Down and dirty
Housekeeping departments have the highest turnover rates among non-nursing job categories, one report found.
Most who work on the inside would call long-term care laundry and housekeeping a dirty business. Government regulators and operators try to keep it clean while constantly struggling to balance the need for worker and patient safety against the realities of time and money.
Most recently, the U.S. Occupational Safety and Health Administration has promised to release its findings after a late fall “pre-rule” exercise designed to keep current the most impactful regulation affecting these two departments — the blood-borne pathogen (BBP) standard that emerged from the AIDS pandemic of the 1980s.
Observers interviewed by McKnight's predicted a range of outcomes, from no changes to a tweak of the rules. Others say if anything changes about current regulations affecting laundry and housekeeping, it likely will reflect the current onslaught of super-bugs and virulent strains that seem to pop up these days with alarming regularity.
They would explore whether the current weapons that nursing homes and others have to fight them, including disinfectants, cleaning, protective gear and work practices, are enough.
In recent examples with commercial laundries, work practices apparently haven't been enough.
A cautionary tale
In mid-January, an epidemiologist confirmed that Rhizopus microspores, a rare flesh-eating fungus found in linen samples, was a contributing factor in the deaths of three people at a Hong Kong hospital in July 2015. Investigations at Queen Mary Hospital revealed that the facility's laundry department had deficiencies in the physical environment, transportation of the linen and discrepancy in wash water temperatures, according to a January 19 news release by the Association for Linen Management.
Officials recommended a series of changes be implemented, including thorough cleaning, disinfection and after dusting of the laundry and its delivery vehicles. Other suggestions include recalibrating washing machine temperature sensors, better segregation of clean and soiled linens, and regular monitoring of laundry processes such as moisture control during textile drying and packing.
To ALM Executive Director Linda Fairbanks, the incident seemed eerily similar to what happened eight years earlier at New Orleans' Children's Hospital after Hurricane Katrina. A similar strain of the fungus, which was suspected as a contributing factor in the deaths of four children, was reportedly sourced to “sloppy linen handling” at an offsite commercial laundry in the city's Ninth Ward, a 2014 New York Times article found.
Even so, leading experts are quick to point out that healthcare facility laundries here have yet to be major culprits in spreading disease.
In its own “Guidelines for Environmental Infection Control in Healthcare Facilities,” the Centers for Disease Control and Prevention acknowledges that “although contaminated textiles and fabrics in healthcare facilities can be a source of substantial numbers of pathogenic microorganisms, reports of healthcare-associated diseases linked to contaminated fabrics are so few in number that the overall risk of disease transmission during the laundry process likely is negligible.”
In the CDC's “Best Practices Highlighted to Prevent Infections During Laundry Process of Healthcare Textiles,” lead author and epidemiologist Lynne Sehulster, Ph.D., notes that “outbreaks of infectious disease associated with laundered [healthcare textiles, or HCT] are rare: only 12 such outbreaks have been reported worldwide in the past four decades.” Sehulster adds that inadvertent exposure of clean healthcare textiles to environmental contamination, including exposure to dust in storage areas, or a process failure during laundering are the culprits. The document was published by the Society for Healthcare Epidemiology in America.
Even as laundry operators are generally lauded for their passion in producing clean and germ-free textiles, the point isn't lost on nearly everyone asked that housekeeping (whose hospital equivalent is called “environmental services”) and laundry can be dangerous workplaces.
In its own “eTools” for frontline workers, OSHA presents a litany of hazards for housekeeping, including: exposure to environments, equipment, laundry and sharps contaminated by blood or other potentially infectious materials; caustic chemicals that can cause burns and a host of skin problems; skin allergies linked to latex-containing protective gear; and slips, trips and falls.
Laundry dangers are much the same, with additional hazards such as ear-piercing noises from on-site washers and dryers; heat stress that leads to exhaustion or stroke; fires caused by lint build-up on ceilings and other surfaces; and lifting and pushing dangers from overloaded soiled linen bags.
“The speed in which a facility must react to and address new needs as they arise has been the most recent change in the environmental safety landscape,” says Bill Brooks, North American sales manager at UniMac. “A long-term care facility must be able to respond to new threats — everything from unnamed viruses to bedbugs — immediately.”
A host of issues that facilities deal with only pile on to the hazards housekeepers and laundry personnel confront.
As if playing whack-a-mole with superbugs isn't enough, administrators have to deal with declining funds to pay for more protective equipment and the incessant turnover in housekeeping, which at 44% leads every single non-nursing category in nursing homes, according to a recent American Health Care Association “Quality Report.”
Add to that huge increases in the cost of linens since 2010, when cotton prices worldwide spiked nearly 40%. In the face of declining reimbursement, it's a recipe for disaster.
“Where linen used to be 16 percent of the operating dollar in an on-premise laundry, it's now about 24 percent,” observes Richard Case, director of institutional product management at Betco Corp. “That's huge. When you look at the chemistry part, it's about 6 percent to 8 percent of the operating dollar, while [half] is labor.”
And in places affected by drought, like California, water and heating bills are skyrocketing.
As a result, most housekeeping and laundry staffs in smaller nursing homes are one and the same, according to Fairbanks.
Workers become over-stressed, and mistakes happen. Corners are cut. Laundry workers might haphazardly mix chemicals to get linens “cleaner,” or whiter, a practice that greatly shortens linen life.
Housekeeping is not any different. “There's a greater demand for infection preventionists and technology, but the money isn't there,” says John Scherberger, president of the Healthcare Laundry Accreditation Council Board of Directors. “C Diff. has become a scourge, yet so many nursing facilities tend to latch on to the chemical du jour, which in this case is bleach. So many people tend to think that if a two-ounce per gallon rate is good for chemical additives, then four ounces per gallon is better. This leads to pollution, and ruins environmental services.”
Personal protection equipment sometimes isn't used and even when it is, it's often not applied or removed properly. (A recent JAMA Internal Medicine article, for example, concluded that half of workers contaminate themselves when removing PPE.)
According to a white paper produced by CleanTex, many facility laundries can no longer keep up with swelling baby boomer populations. New equipment and added personnel are required, driving up costs. Many turn to outsourcing.
“Operators of long-term care facilities do many things well, but laundry is not their core function,” says David Potack, vice president at Unitex. “They are typically ill-equipped in terms of their physical layout, their technology, and their understanding of the many complex regulatory guidelines that promote the safety of workers and patients. Consequently, they have a tendency to overlook important infection control details when operating their laundry facilities.”
Good intentions awry
Yet even when they outsource their laundry or housekeeping chores, nursing facilities are still responsible for ensuring third parties adhere to the same rules and standards they had to before, Fairbanks adds.
As the saying goes, it's an uncomfortable destination one arrives at even after following seemingly good advice.
For long-term care laundry and housekeeping workers and those who manage them, the plethora of government agencies issuing guidelines, rules, recommendations and regulations have created a world of often confusing and conflicting information.
There's the Environmental Protection Agency, which regulates the makers of sterilants and disinfectants and ensures workers understand how to use both properly and safely. Then there's the CDC, which promulgates guidelines based on its surveillance of current and emerging diseases. Next is OSHA, the Department of Labor agency whose mission is to create a safe environment for workers. Finally, there's the Centers for Medicare & Medicaid Services, which rewards and punishes based on healthcare quality.
“The long-term care community is asking the government for some conciseness and [consistency with] all of the regulations,” Scherberger tells McKnight's. “There are so many regulations now, many nursing homes are shutting down their on-premise laundries.”
Vendors have their own “issues” with the regulatory onslaught. Disinfectant manufacturers, for example, were recently told by the EPA to adopt the European Globally Harmonized System of Classification and Labeling of Chemicals (GHS), a costly move that involved some expensive re-tooling, says Case.
“When the bloodborne pathogen rule first came out years ago, it required laundries to build either a negative pressure room for hundreds of thousands or launder soiled linens, fecal matter and all,” Case added. “Eventually they revised that.”
Meanwhile, absent regulations, the industry took a proactive step several years ago to develop and implement closed-loop dispensing systems to stem the incidence of chemical exposure to workers, Case added.
Individuals interviewed for this article, meanwhile, were scratching their heads about the outcome of OSHA's bloodborne pathogen review. The biggest changes could involve a sharper focus on work practice and engineering controls to combat emerging and re-emerging pathogens.
“I would see this as a healthy effort on OSHA's part, given the Ebola issues of 2014 and 2015, and the continued concerns with disease transmission in the workplace,” says Mike Weber, former principal scientist, technical and science liaison with Procter & Gamble Professional. “They likely have heightened concerns with the increased prevalence of antibiotic resistant strains, or ‘superbugs,' and are evaluating how to provide guidance and improve standards.”
Fairbanks says she welcomes any upgrades to the rules because she believes on-premise laundries in nursing homes and other long-term care sites “have become lax on the practice side about applying the BBP regulations.”
“Everyone in healthcare was tuned in when HIV first came to light,” she says. “But today, I think laundry workers are not as cautious in their actions and behaviors as they should be. No regulation will change that.”
“Every two years, the CDC plans a sit-down with CMS to look over environmental services and laundry guidelines,” Weber adds. “The most extreme change OSHA would make would be lining up with the CDC laundry guidelines, and I'm not certain that's going to happen anytime soon. All OSHA deals with right now is handling and isolation — not anything to do with washing or drying garments at all.”
Joel Rich, the director of long-term care for PDI, also welcomes upgraded rules.
“I would anticipate that newer regulations will [regard] stronger compliance and adherence to proper procedures and protocols related to the actual cleaning and disinfecting of room processing, as well as the documentation that relates to such activities,” he says. “The accountability of reducing healthcare associated infections lies within every component of the facility's care network, and environmental services should play a very active role in ensuring that residents' environmental safety is top of mind.”
Another possibility, according to Weber: OSHA might consider changes to its disinfectant criteria regarding equipment and work surfaces contaminated with blood or body fluids. What's really needed, he adds, “is a greater emphasis on the impact of cleaning. Whatever OSHA changes may be coming, I hope they address the importance of cleaning — not just disinfecting the surface with a product that doesn't have cleaning capability. More and more disinfectants are being approved out there that work well in a laboratory setting but not in real life. There are some manufacturers that can't make a product that's stable but also cleans.”
The CDC's Guidelines for Environmental Infection Control in Healthcare Facilities, last updated in 2003, are one of the major guidances for long-term care laundries and housekeeping departments. The other, of course, is OSHA's bloodborne pathogens standard.
About eight months ago, the Society for Healthcare Epidemiology of America released its “Best Practices” for laundry, which included recommendations for personal protective equipment, minimal “agitation” or shaking of soiled linens, stronger rules around linen storage and transport, various chemical additives and the use of disinfecting laundry chemicals in the absence of other accepted sanitizing methods.
In December, the Textile Rental Services Association produced a 13-minute video to educate hospital and long-term care workers on safe laundry practices. The video is based on OSHA's Universal Precautions, which instruct workers to treat anything exposed to blood or body fluids as potentially infectious and lethal. The group also has published best practices to manage textile assets.
It's one of many signs that the industry recognizes the need for better education and greater awareness to the ways laundry and housekeeping best practices can enhance worker and patient safety.
Case and others say they work tirelessly to show nursing homes ways to extend linen life, like monitoring rewash rates. (If more or less than 4% of your textile poundage isn't getting clean, you have a problem.)
Experts such as P&G's Mike Weber never miss the chance to remind frontline laundry and housekeeping staff that bleach may be great at killing most germs, “but it's not meant to get things truly clean. We try to educate people on the importance of cleaning as opposed to obliterating soil with bleach,” he says. “Most disinfectants are not effective cleaners, and cleaning well allows disinfecting agents to work more effectively than disinfecting alone.”
Steve Hietpas, new business development manager at Maytag Commercial Laundry and American Dryer, reminds providers to invest in energy- and water-efficient commercial laundry equipment and “teaching employees to handle linens appropriately.”
People like Fairbanks are constantly reminding people about the need for constant and vigilant staff training.
“[Administrators] need to know what the recommended practices are, or that little room in your facility no one is quite sure of — the laundry — could get you in big trouble, not only with patients but regulators,” she says.
“Regulators are drilling down now. Infections cost big money. They're paying attention and they want to know,” she adds.