Environmental sources of pathogen organisms can sometimes be difficult to narrow down in a healthcare facility. One possible source of transmission is the laundry used, and not maintaining strict cleanliness attention can put both patients and workers at risk as there are many ways for pathogens to hitch a ride in the hospital environment. A healthcare facility is a busy place, filled with a myriad of devices and complex situations. Preventing hospital associated infections feels like it requires an encyclopaedic knowledge of every new and complicated healthcare intervention. Potential sources of transmission in the hospital include a remarkable array of specialised risks, but there are mundane, everyday risks like healthcare laundry too.
Which textiles are re-used and laundered varies from healthcare facility to healthcare facility. Typical healthcare linens include patient and staff bedding, towels, clothing (scrubs, coats, uniforms, patient pyjamas and gowns), surgical drapes, curtains and reusable mop heads. Hospital linens can harbour a significant density of pathogenic organisms, from 106 to 108 colony-forming units per 100 cm2. Those most commonly isolated include gram-negative organisms Enterobacterales, Pseudomonadaceae as well as Staphylococcus species.
Despite this noteworthy pathogenic burden, the significance of linens in healthcare transmission is unclear. When an infection occurs, it may not be possible to identify the exact environmental source of transmission because multiple potential environmental reservoirs exist in parallel. Although healthcare linens are not often implicated, it makes intuitive sense that they are a potential reservoir for transmissible organisms.
Workers who handle laundry are at increased risk of transmission, including of gastrointestinal pathogens. Definitive associations between linen contamination and patient infections are harder to analyse. Nevertheless, there is a need for meticulous attention to maintaining linen cleanliness. It may be simplest to separate hospital linen-associated risks into 3 distinct sections: 1) removal; 2) cleaning; and 3) storage.
Ensure linens are removed, stored (if necessary), and transported safely to the cleaning facility. Soiled linen poses a danger to healthcare staff and possibly to patients. All used linen should be considered potentially infectious. Linen should not be shaken or disturbed in a way that could aerosolise infectious particles.
Personal protective equipment that would be worn around the patient should also be worn when removing and packaging soiled linen for transport. If there is gross contamination without transmission-based precautions, standard precautions will necessitate the use of additional personal protective equipment. Some infections, including orthopoxviruses, are transmitted by contaminated linen. Linen should be contained before removal from a patient’s room, taking care not to disturb or aerosolise any infectious particles.
Note should be taken that the exterior of bagged linens may become contaminated, even with double bagging. In many healthcare settings, soiled linen must be gathered and transported to an off-site location.
Adequate cleaning and disinfection is essential. The 2003 Guidelines for Environmental Infection Control in Health-Care Facilities from the CDC and the Healthcare Infection Control Practices Advisory Committee provides detailed standards for healthcare laundering, including achieving minimum temperatures and disinfection concentrations that ensure pathogens will be inactivated. In most cases, processing according to these standards should be effective, even with the monkeypox virus.
A few organisms may resist disinfection in the laundry. A study looking at the relative thermotolerance of enterococci showed that they were inactivated during the washing cycle, despite tolerance to the high temperatures alone. Clostridioides difficile spores inoculated into cotton sheets and run through a simulated hospital linen washing cycle were noted to remain viable after cleaning. An obvious potential pitfall during cleaning is failure to achieve intended time, temperature or disinfectant concentration minimums. Excursions may be difficult to detect if laundry is managed off-site or by a contractor.
A busy infection prevention service may not have the bandwidth to survey off-site or contracted linen services more than once or twice a year. Trust and communication with those responsible for linen processing are critical to ensuring prompt notification and resolution if an issue is discovered. Processed linen should make it to the patient’s bedside clean. The quintessential infection prevention standard – separation of clean and dirty – must be baked into the management of clean linen.
A unidirectional flow at the laundry-processing facility will help prevent pathogens from soiled linen coming into contact with the clean linen, even indirectly from the hands or clothing of workers. Laundry surfaces should be routinely disinfected, and hand hygiene should be monitored for compliance. Laundering requires both heat and water – prerequisites for the growth of pathogenic mould. Healthcare outbreaks of mucormycosis have been linked to linens. In a vulnerable patient population, mould exposure is associated with severe or life-threatening infections. If linen must be transported from an off-site facility, it should be covered during transport to prevent contamination. Linens still warm from processing should be allowed to reach ambient temperature before covering, as condensation and reduced airflow promote mould growth.
Once linen arrives in the hospital, it should be unloaded promptly and stored in a manner that prevents contamination.
Within the clean-linen supply, contamination may occur from hands of healthcare workers accessing clean linens without first performing hand hygiene. Clean storage rooms should be protected and monitored for excursions of temperature, humidity and damage associated with floods. Co-storage with soiled items or devices like refrigerators that include fans and condensation or generate heat should also be avoided.
Prevent contamination by ensuring covers or cabinets are kept closed. Methods of storing and using linens may vary. The astute infection preventionist may need to use shoe-leather epidemiology to identify how linens make it ‘the final mile’ if there is a concern for potential transmission.
If there is a delay from when a bed is made to when a patient occupies the room, how long before linens would need to be replaced? Is there a mechanism to identify if a bed is used surreptitiously? This may not be a concern for busy facilities with high occupancy, rapid turnover and adequate call room space, but with the change in elective procedures during the COVID-19 pandemic, there may have been changes to patient and employee flow.
A process to ensure linens are freshly made immediately before patient arrival will reduce the risk of contamination. There are many ways for pathogens to hitch a ride in the hospital environment. Linen is only one of many potential fomites that could be implicated in environmental transmission of hospital pathogens. Ensuring soiled linen is appropriately contained, transported, cleaned and stored is essential to preventing transmission from this easy to-overlook aspect of the healthcare environment, according to Infection Control Today.