ICT spoke with Joseph Ricci, president and CEO of TRSA -- an international organization representing companies that supply laundered garments, uniforms, linens, and other products to the healthcare industry -- about the home laundering of medical scrubs. In a recent survey, TRSA found that at more than half of the healthcare facilities polled, workers are allowed to wear scrubs home and wear them into work, yet infection preventionists at these facilities overwhelmingly say that these practices present a risk to the public and to patients. TRSA conducted the survey in November 2017 among 1,400 infection prevention experts at hospitals and healthcare facilities. The key findings present a disparity between actual practices, the measures necessary to contain the risk of infection.
Q: What was the impetus of the survey?
A: Wearing scrubs in public and washing them at home has long been recognized as a risk, but it’s not on the front burner in consumer media. In 2012, a study in the Journal of Public Health and Epidemiology on bacteria carried by nurses’ uniforms concluded this research supported previous studies that indicated the risk to communities. The 2012 study included references to a 1998 study with the same tittle and 12 other related journal articles since then. Still, the idea that healthcare workers’ clothing becomes contaminated doesn’t sound like a good story to consumer news editors and producers. Of course, healthcare workers’ clothes get soiled. But our new survey enables us to show them the risk from such contamination may be surprisingly high. The 2012 study authors gave us a clue about how to do that. They pointed out that no studies had investigated the frequency to which hospital uniforms are worn outside the workplace. Now that we’ve done that, we’ve helped quantify the risk.
Q: Why are some institutions allowing home-laundering of scrubs if the evidence indicates the risk?
A: Lack of consumer media attention. When threats are reported in the “lay press,” they get the attention of consumers, legislators and regulators. In this case, the only substantial consumer media attention to contamination of healthcare workers’ clothing has consisted of stories about lab coat sleeves. Even these reports have not been enough to eliminate lab coat use or heavily regulate it. The lab coat studies documented risk that’s easy to understand because it involves the possibility of clothing spreading infection inside a healthcare facility. Ceasing the wearing and washing of scrubs outside the workplace is an even tougher sell for voluntary or legal elimination. Some countries, including Canada, Belgium and Australia, have prohibited wearing hospital clothing outside the workplace and required healthcare facilities to provide clean uniforms to their workers. In the U.S., home washing is respected more, and why not? It’s extremely rare that any of us would operate our home washing machines improperly and fail to clean our clothes. There are no stories about healthcare workers experiencing such failure and spreading contamination as a result. Without such widespread failure, the risk is perceived as essentially nonexistent. Now we have data that shows the extent of the risk. Even without these failures, we don’t have to wait until something devastating happens to make our case. Rather than backtrack at that time, we can act now to prevent it. We know how.
Q: Why do you think that some facilities have no policy in place regarding home-laundered scrubs?
A: Most likely because there hasn’t been a crisis that has called for action. Unfortunately, many organizations and industries are reactive; we are saying let’s be proactive.
Q: Were you surprised by the findings?
A: No. Our 2015 B2B research covering all laundry markets (all businesses across the economic spectrum) included interviews with healthcare professionals who currently procure linen and/or uniform service. Forty-four percent indicated their employees are responsible for cleaning their own company-mandated garments (no uniform service); 45 percent said there is no training for employees in cleaning their own uniforms. We conducted our recent survey believing uniform policies were largely loose and/or inconsistent. And we’d seen enough healthcare workers in uniform on their way to or from work.
Q: How big of an infection prevention issue is this if the results are extrapolated beyond the number of survey respondents?
A: If we define the total potential at-risk population as U.S. hospital employees in RN, LPN, LVN and nursing assistant positions, that’s nearly 2.2 million people who are potential carriers. Our most recent survey says 60 percent of facilities allow employees to wear scrubs into the hospital prior to beginning work and 54 percent allow cleaning scrubs at home. The 2012 Washington state study found MRSA on 70 percent of nurses’ uniforms. Factoring in these findings translates to around 900,000 likely carriers considering hospital employees alone. Now consider that another 3 million people work in these positions in outpatient facilities. Conservatively, the U.S. has 1-million-plus likely carriers, which should be enough to merit consumer media attention and call the healthcare industry to action.
Q: What are the most significant risks related to home laundering of scrubs?
A: Our industry serves the full spectrum of businesses across the economy; linen and uniform laundries neutralize and dispose dangerous soils from uniforms from healthcare and other commercial and industrial settings. In all such cases, we are primarily concerned about the wearer, because the uniform’s primary job is to protect the wearer. If wearers do not receive uniform service and must wash their contaminated uniforms in their home laundries, the risk of infection spreads to family members via the washing machine. In serving healthcare, we add the risk of carrying infection to the general public from the healthcare setting and into the hospital from the street. While there are any number of contaminants and risks to patient and public health, the Washington state study most often found Bacillus species, Micrococcus luteus, Staphylococcus aureus (MRSA Negative) and Staphylococcus epidermidis on nurses’ uniforms.
Q: AORN guidelines indicate that “Scrub attire and cover apparel (such as lab coats) should be laundered in a healthcare-accredited laundry facility after each daily use and when contaminated.” What are the advantages of third-party laundering services and why?
A: Only a handful of on-premises laundries (OPLs) are certified. Hygienically Clean certification verifies a laundry’s process, ensuring compliance with industry best practices through laundry inspection; and quantifies the outcome of hygiene through quarterly microbiological testing of cleaned items. Most certified laundries are privately owned and operated; in almost all cases, linen, uniform and facility services is the organization’s only revenue-generating function. Such management dedication makes for high efficiency and effectiveness in ensuring the hygiene of uniforms and other textiles. Compare this with hospital administration, which must focus on patient care (their only revenue-generating concern); to them, laundry is an expense. It’s worse when the OPL doesn’t handle worker uniforms or the hospital outsources only some laundry work (such as bed linen) and doesn’t use uniform service. There’s little incentive to provide a clean uniform after every shift. A 2015 U.K. study noted that among nurses responsible for washing their own uniforms, 23 percent changed their uniforms after every other shift and 3 percent after every third shift or more.
Q: How do you convince skeptics of third-party laundering that the benefits are real? What about cost objections?
A: Our best argument is that certified uniform hygiene is the only way to go because home laundering is unreliable. In the 2015 U.K. study, researchers from De Montfort University, Leicester, England, surveyed 265 hospital staff at four hospitals and found that 49 percent of them didn’t wash their uniforms at the recommended 60°C (140°F) temperature. Many staff are failing to follow other guidelines for cleaning their uniforms (possibly increasing the risk of spreading healthcare-associated infections) such as failing to wash their uniforms separately from other clothes (40 percent of staff).
Evidence of increased risk was presented in November 2017 when the De Montfort research team published microbiological research on the effect of low temperature laundering and detergents on the survival of E. coli and S. aureus on textiles used in healthcare uniforms. This study showed that most of the microorganisms are removed at 40 degrees C (104 degrees F, a home washing temperature), but those cells still remaining may have the potential for cross-contamination to other textiles in the wash and further contamination to the clinical environment and patients. This represents enough of a risk that greater research is required to determine the effectiveness of detergents against microorganisms at such temperatures to define best practices for home washing. At the same time, 60 degrees C is unquestionably effective, prompting the researchers to suggest that an effective public policy would be to require industrial or on-site laundering of scrubs (which can routinely achieve this level). Explaining the low-temperature risk can be enough to overcome cost objections to outsourcing. If not, we point to hospitals’ hidden costs of their existing uniform programs, such as purchasing and inventory control. If they wash uniforms in their OPLs, they are awakened to OPL labor and utility costs per uniform that exceed those of outsourced laundries. Economies of scale in linen and uniform service, attained by serving hundreds or even thousands of customers from a single laundry, enable these laundries to purchase and produce for less, passing these savings along to customers.
Q: What can infection preventionists do to minimize risk to healthcare personnel and patients?
A: Become the leading advocate for uniform service within your organization. Hospital staff who need to buy into this decision may include administration, facilities management, environmental services, materials management and more. Not all Hygienically Clean Healthcare certified uniform service providers are totally dedicated or very heavily specialized in the healthcare market. But uniform rental generates more of our industry’s sales than any other service, with hospitals and outpatient facilities as a growing source of this revenue.
TRSA Survey Results
• At your facility, are employees allowed to clean scrubs at home?
Yes: 54 percent
• At your facility, are employees allowed to wear scrubs into the hospital prior to beginning work?
Yes: 60 percent
• Do you believe that wearing scrubs into the hospital facility from home presents an infection or contamination risk to patients?
Yes: 79 percent
• Do you believe that wearing scrubs home from the hospital presents an infection or contamination risk from the hospital to those outside/general public?
Yes, 86 percent