Corporate Laundry SOP Document Control Summary Status: Version: Author/Title: Owner/Title: Approved by: Ratified: Related Trust Strategy and/or Strategic Aims Implementation Date: Review Date: Key Words: Associated Policy or Standard Operating Procedures Replacement of Laundry SOP v1.0 v1.1 Date: 07/07/2017 Mark Cooper/ Senior Facilities Manager Robert Graves/Director of Facilities and Estates Policies & Procedures Committee Date: 20 July 2017 Policies & Procedures Committee Date: 20 July 2017 Clean and Safe Environment August 2017 August 2020 Laundry, Linen, Clean, Soiled, Infected Facilities and Estates Management Policy
Contents 1 Introduction... 3 2 Purpose... 3 3 Scope... 3 4 Procedure... 3 4.1 Handling dirty linen... 3 4.2 Categorisation and segregation of linen... 4 4.3 The laundering process... 4 4.4 On-site laundry facilities... 5 4.5 Use of linen in the community, e.g. health centres, GP surgeries... 6 4.6 Advice on dealing with soiled / infected linen in the patient s home... 7 5 Process For Monitoring Compliance And Effectiveness... 7 6 References... 7 Appendix 1 Advice to staff on laundering of uniforms... 8 Change Control Amendment History Version Dates Amendments v 1.1 07/07/2017 Appendix 1 advice to staff on laundering of uniforms Removed specific temperature and time requirements for home laundering. Page 2 of 8
1 Introduction The provision of clean linen is a fundamental requirement for patient care. Incorrect procedures for handling or processing of linen can present an infection risk both to staff handling and laundering linen, and to patients who subsequently use it. This policy describes the steps which must be taken to minimise this risk. The Policy will also ensure that any contracted services will be required to have quality systems in place based on the BS EN ISO 9001-2000 Quality Management System Model. 2 Purpose To protect staff and patients from any infection risk from used linen To eradicate or significantly reduce the number of micro-organisms on linen To minimise the use of linen where no laundry service is available 3 Scope To describe the responsibilities of managers and staff for correct handling and processing of contaminated laundry, to minimise infection risk throughout the Trust. This policy should be followed in conjunction with the Uniform Policy where appropriate. 4 Procedure 4.1 Handling dirty linen All dirty linen must be handled with care, to minimise transmission of microorganisms via dust and skin scales. Plastic disposable aprons must be worn when there is potential for contamination of the clothing, i.e. when changing beds. All dirty linen must be placed carefully and directly into the appropriate laundry bag on removal from the bed or patient. Dirty linen must never be transported around the care environment unless within a linen bag and appropriately labelled. Transportation of linen between premises or to and from the laundry service must be in accordance with the contract specifications. Hands must be washed immediately following the handling of any dirty linen. If linen is soiled with blood or body fluids, or from an infected patient, disposable gloves must be worn. Care must be taken to remove any non-laundry items from dirty linen before it is placed in laundry bags. These can cause injuries to staff handling the laundry, and may also damage laundry equipment. To avoid spillage of dirty linen, linen bags must never be more than two thirds full, and must be securely tied with a knot prior to transport to the laundry and appropriately labelled. Vehicles or trolleys used for the transportation of dirty linen must be easy to clean, and must never be used to transport clean linen. Page 3 of 8
4.2 Categorisation and segregation of linen It is the responsibility of the person disposing of the linen to ensure that it is segregated appropriately. All linen can be categorised into the following three groups: a) Clean / Unused Linen b) Soiled / Infected Linen c) Dirty / Used Linen Any linen that has not been used since it was last laundered. All clean linen must be stored off the floor in a clean, closed cupboard, and must be segregated from used / soiled linen. Linen cupboard doors must be kept closed to prevent airborne contamination. Linen must not be stored within the sluice or bathroom. If taken into an isolation room and not used, linen must then be laundered before use. Clean linen must be in a good state of repair, as tearing or roughness can damage the patient s skin. The condition of linen in use should be monitored by the laundry contractor and by the Trust staff. Any used linen which is soiled with blood or any other body fluid. All linen used by a patient with a known infection (whether soiled or not). All soiled / infected linen must be placed in a red soluble alginate bag, inside a clear plastic laundry bag. The soluble bag must be placed directly into the washing machine to minimise contact and prevent transmission of infection to laundry staff or contamination of the environment. The outer clear plastic bag should be disposed of as clinical waste. All used linen other than that listed above. All linen that falls within this category must be placed within a clear plastic laundry bag. This system of categorisation applies whether the items are being laundered on-site or by the laundry contractor. Bags of dirty / used or soiled / infected linen must be stored in a secure area, away from public access, whilst awaiting collection. 4.3 The laundering process Many micro-organisms will be physically removed from linen by detergent and water, and most are destroyed by a high temperature wash. Any remaining micro-organisms are likely to be destroyed by tumble drying and ironing. Page 4 of 8
Bed linen - All bed linen must be laundered by the laundry contractor. The Infection Control Team must be consulted on the negotiation of any contract or specification for laundry services. Personal items - All personal items of clothing which cannot be taken home by visitors / relatives should be laundered on-site. Personal items must be bagged as above, before being transported to the laundry. Each patient s items must be bagged and washed separately on the appropriate cycle. Manual soaking / washing of soiled items must never be carried out. A sluice cycle or cold pre-wash must be used for all soiled items. Care should always be taken not to overfill the washing machine drum. Heat resistant items must be processed in a cycle which reaches 71ºC (for not less than 3 minutes) or 65ºC (for not less than 10 minutes). Heat labile items should be washed on the hottest cycle possible for that item. If soiled items are taken home by relatives for laundering, no pre-washing or soaking of the item must take place in the clinical area. If alginate bags are provided for use in domestic machines, they must be the type with a dissolvable seam, as fully soluble bags may cause machine blockage. Curtains / Soft Furnishings - Curtains in clinical areas must be laundered on a six monthly basis and when soiled or potentially contaminated through contact with an infected patient. This can be organised through the Facilities & Estates Department. Any curtains purchased for clinical areas must be machine washable. Alternatively, the use of disposable curtains may be considered. Within clinical areas, soft furnishings such as chairs should be purchased with wipeable coverings. Any stained or soiled chairs should be steam cleaned or discarded as soon as possible. This should be carried out by the cleaning contractors in accordance with the contract specification. Pillows - Pillows must not be laundered. All pillows must be covered with an impervious waterproof covers If the pillow itself becomes soiled, it must be discarded. Mop heads - Mop heads must be machine washed on a weekly basis, separately from other items, unless they are disposable. Should new equipment be made available, mop heads should be cleaned in accordance with the contract specification. 4.4 On-site laundry facilities No washing machine must be purchased without the involvement of Facilities & Estates and the Infection Control Team. There are legal requirements for the fitting of non-return valves in the healthcare setting to prevent backflow of blood or body fluids into the mains water system. Page 5 of 8
An on-site laundry must be situated within a designated room that is used for laundry purposes only. Access to this room should be limited to staff involved in the laundry process. The room should be well lit and well ventilated. The floors, walls, splash-backs and work surfaces must be impervious and easy to clean. Cleaning of the room should take place on a daily basis. No eating, drinking or smoking is permitted in the laundry. The design of the laundry should facilitate the creation of clean and dirty areas, i.e. dirty linen can be brought into the laundry, processed and come out as clean linen, without it becoming re-contaminated by dirty linen. Soiled or infected linen (which should be placed into the machine in a red alginate bag) should be washed separately, after all other laundry, using the hottest wash possible for the fabric. The washing machine must not be overloaded. Hands should be washed after any contact with dirty linen, and gloves and apron worn for any contact with blood or body fluids. Laundry bins should be cleaned with hot water and detergent at least weekly. Washing machines should be disinfected weekly by running a hot programme without a load. On-site laundries must have the following facilities and equipment:.. Washing machine/s (industrial type with a sluice cycle) and tumble drier/s.. Hand washing sink with lever-operated mixer taps, liquid soap and paper hand towels.. A pedal-operated bin for paper towels.. A pedal-operated clinical waste bin.. Disposable gloves and plastic aprons.. Waterproof plasters (so that staff can cover cuts or abrasions).. Segregated area for dirty linen / linen skips.. Segregated area for clean linen storage.. Ironing and folding area Staff who undertake laundry duties must be fully trained in safe working practice and fully immunised against hepatitis B. They should be aware of the risk of sharps in laundry and the actions to take in the event of a sharps injury or other exposure to blood or body fluids. All washing machines and driers must be subject to a planned programme of service and maintenance at least annually via the Estates Department. 4.5 Use of linen in the community, e.g. health centres, GP surgeries The use of linen should ideally be avoided in community healthcare settings. Disposable sheets and pillow cases may be purchased, and paper couch roll should be used as a covering for examination couches and changed between each patient use. Page 6 of 8
If linen is used, e.g. towels for physiotherapy, it should be changed between patients and there must be access to a laundry service. Examination couches and pillows must have intact impervious coverings, so that they can be cleaned and disinfected between each patient use and in the event of a body fluid spillage. 4.6 Advice on dealing with soiled / infected linen in the patient s home In the patient s home the washing machine may be in the kitchen. If soiled or infected linen needs to be washed, this should not be done at the same time as food is being prepared. Soiled or infected linen should be washed separately, after all other laundry, using the hottest wash possible for the fabric. Overloading of the machine should be avoided. Hands should be washed after any contact with dirty linen, and gloves and apron worn for any contact with blood or body fluids. 5 Process For Monitoring Compliance And Effectiveness To ensure that the Laundry SOP is operating correctly and that the quality and quantity of linen is being maintained, the system will be monitored on a periodic basis. Checks will be carried out by: Monitoring by portering staff on delivery of laundry to the hospital site with additional checks by the Housekeeper at the Ward. Bi-monthly meetings with the supplier to discuss the contract and address any issues. Annual audit of the laundry provider by the Facilities Management Team and the Infection Control Team. Where monitoring has identified deficiencies recommendations and actions plans will be developed and changes implemented accordingly. The Policy will be reviewed and updated every three years or sooner if regulations or documentation are revised. 6 References Health and Safety at Work etc. Act (1974) Management of Health and Safety at Work Regulations (1999) Control of Substances Hazardous to Health Regulations (2002) HTM s (Health Technical Memoranda) relevant to laundry processes The Health and Social Care Act 2008 NHS Estates. Health Technical Memorandum 2030 Washer Disinfectors. UK Health Departments; 1997 NHS Executive. Hospital Laundry Arrangements for Used and Infected Linen. Health Service Guidelines. HSG (95) 18; 1995 Page 7 of 8
Appendix 1 Advice to staff on laundering of uniforms If uniforms are not sent to the laundry service, they should be machine washed at home, separately from any other items. If a uniform becomes contaminated with blood or body fluid, it must be changed for a clean one as soon as possible. It may therefore be necessary to keep a few spare uniforms at each site. The contaminated item should be placed in an alginate bag. Ideally, it should be sent to the laundry service or to an on-site laundry, rather than taken home. If the uniform is taken home, it should be washed separately from other items on a hot wash (60ºC). If alginate bags are provided for use in domestic machines, they must be the type with a dissolvable seam, as fully soluble bags may cause machine blockage. The above principles also apply to the laundering of healthcare workers own clothing if worn for clinical work. Clothing should be worn that can withstand domestic laundering at 60ºC (Hot Wash) Page 8 of 8