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CDC Guidelines for laundry operations.doc - NISH Laundry Services by liuhongmeiyes


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                        Guidelines for Laundry in Health Care Facilities


Although soiled linen has been identified as a source of large numbers of pathogenic microorganisms, the risk of actual
disease transmission appears negligible. Rather than rigid rules and regulation, hygienic and common-sense storage and
processing of clean and soiled linen are recommended. Guidelines for laundry construction and operation for health care
facilities have been published (1,2).

Control Measures

Soiled linen can be transported in the hospital by cart or chute. Bagging linen is indicated if chutes are used, since improperly
designed chutes can be a means of spreading microorganisms throughout the hospital (3). Recommendations for handling
soiled linen from patients on isolation precautions have been published (4).

Soiled linen may or may not be sorted in the laundry before being loaded into washer/extractor units. Sorting before washing
protects both machinery and linen from the effects of objects in the linen and reduces the potential for recontamination of
clean linen that sorting after washing requires. Sorting after washing minimizes the direct exposure of laundry personnel to
infective material in the soiled linen and reduces airborne microbial contamination in the laundry (5). Protective apparel and
appropriate ventilation (2) can minimize these exposures.

The microbicidal action of the normal laundering process is affected by several physical and chemical factors (5). Although
dilution is not a microbicidal mechanism, it is responsible for the removal of significant quantities of microorganisms. Soaps
or detergents loosen soil and also have some microbicidal properties. Hot water provides an effective means of destroying
microorganisms, and a temperature of at least 71 C (160 F) for a minimum of 25 minutes is commonly recommended for
hot-water washing. Chlorine bleach provides an extra margin of safety. A total available chlorine residual of 50-150ppm is
usually achieved during the bleach cycle. The last action performed during the washing process is the addition of a mild acid
to neutralize any alkalinity in the water supply, soap, or detergent. The rapid shift in Ph from approximately 12 to 5 also may
tend to inactivate some microorganisms.

Recent studies have shown that a satisfactory reduction of microbial contamination can be achieved at lower water
temperatures of 22-50 C when the cycling of the washer, the wash formula, and the amount of chlorine bleach are carefully
monitored and controlled (6,7). Instead of the microbicidal action of hot water, low-temperature laundry cycles rely heavily
on the presence of bleach to reduce levels of microbial contamination.

Regardless of whether hot or cold water is used for washing, the temperatures reached in drying and especially during
ironing provide additional significant microbicidal action.


1. Routine Handling of Soiled Linen

   a. Soiled linen should be handled as little as possible and with minimum agitation to prevent gross microbial
      contamination of the air and of persons handling the linen. Category II
    b. All soiled linen should be bagged or put into carts at the location where it was used; it should not be sorted or pre-
       rinsed in patient-care areas. Category II
    c. Linen soiled with blood or body fluids should be deposited and transported in bags that prevent leakage. Category II
    d. If landry chutes are used, linen should be bagged, and chutes should be properly designed. Category II

2. Hot-Water Washing

If hot water is used, linen should be washed with a detergent in water at least 71 C (160 F) for 25 minutes. Category II

3. Low-Temperature Water Washing

If low temperature (<70 C) laundry cycles are used, chemicals suitable for low-temperature washing at proper use
concentration should be used. Category II

4. Transportation of Clean Linen

Clean linen should be transported and stored by methods that will ensure its cleanliness. Category II


    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.

Reference: 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

Office of Health and Safety, Centers for Disease Control and Prevention,
1600 Clifton Road N.E., Mail Stop F05 Atlanta, Georgia 30333, USA
Last Modified: 02/05/02

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Laundry Module

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Common safety and health topics:

                           Contaminated Laundry                             Noise Exposure
                           Personal Protective Equipment                    Heat Stress
                           Sharps Handling                                  Lifting Hazards
                           Hazardous Chemicals                              Fire Hazards
                           Latex Allergy                                    Slips/Trips/Falls

                                                     Virtual Reality
                                Review the hazards and then tour the virtual reality room.

                                                    Contaminated Laundry

                 Contaminated Laundry as outlined in the Bloodborne Pathogen Standard definitions Section
                 (b) as: laundry which has been soiled with blood or other potentially infectious material or
                 may contain sharps.

                 Potential Hazard
                 Exposure to blood or other potentially infectious materials through contaminated laundry
                 that was improperly labeled, or handled.
                 Possible Solutions
                 Follow the procedures outlined in the Bloodborne Pathogens Standard,
                 1910.1030(d)(4)(iv) handling contaminated laundry such as:
                           Handle contaminated laundry as little as possible with minimal agitation.

                               Bag contaminated laundry at the location of use. Do not sort or rinse
                                laundry at the location where it was used [1910.1030(d)(4)(iv)(A)(1)].

                               Place wet contaminated laundry in leak-proof, and color-coded or labeled
                                containers, at the location where it was used [1910.1030(d)(4)(iv)(A)(2)].

                               Whenever contaminated laundry is wet and presents a reasonable
             likelihood of soak-through of or leakage from the bag or container, the
             laundry shall be placed and transported in bags or containers which
             prevent soak-through and/or leakage of fluids to the exterior

                   Contaminated laundry must be placed and transported in bags or
                    containers labeled with the biohazard symbol or put in red bags in
                    accordance with 1910.1030(g)(1)(i).

                        o   In a facility that utilizes universal precautions in the
                            handling of all soiled laundry-alternative labeling or color-
                            coding is sufficient if it permits all employees to recognize
                            the containers as requiring compliance with universal
                            precautions [1910.1030(d)(4)(iv)(A)(2)].

                        o   Use red bags or bags marked with the biohazard symbol, if
                            the facility where items are laundered does not use
                            universal precautions for all laundry

                   For more information on labeling requirements see:

                        o   Labeling Requirements Table. (Taken from Bloodborne
                            Pathogens and Long-term Care Workers OSHA document

            Contaminated laundry bags should not be held close to the body or
             squeezed when transporting to avoid punctures from improperly discarded

            Normal laundry cycles should be used according to the washer and
             detergent manufacturer's recommendations.

                o   Guidelines for Laundry in Health Care Facilities. CDC/OhASIS

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                        Personal Protective Equipment (PPE)
Potential Hazard
Exposure to bloodborne pathogens through contact with contaminated laundry by not
wearing appropriate PPE.
Possible Solutions

            Employers must ensure that employees who have contact with
             contaminated laundry wear appropriate PPE as discussed in the
             Bloodborne Pathogens Standard 1910.1030(d)(4)(iv)(B) when handling
             and/or sorting contaminated laundry.

            Employers must ensure employees wear appropriate PPE such as gloves,
             gowns, face shields, masks, when sorting contaminated laundry

            The use of thick utility gloves when sorting contaminated laundry may
                provide workers with additional protection.

                    o   Utility gloves may be decontaminated for re-use if the integrity of
                        the glove is not compromised.

                    o   However, they must be discarded if they are cracked, peeling, torn,
                        punctured, exhibit other signs of deterioration, or when their ability
                        to function as a barrier is compromised [1910.1030(d)(3)(ix)(C)].

               Disposable (single use gloves shall not be washed or decontaminated for
                re-use [1910.1030(d)(3)(ix)(B)].

    For additional information, see HealthCare Wide Hazards - PPE.

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                                        Sharps Handling
Potential Hazard
Exposure to bloodborne pathogens from contaminated laundry that contains sharps.
Possible Solutions
A safety and health program that includes procedures for appropriate disposal and
handling of sharps and follows required practices outlined in the Bloodborne Pathogens
          Contaminated needles and sharps shall not be bent, recapped or removed.
             No shearing or breaking permitted [1910.1030(d)(2)(vii)(A)].

               Sharps Containerization:

                   o    Immediately or as soon as feasible, contaminated sharps need to
                        be discarded in appropriate containers [1901.1030(d)(4)(iii)(A)(1)].

                   o    Needle containers need to be available, and in close proximity to
                        areas where needles may be found, including laundries

   For additional information, see HealthCare Wide Hazards - Bloodborne
Pathogens, and Needle Stick Injuries.

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                                        Hazardous Chemicals
Potential Hazard

      Employee exposure to hazardous cleaning chemicals found and used in the
      laundry or housekeeping process.

                Unlabeled chemicals.
             Splattering when pouring from larger container to smaller container.

             Soaps and detergents may cause allergic reactions and dermatitis.

             Broken skin from soap or detergent irritation may provide an avenue for
              infection or injury if exposed to chemical or biological hazards.

             Never mix together cleaning solutions that contain ammonia and chlorine.
              When mixed together these chemicals form a deadly gas.

Possible Solutions

     Implement a written program which meets the requirements of the Hazard
     Communication Standard (HCS) to provide for worker training, warning labels, and
     access to Material Safety Data Sheets (MSDS).

     Medical Services and First Aid: Where the eyes or body of any person may be
     exposed to injurious corrosive materials, provide suitable facilities for quick
     drenching or flushing the eyes and body within the work area for immediate
     emergency use [1910.151(c)].

    For additional information, see HealthCare Wide Hazards - Hazardous Chemicals.

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                                      Latex Allergy
Potential Hazard

     Exposure of worker to latex allergy from wearing latex gloves, while handling or
     sorting contaminated laundry.

Possible Solutions
Use appropriate gloves for latex-sensitive employees:
             Employers must provide appropriate gloves when exposure to blood or
              other potentially infectious materials (OPIM) exists [1910.1030
              Bloodborne Pathogens Standard].

             Alternatives shall be readily accessible to those employees who are
              allergic to the gloves normally provided [1910.1030(d)(iii)].

   For additional information, see HealthCare Wide Hazards - Latex Allergy, and
Pharmacy Module.

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                                     Noise Exposure
Potential Hazard
Occupational exposure to high noise levels from loud
machinery in the laundry area can lead to occupationally
induced hearing loss, hearing impairment, hypertension,
elevated blood pressure levels and other health hazards.

                                                                    Folding/Ironing Machine
Possible Solutions
A safety and health program that recognizes and addresses the hazards created by noise
    For additional information, see HealthCare Wide Hazards - Noise.

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                                        Heat Stress

Exposure to excessive heat can result in heat exhaustion and heat stroke. At high
temperatures, the body circulates great amounts of blood to the skin in an effort to
eliminate heat through perspiration. As a result, less blood is circulated to the body's vital
organs including the brain. Heat exhaustion can lead to dizziness, blurred vision, nausea,
and eventual collapse. If not treated promptly, by lowering the person's body temperature,
a person suffering from heat exhaustion could suffer brain damage.

Even more serious than heat exhaustion is heat stroke. During heat stroke the body stops
sweating, making it impossible to dissipate heat. The body temperature may rise to a
dangerously high level in a short time and cause death.

Potential Hazard
Workers may be exposed to excessive heat from working in laundry areas. Exposure to
excessive heat may lead to heat exhaustion, heat stroke, and possible death.
Possible Solutions
Good work practice includes educating and training employees and supervisors to detect
early signs of heat-related illness and have available first aid workers to recognize and
treat these illnesses.

      Recognize the first signs of heat exhaustion, (e.g., dizziness, lightheadedness,
       weakness, blurred vision, nausea) and take immediate action to lower the
       employee's body temperature to prevent the progression of symptoms. Workers
       suffering from heat exhaustion should be removed from the hot environment and
       immediately given cool water to drink. Lay them on their back and raise their legs.
       If they are sick to their stomach lay them on their side. If the person does not feel
       better in a few minutes call for emergency help.

      Recognize the signs of heat stroke (which can be fatal). The symptoms are
       severe headache, mental confusion, loss of consciousness, flushed face, and hot,
       dry skin, with no sweating. If someone has stopped sweating, seek medical
       attention immediately. If a worker shows signs of possible heat stroke, professional
       medical treatment should be obtained immediately.

           o   The worker should be placed in a cooler, well ventilated area and the outer
               clothing should be removed. The worker's skin should be wet and air
               movement around the worker should be increased to improve evaporative
              cooling until professional methods of cooling are initiated and the
              seriousness of the condition can be assessed. Fluids should be replaced as
              soon as possible. The medical outcome of an episode of heat stroke depends
              on the victim's physical fitness and the timing and effectiveness of first aid
              and medical treatment.

Good work practice encourages employers to assess worksites for potential hot
work environments and identify and address ways to decrease heat hazards in
these areas.

Employers should be aware of engineering and work practice controls such as:

      General ventilation and local exhaust ventilation at points of high heat production.

      Spot cooling fans.

      Shielding from radiant heat.

      Evaporative cooling and air conditioning.

      Protective clothing and equipment.

      Provide plenty of drinking water.

      Acclimatize, or gradually introduce employees to the hot environment, because the
       body gradually builds up a tolerance to high temperatures. This process usually
       takes up to 2 weeks.

      Encourage employees to perform the heaviest work in the coolest part of the day.

      Encourage employees to wear light, loose-fitting, breathable (like cotton) clothing.

      Consider the employee's physical condition and recognize that older or obese
       workers and personnel on some types of medication are at greater risk.

      Understand the danger of using drugs, including therapeutic ones, and alcohol in
       hot work environments.

      Encourage employees to avoid using caffeine and alcoholic beverages while working
       in hot environments. These beverages make the body lose water and increase the
       risk for heat illnesses.

      Alternate work and rest periods. Encourage frequent short breaks in cool areas to
       allow your body to cool down.

      Monitor temperatures, humidity and workers' responses to heat at least hourly.

      Supervisors should be able to detect early signs of heat-related illness and permit
       workers to interrupt their work if they are extremely uncomfortable.

      Educate employees to recognize the need to replace fluids and salt lost through

Additional Information:

      Heat Stress, Safety and Health Topics Page.
      OSHA Technical Chapter: Section III: Heat Stress.
          o Appendix III: 4-2. Heat Stress Related Illness or Accident Follow-up. Lists
               factors to be evaluated when reviewing a heat stress situation.
           o Appendix III: 4-1. Heat Stress General Workplace Review.
      Protecting Workers in Hot Environments. OSHA Fact Sheet 95-16 (1995, January
      The Heat Equation. OSHA Office of Occupational Health Nursing, 3154 (English)
       3155 (Spanish), 1998, PDF.

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                                   Lifting/Pushing Hazards
Potential Hazard
Excessive reaching/pushing and/or lifting wet heavy laundry can cause work related
musculoskeletal disorders such as strains and sprains to the back or shoulder area.
Possible Solutions
Assess the laundry area for ergonomic stressors and identify and address ways to decrease
stressors such as:
         Use proper lifting techniques:

              o   Avoid lifting bulky or awkwardly weighted objects.

              o   Avoid lifting/reaching or working above shoulder height.

              o   Avoid awkward postures, such as twisting while lifting.

              o   Lift items close to the body.

              o   Limit the weight of the item to be lifted.

          Use well maintained carts with large, low
           rolling, low resistance wheels, that can roll
           easily over mixed flooring as well as gaps
           between elevators and hallways.

                                                               Well Maintained Cart
              Use mechanical aids to reduce the need to
               lift, such as:

                  o   Spring-Loaded Laundry Platforms to
                      help lift wet heavy laundry, and
                      keep laundry at a comfortable
                      uniform work level.

                                                                 Spring-loaded Platform
              Washers that automatically dump their
               loads into baskets so workers don't have to
               reach in and pull out wet heavy laundry

                                                               Automatic Dumping Washer

    For additional information, see HealthCare Wide Hazards - Ergonomics.

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                                            Fire Hazards
Potential Hazard
Increased fire hazard because of lint build-up on ceilings and other surfaces such as heat
producing equipment. Lint build-up in lint traps can also be a hazard.
Possible Solutions

     Routine cleaning surfaces of lint, and emptying of lint traps.

                "Housekeeping." The employer shall control accumulations of flammable
                 and combustible waste materials and residues so that they do not
                 contribute to a fire emergency. The housekeeping procedures shall be
                 included in the written fire prevention plan [1910.38(b)(3)].

                The employer shall apprise employees of the fire hazards of the materials
                 and processes to which they are exposed [1910.38(b)(4)(i)].

                The employer shall review with each employee upon initial assignment
                 those parts of the fire prevention plan which the employee must know to
                 protect the employee in the event of an emergency [1910.38(b)(4)(ii)].

                "Maintenance." The employer shall regularly and properly maintain,
                 according to established procedures, equipment and systems installed on
                 heat producing equipment to prevent accidental ignition of combustible
                 materials. The maintenance procedures shall be included in the written fire
                 prevention plan [1910.38(b)(5)].
                     For additional information, see HealthCare Wide Hazards - Fire Hazards.

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                 Potential Hazard

                 Employee exposure to slips/trips/falls from the wet floors
                 found in the laundry area.

                 Possible Solutions
                 A safety and health program that recognizes and addresses slip/trips/falls hazards.
                     For additional information, see HealthCare Wide Hazards - Slips/Trips/Falls.

Q: What kind of regular and multidrug-resistant pathogens do contaminated healthcare linens tend to harbor?

A: Healthcare linens are known to harbor a number of microorganisms. Most notably, there is an increased concern that
methicillinresistant Staphyloccus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) can survive for days on
linens. There is further concern that these contaminated linens then become a potential source of cross-contamination.

Q: Why are contaminated healthcare linens a perfect breeding ground for bacteria?

A: The environment in which linens are used in healthcare is often ideal for the proliferation and spread of bacteria and
viruses. Often the patient, in a weakened or compromised state, is lying on a sheet. That sheet under the patient’s body is
warm, dark, and sometimes damp. Most would agree that those conditions are considered ideal for bacteria and viruses to

Q: Why should contaminated healthcare linens be handled carefully so as not to create airborne dispersal of
pathogens and facilitate cross-contamination?

A: There is now a common understanding that linens, once in use, are usually contaminated and could be harboring
microorganisms such as MRSA and VRE. Further, the Centers for Disease Control and Prevention (CDC) cautions that
healthcare professionals should “handle contaminated textiles and fabrics with a minimum agitation to avoid contamination
of air, surfaces, and persons.” Even one of the leading nursing textbooks, Fundamentals of Nursing, states, “Soiled linen is
never shaken in the air because shaking can disseminate secretions and excretions and the micro organisms they contain.”
This text also states, “...linens that have been soiled with excretions and secretions harbor microorganisms ... can be
transmitted to others.”

Q: What is the proper way to remove contaminated healthcare linens from the patient room?

A: According to Fundamentals of Nursing, when handling linens:

1. You should always wash your hands after handling a patient’s bed linens.

2. You should hold soiled linen away from your uniform.

3. Soiled linen is never shaken in the air because shaking can disseminate the micro-organisms they contain.

4. Linen from one patient’s bed is never (even momentarily) placed on another patient’s bed.

5. Soiled linens should be placed directly into a portable linen hamper or tucked into a pillowcase and the end of the bed
before it is gathered up for disposal in the linen hamper or linen chute.

Q: How is new technology advancing the fight against infectious agents that thrive in contaminated healthcare linens?

A: In the 1990s, a new class of chemicals was patented for use as a chlorine-binding biocide. These chemicals are capable of
permanently binding cellulose, such as cotton and rayon, while acting as chlorine reservoirs — reversibly binding powerful
chlorine molecules onto the surface of the cellulose material.

Healthcare laundry protocols have long relied on chlorine-based sanitizers to kill bacteria in bed linens and other fabrics.
While chlorine is known as one of the best antimicrobial agents in the world, its power has been limited because it
evaporates from untreated fabric soon after laundering. But with this new patented technology in HaloShield® linens, the
chlorine keeps killing bacteria right up until the next laundering.

In 2003, two U.S. companies, Medline Industries, Inc. and Vanson HaloSource, teamed up to develop HaloShield healthcare
fabrics, which are grafted with the patented antimicrobial technology. HaloShield harnesses the antimicrobial properties of
chlorine-based sanitizers used during a regular wash cycle to kill infection- and odor-causing bacteria. The coating is actually
rechargeable, meaning the antimicrobial properties of the chlorine are renewed each time the sheet is laundered in an EPA-
registered chlorine-based sanitizer. The HaloShield treatment maintains its ability to bind chlorine to the product throughout
its life cycle.

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