Industry Roundtable: Healthcare Laundry

Infection Control Today invited the Healthcare Laundry Accreditation Council (HLAC) and TRSA to address pertinent issues in healthcare laundry relating to infection prevention and control; here are their perspectives.

ICT: What are the knowledge gaps around healthcare laundry-related infection prevention that persist?

There remains a tendency among some infection preventionists (IPs) to reduce to a singular activity the safeguard that ensures hygienic healthcare textiles (HCTs) for every patient in the hospital; that is, they see it as laundering alone, as in the task of “doing the laundry.” Nothing could be further from the truth. The use of reusable HCTs is a circular process. This process includes specific procedures: laundering, transportation to the healthcare facility, storage and distribution within the hospital, placement (but not storage) of the HCTs in a patient or treatment room, removal and placement into a soiled linen bin after use, transportation to the soiled linen depot at the hospital, and loading and transportation back to the healthcare laundry. When the process is overlooked or shortchanged, things can fall apart. This is especially true with matters after the wash process. For example, healthcare laundries accredited by the Healthcare Laundry Accreditation Council (HLAC) are in the business of ensuring that HCTs are processed and delivered to their partners in a hygienically clean manner. But once they’ve arrived from the laundry to the healthcare setting, that integrity needs to be maintained. In fact, maintenance is as important to quality patient outcomes as is the organization’s commitment to practicing proper hand hygiene. HCTs should not and cannot be viewed with a lesser concern than other healthcare interventions.  
-- Gregory Gicewicz, president of Sterile Surgical Systems; past-president and inspection committee chair for Healthcare Laundry Accreditation Council (HLAC)

There will always be knowledge gaps about laundry because cleaning technologies will continue to improve. Linen and uniform services will be first to implement improvements successfully and then other stakeholders will need to learn about them. Perhaps our most visible example of this involves California law, where healthcare laundry cycles are specified to be 24 minutes long at 160 degrees F. This rule was in force before development of wash chemistries of equal or greater effectiveness at lower temperatures. Recently, the state legislature has taken steps to change this rule so we are confident their knowledge gap will close. The need to close knowledge gaps is evident when laundry certification inspection protocols become unwieldy. Business technology improvements frequently provide alternative means to accomplish the same end; in this case, laundry hygiene. Lack of understanding of this flexibility can result in an excessively long list of inspection requirements that can’t be covered in an inspector’s daylong assessment of a laundry. Focusing on mandatory best practices that incorporate a variety of techniques that maximizes hygiene makes for a robust inspection and microbiological testing of clean textiles from the end of the laundry production line quantifies product cleanliness. This combination of process and outcome measures has long been practiced by the industry across the globe and is catching on here. 
-- Joseph Ricci, president and CEO, TRSA

ICT: What are some ways to improve infection prevention awareness relating to healthcare textiles?

For the IP, improving awareness is all about good communications and we see three messages worth spreading that are relevant to healthcare textiles: 
- While outbreaks of infectious diseases associated with laundered HCTs are extremely rare (there have been only 13 outbreaks over the past 40 years attributed to laundered, clean HCTs), when they do happen, they can affect not only the lives and safety of patients and staff but a facility’s reputation and financial health. To maintain the quality and cleanliness of processed HCTs for use in a clinical setting, it is worthwhile to have an awareness of when and where, and how HCTs can become contaminated prior to their use and to take measures accordingly.1
- IPs can actually affect a hospital’s bottom line and improve infection prevention efforts with effective linen strategy. Key considerations where the knowledgeable IP can make a difference include: linen vendor choice, linen choices, linen care, linen management, and a trusted partnership with a healthcare laundry (on- or off-premise) whose processes are based on the highest professionally recognized standards.2
- To improve infection prevention awareness among the C-suite, IPs need to speak the language of the C-suite. This means to link the details about infection prevention to larger topics of patient safety and satisfaction, financial health and stability, compliance, strategic planning and innovation, and environmental stewardship. Align your messages with the C-suite’s mindset and you’ll get their attention.3
References:
 . Sehulster LM. Diligence in Infection Prevention is Key to Maintaining the Quality of Laundered Healthcare Textiles. Infection Control Today. Oct. 26, 2017.
2. Gicewicz G and Larson JC. How Infection Preventionists Can Affect a Hospital’s Bottom-Line With Effective Linen Strategy. Infection Control Today. Nov. 27, 2017.
3. Gicewicz G, Scherberger J and Sehulster L. Aligning the IP’s Laundry Message With the C-Suite Mindset. Infection Control Today, Dec. 11, 2017.
-- Gregory Gicewicz, president of Sterile Surgical Systems; past-president and inspection committee chair for Healthcare Laundry Accreditation Council (HLAC)

Since the late 1970s, the CDC has identified just 14 incidents worldwide connecting laundry hygiene to healthcare associated infections and only four of these in the United States. The odds that a patient would obtain a healthcare associated infection (HAI) from linen are 1 in 77 million, making it 1,000 times more likely to be struck by lightning then than obtaining an HAI from linens. It’s essential to understand that the challenge is to reduce a tiny risk even more, not to portray the situation as a high infection risk. Healthcare facilities can maximize awareness by paying closer attention to how they handle and store healthcare textiles (HCTs) following their delivery as clean. We advocate training and retraining of medical facility staff in best practices based on OSHA’s universal precautions for handling soiled linen saturated with blood, bodily fluids, harmful residue from treatments and other potentially infectious materials. Training can be low impact for information complexity, but high impact with simple steps that everyone can take to improve the continuum of care and reduce linen loss. Similarly, steps can be taken to increase attention to handling clean linen. Healthcare facility management can develop a written policies and procedures manual outlining their own best practices for the various aspects of such handling. Use of a manual expressly for this purpose helps train new staff members and supports monitoring and evaluating the linen-handling process. Every stage of this process runs the risk of contamination as every surface that touches an HCT is arguably a determinant of the cleanliness of the textile itself.
-- Joseph Ricci, president and CEO, TRSA

ICT: What role can infection preventionists play in enhancing infection prevention relating to safe handling of healthcare textiles?

We firmly believe IPs can make a significant difference toward enhancing infection prevention efforts relevant to HCTs. And we would encourage as a reinforcing step in this direction the establishment of open communication and collaboration between the healthcare IP and the laundry profession, specifically the laundry vendor. A good practice is for the hospital IP team members to treat their healthcare laundry professionals as part of their extended team, where there’s an ongoing sharing of updates in infection control and prevention efforts and in the regulatory and licensing arenas. Important to this team-style relationship is for the IP to visit the healthcare laundry to become acquainted with the personnel responsible for administering the laundry. In fact, the laundry should be open to at least yearly visits from their IPs. These visits are more productive when they’re treated collaboratively. From this collaboration, the IP will become well-versed in the end-to-end healthcare laundry process, especially in the context of potential infection risks from contaminated HCTs. The IP will become aware of how contamination risks can extend well beyond the actual wash process. In fact, we would encourage IPs to work closely with the laundry vendor in developing ways to educate staff in the proper and safe handling of HCTs in the hospital. Safe handling procedures would include everything from hand hygiene and functional separation to proper airflow in linen rooms and use of exchange carts. Last but certainly not least, we would recommend the IP demand their laundry be accredited by HLAC.   
-- Gregory Gicewicz, president of Sterile Surgical Systems; past-president and inspection committee chair for Healthcare Laundry Accreditation Council (HLAC)

In addition to handling linens more carefully, greater attention to handling uniforms is warranted. Several studies in recent years have expanded evidence that the risk-reduction value of professionally laundering employees’ garments is worth the additional cost to a healthcare facility that currently makes employees responsible for such washing. Infection preventionists can advocate such change.  Common sense and guidelines long established by the Association of periOperative Registered Nurses (AORN) prompt caregivers working in surgical suites to change at work rather than wearing their scrubs outside the facility. Infection preventionists now can cite research that garments are soiled significantly from caregiving other than surgery and that home washing inadequately addresses the contamination risk. Shifting this washing to a certified linen and uniform service (as AORN recommends for surgical garments) or assigning this work to an on-premises laundry is a key first step but doesn’t guarantee success, which is where infection preventionists can step in. Linen and uniform laundries’ inventory tracking indicates the prominent role of “walking scrubs” in the premature demise of HCT inventory. Facilities that offer to wash employee scrubs can quantify the extent of the problem and determine the variety of its causes. In many cases, employees feel it’s a waste of time to change at work. Inadequate or poorly located changing facilities may play a role. Employee education can incorporate these concerns. The smallest medical practices are less likely to outsource or wash onsite. Infection preventionists responsible for such facilities can encourage these employees to change at work and carry their clothes home to wash-a tall order. Guidelines for home washing must be provided and somehow enforced. Outsourcing is clearly the better choice.
-- Joseph Ricci, president and CEO, TRSA