LAUNDRY AND TEXTILE (LINEN) SERVICES

INFECTION CONTROL

The Centers for Disease Control and Prevention (CDC) has recognized that the risk of disease transmission associated with soiled linen is negligible^1-2. This statement was also addressed in the CDC’s universal precaution guidelines for prevention of transmission of bloodborne pathogens³. Rather than rigid rules, common sense and hygienic approaches for handling, processing and storage of textiles are recommended to reduce the risk of cross-infection. More than 5 billion pounds of soiled patient care textiles are produced annually by United States health-care facilities⁴. Many acute health care facilities are using off-site laundry facilities (National Association of Institutional Linen Management - NLM). Regardless of the use of "in-house" or off-site contract services, appropriate procedures are required to minimize potential nosocomial and occupational risks associated with soiled textiles handling⁵.

A few reports in the literature have suggested that textiles may have been the source of patient infections, including staphylococcal and Bacillus cereus, colonization, and infection in newborns, and antibiotic-resistant organisms in catheterized patients^6-12. The actual link between contaminated textiles and patient infections is not clear because the implicated organisms were generally found in multiple environmental sources and also on the hands of health-care workers. The textiles may have been intrinsically contaminated or secondarily contaminated from airborne organisms or by the hands of personnel or from infected/colonized patients.

When occupational infection occurred, it was generally found in laundry personnel who did not wear appropriate barriers such as gowns or gloves or were inconsistent in washing their hands. Infections in laundry personnel are rare and have been associated primarily with handling of soiled textiles. Reported infections in laundry workers over the past 50 years have included Q fever, Salmonella sp., fungal infections, hepatitis A, smallpox and scabies^13-25. Efforts to reduce occupational risk of infection transmission and/or exposure to laundry personnel primarily focuses on appropriate use of hand washing, protective barriers, removal of sharp objects, and reduction of the volume of blood, excreta, body fluids, excretion, and secretions in patient textiles²⁶.

The laundry facilities shall be designed, equipped and ventilated to reduce the dissemination of microorganisms onto finished textiles. The ventilation shall include adequate intake, filtration, air exchange rate (5 - 10 per hour) and exhaust in accordance with local, state and federal regulations²⁷.

Wherever located (within facility, off-site commercial operation or multi-center shared laundry), the soiled textile processing area should be separated from clean textile storage, patient care areas, food preparation areas and clean supply and equipment storage. Functional separation may be achieved by one or more methods including physical barriers, negative air pressure systems in the soiled linen area, or positive air flow from the clean area to the soiled linen area²⁷.

Soiled textiles should be collected in a manner that minimizes agitation to prevent contamination of the environment and personnel and should be appropriately bagged at the site of use¹. Textiles should be placed in bags that prevent leakage onto the environment or contamination of transporting personnel. Both plastic and cloth bags are available. Cloth bags are adequate for the majority of patient care textiles and require the same processing as their contents.

There is no infection control advantage of double-bagging soiled textiles unless the healthcare worker feels that the primary bag cannot contain the body fluids. Two studies have shown that single bagging found no significant levels of bacterial contamination outside the bag^26,28. Double bagging of soiled textiles is not necessary unless the primary bag leaks²⁹.

Transportation of collected and bagged textiles can be accomplished by hand cart or soiled linen chute. Linen chute use is often complicated by design problems including mechanical obstruction by overfilled linen bags. In addition, there have been concerns related to the use of linen chutes because of the piston action of textiles transported vertically, potentially discharging ground-level contamination to upper floors and patient care areas^30,31. However, there have been no documented infections associated with linen chutes.

The use of water-soluble bags is unnecessary for the following reasons: a. water-soluble bags increases the cost of bagging and processing; b. water-soluble bags dissolve only in hot water which may not be used in the initial flush of the laundry cycle if stain removal needs to be achieved; c. stains that can not be removed eliminate the possibility of reuse of the textile; d. textiles almost always have to be re-washed adding to the expense of processing; and e. non-textile materials may be present in the water soluble bag such as underpads, chucks or personal items that can create an increase in linting or may contain objects that may possibly damage equipment²⁷.

Special care should be taken to prevent worker contamination when collecting or handling soiled textiles. In situations in which the textiles are heavily soiled with blood or body fluids, protective barriers such as gowns (if soiling of clothing is anticipated) and gloves should be worn. The Occupational Safety and Health Administration (OSHA) blood-borne pathogens standard³² requires that specific procedures be followed by workers handling textiles "contaminated" with blood or other potentially infectious body fluids. These requirements include special precautions for bagging and handling of contaminated textiles and use of protective apparel to reduce the risk of employee exposure and sharp disposal device accessibility. In situations in which standard precautions (formerly called universal precautions)³³ are not practiced on all textiles, specifically labeled collection bags (color coded or marked with biohazard symbol) must be used³².

All personnel involved in collection, transport, sorting, and washing of soiled health-care textiles should be appropriately trained, have adequate access to hand washing facilities, use appropriate personal protective equipment (PPE), and be supervised to assure compliance with protective procedures^3,32.

Inadvertent disposal of foreign objects such as surgical instruments, chucks, remotes from television sets, dentures, eye glasses and hearing aids in linen bags is a common problem³⁴. Processing textiles without removing these objects can result in significant expense and extensive damage to laundry equipment. In addition, contaminated sharps in textiles, such as needles and surgical instruments, pose a risk of injury and occupational exposure and infection from blood-borne pathogens.

Standard precaution guidelines from the Centers for Disease Control and Prevention as well as the Occupational Safety and Health Administration’s blood-borne pathogen standard recommend against sorting and rinsing of soiled textiles in patient care areas^3,32. However, this requirement does not preclude the rinsing of textiles soiled with feces in dirty utility room hoppers that may be located on floors that house patients or residents³⁵.

The duration of time that soiled textiles may be stored before processing is related to practical issues such as stain removal and aesthetics rather than infection control concerns.

The laundering process is designed to remove organic soil and render the textile incapable of causing human illness³⁶. No microbiology standards exist to define "safe" levels of bacteria in textiles because of the variability in microbial survival, degree of soiling, specific laundering techniques employed, fabric content, and ability of various organisms to adhere to certain fabrics.There are many factors in the processing of textiles that contributes to a bacteriologically safe product: a. detergents act as surfactants and loosen and lifts the soil from the fibers; b. chlorine bleach if used has bactericidal and viricidal activity; c. rinsing creates mechanical action which induces soil removal; d. temperatures of 140 F or higher has bactericidal activity on non-spore forming organisms; e. sours (acids) shift the pH from 12 to around 5 which helps in the inactivation of organisms and reduces the risk of skin irritation; and f. drying and ironing (if performed) completes the destruction of organisms²⁷.

Surgical gowns and drapes that come into contact with the operative field must be sterile. Reusable gowns and drapes are usually sterilized by steam autoclave after laundering. Sterile linen in the nursery is no longer recommended by the American Academy of Pediatrics³⁷.

Back in the early 1960’s CDC advocated the use of 160^o F for 25 minutes to process textiles^1,2. This was based on a 1938 publication by Arnold³⁸ that the use of this temperature destroyed nearly all bacterial forms except spore formers. Lower temperatures were less effective because the types of soaps and detergents used during this time required hot water for emulsification. The newly developed synthetic detergents and enzymes in the past 10 years do not require high temperature laundering²⁷. 

Several studies have demonstrated that a significant reduction of microbial contamination could be achieved at a significantly lower water temperature (71.6° to 122° F, 22 - 50 C) if the laundry chemicals, including volume of bleach used, are carefully controlled^39,40. Both cold and hot water washing cycles that included the bleach cycle reduced bacterial counts in fabric by 3 log₁₀. An additional 0.5 to 1 log₁₀ reduction was produced during the drying cycle. Lower-temperature laundering processes were found to be comparable to high-temperature washes with regard to bacterial counts and species⁴¹. At the time these studies were published, annual cost savings attributable to "cold-water wash" were estimated to range between $17,000 and $33,000 for an average size hospital laundry⁴².

Clean and soiled textiles should be transported separately and in a manner that will minimize microbial contamination. The use of hampers or carts to transport soiled textiles should be appropriately cleaned before use in transporting clean textiles. Carts that are going to be used to store textiles on the floors (hallways) should have covers on them during the transportation and storage. These covers should not be removed or adjusted in a manner that will expose the textiles to common traffic²⁷.

Textiles that are normally processed in health care or hospitality settings do not need to be treated differently in order to obtain a "hypoallergenic quality". In the wash process, water is combined with precise quantities of detergent and alkaline builders to remove soil. Once the soil is suspended in the solution, chemicals such as bleach are added to assist in removing stains and destroying microorganisms. Temperatures of 140 F (higher temperatures may be needed for different formulations and not for infection control purposes) are used for oxidation, creating a more efficient stain removal. Two rinse cycles, a softener (does not need to be a bacteriostatic in quality), and a souring cycle are used after the bleaching process to ensure that the chemicals are removed and the pH of textiles (linens) drops to just below neutrality to match the pH of the human skin²⁷.

The following recommendations⁴⁷ are for the use of home-style washing machines to wash the personal clothing of residents and patients in healthcare settings:

a. Do not place clothing with bulk fecal matter in the washing machine. Bulk fecal matter should first be rinsed from the clothing. Rinsing of fecal matter from clothing, or any other linen, should be performed in a clinical sink (commonly called a hopper,) and follow the required policy for gowning and gloves.

b. Clothing should be transported to the washers in hamper bags or plastic bags that will minimize the potential for contamination of personal or the environment.

c. There is no need to wash clothing separately if it has been contaminated with blood. There is not a separate standard for the end result for washing clothing that has been contaminated with blood than for clothing that has none. The washing process must render blood contaminated clothing clean and sanitary. If the clothing has been grossly contaminated with blood (soaked or dripping), and if a cold water wash must be used, and, if a chlorine bleach cannot be used, then the grossly contaminated clothing should be washed once separately. After first washing, clothing which was grossly contaminated should be washed a second time. The second washing can be combined with other clothing.

d. It is critical that the washing machine not be overloaded. The water level in the washing machine should be higher than the top of the load of clothing. It is the complete submersing of the clothing in the water and the bath exchanges (successive fill, drain, fill, drain) which plays a critical role in removing soil and microorganisms.

e. When washing clothing, use detergents, bleaches, etc. that are designed for water washing of linen. Do not add other chemical disinfectants that are not part of normal washing products (i.e. Lysolâ ) to the wash cycle. These products can actually inhibit the effectiveness of detergent and bleaching action.

f. Do not add extra wash chemicals. The premise that more is better does not work in the laundering process. Too much detergent can create over sudsing that can actually reduce the soil removing capacity of the water.

g. It is possible for the opening to the washing machine to be contaminated when loading grossly soiled clothing. When this happens, clean the area around the door of the washing machine to prevent contamination of the clean textile when removing the washed linen from the machine. A general cleaning agent or disinfectant can be used. The mechanical action used to clean around the door is more important than the cleaning agent. In other words, disinfectants are not a substitute for the cleaning action itself.

h. Wash hands after placing soiled linens in the washing machine.

i. There are no requirements to clean or disinfectant the inside of the washing machine between loads. The washing process, which cleans the clothing also, cleans the inside of the washing machine. If the inside of the washing machine is not clean, than neither are the clothes. In addition, the design of a washing machine is such that it is not practical to physically clean the machine. There is an inner, perforated basket that holds the clothes. The inner basket sits inside a second, solid basket that holds the water. There is no way to manually clean the space between the two baskets without dismantling the machine.

Textiles and fabrics (e.g., protective clothing, bed linens, clothing) from patients and their immediate contacts should be handled with minimum agitation to avoid contamination of air, surfaces and persons⁴⁴. This prevents the dispersion of potentially contaminated sloughed-off scabs and skin squames into the air. Textiles and clothing should be bagged or contained at the point of use in accordance with OSHA regulations ³². These items should not be sorted prior to laundering. Most, if not all forms of containment used for routine healthcare laundry are acceptable for containing textiles and fabrics generated in care-areas for smallpox patients. Wet textiles should be bagged first and then placed in a leak-proof container. Reusable fabric laundry bags commonly used for laundry transport can be laundered along with the clothing and other fabrics. If laundry is transported to an off-site facility, the procedures that are currently used for transporting and safe handling of contaminated textiles off-site will be adequate for these situations. Laundry should be labeled in such a way that laundry staff should be prompted to wear appropriate PPE and handle potentially contaminated laundry with minimum of agitation³².

The laundry area in a health-care facility that receives potentially contaminated textiles and clothing should be set at negative pressure as per normal operating standards, and be physically separated from the area where clean laundry is dried, folded and packed for transport and distribution⁴⁵.

No special laundering protocols are required, nor is it necessary to wash materials from smallpox care areas separately from textiles generated elsewhere in the facility.

The use of cold water washing has not been evaluated with respect to the inactivation of variola virus⁴³. If no other wash cycle other than cold water are available, use detergents and laundry additives that are specially formulated for cold-water washing and dry using a hot air cycle for the dryer⁴⁶.

Commercial laundry service contractors are not required to be accredited by state or federal law; however, many voluntarily comply with the processing guidelines and recommendations developed by the Joint Committee on Healthcare Laundry Guidelines. The 1999 edition of this guideline addresses the many handling, processing, transportation, storage, cleanliness, and sanitation considerations involved in health-care laundry service operations⁴⁴.

The Occupational Safety and Health Administration’s (OSHA) blood-borne pathogens standard details regulatory requirements for workers exposed to "contaminated" laundry³². These requirements involve training, sharps disposal device accessibility, and written institutional procedures to reduce risks of exposure. Additional OSHA standards that apply to the laundry industry include hazard communication and ergonomics.

The 1996 Joint Commission on Accreditation of Healthcare Organization standards for hospitals has dropped the specific reference to laundry facilities and handling of textiles. However, the delivery of textiles that minimizes the microbial contamination from surface or airborne deposition and the collection of soiled textiles in a manner that minimizes microbial dissemination into the environment is still the responsibility of each healthcare facility regardless whether in-house or contract commercial laundry is used^{27, 44}.

3. SUMMARY AND CONCLUSIONS

The purpose of this document on Laundry and Textile Services is to give the healthcare worker both in the medical and service areas a workable knowledge on how textiles should be collected, transported and processed. It is important that procedures performed are not based on old theories that have no relevance in today’s modern technical advances. Too often we make judgments based on what we have done in the past rather than what should be done because of "we have always done it that way".

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