Navigating the Intersection Where Healthcare Laundry and Infection Prevention Meet

By John Scherberger BS, FAHE, CHESP

Editor’s note: This is the first of a series of articles about the role of healthcare laundry in infection prevention.

Remember learning intersection safety in driver’s ed? We were warned that intersections could be dangerous because they’re where vehicles, pedestrians, runners and cyclists are converging in the same space. We were told that about 20 percent of all crashes happen at intersections. We learned that – whether it’s one without a signal, one with signals, or one with a roundabout – it is important to understand how to navigate an intersection safely and under many different conditions.

Similarly, in the hospital, the infection preventionist (IP) must understand how to navigate the intersection where healthcare laundry and infection prevention come together. The good news is, outbreaks of infectious diseases associated with laundered healthcare textiles (HCTs) are extremely rare . Yet, like with driving, this is an intersection with potential for risk for the inexpert, where unforeseen accidents can happen if unaware, and where certain “laws” apply – but you must know them.

Of course, in driver’s ed, the goal of understanding how to navigate intersections is all about crossing to one’s own personal safety. For the IP, the goal of navigating the intersection of healthcare laundry and infection prevention is to ensure hygienically safe healthcare textiles (HCTs) for every patient in the hospital. This is especially true for those IPs who are part of a multidisciplinary team approach to infection prevention strategy.

That’s a big responsibility for an already complex job. Here are some points to know about this intersection to help steer in the proper direction:

Maintaining hygienic HCTs is as important to quality patient outcomes as practicing proper hand hygiene.

The healthcare textile is the one common factor of every patient experience in their hospital or long-term facility encounter. Every patient’s skin will touch a sheet, towel, bed pad, washcloth, bedspread or blanket. Not every patient will have physical contact with a physician, nurse or other clinician.

Unfortunately, many healthcare professionals fail to maintain the hygienic integrity of HCTs. HCTs are dropped to the floor and picked up and used rather than being placed in a soiled/contaminated linen hamper. Many staff clutch hygienically clean HCTs to their uniform while transporting them, thus contaminating them.  Many staff embrace HCTs in uncovered arms and consequently transfer skin cells and their own microbiome to the HCTs, thus contaminating them. And those are just three opportunities for contamination by the staff; there are countless other examples that can be provided but three alone should give one pause.

Regrettably for patients, many hospitals have taken the ill-conceived step of not changing a patient’s bedding daily due to cost-cutting measures. They have failed to view hygienic HCTs as one of the multidisciplinary and multimodal interventions and tools needed to work toward quality patient outcomes. And, given unforeseen events, some hospitals may not change the bedding for three or more days. In 2012, the latest year for which data are available, the average length of stay for an acute-care hospital admission was 4.5 days. That means the bedding was changed only once.  This may be a potentially great cost cutter, but at what cost to the patient and possible exacerbation of co-morbidities, or exposure to healthcare associated infections (HAIs)?

When a patient’s sheets are not changed daily, the environment of the bedding is a great place for microbiota to propagate.

Healthcare laundries accredited by the Healthcare Laundry Accreditation Council (HLAC) are in the business of ensuring that HCTs are processed and delivered to their healthcare partners in a hygienically clean manner. But, as the aforementioned examples point out, the hygienic integrity of the laundry can be compromised once it’s at the hospital.

We go to great lengths to foster proper hand hygiene. We need to do the same to maintain hygienically clean HCTs.

Ensuring hygienic HCTs is not exclusive to the launderer – it’s everyone’s job.

There are more than 600 standards to ensure that accredited laundries are producing hygienic linens. But as already put forth, an article of linen can become contaminated at the healthcare facility whether or not it was processed properly to these standards at the healthcare laundry.

This make makes the job of maintaining hygienic HCTs everyone’s – the nurse, the environmental services (EVS) technician, the IP and the launderer (and transporter).

Linens that touch the patient: In the hospital, the job of those who are responsible for making sure that only hygienic HCTs ever touch the patient begins when the linen cart is unloaded at the dock and continues to the linen room, linen closet, patient room and then finally to when they’re used by the patient. Matters of importance include functional separation, environmental cleaning of surfaces, cart disinfection, transport protection, hand hygiene, airflow quality, and lint control.

Linens that are used: All HCTs that are used are considered contaminated and must be treated as such. For example, staff should handle contaminated laundry as little as possible with minimal agitation (e.g., bedding should be rolled into itself, not shaken). This process will also provide the staff the opportunity to view the linens and avoid trapping sharps and patient items such as hearing aids, glasses and dentures. Bedding and especially bed pads containing feces should be taken to the nearest toilet and the feces carefully deposited into the commode; feces should never be rolled into linens and placed in soiled linen bins.

Contaminated laundry bags should not be held close to the body or squeezed when transporting to avoid punctures from improperly discarded syringes.

Regarding sorting, soiled textiles should be sorted by classification and/or type of goods, i.e., soiled loads must be segregated into proper hampers and fluid-proof bags. Also, soiled linen bags should only contain soiled linens, meaning there should be in place both foreign objects (food, pharmaceuticals, adhesives, etc.) and sharps policies. Last but not least to the sorting process is following Universal Precautions by all personnel who handle used HCTs (avoiding contact with patients’ bodily fluids through the use of appropriate PPE).

It’s important to know that Occupational Safety & Health Administration (OSHA) regulations do not recommend the disposal of contaminated reusable textiles that have been contaminated by blood and/or other potentially infectious material (OPIM). On the contrary, OSHA allows for these contaminated textiles to be send to the laundry for processing; and in fact discourages the disposal of reusable textiles, recommending instead their processing in a healthcare laundry.
 Linens at the laundry: The job of the healthcare laundry is to follow standards like HLAC’s and OSHA’s, which cover the complete textile processing cycle: from handling and transporting to laundering and finishing to customer use. HLAC Accreditation Standards have been developed based on federal regulations and guidelines as well as best industry practices.

The use of reusable HCTs is a circular process of proper 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. As a process, it’s just like nursing and all of healthcare and it requires attention to detail for proper outcomes – it’s everyone’s job.

It’s not an “either/or” decision when choosing a laundry as an infection prevention partner.

Because laundering of HCTs is a process with distinct stages that requires adherence to standards every step of the way, choosing a laundry as an infection prevention partner is not an either/or decision, even though choices are available. This is true whether your facility has its own on-premises laundry or you contract with an outside vendor, or whether yours is a hospital or another kind of healthcare facility.

Selecting the right laundry service has been an often-overlooked decision for a hospital. There has been a tendency to focus solely on the lowest-priced provider. Fortunately, the healthcare industry is beginning to realize the importance of having proper textile care as part of infection prevention strategy. This is due to the realization that HAIs affect not only the lives and safety of patients but a facility’s reputation and financial health.

Among leading healthcare facilities, HLAC accreditation is considered a requirement to be considered a healthcare laundry vendor. Here’s why:

The HLAC accreditation process covers the entire laundry process, end-to-end. It begins with a day-long inspection whereupon an independent inspector, trained on HLAC standards, ensures that a laundry has quality control, quality assurance and quality monitoring processes in place to provide hygienic linen not just once, but every time. The inspection aligns with the specifics of the HLAC Accreditation Standards document, “Accreditation Standards for Processing Reusable Textiles for Use in Healthcare Facilities, 2016 Edition.”

HLAC standards cover the complete textile processing cycle, from handling and transporting soiled healthcare textiles, to in-plant processing and delivery back to the customer. The standards also cover many basic considerations, such as facility layout, personnel training, and customer service.

The standards include strict adherence to federal government regulations and guidelines. Special attention has been given to laundry processes directly related to patient safety and OSHA required practices, including bloodborne pathogen exposure control standards. Part III of the Standards addresses the surgical pack assembly room and its activities. This section is based on the American National Standards Institute (ANSI)/Association for Advancement of Medical Instrumentation (AAMI) reference regarding reusable surgical textiles processing.

It’s worth noting here that an earlier-referenced report  highlighting evidence-based strategies observes that proper laundering and handling are important in achieving and maintaining the hygienic quality of healthcare fabrics and textiles delivered to the point of care. This study is comprehensive – it is based on findings and recommendations from peer-reviewed studies, as well as current standards and guidelines to inhibit serious contamination during the processing of HCTs, many of which are applicable to HLAC’s standards.

Clearly, when healthcare laundry and infection control intersect, you want to have the confidence that the former is in its proper state. This makes the case for specifying in any request for proposal that your textile laundry service company be accredited by HLAC. It’s not an either/or decision.

At a traffic intersection, what happens when just one driver irresponsibly, recklessly or ignorantly flouts the rules of the road? The outcome is an accident or worse -- serious injury or death.

The same misfortune can happen with HCTs, even though outbreaks of infectious diseases associated with laundered healthcare textiles are rare. If everyone isn’t doing what is required of them at the intersection of healthcare laundry and infection processing, someone is going to be adversely affected.

The percentage of hospitalized patients who are severely immunocompromised has increased in the past decade. Hospitals and long-term care facilities are caring for more patients who are extremely susceptible to infection by environmental pathogens. More hospitals are performing technically and medically complex, life-saving interventions, but if hospitals fail to do all they can for infection prevention they run the risk of losing these patients to contaminants.

HCTs should not and cannot be viewed with a lesser concern than other healthcare interventions. They must be viewed as a very important intervention to attain quality patient outcomes. The intersection of healthcare laundry and infection prevention can be safely navigated, and everyone approaching this intersection has a responsibility to, as we say, “First, do no harm.”

John Scherberger is board president of the Healthcare Laundry Accreditation Council (HLAC). The Healthcare Laundry Accreditation Council (HLAC) is a nonprofit organization formed for the purpose of inspecting and accrediting laundries processing healthcare textiles for hospitals, nursing homes and other healthcare facilities.

Reference: Sehulster LM. Healthcare Laundry and Textiles in the United States: Review and Commentary on Contemporary Infection Prevention Issues. Infection Control & Hospital Epidemiology. Available on CJO 2015. doi:10.1017/ice.2015.135