Jackie Hook CChem, MRSC, and Lucy Cripwell (BSC Hons), of the Research and Development team at JLA – a specialist in the supply and servicing of catering, laundry, infection control, fire safety and security, and heating and air-conditioning systems, discuss the contribution of laundry facilities as part of a hospital or other healthcare facility’s overall ‘infection control care bundle’. They also highlight some of the key priorities to ensure that such laundries are operated in a compliant and safe manner that minimises any risk of infection transmission.
In all our lives laundry is part of our everyday routine, but it is often considered a low-risk area of activity in healthcare, with its potential value to sound infection control greatly underestimated. The global impact of the COVID-19 pandemic has undoubtedly raised the profile of disinfection, stringent infection control, and and the need for strict hygiene measures throughout healthcare and other public buildings in order to minimise outbreaks of infection, and help to contain them when they occur. Perhaps for the first time an efficient and effective healthcare facility laundry process was recognised as a key part of the infection control regime; existing processes were scrutinised, and careful consideration afforded to what measures were required to cope with the virus, in the light of research confirming its persistence on textiles for long periods. Additionally, with increased concerns over the availability of effective antibiotics, particularly given the antibiotic-resistant nature of a number of microorganisms, attention is now being focused on reducing infections at source. As a consequence, many infection control practitioners are now focusing heavily on areas previously considered low risk, such as laundry
Published cases
There have been a number of published cases highlighting the risk of infection from inadequate disinfection of laundry. In 1992, Bacillus cereus meningitis was found in two neurosurgical patients; an investigation resulted in linen being considered as the possible source of infection.1 It seemed probable that lint from contaminated fabric was the vehicle of transmission of the organism during surgery. Bacterial contamination of gowns was also the subject of a study by North Bristol NHS Trust in 2001.2 Staphylococcus aureus, Clostridium difficile, and Vancomycin-resistant enterococci, were detected on uniforms before and after a span of duty, confirming contamination of nurses’ uniforms and the risk of transmission to patients. Evidence was presented as far back as 1995 in The Lancet by WA Telfer Brunton,3 who recommended that Infection Control teams take laundering very seriously. This was as a result of an investigation into an outbreak of streptococcal infections associated with a maternity ward. Investigation of the laundry revealed extensive contamination of the strain involved in the outbreak. Some 24 years later, and evidence is still being published on inadequate laundry facilities playing a key role. A published report in the Applied and Environmental Microbiology Journal4 in 2019 raised concerns on the possibility of a domestic washer acting as a reservoir for the transmission of Klebsiella oxytoca in a German hospital neonatal ward
HTM’s specific guidance
In March 2016 the Department of Health published HTM 01-04: Decontamination of Linen for Health and Social Care, which superseded the old HSG 95 (18), which was based on laundry research from the 1960s. This now provides a risk-based management approach to those providers who process linen used in health and social care settings. Guidance is given on laundry design, engineering, procurement of equipment, management, and provision, as well as validation of the laundry process. There is a partial adoption of these guidelines within healthcare, with the Scottish NHS preferring a modified version of the original HSG procedures. The guidelines are not widely acknowledged within the industry, but are becoming increasingly referenced by some Trusts. With all versions there is the option of utilising chemical disinfection, as well as thermal processes. Thermal disinfection is described as a laundry process with a main wash section maintained at either 65 °C or 71 °C for a minimum of 18 and 11 minutes respectively. This is inclusive of the obligatory mixing time required to allow the temperature to penetrate the whole load within the washing machine drum.
Different interpretations
This mixing time is sometimes interpreted differently by machine suppliers/ manufacturers, in an attempt to provide a machine with a quicker, more economic wash cycle, with obvious conclusions. Chemical disinfection, although present in HSG 95 (18), was deemed acceptable, but details of how this should be validated and verified were not included. Chemical disinfection provides the end-user with an alternative means of disinfection provided that it can be proven that the process is as effective or better than thermal. Advantages can include lower operating temperatures, which can be more practical for personal clothing, and also linen which might be heat-sensitive, such as microfibre cloths/mops, hoists, and slings, and specialist hospital mattress covers. In the current climate the cost for utilities may also be a driver for chemical disinfection, provided that the system is adequately validated, with machine-type tests carried out by the supplier, as well as a means of verifying the process through parametric release and real-time monitoring
Often given a low priority
The provision and design of the laundry is often a low priority, even to the extent that it is sometimes overlooked from the specifications of new builds. Outsourcing is not always the answer, and the logistics of transporting infected linen to an external laundry are not without risk. While hospital bedding is usually outsourced, the laundering of mops and cloths utilised on site, and departmental linen such as neonatal etc, is normally undertaken ‘in house’, as is most care home laundry. The design of the laundry should take into account the provision of sufficient space within the room to establish clearly defined ‘clean’ and ‘dirty’ areas to reduce the risk of cross-contamination. This may take the form of a physical or functional barrier.
Protecting staff and minimising transmission
Handwashing facilities should be provided to protect staff working in the laundry, and to reduce the risk of transmission. HTM 01-04 details the requirements for good water quality supplying the laundry, detailing the level of microbial challenge. The water supply should not have any pathogens present, and the microbiological level should be less than 100 cfu (colony forming units) per ml. From experience, the level can often be much higher in such facilities, so there is a need for risk assessment to ensure that, where bacterial levels are higher, the laundry is not being compromised. High microbial challenges will impact both thermal and chemical disinfection processes, as well as handwashing. Hard water is definitely undesirable for all laundries; its presence will impact on both the wash quality – by compromising the laundry detergents – and potentially the disinfection efficacy. The presence of scale may also encourage the growth of biofilms in pipework and machines
Washers need to be installed connected to sealed drains with traps to reduce cross-contamination. Washing machines need to be approved under the Water Regulations Advisory Scheme (WRAS) for the type of linen they are processing – with healthcare linen this is normally considered as WRAS Category 5 under the UK Water Regulations. Prospective purchasers of such equipment can check the suitability or category rating by accessing the WRAS directory and searching under the manufacturer’s details.
Domestic or commercial washing machines?
While the Department of Health’s guidelines on the decontamination of healthcare linen accept that small care homes provide a linen processing service comparable to domestic arrangements, the use of domestic washers in healthcare has received limited research, and may fall foul of the UK Water Regulations if not approved. In research carried out pre-COVID by JLA, a number of domestic washers with varying energy ratings were tested, focusing on their temperature control mechanisms. This was the subject of a poster presentation at the Federation of Infection Societies (FIS) Healthcare Infection Society (HIS) International Conference in London last year. The tests demonstrated that while domestic washers offer greater utility optimisation, their ability to reach the programmed temperature, and provide any form of heat, penetration throughout the load, was questionable. This demonstrates the inadequacies of domestic washing machines for healthcare linen, where both precise temperature control and distribution of this heat throughout the load are required to facilitate disinfection. The recent published report previously mentioned on the outbreak in a German hospital4 also highlights the potential risks associated with this type of washer in a healthcare environment.
Drying guidance
Tumble drying is another essential part of a robust laundry process, to minimise the risk of infection within healthcare establishments. HTM 01-04 recommends that thorough drying of laundry reduces contamination to a level that no longer poses an infection risk. The guidance suggests that commercial tumble dryers should be used to dry all linen and personal clothing, irrespective of the infection status.
In line with current financial challenges, and the push to be more sustainable, energy reduction is a significant challenge facing hospitals and the broader healthcare sector. There are, however, steps which can be put in place to ensure that tumble dryers are used in an energysaving and cost-efficient way, while simultaneously ensuring that infection control standards are not compromised.
Regular maintenance is crucial to making sure tumble dryers run efficiently. This means regularly cleaning lint trays and ducts, as poorly maintained exhaust ducts risk reducing efficiency significantly. Regular service and maintenance schedules, carried out by a trusted company, should be in place for all washing machines and tumble dryers, to ensure that linen is cleaned thoroughly, and to also avoid substantial costs and disruption if a machine were to break down.
Sorting of fabrics
As with any laundry equipment, sorting fabrics into different drying types makes linen processing more economical. Sheets, for example, require far less energy to dry than towels. Loading your machine correctly can also improve the efficiency of the process – items need movement in the drum to dry efficiently, so over- or under-loading should be avoided
Technology in tumble dryers has also improved vastly over the years. Changes to the design of drums, and improved heat control, mean newer models are typically more energy-efficient. If it is time to replace the laundry equipment in your laundry, research all options available on the market. For example, some tumble dryers now have auto-dry programmes that utilise sensors inside the drum to monitor moisture levels, and can, depending on the load, automatically finish the load once the linen has reached a specific moisture level.
Ultimately, the emphasis on low energy requirements, especially in the light of the current economic climate, should not overshadow the need for healthcare linen to be adequately disinfected.
Jackie Hook
Jackie Hook, head technical chemist (CChem, MRSC) at JLA, joined the business in 2004, and has since worked closely with microbiologists and healthcare professionals to introduce ozone disinfection systems into the UK.
Lucy Cripwell
Lucy Cripwell, BSc (Hons), assistant chemist at JLA, joined the team in 2021 with a demonstrated history of work in the healthcare, facilities services, and hospitality sectors. She is ‘an expert on ozone disinfection and upholding high standards of infection control’.
References
1 Barrie D et al. (1992) Bacillus cereus meningitis in two neuro surgical patients: An investigation into the source of the organism. Journal of Infection 1992; 25 (3): 291-297.
2 Perry C, Marshall R, Jones E. (2001) Bacterial contamination of uniforms. Journal of Hospital Infection, 48(3): 238- 241.
3 Telfer Brunton WA. (1995) Infection and Hospital Laundry. The Lancet 1995; 345 (8964): 1574–1575.
4 Schmithausen RM et al. The Washing Machine as a Reservoir for Transmission of Extended-Spectrum-Beta-Lactamase (CTX-m-15)-producing Klebsiella oxytoca ST201 to new-borns. Applied and Environmental Microbiology 2019; 85 (22).