Operating Room

Linen replacement costs and patient welfare

by Nathan L. Belkin

The focus of many of the presentations and poster sessions at the recent Association for Practitioners in Infection Control and Epidemiology (APIC) convention was on the transmission of a totally new generation of infectious organisms that are challenging not only the health of our society in general but even more so the welfare of the hospital patient. Specifically, these organisms are the multi-resistant staphylococcus aureus (MRSA) and vancomycin resistant enterococci (VRE).

Considering the variety of the modes of transmission that were discussed, one could not help but wonder what role, if any, the manner in which textiles (linens) are laundered could have in their transmission.

For example, for some time now, there has been concern about the nosocomial pathogen VRE. In addition to patient gowns and linens, its transmission from a number of heretofore unlikely thought of environmental surfaces, i.e., door handles, blood pressure cuffs, overbed tables, etc., have been cited in the literature.1
A number of other unlikely locations that have been found to provide refuge to a large number of organisms are worthy of note. In a study done at a 450-bed general hospital, researchers found that only 22 percent of their healthcare workers, including house physicians, cleaned the membranes on their stethoscopes on a regular basis.2 In another institution, an examination of pagers also revealed that a variety of organisms had similarly found refuge on those devices.3

More recently, the transfer of gram-positive bacteria, particularly MRSA and VRE, among patients has been disclosed. One critical aspect of the bacterial transfer is the ability of these microorganisms to survive on a variety of commonly used textiles such as those made of all-cotton, 50/50 poly-cotton, 65/35 poly-cotton and 100 percent polyester. The study was specifically designed to determine the survival of 22-gram positive bacteria on five such materials. The researchers found that the MRSA was able to survive from 1-56 days and that the survival of the VRE ranged from as few as 11 days to more than 90.4 

In another study, the upholstery on three of the 10 seats on the chairs in a patient’s room were found to be contaminated with MRSA.5 

The list doesn’t stop there. Other surfaces on which MRSA has been found are computer keyboards and faucet handles — both of which obviously are able to easily provide vehicles for transmission to a susceptible host.6 
As remote as it may seem, there is a report of an outbreak of rotavirus on a pediatric oncology floor this is believed to have spread by toys shared by the patients.7 

Last but not least is the report that revealed the impact that the level of the “cleanliness” of textiles can have on patients in isolation units whose immune response systems have been compromised.8 

What does all of this have to do with the manner in which healthcare textiles are laundered?
Not known by many is that the first scientific paper on the effectiveness of laundering practices was published in 1938 by Dr. Lloyd Arnold, a Fellow in the American Public Health Association.9 Arnold specifically recommended the use of wash water temperature of 165 degrees F or higher with a chlorine bleach dosage of 100 parts per million just before the rinsing cycle.

In the absence of any standards for institutional laundries, Arnold’s data became the basis for procedures adopted by the American Hospital Association10 and were subsequently promulgated by the former American Institute of Laundering (AIL) [predecessor to today’s International Fabricare Institute. (IFI)].11 

For all practical purposes, the laundry industry has been guided by Arnold’s formulations and its effectiveness has more than likely been accountable for the Centers for Disease Control and Prevention (CDC) position that “although soiled linen may be contaminated with pathogenic organisms, the risk of disease transmission is negligible if it is handled, transported and laundered in a manner that avoids transfer of microorganisms to patients, personnel and the environment.” The key phrase in that statement, of course, is “laundered in a manner that avoids transfer of microorganisms to patients.”

In today’s environment, this underscores how important it is for the entire community to be certain that all chemical formulations used for laundering items provided to the patients as well as healthcare workers are properly disinfected rather than being sanitized.

Some definitions
Is there a difference between sanitizing and disinfecting? According to APIC, there definitely is.12 Sanitize refers to a process that results in a reduction in the microbial population on an inanimate object to a safe or relatively safe level. 

Disinfect on the other hand is a process that kills or destroys all disease producing microorganisms, with the exception of bacterial spores, and is similarly used on inanimate objects.

There are a number of other relevant terms found in the Occupational Safety and Health Administration’s (OSHA) Final Rule on the Occupational Exposure to Bloodborne Pathogens that warrant repetition.13

First is the term “contamination” that is defined as “the presence of blood or other potentially infectious materials on an item or surface”. The term is again used in describing contaminated laundry as “laundry that has been soiled with blood or other potentially infectious materials or may contain sharps.” Both terms are particularly important to those that have adopted what the agency refers to as Universal Precautions — a policy that considers all textile products that need to be laundered as being contaminated. 

All things considered, and particularly in those situations where a healthcare provider has implemented the principles of Universal Precautions, one would be inclined to believe that the well-established principle of including the use of a proven disinfectant such as sodium hypochlorite, aka chlorine bleach, in the laundering formulation would not be abandoned. Unfortunately, since the continuous and powerful pressure to reduce every healthcare expense is further intensified by the competitive nature of the laundry industry itself, this may not be the case.

Historically, as a rule of thumb, it has been recognized that laundry services for a tertiary care hospital constitute about 2.5 percent to 3 percent of its operating budget. Although that cost may seem relatively insignificant when compared to a facility’s total operating expenses, it is nevertheless a substantial amount of money. For that reason, aside from the costs directly associated with the laundering of the textiles, considerable amounts of money are frequently allocated to administrative programs designed to reduce ‘linen replacement’ — the second largest expense in a laundry department’s budget. These noble efforts focus on such items as pilferage, internal distribution, inventory controls, etc. But one of the easiest and simplest ways of reducing that expense is to abandon the use of chlorine bleach and replace it with a another type of oxidizing type of bleach, i.e., hydrogen peroxide, which is known to be effective in removing stains and not as harsh on the textiles.

Sound good? But what about the quality of the product delivered for the patient’s use?

Aesthetics or aseptics?
The quality of any reusable textile in a healthcare application should not simply be one of aesthetics, but just as much if not more so its aseptics, or suitability for use. Despite the fiscal condition of many healthcare providers in our nation’s healthcare delivery system, this simply does not appear to be an appropriate time to compromise the aseptic aspect of the products’ quality.

The war against the transmission of infectious diseases and nosocomial infections dates back to the days of Semmelweis who, some 150 years ago, introduced the need for people to wash their hands. Judging by the array of waterless products that were on display on the APIC exhibit floor in San Antonio, the marketing battle is obviously considerably larger in scope in a community is confronted with the formidable task of attempting to reduce the incidence of hospital acquired infections. The costs associated with treating those infected patients are a financial burden on our already fiscally strained healthcare delivery system and cannot be ignored. Under the prospective reimbursement system, the most recent 1995 estimate indicated that the cost to healthcare providers is $583 to $4,886 for every infected patient they are required to treat.14

The fact of the matter is that until this very day there is no evidence available to indicate that a patient has been the victim of a nosocomial infection transmitted by linen. This impeccable record can only be interpreted to mean that the manner in which the linens have been laundered during this prolonged period has been in the best interest of the health and welfare of those that are using them — namely the patient.

All things considered, it does not seem reasonable for those processing textiles or linens should risk having their reputation for what they have been doing so effectively go down the drain for whatever alleged economic benefit they feel may be derived from reducing their linen replacement costs. As a recognized bactericidal disinfectant,15,16 they should continue to include chlorine bleach as an integral part of their laundry formulation and processing cycles and do so until a replacement becomes commercially available that has been found to be its equal in effectiveness and cost. 

HPN

References
1) Weber, DJ and Rutala, WA, Role of Environmental Contamination in the Transmission of Vancomycin-resistant Enterococci, Infection Control and Hospital Epidemiology, May 1997, Vol. 18, No. 5, pp. 306-309.

2) Bernard, L, Kereveur, A, Durand, D et al, Bacterial Contamination of Hospital Physicians’ Stethoscopes, Infection Control and Hospital Epidemiology, 1999, Vol. 20, pp. 626-628.

3) Singh, D et al, Bacterial Contamination on Hospital Pagers, Infection Control and Hospital Epidemiology, May 2002, Vol. 23, pp. 274-276.

4) Neely, AN and Maley, FE, Survival of Enterococci and Staphylococci on Hospital Fabrics and Plastic, Journal of Clinical Microbiology, February 2000, Vol. 38, No. 2, pp. 724-726.

5) Noskin, GA, Bednrz, P, Suriao, T et al, Persistent contamination of fabric covered furniture by vancomycin-resistant enterococci: Implications for upholstery selection in Hospitals, American Journal of Infection Control, August 2000, Vol. 28, No. 4, pp. 311-313. 

6) Bures, S, Fishbein, J, Uyehura, CFT et al, Computer keyboards and faucet handles are reservoirs of nosocomial pathogens in the intensive care unit, American Journal of Infection Control, December 2000, Vol. 23, No. 6,pp. 465-470]

7) Rogers, M, Weinstock, DM, Eagan, J et al, Rotavirus outbreak on a pediatric oncology floor: Possible association with toys, American Journal of Infection Control, October 2000, Vol. 28, No. 5, pp. 378-380.

8) Dart, BL and Obendorff, SK, Retention of Aspergillas Niger Spores on Textiles, American Society for Testing and Materials, Standard Technical Publication 1386, 2000, West Conshohocken, PA.

9) Arnold, L, A Sanitary Study of Commercial Laundry Practices, American Journal of Public Health, 1938; 28:pp. 839-844.

10) American Hospital Assn., Hospital Laundry Manual, M7-49, 1949. 

11) American Institute of Laundering, Fighting Cross Infection in Hospital Linen, Service Bulletin, December 1958, 523:pp. 67-70.

12) Rutala, WA and Shafer, KM, General information on Cleaning, Disinfection and Sterilization, Chapter 15, Association of Practitioners in Infection Control and Hospital Epidemiology Manual, Arlington, VA

13) Occupational Health and Safety Administration: Occupational Exposure to Bloodborne Pathogens; Final Rule: 29 CFR Part 1910.1030, Federal Register, December 6, 1991, p.64175.

14) Jarvis, WR, Selected aspects of the socioeconomic impact of nosocomial infections, morbidity, morality, cost and prevention, Infection Control and Hospital Epidemiology, 1996, Vol. 17, pp. 552-557.

15) Rutala, WA and Weber, DJ, Use of Inorganic Hypochlorite (Bleach) in Health-Care Facilities, Clinical Microbiology Reviews, October 1887, Vol. 10, No. 4, pp. 597-610. 

16) Parnes, CA, Efficacy of Sodium Hypochlorite Bleach and ‘Alternative’ Products in Preventing Transfer of Bacteria to and from inanimate Surfaces, Journal of 

August
2003