb/pork/poultry
cooking, portions
analysis
Delivery
Frozen
hospital
bacterial
measures
Check van’s temperature chart and temperature on delivery Chlorination of wash water. Slicing and chopping in clean area Ensure water is boiling Ensure required cooking temperatures are reached by probing joints Quick chill and storage at 4°C Clean slicing machine. Do not slice cooked and processed meats in same session Ensure required temperatures are reached by temperature probing
and between 60 and 90 min later, as they were served in individual on the wards. Results
The HACCP Team met approximately every 3 weeks for the first 6 months of the study. Given the complexity of the kitchen activities, and the numerous processes carried out on a regular basis, it was decided to examine foods under the following categories: Frozen (meats, vegetables, fish); fresh vegetables; fresh meats; bread; milk; dry goods (including cans and packed drinks); eggs; cooked meats; dairy produce (including cheese, butter, margarine, yoghurts). Following the application of the steps outlined in the methods section, the hazards and CCPs shown in Table I were identified. The risks identified were in four areas: procurement (purchase and delivery), preparation (peeling, mixing, slicing, shaping), cooking (baking, roasting, stewing, reheating) and hold/storage. Time/temperature control was perceived as the most critical point throughout the whole process. Stringent standards were set to ensure adequate delivery, cooking and hold temperatures. Microbiological sampling did not detect any significant bacteriological problem. Total viable counts in all areas sampled were within acceptable limits, and no pathogens were found.
J. Richards
278 Table
II. Sampling following TVC
Steak & kidney pie Roast beef Turkey curry Beef stew Vegetable pizza Cottage pie Gravy
x x x x x
al.
identi’catin
(cfu g-‘)
2.0 1.7 3.5 2.1 8.0
et
105 106 105 lo5 lo5
2.8 x lo5 7.5 x 104
of hazards and CCPs Coliforms
(g-i)
E. coli (g-l)
40
9
Limits of acceptability TVC: satisfactory < 10’; fairly satisfactory 10’ to 106; unsatisfactory coli: satisfactory < 20; fairly satisfactory 20 to 10’; unsatisfactory > 10’.
Table
III. TVC
Beef casserole Beef casserole Chicken curry Chicken curry Steak & kidney Steak & kidney Lasagna (1) Lasagna (2) Liver stew (1) Liver stew (2)
(1) (2) (1) (2) (1) (2)
Random sampling, validation
stage
Coliform
(g-i)
(cfu g-‘)
Cl.0 Cl.0 Cl.0
x x x x x x x x x x
103 103 10’ IO’ IO’ 103 10’ IO’ lo3 103
E. coli (g-‘)
<3 <3 <3 <3 <3 <3 <3 <3 <3 <3
(1) sampled in kitchen; (2) sampled on wards. Limits of acceptability
> 106; E.
<3 x3 <3 <3 <3 <3 <3 <3 <3 <3 as per Table II.
The results of the TV&, coliform and E. coli counts are summarized in Tables I I and I I I. No Staphylococcus aureus, Salmonella spp., Listeria spp. or C. perfringens were isolated in any of the samples. While setting the standards, it was realized that some of the existing working practices would have to be modified to ensure an effective control at some of the hazard points, and to facilitate monitoring. These required extensive consultation with the rest of the kitchen staff, and resulted in changing practices such as modification of the times during the day when cooked meats were sliced, to allow a more effective cleaning schedule of the slicing machine. Additional changes are listed next to each CP in Table IV. Log charts were devised for each section where a CCP had been identified (Figure 3). Chefs or senior cooks were nominated in each section as being responsible for the monitoring of these charts, and given the authority to take corrective action as required. It was also agreed that when any such action had to be taken, this would also be logged, and signed by the person in charge. After the system had been in operation for 3 months, the Environmental Health Officer in the team and a colleague (acting as an outside observer)
HACCP in conventional Table Control
hospital
catering
279
IV. Changes introduced in working practices as a result of HACCP
point
Delivery of milk in glass containers with foil tops Hypochlorite rinse for salads and vegetables Cleaning of meat slicing machine between meat products Control of salmonella risk from eggs Purchase and delivery of meat and poultry Delivery of all perishable/frozen products at adequate temperatures
Changes
introduced
Purchase
of milk
in plastic
containers
All vegetables to be washed a.m., with constant monitoring of hypochlorite levels All meat products to be sliced at quiet time p.m., cooked meats first, with adequate cleaning schedules between products Cease offering lightly boiled eggs to patients. Purchase only from local egg producers that could ensure lay-date and Salmonella-free flocks Purchase only from producers able to ensure refrigerated delivery. Revision of contracts. Negotiate delivery only during kitchen working hours when staff available to receive and check product and temperatures.
Figure 3. Example of log chart for recording food temperatives at supper meal. Notes: Target cooked temperature is 80”C-if this is not reached when probed continue cooking. Holding temperature refers to time prior to plating the meals. Service temperature refers to the time the meal is taken out of the trolley to be served.
280
J. Richards
et al.
audited the whole process, critically examining the completion of the log charts, the corrective actions taken when required, and ascertaining the value and efficiency of the changes in working practices.
Discussion
The HACCP approach is becoming increasingly accepted as a valuable means of ensuring quality and safety in food production services. It offers a number of advantages over conventional end-point testing, which include the identification of potential hazards before they occur, its proactive approach to prevention and its application to the whole process rather than just the areas sampled. The system has received national and international recognition. The recent report on the Microbiological Safety of Food,” made frequent references to it, and the Codex Alimentarius Commission has drawn up a HACCP code, in an attempt to establish an internationally agreed set of principles.12 Although there is no legal requirement to introduce HACCP, many organizations see the introduction of an effective HACCP system as an important step in the development of a ‘due diligence defence’ (section 21 of the 1990 Food Safety Act). The system presents itself as a logical, step by step approach to the analysis of potential hazards and to their control. Various areas of infection control would benefit from a systematic exploration of hazard points, and an analysis of preventive measures. The management of central intravenous and feeding lines, disinfection of endoscopes, venesection and the use of peripheral lines are just a few examples. Microbiologists and Infection Control Officers have been rather slow in applying the methods to the field of Hospital Food Hygiene and Infection Control. Food hygiene in hospital catering usually falls within the remit of hospital infection control. It is no different from conventional ‘outside’ catering and yet to date most of our efforts have been directed towards the traditional approach of inspection and examination of premises and practices, supplemented by end product bacteriological sampling. This approach has been seen as a threat by staff, who until now had very little control over their own practices. By carrying out this HACCP exercise we achieved a high degree of involvement of all levels of staff. Actual practices were compared with theoretical ones. In devolving responsibility to the employees carrying out the day to day activities, their interest in improving practices was reinforced. As the monitoring systems were introduced and practices changed during their implementation, all the groups involved felt that their contribution was valuable. The multidisciplinary team effort also improved the interaction with the local EHOs. The relationship became less confrontational. Their contribution to discussions on standards and
HACCP in conventional
hospital
281
catering
monitoring was seen as valuable and their expertise in interpreting the law provided useful insight. The traditional HACCP approach used in food manufacturing has concentrated on one or two products at a time, dissecting the manufacturing process carefully into its component parts. Some of the early workers in the field applied HACCP principles to catering establishments, looking at food items already considered to be high risk, such as scrambled eggs, pork, beef, chicken and sausages. 3 Bobeng applied the concept to the study of entree production, using the risk of salmonellosis as the identified microbiological hazard.13 In our study we tried to take into account all the possible microbiological risks. Given the large number of food products under consideration, and the diversity of processes involved, it was decided to analyse them from a general viewpoint. We thus attempted to establish some basic principles which can be applied to all the products and processes considered to present similar risks. This approach has enabled us to produce some guidelines for our catering department which are applicable to other hospital kitchens. The use of log charts not only serves its primary function of monitoring agreed standards, but constantly reminds staff of the need to be vigilant, and prompts immediate preventive action when there is a system failure. The regular inspection by EHOs is now not seen as a threat, but as an important part of the audit loop, providing reinforcing messages about the quality of the work carried out and the performance of the catering department in the area of food hygiene. We thank all the members collaboration.
of the West
Norwich
Hospital
catering
department
for their
Other members of HACCP team were: Mr W. Gibbons, Assistant Hospital Manager; Mr D. Green, Head Chef; Mr T. Cooper, Head Chef; Mr S. Coote, Assistant Head Chef; Mr P. Bush, Dining Room Supervisor; Mrs S. Machin, Ward Supervisor; Mrs P. White-Miller, Ward Supervisor; Mrs A Perkin, Ward Supervisor; Mrs S. Nappin, Ward Supervisor.
References 1. Hunter PR. Applications of Hazard Analysis Critical Control Point (HACCP) to the handling of expressed breast milk on a neonatal unit. J Hosp Infect 1991; 17: 139-146. 2. Bryan FL. Hazard Analysis Critical Control Point approach: epidemiological rationale and application to foodservice operations. J Environ Health 1981; 44: 7-14. 3. Bryan FL, Lyon JB. Critical Control Points of hospital foodservice operations. J Food Protect 1984; 47: 95&963. 4. Department of Health. Chilled and Frozen. Guidelines on cook-chill and cook-freeze catering systems. London: HMSO, 1989. 5. Bobeng BJ, David BD. HACCP Models for quality control of entree production in foodservice systems. J Food Protect 1977; 40: 632-638. 6. Bryan FL. Hazard analysis of food service operations. Food Technology 1981; 78887. Food Safety Act 1990-London: HMSO, 1990. i: Guidelines for the Microbiological Assessment of Foods. Method 2.6, PHLS, 1986. 9. Microbiological Examination of Food and Animal Feeding Stuffs. BS 5763. BSI 1991.
282
J. Richards
et al.
10. Gilbert RJ. Provisional microbiological guidelines for some ready-to-eat foods sampled at point of sale. Notes for PHLS food examiners. PHLS Microbial Digest 1992; 9: 98-99. 11. The Microbiological Safety of Food, Parts I & II. Committee on the Microbiological Safety of Food. (Chairman, Sir Mark Richmond) London: HMSO, 1990, 1991. 12. Codex Alimentarius Commission. Draft principles and application of the HACCP system. Codex Alimentarius Commission Dot Alinorm 93/l 3 Appx VI 1991. 13. Bobeng BJ, David BD. Development of Hazard Analysis Critical Control Points model. HACCP models for Q C of entree production in hospital foodservice systems. J Am
Dietetic Assoc 1978; 73: 524429.
of Hospital
Infection
(1993) 24, 273-282
Hospital food hygiene: The application of Hazard Analysis Critical Control Points to conventional hospital catering J. Richards*,
E. Parrj-
and P. RiseboroughS
Public Health Laboratory* and Catering Department?, West Norwich Hospital; Environmental Health OficeS, Norwich City Council, Norwich, UK Accepted for publication
30 April
1993
Summary: The Hazard Analysis Critical Control Point (HACCP) concept is a preventive approach to quality control. It is based on a logical, structured exploration of potential hazard points in a food operation and the introduction of control and monitoring measures. HACCP studies have been extensively applied to manufacturing systems. It has been difficult to extend this detailed systematic analysis to conventional catering, partly due to the wide range of foods being processed. We describe here the application of HACCP methods to a hospital department that uses conventional catering methods. Basic principles, based on the work flow and the range of products are established. The guidelines produced can be applied to any kitchen using similar catering methods. Examples of log charts used for monitoring are provided. Keywords:
Hazard
Analysis
Critical
Control
Point;
hospital
catering.
Introduction The concept of Hazard Analysis Critical Control Points (HACCP) has been used and actively promoted by the food industry for over 20 years, and has been accepted nationally and internationally as a powerful tool for ensuring food quality and safety. HACCP is a logical, structured approach to the analysis and control of the potential hazard points in a food operation. This simple and logical system makes it an ideal tool for hospital infection control and food hygiene practices, yet to date only limited work has been done on its application to these areas. ’ Early workers in the field of food hygiene2 applied HACCP principles to catering practices but concentrated mainly on foods and processes already perceived as high risk.3 Some large cook-chill and cook-freeze production units were also able to adopt * Correspondence Norwich Hospital, 0195%6701.‘93r080273+
to: Dr J. Richards, Consultant Microbiologist, Bowthorpe Road, Norwich NR2 3TX.
Public
Health
Laboratory,
c 1993 The Hospml
10 908 ON0
273
lnfectxm
West
Society
274
J. Richards
et al.
HACCP systems.4 To our knowledge few attempts have been made at obtaining a total evaluation of kitchen facilities,5’6 possibly because of the wide range of foods being assessed. We describe here the application of HACCP by a Hospital Food Hygiene Committee to a hospital kitchen employing conventional catering practices. The introduction of the 1990 Food Act,7 with its emphasis on self assessment and self regulation (due diligence defence) provided the impetus for the Norwich Food Hygiene Committee to initiate an evaluation of practices in one of its kitchens. The West Norwich Hospital kitchen already functions at a high quality level in areas such as preparation and delivery of nutritious and palatable food. It was awarded the Heart Beat Award in 1991 and is a catering department with highly motivated staff, whose keenness was seen as an important factor in establishing a team that would not be afraid to examine critically its practices. The agreed aim of the exercise was ‘to promote risk assessment and self evaluation by means of a HACCP exercise’. Methods The team The first in the series of interlocking steps that form the HACCP method is the assembly of the team. It normally entails a multidisciplinary approach, involving key members of all the areas associated with the products under consideration. Selected members of the Norwich District Food Hygiene Committee attended a series of preliminary meetings. It was decided that a team consisting of Catering Manager (l), Senior Chefs (4), Servery and Ward Waitress Supervisors (2), Consultant Microbiologist (l), Environmental Health Officer (EHO) (1) and Hospital Manager (1) would constitute the core group with others, such as representatives of the Works Department, co-opted as required. The product The next step in HACCP is the description of the product, identification of its use, and a careful description of all steps involved in the process. The variety of procedures used in the kitchen and the complexity of the operation made it very difficult to apply strictly conventional HACCP criteria. The team decided instead to divide all the categories of foods purchased and processed into fresh and frozen, meat, poultry, dairy etc, and examine each of them separately under headings representing the flow of work from purchase and delivery through preparation and cooking to serving (Figure 1). The hazards At this stage, potential described. As food
hazards were identified, and preventive measures poisoning was perceived as the main risk,
HACCP in conventional Purchase
hospital
catering
275
and delivery I
Preparation
Defrost
4 * Storage
(2)
cooking I
t Cold hold I
Reheating : Hold
Delivery
I
I
Figure 1. Flow diagram for the steps involved in processing food in the kitchen. microbiological hazards and their preventive measures were listed. Physical hazards such as the presence of foreign bodies were also taken into consideration. To complement the assessment of theoretical microbiological hazards, and to provide a useful database for future audit, environmental and food sampling was carried out. Sampling was performed at stages of the food production where hazards had been identified. Food samples included steak and kidney pie, roast beef, turkey curry, beef stew, vegetable pizza, cottage pie and gravy. Total viable counts (TVC) were obtained by spiral plating on to Plate count agar (Oxoid, Basingstoke, Herts.). Coliforms including Escherichia coli were enumerated by the Most Probable Number (MPN) method as described in the Public Health Laboratory Service (PHLS) Food Method Manual.8 Isolation and enumeration of Salmonella and Listeria spp. in 25 g of food and isolation methods for Staphylococcus aweus and Clostridium perfringens were based on methods published in British Standard (BS) 5763.9 Limits of acceptability were defined in accordance with guidelines recently published by the PHLS.‘” Critical control points (CCPs) The determination of CCPs is The HACCP ‘decision tree’ process. A decision is reached and preventive measures, and the product.
the most crucial step in (Figure 2) is applied about the relevance of how critical they are in
the HACCP analysis. to every step of the all the control points ensuring the safety of
Application of controls Once the critical control points have been established, the exact limits required for each preventive measure to be effective have to be specified.
J. Richards
276
et al.
Hazard
-
This hazard is not a Critical Control Point A m
V
-
Could contamination due to identified hazard occur in excess of an acceptable level or could this fi;;;se to an unacceptable
No
Figure
2. The HACCP
‘decision tree’.
Simple and easily measurable characteristics such as temperature, pH, available chlorine are preferred. Target values, and limits of acceptability, are set. For each of these points a monitoring system is established, and the team agrees on what action to take if these limits are breached. A member of staff is designated both to carry out the monitoring, and to take remedial action if a fault is found. The final step in the whole process is to verify that the controls are in place, and audit the monitoring system. Random bacteriological checks were incorporated to this stage of the exercise as part of the validation exercise. The same methods as described in the previous section were applied. Foods sampled included beef casserole, chicken curry, steak and kidney pies, liver stew, and lasagna. These products were sampled shortly after
HACCP in conventional Table Food
I. Summary
of hazard
Production
type
Fresh vegetables
(salad)
phase
Preparation: cooking Cooking
Meat: beef/lamb/pork/poultry Meat: beef/lamb/pork/poultry
Storage
Meat: beef/lamb/pork/poultry
Slicing
Re-heating
control
points Control
Hazard
during
Cross-contamination; excessive contamination of wash/rinse water Inadequate cooking temperature Inadequate bacterial kill if required cooking temperature not achieved Overgrowth of bacteria/spores/toxins Cross contamination
Inadequate kill
277
catering
and critical
Inappropriate temperature delivery
Preparation: washing and slicing
Fresh vegetables (cooked) Meat: beef/lamb/pork/poultry
cooking, portions
analysis
Delivery
Frozen
hospital
bacterial
measures
Check van’s temperature chart and temperature on delivery Chlorination of wash water. Slicing and chopping in clean area Ensure water is boiling Ensure required cooking temperatures are reached by probing joints Quick chill and storage at 4°C Clean slicing machine. Do not slice cooked and processed meats in same session Ensure required temperatures are reached by temperature probing
and between 60 and 90 min later, as they were served in individual on the wards. Results
The HACCP Team met approximately every 3 weeks for the first 6 months of the study. Given the complexity of the kitchen activities, and the numerous processes carried out on a regular basis, it was decided to examine foods under the following categories: Frozen (meats, vegetables, fish); fresh vegetables; fresh meats; bread; milk; dry goods (including cans and packed drinks); eggs; cooked meats; dairy produce (including cheese, butter, margarine, yoghurts). Following the application of the steps outlined in the methods section, the hazards and CCPs shown in Table I were identified. The risks identified were in four areas: procurement (purchase and delivery), preparation (peeling, mixing, slicing, shaping), cooking (baking, roasting, stewing, reheating) and hold/storage. Time/temperature control was perceived as the most critical point throughout the whole process. Stringent standards were set to ensure adequate delivery, cooking and hold temperatures. Microbiological sampling did not detect any significant bacteriological problem. Total viable counts in all areas sampled were within acceptable limits, and no pathogens were found.
J. Richards
278 Table
II. Sampling following TVC
Steak & kidney pie Roast beef Turkey curry Beef stew Vegetable pizza Cottage pie Gravy
x x x x x
al.
identi’catin
(cfu g-‘)
2.0 1.7 3.5 2.1 8.0
et
105 106 105 lo5 lo5
2.8 x lo5 7.5 x 104
of hazards and CCPs Coliforms
(g-i)
E. coli (g-l)
40
9
Limits of acceptability TVC: satisfactory < 10’; fairly satisfactory 10’ to 106; unsatisfactory coli: satisfactory < 20; fairly satisfactory 20 to 10’; unsatisfactory > 10’.
Table
III. TVC
Beef casserole Beef casserole Chicken curry Chicken curry Steak & kidney Steak & kidney Lasagna (1) Lasagna (2) Liver stew (1) Liver stew (2)
(1) (2) (1) (2) (1) (2)
Random sampling, validation
stage
Coliform
(g-i)
(cfu g-‘)
Cl.0 Cl.0 Cl.0
x x x x x x x x x x
103 103 10’ IO’ IO’ 103 10’ IO’ lo3 103
E. coli (g-‘)
<3 <3 <3 <3 <3 <3 <3 <3 <3 <3
(1) sampled in kitchen; (2) sampled on wards. Limits of acceptability
> 106; E.
<3 x3 <3 <3 <3 <3 <3 <3 <3 <3 as per Table II.
The results of the TV&, coliform and E. coli counts are summarized in Tables I I and I I I. No Staphylococcus aureus, Salmonella spp., Listeria spp. or C. perfringens were isolated in any of the samples. While setting the standards, it was realized that some of the existing working practices would have to be modified to ensure an effective control at some of the hazard points, and to facilitate monitoring. These required extensive consultation with the rest of the kitchen staff, and resulted in changing practices such as modification of the times during the day when cooked meats were sliced, to allow a more effective cleaning schedule of the slicing machine. Additional changes are listed next to each CP in Table IV. Log charts were devised for each section where a CCP had been identified (Figure 3). Chefs or senior cooks were nominated in each section as being responsible for the monitoring of these charts, and given the authority to take corrective action as required. It was also agreed that when any such action had to be taken, this would also be logged, and signed by the person in charge. After the system had been in operation for 3 months, the Environmental Health Officer in the team and a colleague (acting as an outside observer)
HACCP in conventional Table Control
hospital
catering
279
IV. Changes introduced in working practices as a result of HACCP
point
Delivery of milk in glass containers with foil tops Hypochlorite rinse for salads and vegetables Cleaning of meat slicing machine between meat products Control of salmonella risk from eggs Purchase and delivery of meat and poultry Delivery of all perishable/frozen products at adequate temperatures
Changes
introduced
Purchase
of milk
in plastic
containers
All vegetables to be washed a.m., with constant monitoring of hypochlorite levels All meat products to be sliced at quiet time p.m., cooked meats first, with adequate cleaning schedules between products Cease offering lightly boiled eggs to patients. Purchase only from local egg producers that could ensure lay-date and Salmonella-free flocks Purchase only from producers able to ensure refrigerated delivery. Revision of contracts. Negotiate delivery only during kitchen working hours when staff available to receive and check product and temperatures.
Figure 3. Example of log chart for recording food temperatives at supper meal. Notes: Target cooked temperature is 80”C-if this is not reached when probed continue cooking. Holding temperature refers to time prior to plating the meals. Service temperature refers to the time the meal is taken out of the trolley to be served.
280
J. Richards
et al.
audited the whole process, critically examining the completion of the log charts, the corrective actions taken when required, and ascertaining the value and efficiency of the changes in working practices.
Discussion
The HACCP approach is becoming increasingly accepted as a valuable means of ensuring quality and safety in food production services. It offers a number of advantages over conventional end-point testing, which include the identification of potential hazards before they occur, its proactive approach to prevention and its application to the whole process rather than just the areas sampled. The system has received national and international recognition. The recent report on the Microbiological Safety of Food,” made frequent references to it, and the Codex Alimentarius Commission has drawn up a HACCP code, in an attempt to establish an internationally agreed set of principles.12 Although there is no legal requirement to introduce HACCP, many organizations see the introduction of an effective HACCP system as an important step in the development of a ‘due diligence defence’ (section 21 of the 1990 Food Safety Act). The system presents itself as a logical, step by step approach to the analysis of potential hazards and to their control. Various areas of infection control would benefit from a systematic exploration of hazard points, and an analysis of preventive measures. The management of central intravenous and feeding lines, disinfection of endoscopes, venesection and the use of peripheral lines are just a few examples. Microbiologists and Infection Control Officers have been rather slow in applying the methods to the field of Hospital Food Hygiene and Infection Control. Food hygiene in hospital catering usually falls within the remit of hospital infection control. It is no different from conventional ‘outside’ catering and yet to date most of our efforts have been directed towards the traditional approach of inspection and examination of premises and practices, supplemented by end product bacteriological sampling. This approach has been seen as a threat by staff, who until now had very little control over their own practices. By carrying out this HACCP exercise we achieved a high degree of involvement of all levels of staff. Actual practices were compared with theoretical ones. In devolving responsibility to the employees carrying out the day to day activities, their interest in improving practices was reinforced. As the monitoring systems were introduced and practices changed during their implementation, all the groups involved felt that their contribution was valuable. The multidisciplinary team effort also improved the interaction with the local EHOs. The relationship became less confrontational. Their contribution to discussions on standards and
HACCP in conventional
hospital
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catering
monitoring was seen as valuable and their expertise in interpreting the law provided useful insight. The traditional HACCP approach used in food manufacturing has concentrated on one or two products at a time, dissecting the manufacturing process carefully into its component parts. Some of the early workers in the field applied HACCP principles to catering establishments, looking at food items already considered to be high risk, such as scrambled eggs, pork, beef, chicken and sausages. 3 Bobeng applied the concept to the study of entree production, using the risk of salmonellosis as the identified microbiological hazard.13 In our study we tried to take into account all the possible microbiological risks. Given the large number of food products under consideration, and the diversity of processes involved, it was decided to analyse them from a general viewpoint. We thus attempted to establish some basic principles which can be applied to all the products and processes considered to present similar risks. This approach has enabled us to produce some guidelines for our catering department which are applicable to other hospital kitchens. The use of log charts not only serves its primary function of monitoring agreed standards, but constantly reminds staff of the need to be vigilant, and prompts immediate preventive action when there is a system failure. The regular inspection by EHOs is now not seen as a threat, but as an important part of the audit loop, providing reinforcing messages about the quality of the work carried out and the performance of the catering department in the area of food hygiene. We thank all the members collaboration.
of the West
Norwich
Hospital
catering
department
for their
Other members of HACCP team were: Mr W. Gibbons, Assistant Hospital Manager; Mr D. Green, Head Chef; Mr T. Cooper, Head Chef; Mr S. Coote, Assistant Head Chef; Mr P. Bush, Dining Room Supervisor; Mrs S. Machin, Ward Supervisor; Mrs P. White-Miller, Ward Supervisor; Mrs A Perkin, Ward Supervisor; Mrs S. Nappin, Ward Supervisor.
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10. Gilbert RJ. Provisional microbiological guidelines for some ready-to-eat foods sampled at point of sale. Notes for PHLS food examiners. PHLS Microbial Digest 1992; 9: 98-99. 11. The Microbiological Safety of Food, Parts I & II. Committee on the Microbiological Safety of Food. (Chairman, Sir Mark Richmond) London: HMSO, 1990, 1991. 12. Codex Alimentarius Commission. Draft principles and application of the HACCP system. Codex Alimentarius Commission Dot Alinorm 93/l 3 Appx VI 1991. 13. Bobeng BJ, David BD. Development of Hazard Analysis Critical Control Points model. HACCP models for Q C of entree production in hospital foodservice systems. J Am
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