Processing Monitoring in a Healthcare Laundry:Trust but Verify
We’re all inundated daily with studies, claims, certifications, and registrations about infection prevention in the healthcare setting. While it is generally understood that proper healthcare textile hygiene must be an integral part of any infection prevention strategy, here are some common assertions and their claims:
Claim 1: Our surface disinfectant kills 99.99% of germs!
Claim 2: Our laundry chemical is certified to kill SARS-CoV-2, the virus that causes COVID-19.
Claim 3: Our laundry plant is certified. We tested samples of finished linen and their CFU counts are < 20.
Claim 4: The air that touches our clean healthcare textiles is clean enough!
Claim 5: Our finished linen treatment chemical kills C-Diff!
We are living in skeptical times, which forces us to ask: Are these baseless claims or should we trust them? So many questions come to mind.
For example, regarding the first claim: Which germs does the disinfectant kill or arguably more important, which does it not kill? What about the other .01% of germs? How must this disinfectant be used?
Regarding the second claim: Does that mean if we do not use your laundry chemical, we can’t kill SARS-CoV-2? Will standard healthcare laundry processes kill SARS-CoV-2?
Does the third claim mean that all my healthcare textiles (HCTs) are clean enough? What do the popular third-party certifications and their designations mean and how are they measured?
In the fourth claim: What does “clean enough” mean for air? How was it measured? Is all the air touching clean HCT clean enough?
And lastly, the fifth claim: Does having to use a finished linen treatment chemical to kill C-Diff spores mean that standard healthcare laundry processes do not?
The following seeks to answer questions like the above and to inform on what can be done to verify the accuracy of such claims. In doing so, we hope to convince you of the importance of monitoring laundry processes to consistently provide hygienically clean and safe HCTs for sick patients. While there are established standards for HCT processing (see: http://HLACNet.org ) we need to go further and monitor the process to give confidence in the finished product.
We know that microorganisms are ubiquitous. There is essentially no environment where microorganisms cannot exist. Therefore, our goal must be to maintain an environment of high microbial integrity around our HCTs
The Problem – No Agreed Upon Measures of Contamination
The problem is there is generally a lack of agreed upon standards of cleanliness in healthcare laundry processes. There is no definition of hygienically clean linen, carts, water, air, surfaces, and even employee hands. Furthermore, there are no standard methods of measurement of laundry processes. This leads to such logical questions as:
How clean is clean enough? (This was discussed in the February 2020 Issue of HHM.)
What contamination values are acceptable throughout the process? There are lots of variables.
Do HCTs need to be sterile in certain areas?
Is my laundry processing equipment performing?
Are my laundry people performing?
Are my laundry processes performing?
Clearly, without a comprehensive process monitoring program around our HCT system and without objective measures of contamination, we are effectively operating blindly.
The Solution – Process Monitoring
Therefore, the first step is to define the areas to test, the testing frequency, the testing methodology, and the acceptable contamination values for each. Important categories to test in any healthcare laundry include the surfaces that touch clean linen; air; laundry process water; laundry employee hands; and the finished HCT product.
Specifically:
Surfaces that touch clean linen
Washed HCTs can become re-contaminated when in contact with dirty surfaces such as those found in a laundry. These include folding tables, linen conveyors, linen shelves, and clean linen carts. We cannot realistically test every surface every minute of every day. Therefore, it is a good idea to choose a variety of key surfaces and regularly test for contamination. Define the test method and define the acceptable contamination values. More on this later. Contamination values found above acceptable levels mean cleaning protocols need to be re-evaluated. Disinfectants or cleaning equipment may need to be adjusted (equipment); Cleaning frequency may need to be increased (process); or cleaning personnel may need additional training (people).
Air
Clean HCTs are exposed to air the second they leave the washer and for the duration of their journey to the patient. Contaminated air can contaminate HCT. Lint and dust can be especially problematic. Areas of a laundry especially susceptible to dirty air include dryers, ironer and piece folder areas, and hand folding stations. As with surfaces, choose a variety of locations and regularly test for contamination. Define the test method and define the acceptable contamination values. Contamination values found above acceptable levels mean air cleaning protocols need to be re-evaluated. Air filters or air handlers may need adjustment (equipment); Blowdown frequency may need to be increased (process); or cleaning personnel may need additional training (people)
Process water
Clean process water is a necessary ingredient in producing clean HCTs. Good places to test process water cleanliness include the main city water supply, cold process water tanks, and final rinse water zones in a tunnel washer. Water should be tested at least monthly and acceptable contamination values should be set. Water contamination values found above acceptable levels mean water protocols need to be re-evaluated. Dirty city water may need additional filtration or treatment (equipment); Dirty clean water tank storage means tank cleaning procedures must be re-evaluated (people/process); Dirty final rinse zones means dirty water will re-contaminate HCT. Tunnel tank cleaning protocols must be re-evaluated and personnel re-trained on these (people/process/equipment)
Employee hands
Laundry finish personnel often touch clean HCT. If their hands are dirty, they will re-contaminate the clean HCT. While it is unrealistic to test every finish employee’s hands every minute of every day, it is a good idea to sample a few employee hands regularly. Define the test method and define the acceptable contamination values. Contaminated hand values found above acceptable levels mean hand hygiene protocols, equipment, and training must be reassessed (people/process/equipment).
Finished HCT
The final step in a laundry process monitoring program is to test the bioburden levels on the finished HCT. Once again, strategic sampling is our best solution. Choose several different textile blends including 100% cotton items (e.g., OR Towels), polyester cotton blends (e.g. blankets, sheets, towels), and 100% synthetic items (e.g., surgery gowns, isolation gowns). Test regularly and be sure they are sampled as close to patient end use as possible. Define the test method and define the acceptable contamination values. Contaminated HCT values found above acceptable levels mean the process needs to be re-assessed. First test the HCT out of the wash to ensure they are within acceptable levels. If not, there is an issue with the wash process that must be addressed. If HCT out of the wash are clean, then the problem lies downstream. Check air, surface, and employee hands for areas where re-contamination may be occurring. Hopefully, our other process monitoring steps have already identified these.
How to test? Tap the latest resources
Any tests for contamination are only as good as the testing methodology employed. Some key test areas to look at include test accuracy/detail, test repeatability, organisms identified, timeliness of results, test labor intensity, and test cost. A test that can identify actual microorganisms is a benefit and can answer some of our questions above. That way, it is possible to determine if your process is killing targeted microorganisms such as SARS-CoV-2 or C-Diff. Tests that can be performed by your staff onsite will be more timely and less costly. Tests that are more thorough and identify more CFU will be more accurate. A superficial bioburden test that shows low CFU but misses many microorganism colony counts gives a false sense of security. Be sure to understand the above when choosing your testing methodology.
Fortunately, there is a newly released Process Monitoring Toolkit (PMTK. Please see https://www.pmtknet.org ) that meets the above criteria and is made for healthcare laundry process monitoring. I suggest giving it a try.
How do we define acceptable contamination levels?
Generally, acceptable contamination criteria do not exist yet for healthcare laundry. Consequently, they must be defined internally and then measured against. As more laundries implement process monitoring and more data is gathered, our industry can develop more accurate contamination standards. It is a good idea to involve hospital infection prevention personnel in any exercises where acceptable contamination criteria are determined. It is also important to note that not all areas and items will have the same contamination criteria. For example, certain areas of a hospital that house immunosuppressed patients may require sterile HCTs. These items must have zero contamination and thus must be handled differently than normal HCT. Incoming city water will most likely have different acceptable contamination levels than tunnel washer press tank water. Soil sort conveyer acceptable contamination levels will certainly be different from those on clean linen carts. The important practice is to define your acceptable contamination levels, measure to them, and then adjust/manage your process when actual levels fall outside of acceptable levels. Then repeat!
Putting it all together
Healthcare laundry process monitoring is the surest way to ensure standard laundry processes consistently provide hygienically clean and safe HCTs for sick patients. Best practices for implementing a laundry process monitoring program are built around:
Defining areas to test. We recommend hard surfaces, air, water, employee hands, and linen
Setting testing frequency. We recommend linen at least quarterly; other areas at least monthly
Choosing a testing methodology. We recommend the HLAC Process Monitoring Toolkit (PMTK: https://www.pmtknet.org/)
Setting acceptable contamination levels across areas – We recommend defining these internally with your hospital infection prevention partners.
Managing to acceptable contamination levels – Make process, equipment, and people adjustments when acceptable levels are not met
Repeat the process
The end result: Hospital patients and their families will thank you for providing them with consistently clean linen and giving them one less thing to worry about as they heal!
Gregory Gicewicz is distinguished in the reusable textile industry as a tireless advocate for increasing awareness of the significant role that having high standards in the processing of healthcare laundry plays in broader infection prevention strategy. He is president & CEO of Sterile Surgical Systems, a full service accredited healthcare laundry & reusable sterile surgical textile pack manufacturer. 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.
