Never before has the healthcare industry been faced with such a large number of challenges from every direction possible: infection prevention policies, staff shortages, rising costs, aging baby boomers, governmental mandates, media pressure and consumers who are taking a more active role in managing their medical care as healthcare reform discussions continue on Capitol Hill. Given these factors, even the most well-managed healthcare facility must not let its guard down or take anything for granted — including how it handles the laundry when developing its infection prevention strategies.
The Healthcare Laundry Accreditation Council (HLAC), established in 2005, has compiled the myriad of protocols, guidelines, standard practices and governmental mandates into one comprehensive document devoted solely to healthcare textile processing, “The Accreditation Standards for Processing Reusable Textiles for Use in Healthcare Facilities,” published in April 2006. HLAC also provides an independent inspection, and accreditation is awarded to healthcare laundries that meet or exceed the Council’s standards. No other organization exists for developing and centralizing information as it relates to proper protocols when it comes to healthcare textile processing.
The Textile as a Fomite
This year’s novel influenza A (H1N1) virus outbreak was a reminder of how quickly the focus can shift from the routine challenges of the day to full-blown pandemic planning and infection prevention. As the numbers of H1N1 cases grew, those in charge of laundry services and textile replenishment began asking whether there was any risk of transmission associated with healthcare textiles. “With proper soiled laundry collection and processing protocols in place, influenza virus transmission, be it seasonal or novel H1N1, is not likely to be associated with soiled textiles,” says Lynne Sehulster, PhD, an infectious diseases health scientist with the Centers for Disease Control and Prevention (CDC). “Transmission is more likely to occur as a result of being within six feet of a person infected with the flu and who is symptomatic with upper respiratory symptoms such as coughing,” says Sehulster.
Studies have shown that a textile can be considered a fomite, an object capable of carrying an organism and serving as a reservoir that can be involved in transmission. In one study, Neely and Maley inoculated clean, sterile textile and plastic samples with various types of bacteria, including vancomycin-resistant enterococci (VRE) and multi-resistant Staphylococcus aureus (MRSA).1 Test results indicated that bacteria did indeed survive for anywhere between one to 90 days, and this is an important observation for the infection preventionist to consider. However, the mere presence of infectious microorganisms on surfaces and fomites is not a sufficient factor by itself to guarantee that transmission and infection will take place. Microorganisms on surfaces and fomites must be physically moved from those surfaces and items and introduced to a susceptible host via a mode of transmission and a correct portal of entry. Proper laundry processing protocols and guidelines, when implemented as recommended, reduce the likelihood that this microbial transfer will occur, thereby minimizing the possibility of textiles posing as a source of infection or danger to the patient or healthcare worker.
Healthcare Laundry Considerations
The handling and processing of healthcare textiles to produce hygienically clean textiles requires additional considerations beyond those standard processes of a non-healthcare laundry. They include:
The laundering process
The laundry facility
Healthcare textiles are unique compared with non-healthcare textiles because they must be considered potentially contaminated with blood, body fluids or other potentially infectious materials (OPIM). Accordingly, all textiles that enter the laundry must be handled with Standard Precautions as recommended by CDC to prevent transmission of a wide variety of pathogens including human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile.
In a healthcare laundry, regardless of whether its operations are located in the hospital or off site as provided by a contractor, exposure to bloodborne pathogens and emerging bacterial pathogens is a potential issue, especially in the soiled textile sorting department. We often associate high rates of transmission of pathogens when we sustain direct contact with body substances that are moist and fluid, but in a laundry, these soils are usually dried by the time they arrive. The potential for transmission is reduced under these circumstances, but it is not eliminated. For example, HBV poses one of the greatest risks to the unvaccinated worker because it can survive in dried blood for at least seven days. Because employees cannot identify when blood may contain a pathogen, textiles must be treated as though they are contaminated, thus the need for Standard Precautions.
Although the OSHA bloodborne pathogen regulations were promulgated during a time when Universal Precautions were the standard of practice, contemporary use of Standard Precautions in any workplace where potential exposure to bloodborne pathogens exists will be fully compliant with the intent of the regulations. The full text of OSHA’s Bloodborne Pathogens standard details what employers must do to protect workers whose jobs put them at a reasonable risk of coming into contact with blood and other potentially infectious materials.2 Those requirements include:
Exposure Control Plan to identify laundry employees at risk
Using engineering controls that isolate or remove the bloodborne pathogen hazard from the workplace, such as using sharps disposal containers
Enforcing of work practice controls to reduce the risk of transmission such as proper hand hygiene, sharps disposal program, contaminated material cleaning
Provision for personal protective equipment (PPE)
Initiating hepatitis B vaccine series to all employees with occupational exposure to bloodborne pathogens within 10 days of assignment
Provision for post-follow-up exposure to any worker exposed to a pathogen at no charge
Using appropriate hazard communication such as color-coded containment and posting warning signs about areas where potentially contaminated textiles are located
Regular training about the hazards of bloodborne pathogens, preventive measures, and post-exposure policies and procedures, and record-keeping related to training and exposure.
The Occupational Safety and Health Administration (OSHA)’s mission is to mandate a work environment free from occupational hazard in efforts to prevent harm to America’s workers. As such, every organization subject to OSHA must ensure it understands which OSHA regulations apply to its business and comply with these standards. Because virtually all of the textiles processed in healthcare laundries are assumed to be contaminated, HLAC focuses on the OSHA bloodborne pathogen regulation during an inspection because it is so central to the best practices used in healthcare laundries.
During a hospital stay, patients are literally surrounded by textiles, including sheets, blankets, gowns, privacy curtains, blankets, nurse scrubs and doctor lab coats just to name a few. This doesn’t include the textiles encountered if surgery is required, which adds to the textile list surgical drapes, towels and gowns. Healthcare professionals and patients have high expectations of clean healthcare textiles. The existence of stains, odors, or other inferior textile attributes can create a negative experience during a hospital stay. Patients may question whether it is safe to be exposed to such textiles, especially if the stay is lengthy. The adherence to proper laundry protocols and practices aligns directly with the goal of healthcare institutions to develop and strengthen quality and infection prevention strategies. CDC guidelines provide the basis for these strategies and gives the infection preventionist evidence-based support to make changes to their policies.3 Healthcare textiles that are hygienically clean, thoroughly dry and delivered to the care area in a manner that prevents inadvertent contamination have a long history of patient safety and satisfaction.
The Laundering Process
Hygienically clean textiles can be achieved by following a proper laundering process. The term “hygienically clean” in the laundry industry is recognized as meaning the textile has been treated in a way that removes bioburden and can be used without fear of being a source of contamination. The Association for the Advancement of Medical Instrumentation (AAMI) defines the term “hygienically clean” as “free of pathogens in sufficient numbers to cause human illness.”4 The laundering process has several factors that have antimicrobial properties to some degree such as hot air drying and use of chemical additives (e.g., chlorine bleach). However, the most important aspect of the laundering process is the removal of soil and bioburden which includes microorganisms.3
The laundering process includes a variety of factors that when combined properly result in a hygienically clean textile. They include:
Chemical sanitizers or bacteriostats
Drying and ironing
Additional factors that affect the laundering process include types of equipment (washer/extractors, tunnel washers), soil levels (light, medium, heavy), and textile types (cotton, poly, synthetic). Achieving a hygienically clean textile involves developing a wash formula specific to all of these factors for each customer. Because of these variables, HLAC Standards do not require specific times, temperature and chemicals, but rather interviews managers, inspects formula and quality documentation and more that helps demonstrate the laundry understands how to create a proper wash formula as well as identify and resolve a problem should a quality issue arise.
The Laundry Facility
The physical layout of a healthcare laundry is very important. The primary concern is that the clean textiles are not re-contaminated during processing, handling, finishing, storage or delivery. Therefore, maintaining a clean, sanitary environment with a workflow that helps prevent cross-contamination is critical to meeting the high standards of healthcare customers.
One of the most important aspects of the plant is “functional separation.” The objective of functional separation is to provide for an operation that prevents clean textiles from becoming contaminated by the soiled textiles. In the laundry, this separation can be achieved by a physical barrier such as a wall, negative air pressure in the soiled textiles area and positive airflow from the clean textile area through the soiled textiles area with venting directly to the outside. Functional separation should also be incorporated into the workflow and traffic patterns, including when textiles are moving through the laundering process, being transported or stored on carts, and loaded onto delivery vehicles.
A regular cleaning and disinfection plan should be established so that work surfaces are treated on a scheduled basis. If surfaces become visibly contaminated during a shift, procedures should be in place which assure appropriate cleaning and sanitizing products are available and employees know how to use them.
Lint control is an important issue in healthcare laundries. Lint can carry bacterial or viral contamination to a work surface or textile. For laundries that process surgical gowns, towels and barriers, lint control is critical. Studies have shown that lint on surgical textiles can hinder a patient’s recovery.5
A healthcare laundry should institute an integrated pest control management system and be inspected regularly for signs of pests.
The Value of Accreditation
In the healthcare industry, individuals demonstrate acumen in their field with degrees or certifications. Hospitals seek the same distinction by working toward accreditation or earning awards. In the laundry industry, there has never been a program that offers independent verification of its credentials until the advent of HLAC’s program. During the past three and a half years, HLAC has accredited more than 75 laundries nationwide and more continue to prepare.
There is little evidence that hygienically clean, dry textiles pose a significant risk for infection transmission. Maintaining this track record requires diligence on the part of laundry team. Accreditation involves a rigorous preparation and dedication to best practices by the entire laundry team. Those who pass demonstrate to customers that they understand the uniqueness of healthcare textile processing and that their work ethic and culture aligns directly with that of their healthcare clients—a culture that includes a commitment to patient and employee safety, process improvement, and most importantly, consistent delivery of a high quality, hygienically clean textile.
Kathy Tinker is executive director of the Healthcare Laundry Accreditation Council. Founded in 2005, HLAC is an independent council that has developed a comprehensive set of standards for healthcare textile processing. It is the only organization that exclusively inspects and accredits laundries that process healthcare textiles. To learn more about the Standards, and the inspection and accreditation program, visit www.hlacnet.org, or contact Kathy Tinker at (708) 790-1749 or firstname.lastname@example.org
1. Neely AN, Maley MP. Survival of enterococci and staphylococci on hospital fabrics and plastic. J Clin Microbiol 2000; 38(2): 724-6.
U.S. Department of Labor, Occupational Safety and Health Administration. Occupational Exposure to Bloodborne Pathogens: Final Rule. (29 CFR 1910.1030). Federal Register 1991; 56: 64004-182.
Centers for Disease Control and Prevention (CDC), Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for environmental infection control in health-care facilities. Full text accessed on 7/29/09 and available at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Enviro_guide_03.pdf
Association for the Advancement of Medical Instrumentation (AAMI). Processing of Reusable Surgical Textiles for use in Health Care Facilities. ANSI/AAMI ST65:2008. Arlington (VA): AAMI, 2009. American National Standard
Barrie D, Wilson JA, Hoffman, PN, Kramer JM. Bacillus cereus meningitis in two neurosurgical patients: An investigation into the source of the organism. J Infect 1992; 25(3): 291-7.