By Kelly M. Pyrek
Although it has always recommended institution laundering of surgical attire, the Association of periOperative Registered Nurses (AORN) is unequivocal on this position in its newly revised Recommended Practices for Surgical Attire, due for release this month. In this recommended practice (RP), AORN is underscoring the science-based rationale for quality assurance monitoring of laundering practices, as well as taking a stand on other attire-related issues that compromise patient safety.
AORN recommends that surgical attire should be laundered in a healthcare-accredited laundry facility, according to Recommendation V within the RP, and all recommendations for home laundering of surgical attire have been removed. This is the most significant change since 2005, when the Recommended Practices for Surgical Attire was first released. Like other recommendations in this updated RP, Recommendation V includes an expanded rationale section that cites literature and guidelines published since the previous version.
For more than a year, members of AORN's Recommended Practices Committee have reviewed existing evidence in the literature, and in the spring, opened the proposed RP for input from the perioperative and infection prevention communities. Ramona Conner, RN, MSN, CNOR, manager of standards and recommended practices for AORN, reports that several hundred comments were received. "This recommended practice incites a great deal of interest," Conner says. "For some people it's an emotional issue. We began working on the review of this RP in January 2009, so this has been a long process and one with which we have taken extraordinary care and invested much thought and discussion in order to reach what we feel are good, achievable recommendations, based on the best evidence we have, with as much consensus from the community as we could achieve."
Conner points to a mounting body of evidence implicating healthcare textiles in outbreaks. "The literature has demonstrated reports of outbreaks directly related to healthcare laundry, and the evidence has really been emerging in the last three or four years," Conner explains. "AORN has always recommended that surgical attire be laundered by a facility or industrial laundry. In our previous edition we had to acknowledge that the evidence was not there and not published; we felt compelled to recommend that people not home launder but our previous edition essentially said that if you are working for an employer that requires you to home launder, we will provide guidance on how to do that safely. As we conducted our literature review for this latest edition we found there is no practical way for people in their homes to be able to meet the same criteria for safe laundering as healthcare-accredited facilities do. Because the evidence has become so much stronger in the last few years we felt compelled to say that surgical attire should be laundered by an accredited laundry facility. I suspect that over the next few years we are going to see even more evidence. Much of the research we have on survival of these pathogens on fabrics comes from laboratory studies, and although we are beginning to see in vivo studies, we still need more information."
At the Fifth Decennial International Conference on Healthcare-Associated Infections held in March, an investigator from the Centers for Disease Control and Prevention (CDC) presented a paper on an outbreak of Zygomycosis, a fungal-based infection, linked to healthcare textiles. Nine cases of the infection had occurred at the hospital since 1993, but six cases occurred between August 2008 and July 2009, with five resulting in serious skin infections in patients ranging in age from newborn to 13 years. Hospital textiles were identified as the only common element among all the cases. Environmental sampling performed at the hospital on the textiles and areas in contact with textiles revealed a 40 percent presence of the pathogen, and only a 4 percent presence in items and areas not in contact with textiles. The hospital changed its laundry provider, replaced all of its linen, and disinfected its linen storage areas. Cultures taken at the hospital three weeks later were all negative. The CDC concluded that the textiles likely acted as the vector for bringing susceptible patients into contact with the pathogen, and that "hospital linens should be laundered, shipped and stored in a manner that minimizes exposure to environmental contaminants."
Accredited healthcare laundry facilities provide a monitored laundering process and must adhere to established standards established by the Healthcare Laundry Accreditation Council (HLAC), an independent accreditation organization. HLAC certifies laundry facilities based on standards such as he ANSI/AAMI ST65:2000 guidance for Processing of Reusable Surgical Textiles for Use in Health Care Facilities and regulations established by the Occupational Safety and Health Administration (OSHA). These standards mandate that healthcare institutions demonstrate regulated practices for the entire spectrum of the laundering process.
"I think laundering surgical attire is a process similar to achieving sterilization," Conner says. "It is a chain of events that must occur in order to do it properly, and if you have a break in the chain anywhere along the line of that process, you could have a failure. That is as true with laundering as it is with sterilization. For example, when the contaminated linen is handled, if the worker isn't well protected and wearing personal protective equipment (PPE), the healthcare worker can be exposed to these contaminants. Once the laundry is sorted and placed into the washers, the temperature, the dilution, the detergent, the pH level, all of those parameters need to be monitored to make certain they are all in correct proportion. Then the wet linen, although decontaminated, needs to be dried and so the temperature of the dryers and the length of the drying cycle must be monitored. The way the washers and dryers are loaded is a critical step; if they are not loaded right, are too heavy or too light, it affects the other parameters such as exposure of all surfaces to the detergent. Once the linens are dried properly, it must be protected from contaminants in the environment then transported to the point of use. Anywhere along that chain, any number of things can go wrong. What's important and why we are focused on recommending accredited laundries is that these laundries conduct stringent quality monitoring and you just can't do that home."