It really does all come out in the wash! A simple washing of soiled hospital laundry, even loaded with pathogenic microorganisms, leaves linens virtually free of all of those nasty infectious bugs, rendering them squeaky clean and ready for reuse. Cross-transmission is no worry here.

Even before washing, the Centers for Disease Control and Prevention (CDC) says that "the risk of actual disease transmission appears negligible."1,2 That’s good news; nevertheless, common sense should prevail when handling linen contaminated with potentially lethal bugs. In the CDC’s guideline on isolation precautions,"2 workers are admonished to handle, transport, and launder soiled linens in a way that avoids transfer of microorganisms to patients, personnel, and environments." The methods used to achieve that goal are a matter of hospital policy, based on any regulations that apply, such as the Occupational Safety and Health Administration (OSHA)’s Bloodborne Pathogen Standard3 and CDC’s guidelines for environmental infection control.4 (See sidebar on page 35).

For workers who handle soiled laundry, there are hazards that must be taken seriously, because they can have life-threatening consequences. Exposures to bloodborne pathogens are a real threat, particularly from used needles and sharps that may have inadvertently been left behind in linens.

Centennial’s story

Keep tabs on dirty laundry

These are only some of the many concerns when operating a hospital laundry. Increasingly, these concerns are being shifted to linen services as hospitals look to outside sources for processing laundry. Why the move? "It’s a really unpleasant business, hot and dirty. There are so many regulations to be on top of. You have to keep records of temperatures and perform cultures every few days to keep on file for the State. There’s so much involved, no one wants to fool with it. It’s a headache," said Jerry Wilson, Linen Manager, Centennial Medical Center, Nashville, TN.

Vivien Conner, Supply Chain Director, Centennial Medical Center, put it in a nutshell: "Outsourcing can just do it cheaper and better." Centennial switched to a linen service 20 years ago and never looked back. What led to their decision? "A lot of things," said Conner. "Space, equipment, employees, cost, and on and on. . . . Hospitals like to use their space for patient care." What kinds of questions should be asked when considering outsourcing? Conner suggests a few, "Can the linen service fulfill the hospital’s needs? What is the cost per pound? What is the replacement cost for lost and stolen linens?" Lost and stolen linens are a huge problem, but we’ll get to that.

Even when linen is outsourced, managing it and finding ways to stay within budget is a huge responsibility. Wilson outlined some of his linen management duties that included: setting the daily par for each of about 100 areas under his direction; each day sending his employees to each area to outfit it with the daily par; billing each department for their consumption; making certain that the terms of the contract with the linen service are met; finding ways to cut costs and reduce consumption; and orientation for new hires.

"There are two ways to do it," said Wilson. "Some hospitals buy linens, replenishing them as they’re lost or damaged; then there’s the rental program." Centennial Medical Center rents linen purchased by National Linen Service, Nashville, TN. Here’s how it works, explained Wilson: "They charge us so much per pound plus replacement costs. When we’re inventoried, any shortage is passed on to us in the form of replacement cost. There’s a set replacement cost, and each month so many cents out of the pound charge is allotted toward replacement of lost or stolen linens. Every 6 months, when the linen service takes inventory, we’ll replace the cost of what they’ve purchased to replenish our supply. If the cost came to more than the agreed upon price, the replacement cost jumps up until the next inventory; so, it’s important to ensure purchases stay within the contracted replacement cost."

How hard could that be? After all, we’re talking about keeping track of fairly large items like scrubs and sheets, not tiny little things like syringes that can get lost in blanket folds or kicked under the bed. But it’s a h-u-g-e problem, a very costly problem. And it happens easy as pie. Scrubs walk out the door on doctors’ and nurses’ backs every day. Non-emergency ambulance employees scoop up linens with patients they’re taking home. Some people mistakenly think that if linen has blood on it, it has to be discarded, and in the trash it goes. Unfortunately not all items disappear accidentally, notes Conner: "Theft of scrubs is a real problem." Wilson expounded: "You can find them at the flea market. The service station down the street sometimes sells scrubs. A couple of times a week, as I walk through the hospital, someone will stop me and ask how they can get a pair of scrubs for home."

Linen tracking

Centennial does have a linen tracking system of sorts, but it’s used mainly for charging departments. "We’re billed for a bulk figure for linen monthly; in turn, we bill each department for its use," said Wilson. Conner and Wilson have investigated a linen tracking system that is similar to a vending machine setup. The system keeps track of linen going in and out when the staff person scans their security badge. The badge scan identifies the staff person and unlocks the bin containing their size scrub set. Typically staff are allowed up to 6 scrub sets a day – if they try to get an extra set, they won’t be able to until they put soiled sets back in. They even have security cameras built in to verify what was put back and by whom. "It’s probably the best program I’ve seen," observed Wilson. The disadvantage? The price tag. "At $40,000 per machine, the cost is prohibitive," said Conner. "Here at Centennial," noted Wilson, "we’d need two machines that would hold 120 sets and two that would hold 60 sets. We’re talking about $150,000, including the computer software."

Centennial once had a problem of nurses stashing linen on their floor, because they didn’t want to run short. "What they didn’t know was they were causing the shortage problem by hiding the inventory," explained Wilson. Another problem was overstocking patient rooms. Wilson said, "Instead of putting out two washcloths, they might put 20 in a patient room. When that patient went home, there are 15 left, and they have to be put in the soiled linen. Once the linen goes to a patient room, it’s considered soiled whether it’s been used or not."

                                       A full time laundry operation

Cost analysis

"Some hospitals have asked how I keep costs down." said Wilson, "They’re running maybe 20 to 26 pounds per adjusted patient-day, and the cost might be $10 to $11." How much does Centennial spend per adjusted patient-day? Wilson declined to provide that figure but did volunteer that a good number would be "anything under $6 to $7 per adjusted patient-day."

How does Centennial keep down adjusted patient-day costs? Control over consumption. Wilson vows, "It depends on what kind of control you have. When I first took over this department, if someone called for more fitted sheets, they just took the fitted sheets up there. No one investigated to see if too many were being used or if they were being hidden. You have to walk a lot, look in a lot of patient rooms, and watch the par level." To figure the daily par level, "take the average daily census and figure what each patient will need on average for one day: say, two gowns, two bath towels, a bed makeup (fitted sheet, flat sheet, pillowcase, spread, incontinent pad). The number of linens required by a certain area for each patient-day is the daily par. Each morning, my employees count linens. When an area comes up short, they build it up to a par I’ve set for that day. For example, when they pull the par slip in the morning, one floor may have a required level of 60 flat sheets, 60 fitted sheets, 60 pillowcases, 100 wash cloths, 80 towels. An area is stocked according to its daily par rather than sending up an arbitrary number of linens each day. They use a new slip every day and keep a running inventory. We key those slips in a computer daily, and at the end of the month we get a total. That’s how we fill the department out. It’s important to watch the census. If a certain floor’s census drops, I go meet with the nurse manager for that floor and determine if we need to drop the par down." Keeping tight control over inventory is the biggest step to cutting costs, but Wilson has a few other tricks up his sleeve, too.

Linen Awareness Day

"We have Linen Awareness Day a couple of times a year. We set up booths and give out little prizes to staff who can answer questions such as ‘What do you think is the cost per adjusted patient-day? How many pounds of linen do you think Centennial uses per day per patient? What do you think we spent last year in replacement costs? What do you guess our total linen cost is for the year?’ The person who gets closest to the correct answer will be awarded a DVD player or something like that. We also give out little prizes just for participating."

Education for new hires is another important avenue for proclaiming the message. "Either I or someone from the linen company goes to orientation each month. I might ask attendees, "How many washcloths do you think we use daily, maybe 1,000? No, we use 5,000 washcloths, 2,500 sheets, 4,000 towels per day. Everyone is just blown away. People don’t realize the volume of linen that comes through a place this size. We have 37 acres at Centennial Medical Center, with 860 beds plus ancillary areas. We deliver to probably over 100 locations."

"We explain to new hires that they must not wear scrubs and that all linen goes in hampers—nothing is to be thrown away, even if it’s bloodied."

Wilson highlighted the importance of communication between departments: "Linens sometimes get thrown in with biohazards. If you build a relationship with the biohazard people, they’ll pull the linen out for you."

1. Centers for Disease Control and Prevention. Guidelines for laundry in health care facilities. www.cdc.gov/od/ohs/biosfty/laundry.htm.

2. Garner JS, the Hospital Infection Control Practices Advisory Committee, Centers for Disease Control and Prevention. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996;17:53-80.

3. US Department of Labor, Occupational Safety and Health Administration. 29 CFR 1910.1030. Occupational exposure to bloodborne pathogens. Final rule. Federal Register 1991;56:64004-64182.

4. Healthcare Infection Control Practices Advisory Committee, Centers for Disease Control and Prevention. Guidelines for environmental infection control in health-care facilities. MMWR 2003;52(RR 10):1-42.

5. US Department of Labor, Occupational Safety and Health Administration. Hospital eTool/Nursing Home eTool. Laundry module. http:www.osha.gov/SLTC/etools/hospital/laundry/laundry.html.

1. U.S. Department of Health and Human Services. Guidelines for construction and equipment of hospital and medical facilities. Washington: Government Printing Office, July 1984. DHHS publication No. (HRS- M-HF) 84-1.

2. Joint Committee on Health Care Laundry Guidelines. Guidelines for healthcare linen service. Mallandale, FL: Textile Rental Services Association of America, 1983; TRSA publication no. 71482

3. Hughes HG. Chutes in hospitals. J Can Hosp Assn 1964:41:56-7.

4. Garner JS, Simmons BP. Guideline for isolation precautions in hospitals. Infect Control 1983:4:245- 325.

5. Walter WG, Schillinger JE. Bacterial survival in laundered fabrics. Appl Microbiol 1975:29:368-73.

6. Christian RR, Manchester JT, Mellor MT. Bacteriological quality of fabrics washed at lower- than-standard temperatures in a hospital laundry facility. Appl Env Microbiol 1983:45:591-7.

7. Blaser MJ, Smith PF, Cody HJ, Wang WL, LaForce FM. Killing of fabric-associated bacteria in hospital laundry by low temperature washing. J Infect Dis 1984:149:48-57.

8. Guideline for Handwashing and Hospital Environmental Control, 1985; Garner, J.S., Favero, M.S., in Guidelines for Protecting the Safety and Health of Health Care Workers