Strategies for healthcare laundering

Suppliers to the healthcare sector face constantly increasing pressure to improve their standards by ensuring that both products and services are consistent and also by raising service levels.

Laundries are finding such demands increasingly difficult to meet and still remain profitable as they are also expected to reduce their charges, be proactive in reducing their carbon footprint and manage their resources more efficiently.

An expanding range of services and technical difficulties places further demands on daily management but these problems can be overcome.

Laundries supplying healthcare institutions with bedlinen, towels and scrub suits on a textile rental basis will find managing their service relatively uncomplicated as long as the customer accepts standard classifications and styles. In this case, the laundry can specify products that are fit for purpose and meet longevity targets.

Laundries working on a return to sender (RTS) contract, where the customer specifies and purchases its own products, will face more problems.

This type of contract needs a different strategy to ensure customers get their own garments and linen rather than an item from pool stock. The RTS business must track the owner and get the right goods back to the right place on the right day.

Most well managed laundries have a specific area or department for handling RTS work with a dedicated employee who will keep the work completely separate from bulk stock items. Ideally this department will have its own washing, drying and finishing equipment, which is often much smaller than that needed for bulk work.

The most important task is to give each soiled item a unique identification with the owner and destination. Each user’s contract should clearly state that every bundle of RTS work must be correctly bagged up by ward or department. Laundries should demand that every item is clearly labelled and ideally there should be a separate bag for every owner or wearer. Each bag should have a label, docket or ticket with the customer’s name and location, the wearer’s name and a list of contents. The identification method is also important. It must be able to withstand fifty or more washing and drying processes and it should also be easy to remove – printed coloured heat-sealable acetate tape is commonly used. The most successful RTS departments have an automatic labelling service and make a separate charge to provide an emergency label for any item that arrives unlabelled.

Processing RTS work also needs great care and attention. Patients’ personal clothing and the slides used to eliminate lifting may well be heat labile so they will be severely damaged by the high wash temperatures used for thermal disinfection. However, these items will also be contaminated with the same micro-organisms that have contaminated the bedlinen. They will often have urine and faecal residues, which increase risks of cross contamination still further.

The wash processes must be designed not only for adequate cleaning but also for disinfection without causing damage. This requires much more sophisticated low-temperature disinfectants than the 150ppm sodium hypochlorite solution specified in HSG(95)18. Peracetic acid, hypochlorous acid and a range of bespoke commercial disinfectants are now emerging to fill this important gap, reducing both carbon emissions and the discharge of hypochlorite residues to drain.

Ironing curtains

Most hospitals will have both window and privacy curtains. Window sizes will often vary considerably so each curtain will be identified with its location. Laundries need to be aware of potential problems.

Most hospitals have specific colour schemes. which can vary from ward to ward, so curtains should be treated as RTS work and carefully identified.

Many of the curtains will be sourced and bought by the hospital and the buyer may not understand the processing requirements to ensure strict hygiene and correct finishing. All textiles suffer some relaxation shrinkage during the first two or three washes.

Many curtains will be patterned or printed with a variety of colours that are not always colourfast.

There are several reputable national curtaining suppliers that provide special materials for use in healthcare environments. However, although they will withstand thermal disinfection temperatures, ironing them at the temperatures achieved by a standard multi-roll ironer may lead to the print dye marking-off onto the ironer clothing and to shadow prints on the fabric.

The FLI/99/02 Curtain fabric/Duvets/Counterpane - Laundering Instructions document says that 100% polyester fabric should never be allowed to reach 120C to minimise print loss.

The following adjustments will reduce the temperatures that the fabric attains during the drying process:

• increase the speed of the ironer

• reduce the bed temperature of the ironer by a using steam reducing valve

• increase the moisture retention of the fabric when it enters the ironer.

Alternatively 100% polyester curtains may be finished by tumble drying and folding, by using a steam tunnel or by using a steam press.

While these methods may not produce the finish the customer expects they will prolong print life. So if the laundry has a polyester curtain that might suffer print damage if it were ironed at 120C then it would be better to wash it in a process that minimises creases and then tumble dry it.

Removing blood stains

A hospital’s textiles will often become soiled with blood and the longer bloodstains are left, the more difficult it will be to remove them.

When someone gets blood on their clothing at home they will usually sluice it or rinse it off quickly before it dries. In a hospital, blood-soiled fabrics will rarely be sluiced immediately and the staining will not be treated until it reaches the laundry several days later.

By this time the blood will have dried onto and into the fabric.

This means that launderers needs to resort to more drastic measures if they are going to remove blood successfully and return the item to the user in a stain-free condition.

Blood is mostly protein and will therefore set permanently if the wash process exceeds 39C at any stage as the higher temperature will effectively “cook” the protein and make it very difficult – if not impossible to remove.

In most cases the blood can be effectively removed by a process that provides good mechanical action and with good levels of a detergent containing plenty of ionic surfactants. The machine should not be overloaded and the process should be carried out for 5 – 7minutes at 30 – 35C. This helps to break up the stain, which can then be readily suspended and rinsed away.

Any residues will invariably be the dye from the blood. This is readily removed by virtually any of the commonly available commercial laundry bleaches – provided the correct concentration is used and it is at the correct temperature.

Remember, each bleach has a different optimum temperature to obtain the best results. Blood that has not been correctly washed in the first instance will often leave behind a stain that can vary in colour from a dark brown to a light orange.

This normally means that the blood was washed at a too high a temperature or that it has been left on the fabric for a long period of time.

Single old blood stain shadows or rings can be removed with a 6% solution of hydrogen fluoride (or ammonium bi-fluoride) in water, provided that the fabric is then washed immediately.

Larger quantities of bloodstained work should be classified together and treated in bulk in the washer-extractor using a 2% solution of dissolved oxalic acid crystals. Follow this rust treatment immediately with a good wash process that includes any of the commonly available bleaches. You may need to use a dosage that is up to 10% higher than normal.

Updating the guidelines

It is now widely accepted that although HSG(95)18 is a valuable document and has served a vital purpose, it no longer addresses every current problem. It does not take account of climate change and does not address the problem of pathogens that mutate into species that resist antibiotics.

Guidance on spore-forming species such as Clostridium difficile is also weak or lacking.

A Department of Health committee was therefore formed to re-write and extend the scope of the document. This revision is currently being finalised.

The main elements that the HTM01-04 document will be addressing are:

• an updated definition of infective linen

• storage and sorting of soiled linen – including best practices and employee protective clothing

• washing – with temperature guides and validation methods

• re-contamination

• transportation

• storage and quality standards for clean textiles

• employee training and auditing/monitoring of the process and results achieved.

These updated guidelines will place a greater responsibility on the launderer to ensure that all the correct systems are in place and being routinely validated. It also will demand that the launderer controls and manages all the critical control points in the laundry to ensure that a hygienically clean product is returned to the customer.

With HSG(95)18, laundry managers would take the precautions and assume everything would be all right. HTM-01-04 requires a bespoke system to assure disinfection and automatic monitoring of the results at each stage of the process.

Spore forming bacteria

Most launderers are aware of their responsibility to ensure adequate thermal disinfection during the wash process. This is normally enough to destroy most harmful pathogens but a number of these micro-organisms are able to change into “spore” form, effectively a type of protective hibernation, when thermal disinfection no longer works. A spore will revive if it finds a source of warmth, moisture and food.

The only effective ways in which spores can be removed are via dilution, using sodium hypochlorite or treatment with ozone. Dilution does not kill any spores but it does thin them out so that there is less risk of colonisation and infection.

Sodium hypochlorite and ozone give only a limited kill, which is far from satisfactory.

Dilution relies upon having good dip levels in both the wash and rinse stages so that the spores can be flushed away down the drain.

While effective, it does not remove all the spores and if the washer is over loaded, its effectiveness is variable as it leaves hot spots of high concentration, which can be fatal for the vulnerable patient.

Sodium hypochlorite bleach will destroy most spores but unfortunately it also destroys cellulose (cotton) and causes chlorhexadine stains to set. Although it kills spores, it can reduce textile life if the hypochlorite is not used correctly, in addition irremovable chlorhexadine stains will increase the number of condemned items.

Ozone offers a good alternative as this produces negligible fabric damage and does not affect residual stains from medication such as chlorhexadine. However, ozone can be difficult to manage and it’s not currently possible to be certain that the correct concentration of ozone is being achieved in the final rinse stages of a tunnel washer to ensure that the spores are being killed.

Healthcare laundering technology is set to change radically over the next few months. The new NHS Framework Contract will start in May and laundries will face intense pressure from the NHS for a lowering of its carbon footprint.