Experts ‘come clean’ on infection control issues, stressing the need for better adherence to standard handling precautions.
Linens have the potential for doing far more than layering beds, lining tables and swathing long-term care residents in thread-counted comfort.
If they’re not sorted, laundered, transported and stored properly, linens also may harbor potentially harmful microorganisms, contaminated sharps and even disease-spreading pests.
“Laundry and linen service is absolutely vital to quality care delivery, but it’s often taken for granted. We just expect that housekeeping staff will show up and that clean linen will be there, when and where it’s needed,” explains infection control consultant Libby Chinnes, IC Solutions, Mount Pleasant, SC.
She adds that just one day without clean, properly handled linens can prove catastrophic for long-term care facilities.
“Many residents are incontinent, so urine and fecal contamination of linens is common. Residents and caregivers rely heavily on both the availability of clean linens and staff who are adequately trained to effectively manage the linen and laundry process,” she said.
Soiled linens constitute one of the largest concentrations of microbial contamination in the healthcare environment. While the Centers for Disease Control and Prevention states that the risk of linen spreading disease is negligible, several reports have linked textiles to infections in residents and laundry staff. The CDC is careful to point out, however, that these textile-related incidents likely stemmed from facilities’ failure to follow standard precautions when handling linen.
Often, the problem lies with laundry staff being unaware that standards related to laundry even exist, according to Linda Spaulding, CEO of InCo and Associates LLC, an international infection control consulting firm in Lakewood Ranch, FL.
“There are good [environmental control] guidelines from the CDC, which clearly outline how to handle linen to reduce the risk of infection and [cross-contamination]. Unfortunately, many laundry personnel in skilled nursing facilities aren’t following the guidelines and are unknowingly putting themselves and others at risk,” Spaulding said.
Regulatory and accrediting agencies have taken notice, and surveyors are more closely scrutinizing facilities’ approach to linen and laundry management. The Joint Commission on Accreditation of Healthcare Organizations and the Centers for Medicare & Medicaid Services, for example, classify soiled linen as infectious and regulated medical waste, and require facilities to effectively manage waste and its associated risks.
“We are looking to see that facilities are [following standard precautions], performing appropriate risk assessments, setting goals and then following through with them to ensure ongoing quality and staff competency,” said Louise Kuhny, RN, MPH, CIC, associate director of standards interpretation for JCAHO. “We certainly expect facilities to adhere to CDC environmental control guidelines and any state regulatory requirements.”
Sorting the risks
Experts agree that the most common gaps in practice relate to linen collection and containment. The CDC recommends bagging soiled linens at the point of use and handling soiled textiles with minimum agitation to avoid contamination of air, surfaces and individuals.
“Staff should be taught how to contain linen safely and to hold linen away from their uniforms when collecting and handling it,” Chinnes said, explaining that doing so will not only help prevent additional contamination but also reduce the risk of coming in contact with sharps that may have been left in linens.
Staff competency is another challenge – not just with the people processing the linen, but also with those who distribute or use the textiles on the floors. According to Jerry Gervais, associate director of standards interpretation for JCAHO, surveyors have witnessed clean linens mixed with contaminated ones and also have seen soiled textiles strewn about the floor. Though she could recall instances where individuals were seen rinsing linens in bathroom sinks, Chinnes stressed that soiled textiles should not be sorted or pre-rinsed in resident-care areas. The safest approach, according to the CDC? Rinsing linens soiled with feces in dirty utility room hoppers and then placing them in the wash.
Failure to provide enough space for the separation of soiled and clean linens in designated laundry areas is another common problem and is the cause for most environment of care citations, Gervais pointed out.
Although some older buildings may lack the necessary square footage in laundry areas to allow for more effective design layout, providers are working to address the need for separate sorting and linen handling areas.
“My buildings all have a separate room dedicated to sorting soiled linens,” said Andrew Pron, environmental services district manager for Genesis HealthCare Corp. “This allows us to keep clean [linens] from being potentially contaminated. It just makes good sense.”
So does the appropriate use of personal protective equipment, although the practice remains a challenge for many facilities. “Making sure everyone wears appropriate PPE is an area that requires ongoing education and training,” Pron added. “Our laundry personnel wear gowns and puncture-resistant gloves, and we have goggles and face shields available.”
When handling soiled linen, both the CDC and the Occupational Safety and Health Administration state that reusable gloves, gowns and aprons should be worn. Although the message is somewhat mixed on the need for masks and eye protection when handling soiled linen, Spaulding also recommends them.
“I know it’s hot in the laundry area and [PPE] can seem uncomfortable, but it’s necessary for the health and safety of laundry [personnel],” she said, adding that if linen is contaminated with the Norwalk virus or other airborne microorganisms, personnel without adequate PPE could easily become sick.
Even if facilities follow standard precautions to the letter, linens still may pose a contamination risk if laundry equipment is poorly maintained or appropriate cycle times and temperatures are not met.
Spaulding explained that different detergents require specific temperatures to clean properly.
“Some facilities are using cold water cycles with hot water detergent,” which can compromise the cleaning effectiveness, she said. “If you’re using low temperature detergent, the water should be less than 160 degrees Fahrenheit. Hot water detergent needs water greater than 160 degrees. It’s important to make sure that the washers can get that hot.” The CDC recommends a minimum 25-minute cycle for hot-water washing.
Dryers also need ongoing attention.
“The amount of air that comes into the dryer is very important. Without adequate air coming in and good exhaust going out, the dryer won’t operate properly,” noted Kim Shady, national sales manager for UniMac, an industrial laundry equipment provider based in Ripon, WI.
Some of the latest laundry equipment features advanced microprocessor controls that allow for greater flexibility in the washing and drying processes.
Aside from offering a wide range of speed and temperature options, the units also can monitor loads to ensure that cleaning and drying parameters have been met.
“These features can be very helpful for long-term care facilities because they help take some of the guesswork out of the process,” said Marcie Dos Reis, marketing coordinator for American Dryer Corp., a manufacturer of commercial drying equipment based in Fall River, MA.
Facilities looking for even more advanced protection against linen contamination can benefit by employing barriers in the laundry area and installing equipment with separate sets of doors — one for loading, one for unloading.
As Gary Gauthier, marketing manager for Milnor Laundry Systems, explained, “The barrier completely separates the soiled side of the washroom from the clean side and further protects linens.”
He added that these machines also should have air control systems to keep bacteria-laden air from being discharged and recirculated in the clean laundry section. The system should permit air to be drawn into each washer-extractor from the clean side only and discharged into the soiled section only.
“This is critical, since large volumes of air are drawn into the machine and expelled during normal operations,” Gauthier noted.
Contamination control dryers that feature advanced HEPA/ULPA filtration systems can further boost facilities’ infection control efforts by controlling airborne particle concentrations, added Dos Reis.
Above all, effective infection control in linen and laundry services requires a multidisciplinary approach. It also must have ongoing attention from — and education provided by — the facility’s infection control practitioner.
“ICPs should visit laundries regularly and make sure that the staff is aware of and adhering to appropriate standards. This includes laundry personnel and [end users],” said Chinnes, the infection control consultant.
“A laundry representative should also be included in the infection control committee to stay [abreast of] issues and educate others on their role in safe linen handling. This is an area that deserves facility-wide attention.”
Nosocomial infection rates
More than 1.5 million cases of nosocomial infection in long-term care facilities and nursing homes occur each year, representing an average of one infection per year per resident.
Facility-acquired infections account for 30% of all hospital admissions from nursing homes. They are the most common immediate cause of death in nursing home residents.
Source: Centers for Disease Control and Prevention, 2006
5 Basic principles
Laundry cannot adequately be cleaned unless five basic factors are present: adequate time, temperature, mechanical action, procedures and chemicals.
To improve cleaning outcomes and maximize infection control efforts, apply the following basic principles:
1. Check that wash water and dryer air temperatures are high enough to ensure that sanitary safeguards can be maintained.
2. Do not overload washers; ensure adequate water levels to allow proper rinsing and dispersal of detergents.
3. Transport clean linens in covered containers and store them in covered areas.
4. Keep dirty linens separated from clean ones at all times; keep soiled linens covered.
5. Clean linen folding surfaces and all laundry appliances (washers/dryers, carts) daily with a detergent germicidal solution.
Source: Gary Gauthier, marketing manager, Milnor Laundry Systems, 2006
Stomping out laundry pest problems
Microorganisms on soiled linens aren’t the only nuisances posing potential problems for long-term care laundry personnel and residents. A host of other pests – from flies and ants to roaches and rodents – also may find laundry areas comfortable and convenient place to set up shop.
“The warmth and moisture in laundry areas create an optimal environment for pests,” noted Zia Siddiqi, PhD, Orkin’s director of assurance. He added that if not eradicated, the creatures can hide easily in folds of clean linen and be unknowingly transported to resident rooms, dining facilities and other common areas.
Pests can make residents and staff more than just squeamish. A common housefly can carry as many as 500 million germs on its body at one time and can cause numerous infections, including salmonellosis. Roaches carry an average of 25 different bacteria, making them a reservoir for a range of microorganisms including salmonella, staphylococcus and streptococcus.
If that weren’t enough, roaches also excrete a protein that becomes airborne and can cause asthma and allergies. In fact, roaches are the number one cause of asthma, Siddiqi pointed out.
Despite the laundry environment’s conducive conditions, Siddiqi reassured that a little due diligence can go a long way in keeping pests at bay.
His top tips:
– Focus on sanitation, keeping lint and other debris off floors and surfaces to prevent microfungal growth that may lure pests.
– Thoroughly clean behind and underneath washers, dryers, cabinets and other stationary structures.
– Do not bring food into laundry areas.
– Seal cracks and crevices.
– Use positive air pressure in laundries to draw inside air out and prevent flies and other insects from being pulled into the facility.
– Ensure that weather stripping and door sweeps are in good condition.
– Fix water leaks immediately.
– Remove floor drain covers and clean drains thoroughly each month with a detergent and brush.
– If pests are present, identify the type and species before selecting the treatment.
– Use baits, which kill entire colonies, rather than toxic chemical sprays. Sprays create a temporary barrier that forces pests to simply find another hiding place.