Washed Away

DURING A 2006 interview with ICT, Andrew J. Streifel, hospital environment specialist with the department of environmental health and safety at the University of Minnesota, Minneapolis, spoke of an outbreak of Aspergillosis among a group of neonates in an American hospital. In this particular case, Aspergillus fumigatus contaminated some linen that was used in the cribs of the neonatal unit. The linen was being stored in a closet nearby where some minor construction was being done. The Aspergillus spores were released into the air during the construction activities and then nestled on top of the fresh linen stored in the nearby linen closet. Streifel noted at the time, “One unit called me because the neonates were getting infections on their backs. That tells you right there they could be contaminated from the laundry. One facility — an oncology unit — called and said they were getting mycetomas. They were jack hammering across from where they were storing the laundry. You have to think not only about where the patients live, but where the supplies are.”

Safe laundry practices should include a cumulative view of personal and patient protective measures, and proper handling, transportation, storage, and cleaning practices.

“It would be good if everyone was concerned with what they’re doing,” asserts Bill Carroll, recent executive director of the Healthcare Laundry Accreditation Council (HLAC). As Carroll points out, infectious materials are not always visible — especially to the naked eye — so precautions must always be adhered to. Such precautions are those set forth by Occupational Safety & Health Administration (OSHA) standard, Toxic and Hazardous Substances. Bloodborne Pathogens Standards 29 CFR 1910.1030.

Carroll explains, “Body fluids that absorb into fabrics aren’t really as visible as dark red blood might be, but the pathogens are still there. I think what we need to do, what we try to do, is communicate with people openly and honestly and answer their questions. They need to know things were put in place for a reason.”

Carroll further explains what he calls his “four C’s” — communication, competency, comfort and commitment.

“We try to bring them up to a level of competency where they feel comfortable and then we insist that they become committed to doing the job as it is supposed to be done — and to have a sincere concern not only for themselves but for others.”

To further solidify the dangers that lurk within linens and other hospital textiles, studies have noted both the transmission of infectious organisms to various textiles and their ability to adhere to various textiles.

For example, a study presented at the 8th annual meeting of the Society for Healthcare Epidemiology of America (SHEA) notes that 69 percent of healthcare worker (HCW) lab coats were contaminated when caring for patients with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE).¹ Moreover, 27 percent of the HCWs’ hands were contaminated after touching the coats.

Researchers at Miriam Hospital in Providence, R.I., studied an outbreak of 38 cases of MRSA.² Ninety-six (27 percent) of the 350 surfaces sampled in the rooms of the affected patients were found contaminated with MRSA. Environmental contamination occurred in the rooms of 73 percent of infected patients and 69 percent of colonized patients. What is interesting to note is that the more frequently contaminated objects included bed linens and the patient gowns, as well as the floor, over bed tables, and blood pressure cuffs. Sixty-five percent of nurses who had performed morning patient care activities on these MRSA-infected patients contaminated their nursing uniforms or gowns with MRSA. Furthermore, researchers found that 42 percent of HCWs who did not provide any direct patient care to these patients still contaminated their gloves with MRSA when they had touched contaminated surfaces.

Potential hazards exist in every nook and cranny of a healthcare facility, but awareness can at least help deter transmission. Various avenues exist for exposure to bloodborne pathogens to occur from contaminated laundry. Sharps can sometimes get lost within laundry bundles, for example. For such instances, a safety and health program that includes procedures for appropriate disposal and handling of sharps, and follows required practices outlined in the OSHA bloodborne pathogens standard can help HCWs protect themselves.³ For optimal protection, HCWs should adhere to the appropriate PPE standards to avoid exposure to pathogens (bloodborne or otherwise) through contact with contaminated laundry. OSHA offers the following “possible solutions”:

• Employers must ensure that employees who have contact with contaminated laundry wear appropriate PPE as discussed in the Bloodborne Pathogens Standard 1910.1030(d)(4)(iv)(B) when handling and/or sorting contaminated laundry 
• Employers must ensure employees wear appropriate PPE such as gloves, gowns, face shields, masks, when sorting contaminated laundry [1910.1030(d)(4)(iv)(B)] 
• The use of thick utility gloves when sorting contaminated laundry may provide workers with additional protection 
• Utility gloves may be decontaminated for re-use if the integrity of the glove is not compromised. However, they must be discarded if they are cracked, peeling, torn, punctured, exhibit other signs of deterioration, or when their ability to function as a barrier is compromised [1910.1030(d)(3)(ix)(C)] OSHA standards for exposure to blood or other potentially infectious materials through contaminated laundry that was improperly labeled, or handled, include:
• 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 [1910.1030(d)(4)(iv)(A)(1)] 
• Place wet contaminated laundry in leak-proof, and color-coded or labeled containers, at the location where it was used [1910.1030(d)(4)(iv)(A)(2)] 
• Whenever contaminated laundry is wet and presents a reasonable likelihood of soak-through of or 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 [1910.1030( d)(4)(iv)(A)(3)]
• Contaminated laundry must be placed and transported in bags or containers labeled with the biohazard symbol or put in red bags in accordance with 1910.1030(g)(1)(i) 
• 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 universal precautions [1910.1030(d)(4)(iv)(A)(2)] 
• Use red bags or bags marked with the biohazard symbol, if the facility where items are laundered does not use universal precautions for all laundry [1910.1030(d)(4)(iv)(C)] 
• Contaminated laundry bags should not be held close to the body or squeezed when transporting to avoid punctures from improperly discarded syringes 

Raymond B. Otero, PhD, an independent healthcare consultant based in Richmond, Ky., says it would be a good idea for laundry departments and all HCWs to have a checklist or some sort of questionnaire to work off of that is specific to laundry and infection control best practices. He also points out that it is a common sense standard that any HCW handling textiles in any healthcare facility must be knowledgeable in how to handle it.

“They need to know when to wear the proper PPE,” he asserts. “When handling soiled linens, laundry managers need reusable gloves — not disposable gloves because disposable gloves are not as protective as reusable gloves — they should wear gowns if soiling is likely; masks are not needed.

“Make sure the environmental surfaces are under scheduled cleaning,” he continues. “For example, the floors should be cleaned regularly so no one slips on feces or urine that may inadvertently contaminate. Make sure that your bags are transferable so that they do not break on transportation. Employees sorting these bags should ensure there are no sharps and that they are wearing appropriate barriers such as the reusable gloves and some type of smock to protect their clothing.”

Otero adds that facilities must know where to draw the line on the use of PPE in the laundry departments. “You can’t tell them to wear masks and all this other stuff. You know, laundry areas are very warm, very hot, and you have to make sure you use a common sense approach otherwise no barriers are going to be used or you’re not going to have any people working there because it is simply too uncomfortable,” he points out.

Transportation guidelines for linen should be developed and adhered to strictly. According to a document by Otero titled, “Laundry and Textile (Linen) Services: Infection Control,” clean and soiled textiles should be transported separately and in a manner that will minimize microbial contamination.³ “The use of hampers or carts to transport soiled textiles should be appropriately cleaned before use in transporting clean textiles. Carts that are going to be used to store textiles on the floors (hallways) should have covers on them during the transportation and storage. These covers should not be removed or adjusted in a manner that will expose the textiles to common traffic.

OSHA’s bloodborne pathogens standard details regulatory requirements for workers exposed to “contaminated” laundry. These requirements involve training, sharps disposal device accessibility, and written institutional procedures to reduce risks of exposure. Additional OSHA standards that apply to the laundry industry include hazard communication and ergonomics.

Commercial laundry service contractors are not required to be accredited by state or federal law; according to Otero, however, many voluntarily comply with the processing guidelines and recommendations developed by the Joint Committee on Healthcare Laundry Guidelines.

In 1996, the Joint Commission on Accreditation of Healthcare Organizations dropped its specific reference to laundry facilities and handling of textiles for hospitals. However, the delivery of textiles that minimizes the microbial contamination from surface or airborne deposition and the collection of soiled textiles in a manner that minimizes microbial dissemination into the environment is still the responsibility of each healthcare facility regardless of whether in-house or contract commercial laundry is used.³ Carroll says he has not in recent years become aware of what he calls “careless handling” paramount with laundry. “Whether they were in-house laundries or off-premise laundries or if they were owned by the hospital or rental,” he clarifies. “I think it’s a level of care and concern for handling the textiles, and at the laundry level and the transport level, they seem to be very good. I have not heard of any major problems.

“The problems I have heard of are that of individuals letting their guard down,” he adds. “An open and honest communication about the situations they have to deal with and make them concerned about the patient and their own protection of what can happen to them if they do not follow the precautions. They need to be committed to doing the job right” 

References

1. Boyce JM, Presented at the 8th Annual Meeting of SHEA; April5-7, 1998, Ontario, Florida; Abstract S74:52.

2. Boyce JM. Environmental contamination due to methicillin-resistant Staphylococcus aureus: possible infection control implications. Infect Control Hosp Epidemiol. 1997 Sep;18(9):622-7.

3. Otero, RB. Laundry and Textile (Linen) Services Infection Control. www.cinetwork.com/otero/laundryservices.html. 

Handling, Collection and Transportation of Soiled Healthcare Textiles

1.1 All healthcare textiles must be handled and collected in accordance with OSHA regulations and federal guidelines, thereby minimizing potential exposure of patients, hospital personnel, or laundry personnel to bloodborne pathogens or other infectious agents. [OSHA: 29 CFR 1910.1030 § (d) (4) (iv); CDC/HICPAC EIC F.III] 

1.2 All soiled healthcare textiles must be assumed to be contaminated, and Universal Precautions (an OSHA term) must apply at all times to all personnel who handle soiled textiles. Standard Precautions (a CDC term) may apply as determined by either the customer or the provider.

1.3 Handling soiled textiles at the points of generation and/or collection:

1.3.1 The collection of soiled textiles begins at the point (or points) of collection designated in writing by the customer.

1.3.2 Soiled textiles shall be collected and handled only as necessary to complete the defined tasks, and in such as way as to minimize microbial contamination of the air and the personnel handling the textiles. Soiled textiles must not be sorted or rinsed in patient-care areas. [OSHA: 29 CFR 1910.1030 (d) (4) (iv) (A) (1)] 1.4 Containment of soiled textiles:

1.4.1 Universal (or Standard) Precautions shall be followed during containment of soiled or contaminated textiles.

1.4.2 The collection bags or containers must functionally contain wet or soiled textiles, preventing contamination of the environment during collection, transportation and storage prior to processing. The containers must not tear when loaded to capacity, be leak-proof, and be capable of being closed securely to prevent textiles from falling out.

1.4.3 The bags or other containers must be specially color-coded or labeled. If only soiled healthcare textiles are coming into the laundry, and all personnel are following Universal (or Standard) Precautions when handling these textiles, the bags do not need to be color-coded or labeled. [OSHA: 29CFR1910.1030 (d)(4)(iv)(A)(2)] 

1.5 Medical waste. The provider must have a written plan with the user detailing the procedures to follow when medical waste is found among soiled healthcare textiles. The plan must be in accordance with state medical waste regulations.

1.6 The service provider shall follow the customer’s policy for returning items found among healthcare textiles that contain personal patient information.

1.7 Functional Separation of Clean from Soiled Textiles. The provider must maintain functional separation of clean from soiled textiles in carts and/or vehicles at all times during collection and transportation of soiled textiles.

1.8 Observe Universal (or Standard) Precautions while moving, loading, and unloading soiled textiles.

Source: The Healthcare Laundry Accreditation Council. Accreditation Standards for Processing Reusable Textiles for Use in Healthcare Facilities. April 2006. http://www.hlacnet.org/HLAC_Standards_042006.pdf.