Lessons in Linen

February 1, 2003

Lessons in Linen
Following Aseptic Technique in the Laundry Department

By Kelly M. Pyrek

When it comes to protecting
hospital personnel from the transmission of infectious diseases, the
patient-care delivery worker is often the person thought of first; however,
infection control practitioners must be aware that the handling of healthcare
facility laundry and linen poses risks to another population of hospital worker.
Laundry personnel are responsible for processing hundreds of thousands of pounds
of contaminated reusable linens annually and can be at risk for injury if
precautions are not taken.

Infection control consultant Raymond Otero, PhD, formerly director of
academic affairs for the National Association of Institutional Linen Management
(NAILM)1 says infection control manuals should be written to allay
fears regarding the processing of contaminated linen, and adds that if common
sense procedures -- dictated by Standard Precautions (SP) -- are followed, the
chance of disease transmission is "almost nonexistent." He
acknowledges there have been several documented cases of contaminated linens
serving as the cause of infections such as scabies, salmonella and smallpox
among laundry handlers, and these can be attributed to breaks in aseptic

While there is ongoing debate as to how big a role linens play in the
transmission of disease, this fomite has been indicted in a number of recent

In a study by Borg and Portelli2 published in 1999 titled,
"Hospital laundry workers -- an at-risk group for hepatitis A?"
researchers related the experiences of 22 laundry personnel at St. Luke's
Hospital in Malta, who were tested for seropositivity to hepatitis A. They were
matched with 37 nursing aides working in pediatric and infectious disease wards,
who were used as controls. IgG antibodies were found in 54.5 percent of laundry
workers and 13.5 percent of nursing aides [odds ratio (OR) = 7.68; 95 percent;
confidence interval (CI) = 1.87-33.83]. Furthermore, laundry personnel
consistently handling dirty linen prior to washing showed an OR of 16.50 (CI =
1.19-825.57) as compared with colleagues handling only clean items. The
researchers say these results suggest that the increased exposure of hospital
laundry workers to potentially infected linen can constitute a risk of
occupational hepatitis A for this group of employees.

In another published study, researchers Standaert, Hutcheson and Schaffner3
examined the nosocomial transmission of Salmonella gastroenteritis to laundry
workers in a nursing home in a rural Tennessee county. Residents and staff of
the nursing home were interviewed and cultures of stool samples examined for
enteric pathogens. Stool cultures from 32 residents and eight employees were
positive for Salmonella hadar. Infection among the residents was foodborne, but
infection among employees likely represented secondary transmission, as none of
the employees ate food prepared in the kitchen and their onset of symptoms
occurred seven to 10 days after that of ill residents. Three laundry personnel
who had no contact with residents were infected. Most of the ill residents (81
percent) were incontinent, which led to an increase in both the degree of fecal
soiling and the amount of soiled linen received by the laundry during the
outbreak. Laundry personnel regularly ate in the laundry room, did not wear
protective clothing and did not wear gloves consistently while handling soiled
laundry. The researchers concluded that linen soiled with feces was the source
of nosocomial S.Hadar infection in laundry workers and underscore the importance
of using appropriate precautions when handling linen.

The Centers for Disease Control and Prevention (CDC)'s Guidelines for Laundry
in Healthcare Facilities say that, "Although soiled linen has been
identified as a source of large numbers of pathogenic microorganisms, the risk
of actual disease transmission appears negligible. Rather than rigid rules and
regulation, hygienic and common-sense storage and processing of clean and soiled
linen are recommended."4-5

Contaminated laundry, as defined by the Bloodborne Pathogen Standard issued
by the Occupational Safety and Health Administration (OSHA), is considered to be
"laundry which has been soiled with blood or other potentially infectious
material or may contain sharps."

OSHA says healthcare facility laundry poses exposure to blood or other
potentially infectious materials through contaminated linen that was improperly
labeled or handled. It suggests the following solutions to healthcare workers
and laundry personnel to avoid occupational exposure:

  • Handle contaminated laundry as little as possible with minimal agitation.
  • Bag contaminated laundry at the location of use. Do not sort or rinse
    laundry at the location where it was used.
  • Place wet contaminated laundry in leak-proof, and color-coded or labeled
    containers, at the location where it was used.
  • Whenever contaminated laundry is wet and presents a reasonable likelihood
    of soak-through or of  leakage from the bag or container, the laundry
    shall be placed and transported in bags or containers which prevent
    soak-through and/or leakage of fluids to the exterior.
  • Contaminated laundry must be placed and transported in bags or containers
    labeled with the biohazard symbol or put in red bags.
  • In a facility that utilizes universal precautions in the handling of all
    soiled laundry alternative labeling or color-coding is sufficient if it
    permits all employees to recognize the containers as requiring compliance
    with standard precautions.
  • Use red bags or bags marked with the biohazard symbol, if the facility
    where items are laundered does not use SP for all laundry.
  • Contaminated laundry bags should not be held close to the body or squeezed
    when transporting to avoid punctures from improperly discarded syringes.
  • Normal laundry cycles should be used according to the washer and detergent
    manufacturer's recommendations.

Otero says that all healthcare workers and laundry personnel must follow SP
when handling contaminated linen, including donning personal protective
equipment (PPE) including gloves and gowns that provide adequate barrier
properties. Handwashing facilities, including a hygienic sink, soap dispensers
and paper towels, must be provided in the soiled-linen processing facility.

The CDC offers the following control measures for proper laundry handling:

  • Soiled linen can be transported in the hospital by cart or chute. Bagging
    linen is indicated if chutes are used, since improperly designed chutes can
    be a means of spreading microorganisms throughout the hospital.6
  • Soiled linen may or may not be sorted in the laundry before being loaded
    into washer/extractor units. Sorting before washing protects both machinery
    and linen from the effects of objects in the linen and reduces the potential
    for recontamination of clean linen that sorting after washing requires.
    Sorting after washing minimizes the direct exposure of laundry personnel to
    infective material in the soiled linen and reduces airborne microbial
    contamination in the laundry.7 Protective apparel and appropriate
    ventilation can minimize these exposures.

The microbicidal action of the normal laundering process is affected by
several physical and chemical factors.8-10 Although dilution is not a
microbicidal mechanism, it is responsible for the removal of significant
quantities of microorganisms. Soaps or detergents loosen soil and also have some
microbicidal properties. Hot water provides an effective means of destroying
microorganisms, and a temperature of at least 71 degrees C (160 F) for a minimum
of 25 minutes is commonly recommended for hot-water washing. Chlorine bleach
provides an extra margin of safety. A total available chlorine residual of
50-150ppm is usually achieved during the bleach cycle. The last action performed
during the washing process is the addition of a mild acid to neutralize any
alkalinity in the water supply, soap, or detergent. The rapid shift in Ph from
approximately 12 to 5 also may tend to inactivate some microorganisms.

Recent studies have shown that a satisfactory reduction of microbial
contamination can be achieved at lower water temperatures of 22-50 degrees C
when the cycling of the washer, the wash formula, and the amount of chlorine
bleach are carefully monitored and controlled. Instead of the microbicidal
action of hot water, low-temperature laundry cycles rely heavily on the presence
of bleach to reduce levels of microbial contamination.

Regardless of whether hot or cold water is used for washing, the temperatures
reached in drying and especially during ironing provide additional significant
microbicidal action.

Otero says airborne transmission notwithstanding, the real threat posed by
contaminated linen is avoiding injuries from sharps like needles, razor blades
and surgical instruments being swept up in patient-room or surgical linens.
Otero says that proper linen handling can help eliminate these kinds of
injuries, and that healthcare workers must be inserviced on how to look for
sharps buried in linen and how to remove and contain them.

A safety and health program that includes procedures for appropriate disposal
and handling of sharps and follows required practices is outlined in the
Bloodborne Pathogens Standard.

OSHA makes the following recommendations regarding sharps handling:

  • Contaminated needles and sharps shall not be bent, recapped or removed. No
    shearing or breaking is permitted.
  • Follow sharps containerization guidelines:

1. Immediately or as soon as feasible, contaminated sharps need to be
discarded in appropriate containers.

2. Needle containers need to be available, and in close proximity to areas
where needles may be found, including laundries.

3. Appropriate containers must be closable, puncture-resistant and leak-proof
on sides and bottom; accessible, maintained upright and not allowed to overfill;
labeled with the biohazard symbol; labeled in fluorescent orange or orange-red,
with lettering and symbols in a contrasting color; red bags or containers may be
substituted for labels.

One more set of related guidelines offered to healthcare laundry services can
be found within the Association for the Advancement of Medical Instrumentation (AAMI)'s
Processing of Reusable Surgical Textiles for Use in Healthcare Facilities (ANSI/AAMI
ST65), a document that discusses clean, non-sterile, reusable surgical textiles
and sterile, reusable surgical textile packs. ST 65 is intended to help
materials managers, laundry managers, central service managers and other
healthcare professionals implement effective quality-assurance systems for the
processing of reusable surgical textiles. The guidelines include instruction for
proper on-site or off-site handling, processing and preparation of reusable
textiles in healthcare facilities as well as design criteria for work areas,
staff qualifications and training, and procedures for receiving and handling
soiled textiles, transporting both clean and soiled textiles, and installing,
caring for and maintaining laundry equipment. ST 65 also explains reprocessing
considerations, quality control practices and regulatory considerations
including regulations from the Environmental Protection Agency (EPA) and OSHA.
For more information, visit www.aami.org and
click on "Standards."