Healthcare Laundry Processes and COVID-19
By John Scherberger, FAHE
Editor's note: This column originally appeared in the May 2020 issue of Healthcare Hygiene magazine.
According to current evidence, SARS-CoV-2 virus is primarily transmitted between people through respiratory droplets and contact routes. Transmission of the SARS-CoV-2 virus can occur by direct contact with infected people and indirect contact with surfaces in the immediate environment or with objects used on the infected person such as stethoscopes, thermometers, or healthcare textiles).
A virus, particularly a coronavirus, can be removed from the healthcare environmental by using time-honored processes: the use of healthcare-grade microfiber infection prevention textiles in conjunction with EPA-registered hospital-grade disinfectants (EPA List N), proper collection and bagging techniques for used healthcare textiles (HCTs), proper functional separation of clean and soiled/contaminated HCTs, and laundering soiled/contaminated HCTs according to CDC Guidelines for Environmental Infection Control in Health-Care Facilities (2003), Laundry and Bedding.
Commercial laundries have consistently provided hygienic HCTs to healthcare facilities, particularly in the U.S., with very rare exceptions. Here are the facts about the laundering processes used by healthcare and other accredited and certified laundries.
Commercial laundries are expected to follow the CDC laundering processes referenced above, follow manufacturers guidelines for all chemicals used in processing HCTs, ensure staff adhere to the use of PPE in handling both soiled/contaminated HCTs, and transport hygienic HCTs to healthcare facilities in a manner that ensures the textiles remain hygienic and assure delivery to facilities following functional separation of textiles. In addition to the CDC Guidelines, all local, state, provincial, and municipal statutes and requirements are followed.
Accredited laundries ensure their staff follows best practices during the entire process, from picking up laundry at the facilities, to delivery to the laundries, and returning of hygienic HCTs. This includes ensuring that the equipment and transportation used is properly maintained, cleaned, and disinfected.
In the U.S., healthcare textiles are disinfected through the use of chemicals and thermal processes. The use of surfactants, disinfectants, and high water and drying temperatures ensures that HCTs are processed to the highest possible standard attainable. When laundries choose to use low-temperature water, additional steps and different chemicals are used that results in hygienic results. HCTs that require sterilization are processed in the same manner as are all HCTs with the added step, typically taken by the hospital sterile processing department.
Accredited and certified laundries assure hospitals that their HCTs are properly collected, sorted, processed, packaged and delivered according to the highest hygienic standards. Following evidence-based practices and scientific principles that include following the current CDC guidelines, ensures a reduction or elimination of microorganisms, including SARS-CoV-2.
Commercial laundering differs drastically from home laundering practices, and those differences are what ensures that scrubs and all other HCTs are consistently more hygienic and better for staff and patients than scrubs and lab coats laundered at home. Commercial healthcare laundries incorporate the following components in the laundering process:
1. Commercial washing machines that ensure time, temperature, agitation, dilution of soils and contaminants to facilitate loosening of bioburdens trapped in textiles, and sufficient rinses based upon load content. CDC guidelines also mandate water temperatures of greater than or equal to 160 degrees Fahrenheit. Low temperature water of 71 to 77 degrees Fahrenheit (22-25 degrees Celsius) with a 125-part-per-million (ppm) chlorine bleach rinse is also an effective way to process laundry.
2. Proper pH chemicals – both high pH (alkaline) and low pH (acid) – to deactivate organisms and viruses. Proper introductions of chemicals at the proper time for the proper amount of time negatively affects both dirt and bioburdens. Controlling the pH levels also ensures that HCTs have a neutral pH and present no issues to sensitive patient skin.
3. Proper oxidation agents also kill and/or destroy pathogens. Commercial laundries have the expertise and chemicals to produce desired results, unlike home washing machines or coin-operated machines for those inclined to launder their scrubs and uniforms at home.
4. Rinsing is a vital step in proper laundering of HCTs and cannot be stressed enough. Rinsing ensures that contaminants are deposited into the waste drain.
5. The final step in the laundering process includes drying HCT at a temperature that exceeds 160° F at the dryer exhaust. That means that the internal drying temperature will far exceed the temperature needed to deactivate or kill any pathogens that potentially have survived the washing cycles. Additionally, sheets and pillowcases are exposed to the heat of a flatwork ironer that typically is 365 degrees, depending upon the equipment manufacturer’s recommendations and the best practices of the laundry facility.
Commercial healthcare laundries and laundries that process scrubs, lab coats, and healthcare textiles such as infection prevention microfiber have been and continue to be significant partners with hospitals and other healthcare facilities. Their processes ensure hygienic HCTs and they are up to date with the latest CDC guidelines.
John Scherberger, FAHE, is the owner of Healthcare Risk Mitigation in Spartanburg, S.C. He is a subject matter expert in healthcare environmental services, healthcare linen and laundry operations, and infection prevention.
Safer, Smarter, More Sustainable: Reusable Healthcare Textiles Outperform Disposables
By Linda McCurdy
Editor's note: This column originally appeared in the March 2020 issue of Healthcare Hygiene magazine.
According to Greek mythology, Prometheus enraged Zeus by stealing fire from the gods and giving it to man. In this tale, fire represents civilization and knowledge, which the gods fear would be dangerous in the hands of mortals.
In modern times, the greater danger is that mankind does not make full use of the tools and knowledge at its disposal.
We know, for example, that single-use items have contributed to explosive growth in landfills and to the pollution of waterways. Yet globally, we find continued resistance to the idea of replacing those disposable products with reusable alternatives despite their superior performance.
We know that in a mobile world, a deadly infection can erupt into a global epidemic in a terrifyingly short time. Yet just weeks into the onset of the coronavirus, China’s National Health Commission issued a statement acknowledging that the country was contending with, as Reuters reported, “a severe shortage of equipment, including suits, masks and goggles.”
To those outside our industry, these may appear to be unrelated events. But we see a strong connection between the threats of greenhouse gas emissions and deadly infections.
In the face of its shortage, the Chinese government issued a directive conserving the use of disposable protective equipment among healthcare professionals. Its communication was an unintentional reminder that all those disposable items were being added to the world’s refuse and adding to greenhouse gas emissions because they could not be sanitized, disinfected, and made safe for reuse.
These events point to an opportunity not merely to promote more widespread adoption of reusable surgical textiles including gowns, towels, and drapes, and other reusable medical products, but also to take a leadership position in the protection of our planet, its people, and its sustainable future.
As the China crisis has shown us, in the face of an epidemic, we cannot afford to rely on single-use gowns and other disposable medical products. All non-renewable resources are, by definition, finite in their availability—and they’re in shortest supply when demand and need are greatest.
If reusables were the standard, healthcare professionals in China would not have to make difficult decisions about reusing or forgoing use of personal protective equipment such as single use gowns and googles. They would not have to hoard supplies. They would not have to take chances with their own health and the health of their families, co-workers and patients.
And yet, this is precisely what they’ve been forced to do by both government policy and by the shrinking stock of disposables available for use as this health crisis continues. This is a manmade complication to already extraordinary healthcare circumstances—a complication that could be eliminated by the adoption of reusables and of our industry standards for their processing and sterilization.
Of course, reusables deliver superior value in terms of cost of use, as well. The price/performance differential has been well established for at least 15 years, as seen in an industry whitepaper, “New Innovations in Reusable OR Textiles: An overview of environmental, cost, and provider comfort issues.”
Citing the 2005 Comparative Operating Revenues and Expense Profile for the Healthcare Textile Maintenance Industry, which covered 49 percent of all U.S. hospital beds, the whitepaper noted that “approximately 6.5 pounds of surgical textiles are used per bed each day in hospitals with 300 or more beds.” The paper went on to provide this calculation: “If a 300-bed hospital chose to use disposable surgical products rather than reusables, they would incur upwards of an additional $250,000 in costs to trash the disposable products.”
And that’s simply the price of disposal. To gauge the full cost, we must account for the impact on human factors with which China is now contending. The financial implications of relying on disposables are reflected not only in their higher price tag relative to overall use but, more critically, in the cost to human life, public safety, and the health of the planet in the face of a serious viral outbreak.
Add to that the economic advantages generated by local employment—jobs creation that spurs growth in each community served by a hospital, medical center, or nursing home—and there’s simply no financial rationale for continued use of disposables.
The ecological argument is equally airtight. Under the best of circumstances, our planet cannot continue to absorb the daily addition of massive quantities of single-use items to our landfills. When those items are not only disposable, but likely to have had contact with life-threatening viruses or bacteria, the peril escalates.
Conversely, reuse of gowns and other reusable medical products reduces both waste and risk of infection, provided that laundering facilities comply with the sterilization and disinfection Standards established by HLAC and recognized throughout the industry.
Let’s look at the coronavirus both as a healthcare crisis and as a wake-up call—a reminder of our ethical obligations to ourselves and our planet—and take up that leadership position to protect both from avoidable harm. We have long had the facts and information at our disposal, and the grave danger, particularly now, is not making full use of that knowledge.
Linda McCurdy is president of the Healthcare Laundry Accreditation Council (HLAC).
Healthcare Textiles: How Clean is Clean Enough?
By Gregory Gicewicz
This column originally appeared in the February 2020 issue of Healthcare Hygiene magazine.
Healthcare textiles (HCTs) directly touch the largest organ on the human body, the skin. So how clean is clean enough for HCTs? Imagine a grossly soiled unwashed patient gown. Would we ever use this to cover a sick patient? Of course not. Now, picture a different patient gown. This one has gone through processing, utilizing the most stringent HLAC standards for infection prevention and patient safety. Is this gown clean enough to cover a sick patient? Unless they are sterilized, all HCT have some level of microbiological contamination. The Association for the Advancement of Medical Instrumentation defines hygienically clean as free of pathogens in sufficient numbers to cause human illness. But there is no absolute scientifically established quantity for sufficient numbers. Therefore, we don’t really know how clean is clean enough. This article will attempt to guide healthcare practitioners in managing the cleanliness of HCT used on their hospital’s patients.
Outbreaks attributed to laundered HCTs have occurred but are rare. Of the billions of pounds of HCTs processed annually, I am only aware of 13 outbreaks in 48 years worldwide, impacting roughly 356 patients. While any outbreak is tragic, this is an impressive track record. Of some concern, however, research has shown that HCTs can transmit pathogens and reports of microorganisms on HCTs are common. Also, research has proven that multidrug-resistant microorganisms (MDRO) can survive on HCTs for weeks and soiled HCTs can contaminate surfaces, and medical devices.
Our Linen Tested Hygienically Clean – We are Fine Right?
Practitioners often incorrectly assume that if a few linen samples test as hygienically clean, then all HCTs in their facility are safe. If it were only that simple. A few samples of linen that test hygienically clean is one indicator out of hundreds of thousands. It should never give a hospital cause to relax scrutiny. Were the other tens of thousands of pieces processed also hygienically clean every time? From where was the sample taken? What if the previously clean samples were contaminated somewhere along the journey to the patient? What method was used to test the linen for microorganisms? Did the method identify all potential contamination or just a subset of microorganisms? Some methods may identify < 20 CFUs on a sample of linen. Other more granular methods may show >500 CFUs for the same piece of linen!
First Agree on your Acceptance Standards
The first step to ensure consistently patient-safe HCTs is to determine acceptable standards of cleanliness for various items in various healthcare uses. Work with your laundry provider to establish linen standards. Identify and agree on what is acceptable for various items. Which stains are too large? Which tears/holes are unacceptable? What is your contamination threshold? How and how frequently will it be measured? Are there super sensitive areas such as the NICU or an organ transplant unit that need an extra level of clean or even sterilization? Once these are established, partner with your laundry provider to ensure the standards are managed to.
Follow the Process.
Now take a process-based approach and consistently monitor the key processes. There are hundreds of standards that must be followed consistently. Here are a few examples:
1. Be sure soiled HCTs are sorted according to type. Wash formulas are specific to soil classifications and types of linen. If heavily soiled surgical towels are mixed with light soiled bath blankets there is a good chance the light soiled bath blankets will emerge from the wash contaminated.
2. Functional separation keeps soiled HCTs separated from clean HCTs. Enforce functional separation physically and logically.
3. Wash formulas must be titrated regularly for proper chemistry, time, water levels, and temperatures. If any of these variables is off the emerging HCTs may not be clean.
4. Ensure linen rinse water is tested regularly for contamination. A perfect wash formula will not produce clean HCTs if the final rinse water is unclean.
5. Are discharge conveyers clean? Clean HCTs on a dirty conveyer will become contaminated. Be sure conveyers and other hard surfaces that clean HCTs touch have a documented cleaning schedule and a documented testing schedule.
6. Make sure employees handling clean HCTs have clean hands. Have a hand hygiene policy. Test employee hands for cleanliness and document the results.
7. Is the air clean in clean areas of the laundry plant? Pay careful attention to dryer and ironer areas for contaminated air. Have the air tested regularly in these areas.
8. Are clean HCT carts really clean? Dirty linen carts can contaminate clean HCTs. Test them for contamination regularly.
9. Measure bioburden levels of HCTs at multiple points up to their point of use. After the washer; after the dryers; after finishing; after cart loading; in the linen room; in the patient room. This will help determine and eliminate where contamination occurred.
Make the Odds Favor Safe HCTs
By following and monitoring the strictest HCTs processing standards for infection prevention, you are stacking the odds in favor of safe HCTs for your patients every time.
Gregory Gicewicz is president of Sterile Surgical Systems. He is past president of the Healthcare Laundry Accreditation Council (HLAC), currently serves as HLAC inspection committee chair, and led a committee that developed the HLAC Laundry Process Monitoring Toolkit.
Striving for Continuous Improvement
By David Potack
This column originally appeared in the January 2020 issue of Healthcare Hygiene magazine.
America’s advanced capability to control infection contributes to our nation’s standard of living. We assert that we prevent healthcare-associated infections (HAIs) better than the rest of the world and conclude that maintaining such performance requires the adoption of American hygiene standards based purely on U.S. research. But this does not consider risk minimization practices superior to our own developed elsewhere, with healthcare textile (HCT) hygiene as an example.
Hospital linen is insignificant to HAIs and probably always will be. Based on the two cases in the U.S. reported by the Centers for Disease Control and Prevention in the 2000s, CDC statistics indicate the chance that an American won’t wake up tomorrow because her/his bed suffocated and strangled the individual to death is 77 times greater than the chance that a U.S. hospital patient will be affected by an HAI transmitted by bed linen.
No matter how small an infection risk may be, however, it’s critical to minimize it. For more than 30 years, the German Certification Association for Professional Textile Services (CAPTS) has established thresholds for HCT cleanliness. Since the 1986 launch of CAPTS’ RAL-GZ 992/2 certification in Germany, the designation has been earned by laundries in 15 other European countries (Eastern and Western), China, Japan, Saudi Arabia and the United Arab Emirates.
TRSA’s inception of Hygienically Clean Healthcare certification introduced CAPTS cleanliness standards to North America in 2012 as an adjunct to robust laundry inspection. Some 150 laundries in the United States, Canada and Mexico have either been certified or have applied for Hygienically Clean. It has become the American microbiological content standard for HCTs.
Europeans have long been ahead of North America in adopting laundry technologies and measures. Tunnel washing was invented in Germany in 1965; with its superior water and energy efficiency and requiring less manual material handling than standalone washers, it was embraced in Europe first. Over the years, visits by North American TRSA members to our overseas counterparts have been invaluable. Now when we tour their laundries, we still see technical advances, but we use essentially the same types of equipment and supplies. This striking similarity validates the adaptation of CAPTS thresholds here.
Calls for U.S. research on HCT cleanliness thresholds overlook the Hygienically Clean certification track record. Certified laundry facilities have tested over 5,500 textile samples using the same or similar protocols and microbiological levels that have been examined, researched, tested and discussed with our global partners for many years.
While sentiment is expressed that an industry benchmark still has not been established, the Hygienically Clean thresholds—on total microbial content (20 colony forming units per square decimeter of fabric in the RODAC plate test), yeast and mold (same) and absence of specified bacteria—have thrived overseas for decades and been accepted by North American healthcare facilities for nearly a decade.
Suggesting other U.S. thresholds are needed could backfire and prompt government rulemaking rather than the stringent self-regulation Hygienically Clean provides. Today in Germany, the Ministry of Health’s Robert Koch-Institute (RKI) sets basic rules for healthcare products and procedures to reduce infection risk in hospitals, including limit values for HCT processing. Microbiological requirements are enforced for hospital linen, hospital laundries, laundry processes and outsourcing to private laundries. Building requirements and recommended procedures and performances are given or referenced.
On a continent-wide level, the European Union standard (EN 14065) on risk analysis and bio-contamination control encourages self-regulation. It fosters a standardized quality management system for RABC for laundries in sensitive sectors including healthcare, food processing, pharmaceutical and medical devices, but isn’t overly prescriptive. Used by most major European healthcare laundry firms, EN 14065 is voluntary, but it guides regulatory, accreditation and certification authorities.
Laundry reflects the positive influence on the U.S. of the worldwide development of international health technology. According to Medical Product Outsourcing magazine 2019 listing of the top global medical device companies, nine of the Top 20 are based outside the United States: seven in Europe and two in Japan.
Europe’s hygiene performance could be considered more successful than ours. Every other year, the World Economic Forum publishes a report that provides a valuable tool for policymakers, companies and complementary sectors to understand and anticipate emerging trends and risks in global travel and tourism. A competitiveness index rates countries on their enabling environment, policy and enabling conditions, infrastructure and natural and cultural resources.
Health and hygiene are pillars in the rating of a nation’s enabling environment. Among the 140 countries, the U.S. is 51st in this category and Canada is 52nd. All European nations (except six) and nine non-European rank higher. Austria and Germany are tied for first. Their rating is 20 percent stronger than that of the U.S. Argentina (14), Japan (16), and the Republic of Korea (17) all are 10 percent better.
Continuous improvement is our goal. With our worldwide counterparts, we anticipate further reducing the already infinitesimal risk of spreading pathogens through HCTs.
David Potack is president of Unitex, a family-owned medical linen and uniform provider. He is the immediate past chairman of TRSA. He currently chairs the board of trustees of Montefiore St. Luke’s Cornwall Hospital and serves on the Yale New Haven Children’s Hospital Council.
Overlooking the Obvious
By John Scherberger, FAHE
This column originally appeared in the December 2019 issue of Healthcare Hygiene magazine.
When the familiar becomes commonplace, it becomes overlooked until it becomes a movement.
The commonplace in healthcare facilities is healthcare textiles (HCTs). The overlooked in healthcare facilities is healthcare textiles. The movement in healthcare facilities is HCTs.
Why is this a movement?
The movement may begin as a result of real concern on the part of healthcare workers. It may be the result of increased scrutiny by infection preventionists and environmental services directors. Faulty extrapolation of information or disinformation has been the cause of some movements. It may be the reaction to not fully understanding that maintaining hygienic textiles is everyone's responsibility.
It is true that some patients have become unwell and even died due to pathogens traced to healthcare textiles. Illness and death are nothing to trivialize. No person is just a number, a statistic, or inconsequential, mainly if that person is a loved one or a friend.
However, the instances of an HCT being a fomite is minuscule, and as widespread as some studies may lead one to believe. This observation is in no way meant to minimize the possibility or the results of HCT being fomites; it is just a fact.
In June 2015, a study by Lynne M. Sehulster, PhD, M(ASCP), titled “Healthcare Laundry and Textiles in the United States: Review and Commentary on Contemporary Infection Prevention Issues,” was published in Infection Control & Hospital Epidemiology. The study was a retrospective review of outbreaks of infectious diseases associated with laundered, reusable HCTs, primarily in North America, Europe, and Japan. Of the 12 reported instances, they appeared over the past 43 years and involved nearly 350 patients.
Before the reader reaches inaccurate conclusions, one must recognize that, in the United States alone, in 1989, healthcare facilities had over five billion pounds of healthcare textiles are processed. The 2019 estimates are to expect closer to 10 billion pounds. Hard to visualize? How about stacking the Pentagon on to itself five times? Or a pile the height of 22 Willis Tower (a.k.a. Sears Tower) in Chicago.
In her 2015 retrospective study, Sehulster reported:
- Of the 12 outbreaks, 4 (33 percent) reported problems with laundered textile storage in the hospital;
- 7 (58 percent) reported contaminated washing equipment, inappropriate wash cycle or water temperature settings, or recycled water issues;
- 1 (8 percent) attributed the outbreak to inadvertent contamination occurring during transit from the laundry to the hospital.
What are all these findings saying to infection preventionists and environmental services directors about their healthcare textiles?
Very clearly, mitigation of infections from HCTs is possible by closer attention to processes both in the healthcare laundry facility and the healthcare facility.
But how? How can infection preventionists, environmental services, and laundry experts ensure that HCTs received from healthcare laundries are hygienic? What are they to do to maintain the sanitary status of the HCTs once introduced into a healthcare facility? How can those entrusted with providing hygienic products to patients earn the trust of patients and healthcare workers?
Healthcare textiles are the one product provided to patients, and many healthcare workers, that are so ubiquitous they are conceded as being appropriate, i.e., "safe" and hygienic, for use by everyone. Right? However, that concession is without its limitations. The limitations are dependent upon processes being in place; in the healthcare laundry and the healthcare facility. Not only must they be in place, but strict adherence is also necessary.
IPs understand there are six points at which a chain of infection chain is susceptible to disruption. When a link in the chain is severed, germs have a lower potential from becoming a pathogen to a vulnerable person.
As a reminder, the six links include the infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host. The Association for Professionals in Infection Prevention and Epidemiology (APIC) has a compelling and illustrative infographic on breaking the chain of infection: http://professionals.site.apic.org/files/2016/09/Break-the-Chain-of-Infection.pdf
So, how do IPs who are not healthcare laundry experts assure themselves that they have broken a link, or links, in the chain? How can IPs and EVS know what processes and procedures are necessary for a healthcare laundry to provide hygienic HCTs? What procedures are necessary for a healthcare facility to maintain the hygienic integrity of the HCT received from the healthcare laundry?
The first step is ensuring the healthcare facility has adopted and implemented a linen laundry processing policy. By the way, California has mandated that healthcare facilities have linen laundry processing policies in place by Jan. 1, 2020. Further, they stipulate "the facility's linen laundry is required to be processed in compliance with the facility's updated linen laundry processing policy, and CDC and CMS standards."
The Assembly Bill indicates that the healthcare facility must incorporate their contractor's linen and laundry processes into their policy facility policy. How? By stating that their laundry and linen services (contractor or on-premises laundry) have processes and procedures that adhere to CDC guidelines and or CMS regulations/F-tags and referencing the contractor and methods in their policy. Perhaps the easiest way to ensure this is to require the laundry facility to be HLAC-accredited. Although specific to California, the requirement contained in the Assembly Bill should be the in-place standard for all healthcare facilities throughout the United States and Canada. It leaves nothing to chance, speculation, or presumption.
Although not mandated by any regulatory agency, IPs are encouraged by APIC and many other professional organizations to visit the healthcare laundry at least annually. Keeping in mind that a lot can happen over a year, a better suggestion is to visit -- unannounced -- at least quarterly. Knowing what to look for during the visit, a more appropriate term would be inspection, may be daunting, but should not be off-putting or intimidating. The Healthcare Laundry Accreditation Council (HLACnet.org) makes available at no cost on their website a checklist that IPs can become familiar with and use during inspections regardless of the laundry's accreditation or certification status.
Don't expect to find a clean-room environment; after all, a healthcare laundry is a production facility that uses large, state-of-the-art equipment, water, and steam lines throughout the facility, as well as fans and electrical conduit. It will be necessarily a manufacturing facility where professionals take dirty, stained, contaminated healthcare laundry products and turn them into sanitary textiles. Laundering on such a large scale requires following standardized processes and procedures meticulously.
The more often the IP visits the healthcare laundry contractor, the more information and understanding of how their job requires regular visits. Visits and knowledge will also improve communication, cooperation, and collaboration in meeting the needs of the healthcare facility and the contractor.
Regardless of the excellence of a healthcare laundry, if a hospital or healthcare facility fails to receive, transport, store, and distribute the HCTs in ways that will maintain the integrity of the textiles, all will be for naught.
People are prone to believe "it's the other guy" that spreads germs and fails to follow the rules, regulations, and guidelines. "It's the other guy" that doesn't wash their hands before encountering hygienic HCT's. "It's the other guy" that carries the clean textiles against their uniform or scrubs and picks up textiles that have fallen to a floor and uses them for patient care. "It's the other guy, not me," that sneezes onto clean textiles or sneezes or coughs into the crook of their arm then gathers HCTs into the same contaminated arm or uniform. "It's the other guy" that wipes sweat from their brow or face and unconsciously puts the contaminated washcloth or hand towel into a patient room for use. And "It's the other guy" that brings an excess of HCTs into a patient room and leaves them on an unclean counter and used for the newly arriving patient. The reality is that everyone is "the other guy."
When the healthcare textile becomes so commonplace that it becomes overlooked and taken for granted, harm may occur to patients and staff. When taken for granted, things may no longer be valued; thus, the laying of a foundation for injury.
Laundry and linen processing must be valued. Healthcare facilities must elevate the value and importance of transporting, handling, storage, and distribution of hygienic HCTs, if for no other reason that the benefit of patients.
John Scherberger, FAHE is the owner of Healthcare Risk Mitigation in Spartanburg, S.C. He is a subject matter expert in healthcare environmental services, healthcare linen and laundry operations, and infection prevention.
Defining and Measuring ‘Hygienically Clean’
By Carol McLay, DrPH, MPH, RN, CIC, FAPIC
This column originally appeared in the November 2019 issue of Healthcare Hygiene magazine.
Laundry services play a critical role in a healthcare facility’s infection prevention and control program. Healthcare textiles (HCTs) include bed sheets, pillowcases, blankets, towels, personal clothing, patient apparel, employee uniforms, scrub suits, gowns, and drapes for surgical procedures. Contaminated textiles often contain large numbers of microorganisms from body substances such as blood, skin, stool, urine, vomitus, and other body tissues and fluids, and it is important to ensure that pathogens are not transferred to patients or healthcare workers.
In addition to normal microbial skin flora, organisms commonly found on HCTs include gram-negative bacteria, coagulase negative staphylococci, and Bacillus species.1 These organisms have the ability to bind to textiles and may survive for as long as 90 days.2-3 Staphylococcus aureus and Pseudomonas aeruginosa in particular have high ratios of binding (80 percent) to polyester or acrylic fibers. Nylon fibers bind S. aureus at low ratios, but P. aeruginosa at intermediate ratios. The binding rate for cotton fibers was reported to be less than 10 percent.4
In addition to bacteria, molds and viruses including rotavirus and parainfluenza virus have been cultured from hospital textiles.1
HCTs have been implicated in hospital outbreaks of fungal and bacterial pathogens; 12 such outbreaks have been reported worldwide in the past 43 years affecting 350 patients.5
Investigators have examined the connection between healthcare textiles and infectious disease outbreaks and their conclusions emphasize that fact that correct laundering of healthcare textiles is an important measure for preventing healthcare-associated infections (HAIs). Through a combination of soil removal, pathogen removal, and pathogen inactivation, contaminated laundry can be rendered hygienically clean.
Hygienically clean is defined by the Association for the Advancement of Medical Instrumentation (AAMI) as “free of pathogens in sufficient numbers to cause human illness.”6 However, AAMI does not quantitatively define the meaning of “sufficient numbers.”
The Centers for Disease Control and Prevention (CDC) also does not provide a quantitative value for hygienically clean textiles in their “Guidelines for Environmental Infection Control In Health-Care Facilities” but do state that proper laundering processes should result in a 3-4 log10 reduction (approximately 99 percent) of microorganisms.7-9 A postprocess level of 10-100 colony-forming units (CFUs) has been suggested.5
The CDC does not currently recommend routine microbiologic sampling of clean textiles, however, sampling during outbreak investigations is appropriate if epidemiologic evidence indicates a role for healthcare textiles and clothing in disease transmission.8
Microbiological testing of laundered textiles is conducted routinely in Europe and Australia as a requirement of their healthcare regulation programs.10-11 The Certification Association for Professional Textiles Services Administration (CAPSTA), which has 400 members in 15 European countries, Japan, China, and the United Arab Emirates, has established safe microbial levels for laundered textiles as 20 CFU per square decimeter (PSD). This microbial threshold has also been adopted by the European Union.
In the United States, microbial levels on hygienically clean textiles have not been reliably measured. To address this gap, Sands, et al. (2019) collected 48 healthcare textile samples from hygienically clean linen on three different patient care units at two separate points in time.12 The researchers reported that only 27 percent of the samples had a total aerobic microbial count below the expected 100 CFU level; the values ranged between 9 and 40,000 CFUs. For yeast and mold counts, more than 81 percent had counts of 100 CFUs or less. Interestingly, the overall average aerobic bacterial, yeast, and mold counts was lower after 24 hours of storage on the patient care units compared to the time of delivery. The authors theorize that the textiles may have been slightly damp, then were folded and placed in plastic carts for delivery allowing microorganisms to proliferate. The textiles would then have had time to dry before the second sample was obtained.
Microbial testing of textiles is a component of the Healthcare Laundry Accreditation Council (HLAC)’s recently introduced Laundry Process Monitoring ToolKit, which validates the effectiveness of a laundry’s processes by measuring the number of microorganisms found in a laundry on hard surfaces, in the air, on linen, in the water and on employee hands.
HLAC is a nonprofit organization that inspects and accredits laundries that process reusable textiles for hospitals, nursing homes and other healthcare facilities. HLAC’s core purpose is to establish and maintain criteria and procedures for accreditation. The HLAC Accreditation Standards are established as the minimum acceptable practice for the preparation of hygienically clean, reusable healthcare textiles for patient care, implemented and executed by accredited laundry facilities processing reusable healthcare textiles.13 The standards incorporate evidence-based, peer-reviewed best practices and recommendations for infection prevention and laundry procedures from federal agencies (e.g., Centers for Disease Control and Prevention (CDC)) and professional entities such as the American National Standards Institute (ANSI), the Association for the Advancement of Medical Instrumentation (AAMI), Association of periOperative Registered Nurses (AORN), the Association for Professionals in Infection Control and Epidemiology (APIC), Facilities Guidelines Institute (FGI), and the Textile Rental Services Association of America (TRSA).
The five specific testing areas that compose HLAC’s process monitoring toolkit include:
- Surface sampling analysis: Monitoring surface cleanliness prevents contamination of clean products that contact surfaces during finishing, transporting, packaging and storing.
- Air sampling analysis: Air sampling analysis provides Total Aerobic Microbial Counts (TAMC).
- Linen analysis: Bioburden testing provides microbial contamination counts measuring the textile provider’s ability to achieve and maintain a state of cleanliness in their products. Products sampled are cotton, polyester and blends, representative of the highest volume materials being processed.
- Water analysis: Water sampling enables the laundry to identify specific areas of concern such as points of suspected contamination, or to determine if a problem has been corrected.
- Hand hygiene analysis: Practicing hand hygiene is an effective way to prevent cross-contamination and infection. This test is designed to measure handwashing practices, not individuals. Samples are blind-coded to assure the anonymity of participants. Testing includes pre- and post-wash; a glove test; and a swab test.
Data from these tests enable laundries to adjust their processes to improve overall plant hygiene, which helps to ensure the safety of the HCTs that contact hospital patients.
Microbial testing of textiles is also a component of TRSA’s “Hygienically Clean Certification” program, which requires third-party, quantified biological testing and inspection.14 Hygienically Clean Healthcare certified laundries use processes, chemicals and best management practices acknowledged by the CDC, Centers for Medicare and Medicaid Services, Association for the Advancement of Medical Instrumentation, American National Standards Institute and others.
Testing is performed using United States Pharmacopeia (USP) 62 (Microbial Enumeration of Nonsterile Products) criterion, which necessitates the complete absence of specified microorganisms, including S. aureus, P.aeruginosa, and E. coli. The Pass/Fail criterion is 0 CFU per square decimeter (PSD). The protocol also includes the Replicate Organism Detection And Counting (RODAC) microbiological test to determine the total amount of micro-organisms (less than or equal to 20 CFU PSD).
Laundries pass three rounds of outcome-based microbial testing. To maintain certification, laundry plants must pass quarterly testing to ensure that as laundry conditions change, such as water quality, textile fabric composition and wash chemistry, laundered product quality is consistently maintained.
Healthcare associated infections resulting from contaminated linen are increasingly being recognized in the literature and result in significant morbidity and mortality. Healthcare safety, including the prevention and reduction of healthcare-associated infections is a national priority. To date there has been a lack of validated measures to assess the effectiveness of processes in healthcare laundries that ensure the cleanliness of textiles.
Quantifying microbial levels on the textiles will support evidence-based practices by enabling identification of contamination sources, key control points in the process and provide recommendations for facility specific microbiological process monitoring as it relates to infection prevention. Healthcare laundries strive to maintain the highest standards of infection prevention and to provide their healthcare customers hygienically clean linen and are an integral component of the multidisciplinary team approach necessary to improve patient outcomes.
- Fijan S, Turk SS. Hospital textiles, are they a possible vehicle for healthcare-associated infections? Int J Environ Res Public Health 2012 September; 9(9):3330-3343.
- Neely AN, Maley MP. Survival of enterococci and staphylococci on hospital fabrics and plastic. J Clin Microbiol 2000;38:724-6.
- Neely AN, Orloff MM. Survival of some medically important fungi on hospital fabrics and plastics. J Clin Microbiol 2001;39:3360-1.
- Takashima M, Shirai F, Sageshima M, Ikeda N, Okamoto Y, Dohi Y. Distinctive bacterial-binding property of cloth materials. Am J Infect Control 2004;32:27-30.
- Sehulster LM. Healthcare laundry and textiles in the United States: review and commentary on contemporary infection prevention issues. Infect Control Hosp Epidemiol 2015;36:1073-88.
- Association for the Advancement of Medical Instrumentation. Processing of reusable surgical textiles for use in health care facilities. 2000. ANSI/AAMI ST65:2000.
- Blaser MJ, Smith PE, Cody HJ, Wang WL, LaForce FM. Killing of fabric associated bacteria in hospital laundry by low-temperature washing. J Infect Dis 1984;149:48-57.
- Centers for Disease Control and Prevention. Guidelines for environmental infection control in health-care facilities. Available from: https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf. 9. Jaska JM, Fredell DL. Impact of detergent systems on bacterial survival on laundered fabrics. Appl Environ Microbiol 1980;39:743-8.
- German Certification Association for Professional Textile Services. RAL-GZ992/2–Hospital Linen. Bőnnigheim, Germany. Available at: http://www.waeschereien.de/en/waeschereien/guetezeichen/9922_healthcare_linen/9922_healthcare_linen.html.
- Institute for Sustainability and Hygiene International. Certification standards for processing reusable linen. (2011). MacKenzie, Brisbane, Queensland, Australia.
- Sands, F, Fairbanks L. How clean is "hygienically clean": Quantitative microbial levels from samples of clean healt care textiles across the United States. Am J Infect Control. 2019 May;47(5):509-514.
- Healthcare Laundry Accreditation Council (HLAC). Accreditation Standards for Processing Reusable Textiles for Use in Healthcare Facilities, 2016. Available at: https://www.hlacnet.org/standards-documents.
- Textile Rental Services Association of America (TRSA). Standard for producing hygienically clean reusable textiles, 2018. Available at: http://hygienicallyclean.org/wp-content/uploads/2018/03/Standard-for-Producing-Hygienically-Clean-Reusable-Textiles-Healthcare-03012018.pdf.
The Modern Healthcare Laundry Will Shoot for the Moon
By Gregory Gicewicz
This column was originally published in the October 2019 issue of Healthcare Hygiene magazine.
This past July marked the 50th anniversary of the first humans landing on the moon as part of NASA’s Apollo lunar mission. Now, NASA is going back to the moon, but it’s not doing it alone. Last May, after a vetting process, the space agency announced its commercial partners in the first phase of its Artemis program to deliver cargo and scientific instruments to the lunar surface in the next few years to support human landings and habitation by the mid-2020s.
In choosing its partners, a NASA spokesperson said, “The companies we have selected represent a diverse community of exciting small American companies, each with their own unique, innovative approach to getting to the Moon.”
I can relate to this, though I’m certainly not in the aerospace industry. Rather, I’m the owner/operator of a healthcare laundry in the greater Seattle area. As such, my company partners with more than 30 acute-care hospitals and surgical centers to annually deliver 10 million pounds of processed, hygienically safe reusable healthcare textiles (HCTs).
Just as NASA has realized through its Artemis program that getting to the moon is no longer a do-it-alone mission, leading hospitals have recognized the role that partners have in their respective successes. And nowhere is this more evident than in their mission to eradicate themselves from the reality of healthcare-associated infections (HAIs), a situation that has reached epidemic proportions.
Where once the selection of a healthcare laundry was a mere decision of choosing the lowest-cost provider, responsible hospitals are now carefully vetting their laundries. What are the laundry’s standards for ensuring infection prevention and patient safety? Do their standards cover the complete textile-processing cycle: from handling and transporting soiled healthcare textiles, to in-plant processing and delivery back to the customer? Do their standards include strict adherence to federal government regulations and guidelines?
A Giant Leap for Healthcare Laundry?
And what about innovation? Indeed, in today’s marketplace, the modern healthcare laundry must be able to demonstrate how it has evolved to better align innovation with a hospital’s infection prevention strategy.
A case in point: innovation in process monitoring. Process monitoring refers to how laundry operators can continually know how well their processes are performing and whether their standards are on target as originally intended.
It used to be that a laundry would establish a baseline of processing standards, followed by documented staff training, and finally proof that the policy was being executed. Monitoring was typically provided in the form of checklists or visual cues, e.g., the carts look clean √; the surfaces look clean √; the hands look clean √; the air looks clean √; the linen looks clean √. The obvious flaw here is that there has never been a way to measure these “checks” with quantifiable data.
That is, until now. A recently introduced innovation in laundry testing and process analysis is enabling laundry operators to recover the most accurate representation of viable organisms (bioburden) on healthcare textiles; and quantifying the sources of potential environmental contamination on textiles that are known to come from air, hands, hard surfaces and in water systems.
Here’s a closer look at the five specific testing areas that compose this next generation of process monitoring:
• Surface sampling analysis: Monitoring surface cleanliness prevents contamination of clean products that contact surfaces during finishing, transporting, packaging and storing.
• Air sampling analysis: Air sampling analysis provides Total Aerobic Microbial Counts (TAMC), or what airborne bacterial contaminants are present in the environment.
• Linen analysis: Bioburden testing provides microbial contamination counts measuring the textile provider’s ability to achieve and maintain a state of cleanliness in their products. Products sampled are cotton, polyester and blends, representative of the highest volume materials being processed.
• Water analysis: Water sampling enables the laundry to identify specific areas of concern such as points of suspected contamination, or to determine if a problem has been corrected.
• Hand hygiene analysis: Practicing hand hygiene is an effective way to prevent cross-contamination and infection. This test is designed to measure handwashing practices, not individuals. Samples are blind-coded to assure the anonymity of participants. Testing includes pre- and post-wash; a glove test; and a swab test.
The high-level of data that come from these tests enable the laundry to adjust accordingly its processes to improve overall plant hygiene, which therefore helps to ensure the ultimate safety of those HCTs that end up in contact with hospital patients. This includes data for:
• Evaluating before and after conditions of cleaning processes
• Isolating problem areas
• Measuring the effects of process modifications and/or system improvements
• Trending over time (e.g., reasons for process variability) for determining process consistency and identifying opportunities for improvements.
I served on a team that helped in the development of this new approach and I can attest to the fact that it’s vastly different in scale from anything else currently available in the industry. It’s a “giant leap,” if you will, that enables operators to demonstrate to their healthcare partners their commitment to quality and patient safety.
If you consider yourself a modern healthcare laundry, maybe you should be shooting for the moon.
Gregory Gicewicz is president of Sterile Surgical Systems. He is past president of the Healthcare Laundry Accreditation Council (HLAC), currently serves as HLAC inspection committee chair, and led a committee that developed the HLAC Laundry Process Monitoring Toolkit.