Infection Control Today - 03/2004: Clinical Update

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Giving Laundry a Clean Bill of Health
How effective is your hospital’s laundry department? Are those linens clean enough to use for the next patient?

By Kathy Dix

There are several myths surrounding commercial laundry, says Raymond Otero, MD, an independent consultant in Richmond, Ky., where he is involved in infection control practices for the long-term care and home health settings.

“One of the myths is that laundry material is infectious,” he says. “One of the myths that nurses have is that if a particular patient has a particular disease — for example, with a multiple drug-resistant organism — that the laundry processing cannot handle it. They’ll throw it away. You’d be surprised how many nurses in acute care and probably also in long-term care discard the linens because they feel they cannot be washed, or they do not want them to return to other patients because they feel the laundry can’t clean them.”

If that were the case, then those items might just as easily transmit pathogens after being buried in a landfill. However, Otero scoffs, “That’s probably another myth, that a landfill may cause problems to the community. It does not. That’s never been proven.”

Otero’s Laundry and Linen Infection Control Practices, available online, also points out that dirty or contaminated linens do not have to be placed in red bags. “At one time they had to be washed separately,” Otero recalls. “That’s no longer the case.”

Asked why, Otero responds, “Because of the processing that we have — better detergents, enzymes, commercial washers — they do a very good job. The only thing you have to control is the human factor, so you don’t overfill it. Most of these washers used commercially in hospitals and nursing homes are all computerized, and are self-feeding with detergents and enzymes.”

Although most hospitals and other healthcare facilities will utilize industrial washing machines, they may include a home-type washing machine in the laundry area for small items, such as personal clothing of a nurse or other healthcare worker who has blood spatters on a uniform or protective clothing. That policy is satisfactory, Otero quips, because if they use the hospital laundry, “they’ll probably never get it back.”

The difference between commercial and home washing machines is that the industrial versions are much more controlled, essentially. The actual temperature may be hotter than what would normally be used in a home — between 140 and 160 degrees Fahrenheit. However, Otero points out, those high temperatures are not always necessary. “There is a misconception that you have to use extremely hot water, 160 degrees or greater, in order to effect a cleaning and sanitation of the linens. But that’s no longer the case.”

In 1960, Otero says, the CDC recommended that hospital linens be laundered at 160 degrees or greater for 25 minutes. “They got that information from a publication back in 1938,” he observes. “140 or less is all that’s really necessary.”

Some facilities, like the VA system, use “cold washes,” with temperatures around 105. The colder water is used to conserve energy. Asked if that will still kill germs, Otero reminds us, “You’re not only dealing with temperature; you’re dealing with enzymes and rinsing and you’re also drying it. All those factors contribute to a biologically safe product. We have newly developed synthetic detergents, washing cycles, commercial washers, rinsing, and the sours.”

Sours can be used to balance the pH of the laundry. “Sours are acids. Because detergents are alkaline, you have to drop the pH down to neutrality or below neutrality, because that’s your skin pH,” Otero says. “You want to make sure that the pH of linens that patients are going to be sleeping on is not too alkaline or too acidic because that’s going to cause irritation. It should be low neutrality, slightly acidic because your skin is slightly acidic, so you want to have it fairly equal.”

Temperatures for drying do not need to be specific to whatever pathogens the laundry was exposed to; instead, the focus should be on a temperature that will dry the linens within a sufficient amount of time but not destroy the fabric. “That’s all controlled by the laundry managers,” Otero says.

Bleach does not need to be used in every cycle; “There are other chemicals that are normally used,” he says. “If they use bleach, you have to think of the fabric, so you don’t destroy it or discolor it. There are various additives used today that won’t destroy fabrics or discolor them. Again, it is the laundry manager who determines this.”

Besides the laundry manager, Otero adds, “The manufacturers of washers also have their own recommendations.”

Basic Safety Policies

Visitors should not be allowed in the laundry; that is for their own safety, so they aren’t at risk of slipping and falling, or of being injured by the machinery. That’s also so that they don’t interfere with the actual work cycle of personnel there.

It is not necessary for laundry personnel to wear masks, either. “The actual particles that are generated in the laundry area that get into the atmosphere do not get into your lungs,” Otero says. “The particles are so large they cannot enter lung tissues. And there has never been any demonstration that I can find in the last thirty years that there has been a respiratory illness created by linen handlers.”

He continues, “The biggest safety problem is that of sharps, that healthcare workers can be injured through razor blades, surgical instruments, that may placed in the laundry bag and inadvertently injure them. Because of Occupational Safety and Health Administration (OSHA) rulings and the various types of sharps disposal kits throughout hospitals or nursing homes, they have to be discarded, and now you don’t see much of those ending up in laundry bags. It’s because of OSHA’s mandate that the safety of laundry personnel has been increased. That’s been in effect since 1989.”

Otero’s guidelines document recommends that all laundry personnel receive immunization for tetanus, hepatitis B and influenza, because of the possibility of sharps injuries. “There’s always that possibility, although far remote,” he cautions. “It’s just common sense for any healthcare worker to keep up their immunizations, specifically tetanus, and get flu shots every year. Not that they’re going to get flu from handling linens — but we know what happened with the flu this year, and when you have individuals who are sick, they can’t come into work, that decreases employee strength and creates problems.”

Otero also recommends against leaving dirty linens in hampers in patient rooms for extended periods of time, explaining, “You’ve got people going in and out, immediate family members and visitors, and they could contaminate themselves. (Dirty laundry) also stinks — so you’ve got aesthetic reasons as well. The linens should be taken from the beds, placed into the appropriate collecting device, then taken to the utility room and eventually to the laundry area. It cuts down on smell, specifically in a nursing home, because you have incontinence, and a lot of fecal and urinary contamination.”

Otero suggests a quality assurance program to determine the cleanliness of the soiled room area. This, he says, is mostly site observation. “You want to make sure you have a schedule of cleaning, that environmental services personnel know how to clean and change mops, that there is not an accumulation of soil on the floors that is visible. It’s more of a common sense approach.”

He points out that when visitors are surveyed after a trip to the hospital, they do not put good nursing care and good physician care at the top of the list. What stands out is cleanliness. “If a particular hospital or nursing home smells and you can see soil all over the place, then you associate that with bad nursing care and bad medical care. The reverse is also true, too. Just because you have a spotless hospital does not mean you have excellent nursing care. But it helps. It’s more public relations.”

He continues, “You’ll notice, for example, that when immediate family members come in to observe a nursing home to decide which one they’re going to send their mothers or grandparents to, just smelling it will give you an indication. Look at your restrooms and how dirty they are, the floors, and observe the smell, the accumulation, the soiled linen not being picked up. All these factors indicate that people just don’t understand how important it is to make sure, for example, there is not gross contamination. That induces smell.”

He recommends that the laundry supervisor be an ad hoc member of the facility’s infection control committee. “If there is a particular problem that the committee may have or has seen, it should be directed to the laundry manager to make sure they correct it. They could be involved, for example, if there are insufficient numbers of linens or textiles getting to the floors. There is a par level that determines how many linens a particular unit requires. What they will do is give that much linen to that particular floor, and it should last them certain number of days. If for some reason that particular par level is insufficient, they may need to increase the number of textiles, or increase the number of times they deliver it to the floor.”

Additionally, Otero says, “If there are going to be any changes in the processing of linens, it should be brought up to the infection control committee: if a lower temperature is going to be utilized, or if different detergents and enzymes are going to be utilized. The purpose is to alert them, just in case something happens, such as irritation, things of that nature.”

When asked for the most important point for healthcare workers to remember, Otero says, “I think it’s important to understand that the laundry processing delivers a biologically safe product. There is no need to discard textiles because a particular nurse feels the laundry can’t get it clean enough for the next patient. We waste an awful lot of money each year, millions of dollars, by discarding linens and pillowcases. Another (item thrown away) is washcloths. In some hospitals, that is a disposable item and it should not be.”

It’s crucial for healthcare workers to remember that the laundry service “creates a biologically safe product for any patient to use. At one time, hospitals used to sterilize newborns’ linens and textiles. They don’t do that anymore. The processing creates a biologically safe product even for neonates, for infants. It’s been that way for years.”

Another way to ensure the best cost efficiencies in the laundry is to avoid unnecessary costs. “Sometimes we use procedures that have never been proven to be effective, i.e., water soluble bags, bacteriostatic softeners, etc.,” Otero writes in his guidelines document. He observes that water soluble bags — those that melt in hot temperatures — sometimes used for the transportation of soiled linens are unnecessary and costly. He also says that it is unnecessary to perform environmental cultures on linens for any reason, as “there are no standards that have been developed for any interpretation.”

“Infection control manuals should be written with the intent of discouraging the creation of anxiety and over-processing of linens. If one follows common sense procedures (Standard Precautions) in handling grossly contaminated linens, the chance of disease transmission is almost non-existent,” he concludes.

For more information, visit Otero’s Web site at www.cinetwork.com/otero

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