CDC stated back in the 1970’s that "Although soiled linen has been identified as a source of large numbers of pathogenic organisms, the risk of actual disease transmission appears negligible. Rather than rigid rules and regulations, hygienic and common-sense storage and processing of clean and soiled linen are recommended"^1,2. This statement has been used in numerous publications throughout the years. The term pathogenic (disease producing) is misleading since most healthcare facilities do not deal with many pathogenic organisms such as Salmonella typhi or Shigella dysenteriae but opportunistic organisms such as Escherichia coli and other organisms that are common to a human host. The common-sense handling procedures for both soiled and clean textiles has not been well understood by many healthcare professionals and has caused a degree of alarm among licensure personnel both state and federal who do not understand what are common-sense procedures.

Proper procedures are required in handling both soiled and clean textiles to minimize the nosocomial (healthcare associated infections) and occupational risks with soiled textile handling.

Clean linen delivered in a timely manner to healthcare areas is important. Many different areas exist in a hospital or long-term care facility that requires processed linens as well as removal of contaminated linens. Infection control manuals should be written with the intent of discouraging procedures that are not necessary for processing and handling of soiled linens in a healthcare setting.

If one follows STANDARD PRECAUTIONS (formerly known as Universal Precautions/Body Substance Isolation) in handling all contaminated linens, the chance of disease transmission will be almost non-existent. There have been few reports in the literature that health-care workers or patients were contaminated and subsequently infected by soiled linens. The implicated organisms that were found in patients could have very easily been from the environment or secondarily contaminated by healthcare workers or from the patient themselves. The healthcare workers that were infected with soiled linens through handling were caused by breaks in techniques.

There are more than 5 billion pounds of soiled linens produced annually by health care in the United States3. If one considers the enormity of soiled linens processed in the United States, and the actual number of infections caused by microorganisms that occur among soiled-linen handlers the percentage is very low. In fact you have a better chance of being hit by lighting or by a car than obtaining an infection from handling soiled linens.

One does have to be very careful of sharps in linen hampers, carts or bags such as needles, razor blades, surgical instruments, broken glass, etc.

If the soiled linen handler is taught how to remove linens from these vehicles (bags, hampers, carts, etc.) correctly, sharp injuries will be avoided.

There are many individuals in a healthcare setting that play an important role in the linen service/management areas. These are the laundry manager or supervisor, the nurses on the floors, the infection control practitioner and the personnel who work in the laundry area.

Laundry Manager

The laundry manager is responsible for all operations in the laundry, reviews equipment and procedures including maintenance, assures adequate inventories, evaluates all products used, helps in the development of infection control policies for laundry and personnel, creates open lines of communication between laundry and nursing, and helps in the development of educational forums for his/her staff.

Nurses

The nurses on the floors are often termed end-users of linens. Their responsibilities are to reduce excessive linen usage and abuse. The following examples are issues that need to be addressed by the laundry manager:

It is the responsibility of the laundry manager to assure that the linen processed is used correctly by the patient and not wasted by the end-users. Part of the sky rocketing healthcare cost today have been partially created by not understanding the role that all of us play regardless of our position in the healthcare field.

Infection Control Practitioner

The infection control practitioner, often called the surveillance officer, reviews all policies that regard infection control practices and assists in the educational programs with the laundry manager. It is important that this individual understands the modes of transmission of organisms so that no unnecessary procedures are created for infection control practices in the laundry.

Laundry/linen Personnel

All laundry personnel will follow standard precautions for handling soiled linens. They shall not eat, drink, smoke, chew gum or apply cosmetics in the soiled room area. Proper barriers and hand washing procedures shall be in effect at all times.

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 reemphasized in the CDC’s universal precautions guidelines for prevention of transmission of bloodborne pathogens⁵. The most practical application of universal precautions is to handle and process any patient’s linen soiled with blood, body fluids, secretions or excretions in the same manner regardless of source⁶. OSHA’s bloodborne pathogen rule applies to healthcare workers handling soiled linens and this document contains specific requirements for identifying, bagging, and handling all contaminated textiles and protective clothing that must be worn to prevent occupational exposure⁷.

Training and educational programs shall be provided on the following topics⁷:

• explanation on the regulatory text standard
  
  
• explanation of the epidemiology and symptoms of bloodborne diseases
  
  
• explanation of the modes of transmission of bloodborne pathogens
  
  
• explanation of the employer’s exposure control plan and the means by which the employee can obtain a copy of the written plan
  
  
• explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials
  
  
• explanation of the use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, work practices, and personal protective equipment;
  
  
• information on the types, proper use, location, removal, handling, decontamination, and disposable of personal protective equipment
  
  
• explanation of the basis for selection of personal protective equipment
  
  
• information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and the vaccine and vaccination will be offered free of charge
  
  
• information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials
  
  
• explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available
  
  
• information on the postexposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident
  
  
• explanation of the signs and labels and/or color coding required
  
  
• explanation on the purpose of personal hygiene and hand washing techniques
  
  
• explanation on proper record keeping
  

Soiled linen should be handled as little as possible and with a minimum of agitation to prevent gross microbial contamination of the air and persons handling the linen. All linens regardless of origin should be handled in the same manner (Standard Precautions). All soiled linen should be bagged at the location where it was used. The collection bag should be of sufficient quality to contain the wet/soiled linens and prevent soak-through (leakage) during handling and transportation. The type of bag that will be used is dependent on the amount of soil generated by the patient. Cloth laundry bags today are of sufficient quality to prevent soak-through with normal handling or being transported in chutes. Plastic bags are commonly used for the transportation of soiled linens in healthcare. Nurses and physicians feel that linens that are soaked with blood or body fluids from trauma patients in the emergency room or surgery must be contained in only plastic bags. This is a misconception that unfortunately has been around since plastic was discovered back in the mid 1950’s. Cloth bags can be washed and reused, are cheaper than the cost associated with single-use plastic bags and reduces the generation of disposable waste⁷.

There is no need to color code laundry bags based on the type of fluids that are contained. According to OSHA, linens must be placed and transported in labeled or color-coded bags or containers. However, OSHA also states that if a facility uses Universal Precautions in the handling of all soiled laundry, methods of labeling or color-coding other than that stated in the second sentence of this paragraph are sufficient so long as all employees in the facility recognize the containers as requiring Universal Precautions. If the laundry is shipped off-site to a facility that does not utilize Universal Precautions for all laundry, then bags or containers must comply with labeling and color-coding as required. Again all bags utilized for the transportation of contaminated linens must be able to contain all fluids to prevent soak-through. It does not make any difference if the bags are plastic or cloth (reusable)⁷. The hospital may select any type of bag or container that will prevent soak-through or leakage of fluids to the outside.

There is no infection control advantage of double-bagging linens unless the worker feels that the fluids can not be contained by the primary bag. Two studies have shown that single bagging found no significant levels of bacterial contamination outside of the bags^12,13.

• adds to the cost of bagging and processing and healthcare
  
  
• 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
  
  
• stains will destroy the textile and can not be reused for patient care
  
  
• linens have to be rewashed adding to the expense
  
  
• non-textile materials may be present in the water-soluble bag such as underpads, chucks, sharps or personal items which can create obvious problems

The use of personal protective equipment such as reusable gloves and gowns or aprons should be made available to all personnel who are handling soiled linens. The use of masks is not required since aerosols generated by inappropriate handling of linens will not cause respiratory illness. The particles generated are so large that they will not enter lung tissues (see http://ww.cinetwork.com/otero/ and click on prevention of diseases).

Reusable gloves should be used rather than disposable because of the thinness of the latter, which do not protect the health care worker from gross contamination or tearing. Latex or vinyl gloves were never intended to receive the physical pressure that sorting of linens creates. It is not unusual for a laundry worker in the soiled area to use a box of latex gloves per day for protection. Every time gloves are torn or removed, handwashing must be performed.

The use of protective eyewear is not necessary because the splashing of blood or body fluids from linens is unlikely. The use of hairnets or foot covers is not necessary and it is up to the discretion of the laundry manager if they are required. For infection control purposes, these items are not necessary.

Handwashing sinks are required in the soiled room area. It would be inappropriate that soiled–linen handlers have to go outside of their area to wash their hands. The sink should be only used for handwashing, it should be clean and contain a soap dispenser, and paper towels. The use of antiseptic soaps in the soiled linen area is controversial. The most important factor is good handwashing. The use of a good lotion soap is more than satisfactory. It is not what you wash your hands with – it is how and when you wash your hands that is important.

If laundry chutes are going to be used to transport contaminated linen, the linen must be bagged and the laundry chute should discharge in the soiled linen collection area¹. It was thought at one time that linen chutes would create a piston like activity when linen bags were transported vertically at a rapid rate thus disseminating organisms to patient care areas. There has been no documented infections attributed to the use of linen chutes⁸.

How often should laundry chutes be cleaned? If the soiled linens are bagged, at least every 6-8 months. If the linens are not bagged prior to placing them in a chute, then it could be a daily chore and no one has the time to perform this function. Chutes are normally sprayed (not aerosolized) with a EPA registered disinfectant (quat) starting from the top floor and working down. For real gross areas, mops can be used to help release the material from the chute walls.

Soiled textiles should not be sorted or prerinsed in patient care areas¹. However, this statement has caused a lot of confusion in its interpretation. Many nurses on the floors have indicated that we can no longer rinse linens that contain excessive body fluids before it goes into the hamper. Therefore, many hospital and nursing home laundries are receiving large amounts of fecal matter in their textiles because of this statement.

Let it be clear – OSHA and CDC has stated the following: contaminated laundry must be handled with a minimum of agitation and must be bagged or containerized at the location where it was used. While it may not be sorted or rinsed in the location of use, this requirement does not preclude "rinsing of linens soiled with feces in dirty utility room hoppers⁹.

These recommendations were intended for processing of linens that contain body fluids of all types. However, in some healthcare settings, patient’s linens and clothing are not routinely soiled with blood or body fluids. In ambulatory care settings, such as psychiatric units, patients’ clothing is often washed in designated locations near patient care areas by the nursing staff or designated individuals or by the patient themselves. In these situations, guidelines should be developed to ensure that staff and patients are instructed properly¹⁰.

The finding of sharps or other items in textiles received in the soiled room area is not unusual. These objects range from human tissue, needles by themselves or attached to syringes, surgical instruments, dentures, eyeglasses, hearing aids, personal property, table ware, TV remotes and a whole host of miscellaneous items¹⁴. If linens are processed containing these items, it could result in extensive damage and significant expense to laundry equipment.

Soiled textiles coming to the dirty-room sorting area should be examined carefully. This will prevent occupational exposures and infections from bloodborne pathogens or other organisms. It is also important that soiled-linen personnel become trained on how to pick up needles and other sharps that may have inadvertently hit the floor (dust pan or forceps only). Remember it is OSHA’s rule that needle boxes must be placed in areas where linens are sorted. It must be clearly visible to anyone entering this area.

The amount of time that linen is stored prior to washing has more to do with stain removal and aesthetics rather than infection control challenges⁸. There is no data that risk of disease transmission increases with soiled linen stored over time. There is no need to prewash linens to reduce microbial contamination.

• detergents – acts as surfactants and loosen and lift the soil from fibers

• enzymes

• chlorine bleach – bactericidal activity

• rinsing – mechanical action

• temperature of water

• sours – acids that shift pH from ~12 to ~5, helps in the inactivation of organisms

• drying and ironing (if performed)

There are no microbiological standards for textiles to determine what level of contamination is acceptable. This is due to the variability of microbial survival based on degree of soiling, laundry processing and the ability of organisms to attach to fibers15. So routine culturing of linens is not recommended.

The use of bacteriostatic softeners in the wash cycle has never shown to increase the textile longevity or to reduce infections. There have never been any studies done in a healthcare setting comparing softeners with or without a bacteriostat¹⁹. Bacteriostat softeners are expensive. Softeners should be used as part of the washing cycle, however, the added cost of a bacteriostat is totally unnecessary.

Back in the early 1960’s the CDC advocated the use of 160^o F for 25 minutes to process linens^1,2. This was based on a 1938 publication by Arnold¹⁶ that the use of this temperature destroyed nearly all bacterial forms except spore formersy . Lower temperatures were less effective because the types of soaps and detergents used during this time required hot water for emulsification¹⁷. The newly developed synthetic detergents and enzymes in the past 10 years do not require high-temperature laundering.

The CDC has recently published on their web site that normal washing and drying cycles are adequate to ensure patient safety. Instructions of the manufacturers of the machine and the detergent or wash additive should be followed closely, see: (http://ww.cdc.gov/)

There are many states that have certain requirements concerning temperatures to be used in the processing of linens (e.g. Kentucky – 160^o F for 25 minutes). These rules were based on CDC’s guidelines^1,2 as mentioned above. Laundry managers need to become more involved with the education of the medical and nursing staff on how textiles are processed in the 21^st century. Who else would know this business better than you? If we can not convince them that the finished textile is bacteriologically safe, then whom can we convince?

In 1993, National Association of Institutional Linen Management (NAILM) Educational Affairs Committee compiled a list of advantages and disadvantages regarding pre-and post-sorting soiled textiles²⁰. The following lists that was compiled will vary in value according to each institution’s space allocations, equipment, operational procedures and local, state and federal regulations.

• longer textile life (e.g., less chemical usage)

• chemical and utility savings (e.g., soil classifications)

• no dye carryover

• less chance of muscle/back strain (e.g., ergonomics)

• control of load classifications

• selection of variety of textile items (e.g., variety of specifications)

• quality of finished product increases

• less damage to textiles and laundry equipment by removal of foreign objects

• less potential damage and replacement cost to hospital property (e.g., surgical instruments)

• less lint (e.g., removing lint producing waste and using less bleach)

• possible identification of textile abuser by user areas

• sharp injuries may increase

• cost of personal protective equipment (PPE)

• employee discomfort of PPE

• employee fear for risk of infection

• increase wages due to working in risk area

• less chance of occupational exposure with bloodborne pathogens

• cost savings of personal protective equipment

• lack of discomfort from personal protective equipment

• separate sorting area not required

• less employee fear or stress over risk of possible infection

• possible lower wage rate for sorters

• sharp injuries can still occur but the potential of bloodborne infections lessens

• shorter textile life (e.g., increased chemical usage)

• increased chemical and utility costs (e.g., limited to heavy soil classification)

• increased potential damage to textiles and laundry equipment (e.g., foreign objects)

• increased potential damage and replacement cost to hospital property (e.g., surgical instruments)

• restricted selection of textile items

• possible dye carryover

• increased possibility of muscle/back strain to sorters (e.g., separating wet textiles)

• increased lint contamination

• no control of load classification

Clean linen shall be transported and stored in a manner that will minimize microbial contamination.

The use of hampers or carts can be used to deliver linens to the floors. These carts must be cleaned prior to accepting processed linens. Placing processed linens in a hamper lined with a clean liner is one way to accomplish this feat. The hamper or cart containing the processed linens shall be covered either with a cover designed for this purpose or textiles can be used as a suitable replacement. The hampers/and or carts should be cleaned on a regular schedule or as needed.

Carts that are going to be used to store linens on patient care areas (hallways) must have covers on them during transportation and storage time. The covers shall protect the linens at all time during storage. They can not be removed or adjusted in a manner that will expose linens to common traffic.

Open carts that are going to be used just to dispense linens on patient care areas need not be covered for this purpose. They can not be used to store linens on the floors. This would only apply if the laundry is in the facility and not in an external building. Remember that the bottom shelf of any cart that is going to be used to transport linens shall be solid.

There has been a misconception concerning the delivery of linens from a laundry from an outside source. Healthcare facilities do not want to use the same truck to transport soiled and clean linens simultaneously. There is no infection control reason for this not to occur if the following measures are taken:

• the soiled linen is bagged in such a manner as to prevent soak-through

• the soiled linen is placed and anchored in the vehicle so that it does not induce spillage

• personnel know their responsibilities in bagging and placement of linens in the transporting truck

• standard precautions are followed by all staff members with this responsibility.

Organisms do not jump from one area to another. If clean linen is protected properly which does not take insurmountable measures, then there is absolutely no reason why commercial trucks need to make special trips to pick up separate loads. Cleaning of trucks is no different then cleaning isolation rooms in hospitals. Spot clean with a disinfectant. If the temperature is too cold (<32^o F), then plain soap and water for spot cleaning is sufficient. There is absolutely no need to spray or aerosol the trucks with a chemical prior to reuse.

Plant Facilities

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 regulations. The soiled linen area shall be separated physically from the clean linen area

Rooms that are used to store clean linen shall follow the following criteria:

• area shall be devoid of vermin

• area shall be devoid of lint

• area shall have temperatures ranging from 68^o to 78^o F

• area shall be properly ventilated to prevent the accumulation of dust and lint

• no drains or hot water pipes shall be placed within this area

• shelves used for storing linen shall be placed approximately 1 – 2 inches from the wall for accessible cleaning

• the bottom shelf shall be 6 – 8 inches from the floor

• the top shelf shall be 12 – 18 inches below the ceiling

• schedule of cleaning should be written which includes floors and shelves

• a wet-vacuum pickup can be used for weekly cleaning

• room shall only be accessible to appropriate personnel – no visitors

• only clean linens shall be stored in this area

• area shall be recognized by all personnel as a linen storage room

• door shall remain closed at all times

• area shall have positive pressure

Hazardous Drugs

Linen contaminated with hazardous drugs or excreta from patients who have received hazardous drugs in the past 48 hours is a potential source of exposures to employees. Linen soiled with blood or other potentially infectious materials as well as contaminated with excreta must also be managed according to the infection control manual of the facility (Universal Precautions). Linen that is grossly contaminated with hazardous drugs such as a spillage should be placed in a chemotherapy waste disposal unit. Linens used by patients who have received hazardous drugs, which are not grossly contaminated, shall be handled as other linen. 

Quality Assurance

The provider of finished textiles shall have written policies and procedures involving all areas of laundry. These policies and procedures shall be made available to the end-user, licensure and regulatory agencies, compliance officers from OSHA, infection control/quality assurance committees from healthcare and personnel working in the laundry area. For those wishing information on how to write an infection control manual for laundry, please see a recent publication on this subject18.

Contingency Plan

The provider shall furnish a contingency plan in writing to the end user indicating:

• alternative provisions that shall be followed if the provider can not meet production requirements

• inclusion of this provision shall be placed in the contract for an outside end-user

Summation

It is important that providers understand infection control practices for handling, processing, storage and delivery of textiles in a healthcare setting. Too often stringent, non-sensible recommendations are made without foundation. It is hoped that these guidelines will help in alleviating some of these misconceptions. If there are any questions concerning these guidelines or any recommendations that can be made to help in furthering their development, please do not hesitate to call me.

Raymond B. Otero, Ph.D.

Consultant

859-623-3973

 

References

1Garner, J. S. and Favero, M. S. Guidelines for handwashing and hospital environmental control. Washington, DC.: US Government Printing Office. 544-436 (2441). 1985.

2Centers for Disease Control and Prevention. Recommendations for prevention of HIV Transmission in healthcare settings. MMWR 36(Supplement 2S):35. 1987.

3Mallison, G. F. Central services and linens and laundry. In: Bennett, J. V., editor: Hospital Infections, 2^nd edition. Little Brown. Pp.251-256. 1986.

4Williams, B. In: Linen Management, a Certified Laundry and Linen Management Course. NAILM Publication. P 7. 1998.

5Centers for Disease Control and Prevention. Update: Universal precautions for prevention of transmission of HIV, HBV and other bloodborne pathogens in the healthcare setting. MMWR 37:377. 1988.

6Department of Labor, Occupational Safety and Health. Occupational exposure to bloodborne pathogens: final rule. Federal Register 56(235):64004-64182. 1991.

7Bennett, J. V. and Brachman, P. S. In: Hospital Infections. Lippincott-Raven Publishers. P. 329. 1998.

8McDonald, L. L. Laundry. In: APIC Infection Control and Applied Epidemiology – principles and practice. Mosby. Pp. 110-1 – 110-4. 1996.

9Richards, M. Bloodborne pathogen standard: OSHA Clarification. Letter from the American Health Care Association. 1993.

10Otero, R. B. and Webster, C. Guidelines for washing residents’ clothing in home style washers. NAILM News. 59(9):34-35. 1999.

11Pugliese, G. Isolating and double-bagging laundry: Is it really necessary? Health Care Facilities Manager. 2:16. 1989.

12Weinstein, S. A. Bacterial surface contamination of patient’s linen: isolation precautions versus standard care. AM J Infect Control. 17:264-267. 1989.

13Maki, D. G., et. al. Double-bagging of items from isolation is unnecessary as an infection control measure: a comparative study of surface contamination with single- and double-bagging. Infection Control. 11:535-537. 1986.

14Taylor, L. J. Segregation, collection and disposal of hospital laundry and waste. J. Hospital Infections. 11(Suppl A):57-63. 1988.

15McDonald, L. L., and Pugliese, G. In: Hospital Epidemiology and Infection Control. Williams and Wilkins. Pp. 805-807. 1996.

16Arnold, L. A sanitary study of commercial laundry practice. AM J Public Health. 28:839-844. 1938.

17Wenzel, R. P. In: Prevention and Control of Nosocomial Infections. Williams and Wilkins. P. 660. 1997.

18Otero, R. B. Infection control manual for laundry and linen service. NAILM News. 60(3):27-30. 1999.

19Palmer, M. B. In: Infection Control – a policy and procedure manual. W. B. Saunders. P. 241. 1984.

20NAILM News. 54(10):27-28. 1993.

 

Other References of Interest

OSHA Instruction – Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens -–Directives Number CPL 2-2.44D. November 1999

NIOSH Alert – Preventing Needlestick Injuries in Health Care Settings. Publication No. 2000-108. November 1999.

Written Safety Plans. J. J. Keller. 2000.

OSHA Compliance Manual- Application of Key OSHA Topics. J. J. Keller. 2000

Laundry Operations Guidelines. NAILM Publication. 2000

Control of Communicable Diseases – American Public Health Association, 17^th Edition. 2000

 

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