6.0 - Linen policy by hjkuiw354


									 This policy has been adopted by NHS Wiltshire for use by all staff. All infection control policies are
 included in a programme of review to ensure inclusion of current best practice and to reflect local
 service needs. Wiltshire Community Health Services (WCHS) is the arm’s length provider body of
 Wiltshire. WCHS is wholly owned by and accountable to NHS Wiltshire.
 This policy will be reviewed in March 2010.

                                LINEN POLICY

Reference Number:                           603/2000

Author / Manager Responsible:               Tracey Halladay

First Reviewed:                             August 2004

Next Review Date:

Ratified by:                                RUH Clinical Governance Board

Date Ratified:                              November 2004

Related Policies

                                      Page 1 of 17

Name and Title of Individual                   Date Consulted
Kim Jacobson – Infection Control Doctor        Oct 2003

Tracey Halladay – Infection Control Manager    Oct 2003
Elizabeth Bowden – Infection Control Nurse     Oct 2003
Denise Meyers – Infection Control Nurse        Oct 2003
Janet Whitwam                                  Oct 2003
Bronia Buckner                                 Oct 2003
Simon Smith                                    Aug 2004

Name of Committee                              Date of Committee
Infection Control Committee RUH                Feb2004
District Infection Control Committee           Feb 2004
Medical Board                                  May 2004
Surgical Board                                 May 2004
Speciality Board                               May 2004
Clinical Practice Committee                    May 2004
Clinical Risk Committee                        May 2004
Clinical Governance Committee                  August 2004

                                Page 2 of 17

Section                                                             Page

Distribution   -      -      -      -      -      -      -      -   - 3

1.0    Introduction -        -      -      -      -      -      -   - 5

2.0    Categories of used linen     -      -      -      -      -   - 5

       2.1     Used linen
       2.2     Known, or potentially, infected/infested linen

3.0     Specific items       -      -      -      -      -      -   -    5

       3.1     Anti Embolic Stockings
       3.2     Pillows, duvets, mattress overlays etc
       3.3     Staff uniforms
       3.4     Patient Handling Aids e.g Slings, slide sheets

4.     Colour coding of laundry bags       -      -      -      -   - 7

5.     Handling and storage of used linen in ward/department        - 8

6.      Transporting used linen from ward/department to         -   - 8
       pick-up point

7.     Transporting used linen from the pick-up point to the laundry - 9

8.     Return of clean linen to the user -        -      -      -        9

9.     Infection control issues in the laundry    -      -      -       10

10.    Laundering in small units (wards, launderettes) -        -       11

11.    Spillage of contaminated linen      -      -      -      -       11

12.    Supplies of laundry bags -          -      -      -      -       11

13.    Managers’ Responsibilities -        -      -      -      -       12

14.    References -          -      -      -      -      -      -       12

Appendix 1     Thermal disinfection times and temperatures              13
               and environmental issues in the laundry

Appendix 2     Audit Checklist      -      -      -      -      -       15

Linen Segregation Guidance Poster          -      -      -      -       17

                                  Page 3 of 17
Distribution List


Name                                 Appointment / Function

E-Mail Distribution

                                     Clinical Directors

                                     Clinical Managers

                                     General Managers

                                     Director of Nursing

                                     Infection Control Committee

                      Page 4 of 17

The purpose of this policy is the prevention of infection or injury in patients
and health care staff involved in the use, handling or laundering of hospital
linen. This policy is based on Health Service Guidance (95)18 "Hospital
Laundry Arrangements for Used and Infected Linen".


2.1    Used linen

       Used linen, which may be slightly contaminated with excreta, blood,
       body fluids and not classed as infected.

2.2    Known, or potentially, infected/infested linen

       All linen which is:

              • grossly contaminated with excreta, blood or body fluids,
              • or contaminated linen from a patient who is known, or
                clinically suspected, to be infectious. For example salmonella,
                hepatitis A, B or C, open pulmonary tuberculosis, HIV.


3.1   Anti Emboli Stockings

       Anti Embolic Stockings are for single patient use only. Stockings
       should not be laundered at ward level or sent to the laundry as the only
       way to dry them in these situations is by use of tumble dryer. Tumble
       drying has an effect on the elasticity and performance of the stocking if
       they are left in for too long or the temperature is too high. Some
       products actually state DO NOT TUMBLE DRY. Drying of items on
       radiators is not appropriate, as adequate air circulation cannot be
       achieved, leaving a moist environment for bacteria to multiply.
       Therefore washing and drying at ward level is not recommended.
       When another pair of stockings is required a new pair should be issued.
       If the patient requires continued use of the stockings on discharge they
       must be supplied with the manufacturers guidance to enable correct
       washing at home.

                                  Page 5 of 17
3.2   Pillows, duvets, mattress overlays

      These must be protected by heat-sealed, waterproof covers which are
      cleaned with detergent and water between patients. Alcohol wipes
      MUST NOT be used to clean these items as alcohol damages the
      cover which may allow fluid to pass through to the mattress foam, the
      life of the mattress and its ability to protect patients form cross infection
      is then reduced. If the cover is damaged or punctured, and the article
      itself is contaminated it must be condemned and disposed of as clinical
      waste. Replacement covers can be purchased and may be used
      providing the mattress itself is not soiled, stained or has a smell.

3.3   Staff uniforms

      There is no service for laundering of uniforms except laboratory coats,
      catering uniform and theatre scrub suits. Aside from those items
      mentioned above it is the responsibility of the member of staff to wash
      their uniform at home, this includes nursing staff and Allied Health
      Professionals. Uniforms should be washed at 60 degrees centigrade
      separately from non-uniform clothing. See Uniform policy.

      If a uniform becomes very heavily contaminated with body fluids it is
      not advisable for the item to be washed at home by the member of staff
      therefore it must be sent to the laundry contained in the appropriate
      colour bags and labelled with the name of the individual, ward and
      hospital to ensure it is returned. After washing, uniforms should be
      protected from contamination with dust during storage. A clean uniform
      is required for each shift for those members of staff having patient
      contact. Staff who are not issued with sufficient numbers of uniforms
      MUST take this up with the relevant manager to ensure an adequate
      number is supplied.

3.4   Patient Handling Aids – e.g slings, slide sheets

      All handling aids must be individualised for each patient. This may be
      achieved by use of single patient disposable products, or washable
      fabric aids. Between patients, or after contamination with blood or other
      body fluids, single patient items must be disposed of in clinical waste.
      If made from washable fabric items must be laundered at 60 degrees
      centigrade. Washable items must be placed in red alginate bags then a
      red outer plastic bag. Ward staff then need to take these items to the
      linen room and not send them to the laundry with other linen. To
      ensure that items are returned to the appropriate ward they should be
      identified, the linen room are able to sew ward names to the labels as
      pen marks often fade over time. It is recommended that new items are
      not put into use until suitable labelling has been carried out.
      These items are washed on site at the RUH and redistributed to the
      wards via the linen room.

                                 Page 6 of 17
      NB. If a fabric sling contains plastic reinforcing struts these must be
      removed prior to the sling being sent for laundering. The strut must be
      wiped firstly with a detergent wipe and then an alcohol wipe before
      being replaced in the clean sling.


      Category                        Type                 Colour of bag

1. Used                    General items and           White plastic laundry bag
                           personal clothing

                           Cleaning mops               Clear plastic

                           Theatre scrubs              Green plastic outer bag

2. Known or potentially    General items and           Red alginate soluble bag
   infected/infested       personal clothing           in red, plastic outer bag

3. Theatre Linen           All linen except scrub      Red alginate soluble in
                           suits                       green
                                                       plastic outer bag

4. Ward curtains
                           Routine clean               White plastic

                           Deep clean                  (Red alginate bag) in red,
                                                       plastic outer bag
5. Returns from CSSD                                   Green plastic/nylon
                           Theatre linen

                               Page 7 of 17

5.1   Used linen must be handled with care to prevent environmental
      contamination with excretion or secretions, skin scales or bacteria.
      Linen must be bagged at the bedside, never shaken or allowed to touch
      the floor.

5.2   No extraneous items must be placed in the laundry bags, especially
      sharp objects. This may contribute to a Health & Safety risk for the
      laundry workers.

5.3   All linen bags must be placed in the correct colour bag, securely tied,
      labelled as appropriate and stored in a room or area designated for the
      purpose, which is safe and separate from patient areas.

5.4   Bags must be less than 2/3 full.

5.5   All items that are sent to the laundry must be appropriately marked
      including mattress overlays, clothing.

5.6   Plastic aprons should be worn when handling dirty or soiled linen.
      Gloves may also be required if linen is wet. Hands must be washed
      after handling soiled or infected linen

5.7   Linen should be held away from the body to prevent contamination of


6.1   Laundry bags must be securely tied.

6.2   The pick-up point must be dry and secure and separate from the clean
      linen area

6.3   The frequency of collection will depend on the volume of laundry.

6.4   Linen handlers must have heavy-duty rubber gloves available.
      Guidance on hand washing technique and frequency must be given.

6.5   Refer to section 3.3 for transportation of Patient Handling Aids

                                Page 8 of 17

7.1   Frequency of collection will be dependent on the volume of laundry and
      the agreed schedule between the Trust and laundry provider.

7.2   The provider is responsible for cleaning and disinfection of the
      container/vehicle in order to prevent contamination of clean linen:

      a)     after any spillage
      b)     after transportation of dirty laundry, if it is to be used for clean
             laundry next
      c)     at least weekly

7.3   There must be no contact between clean and soiled linen at any time. If
      clean linen and soiled/fouled linen are to be carried in the vehicle at the
      same time there must be a waterproof barrier present or a rigid
      container for the used linen.

7.4   The provider must comply with all aspects of the carriage of dangerous
      goods act. The majority of laundry consignments are not classified as
      dangerous for transport. However, there may be occasions when soiled
      linen will need to be classed as dangerous for transport due to it
      containing pathogens which pose a significant risk of spreading
      disease and the load is heavily soiled to the extent that the potential for
      exposure and infection is high. In these instances linen should be
      classed as infectious (i.e. clinical waste).

7.5    All linen identified as being classed as clinical waste will be disposed
      of by the Trust, not the provider.


8.1   Contamination of clean linen must be prevented by:

      a)     ensuring roll cages are adequately covered and cleaned on a
             regular basis.
      b)     storage in a clean, dry area or cage
      c)     transport in a clean, dry container/vehicle which is cleaned and
      disinfected prior to loading with clean linen

8.2   Linen which is (or thought to be) contaminated must be returned to the
      laundry for re-processing.

8.3   Fire access points must not be obstructed by returned linen.

                                 Page 9 of 17

9.1   No person shall be permitted to work in or about the processing or
      handling of any article to be supplied to the Trust while suffering from
      an infection or skin disease. All contractors’ staff must report such
      conditions to the contractor.

9.2   Personal protective clothing will be available and worn when handling
      linen. All such clothing must be removed and changed each time the
      person leaves the department.

      a)     heavy duty rubber gloves
      b)     apron/overall

      Disposable items must not be re-used. Reusable gloves must be
      cleaned and dried at least daily.

9.2   A handwash basin, complete with soap and paper towels, must be
      available close to the working areas.

9.3   Staff must be aware of the possibility of extraneous items and sharps
      containers must be available.

9.4   Staff must be aware of actions to take in the event of a sharps injury.

9.5   All staff handling used linen must have access to the Occupational
      Health Service and receive Hepatitis B vaccination, tetanus and polio

9.6   Laundry processing will be in accordance with HSG (95)18.

9.7   Where used nylon/fabric linen bags will be laundered on each

9.8   Systems and machinery will be designed and operated so as to reduce
      the risk of re-infection of linen during the course of the laundering
      process and, to prevent articles being re-infected after laundering and
      prior to re issue to the Trust.

9.9   Audit of laundry processes will be undertaken annually, by Infection
      Control and a user manager, co-opting others as appropriate.

                               Page 10 of 17
10.    LAUNDERING IN SMALL UNITS (wards, launderettes etc.)

10.1   Ward based washing machines are permitted with the agreement of the
       Infection Control Team.

10.2   Washing machines must be appropriately situated in a designated area
       so as to reduce risk of cross contamination.

10.3   Wherever possible patients’ personal clothing should be given to
       relatives/carers to be taken home for laundering. All such linen should
       be placed in plastic bags and relatives/carers informed of any soiling.
       In exceptional circumstances where it is not possible for
       relatives/carers to take these items home for washing the designated
       ward washing machine may be used.

10.4   An industrial washing machine must be used which is complete with a
       sluice facility and temperature indicator and is checked and maintained
       at regular intervals.

10.3   Items which are grossly contaminated with blood or other body fluids or
       which are known, or thought, to be infected must not be laundered in
       the ward but must be sent to the laundry. See table in section 4

10.4   Items must be washed at the highest temperature the fabric can

10.5   All items must be dried as quickly as possible, using a tumble drier, and
       not left hanging for long periods of time.

10.6   Clean items must not become in contact with contaminated items or
       surfaces. Clean items must be stored in suitable areas to prevent
       contamination prior to use.

10.7   Staff must wear rubber, or disposable latex, gloves and apron/overall
       when handling soiled items and wash hands after removal of gloves.


       Wearing gloves, replace the linen in an appropriate bag. Wash the
       contaminated surface with detergent and water and dry. Wash hands
       thoroughly after removing gloves.


       All outer plastic bags and water soluble bags will be purchased by the
       Trust and supplied to the clinical areas via the RUH linen room.

                                Page 11 of 17

      It is the responsibility of managers to ensure that:

      •     Staff are aware of, and have access to, this policy.
      •     Staff comply with this policy.
      •     Staff receive adequate training.
      •     There is an adequate supply of appropriate protective clothing
      •     There is an adequate supply of all other equipment mentioned in
            this policy available at all times.


      NHS Executive (1995)
      “Hospital Laundry Arrangements for Used and Infected Linen”
      Health Service Guidelines (HSG(93)18)
      Lancashire: BAPS

      Barrie, D (1994)
      “Infection Control in Practice: How hospital linen and laundry services
      are provided”
      Journal of Hospital Infection 27 pp 219-235

      NHS Purchasing and supply Agency (2003) Market testing of laundry
      and linen services, Procurement Guide

                                Page 12 of 17

Thermal disinfection times and temperatures and
environmental issues in the laundry

Disinfection of used (soiled and fouled) linen

A sluice cycle should be incorporated into washing machines for the removal
of organic matter from fouled linen.

Wash loads of 0.056kg/litre or less will have a mixing time of 4 minutes added
to the temperature holding times.

Wash loads of more than 0.056kg/litre will have a mixing time of 8 minutes
added to the temperature holding times.

The wash temperatures will be maintained at:
     71°C for at least 3 minutes + mixing time
     65°C for at least 10 minutes + mixing time

Disinfection of suspected (or known) infected linen

Linen in this category should not be sorted and should be contained within a
soluble alginate bag. The bag containing the linen should be placed directly
into the washing machine.

The temperatures described previously will adequately disinfect linen.

This linen must not be processed in a batch continuous washing machine, but
should be processed in a washer extractor.

Disinfection of heat-labile linen

Linen in this category must be laundered in washer extractors at 40°C and
dried at 60°C using tumble dryers and tunnel finishing systems rather than

Sodium hypochlorite (150ppm available chlorine) may be used in the
penultimate rinse. The Infection Control Committee must approve other
chemical disinfectants.

General measures to prevent infection

Although a physical barrier is not essential there must be systems in place to
separate clean linen from soiled. This is of particular importance for
commercial laundries in which a central disinfection area or barrier room for
infected work is desirable.

Movement of air currents will be from clean to dirty.

                                Page 13 of 17
Clean linen will not re-enter the disinfection area and will be stored off the
ground using shelves or containers.

All surfaces will be kept free from dust, debris and pests. There will be a
system for regular cleaning of the environment including high level surfaces.

All washing machines will be kept clean and free from algae.

All washing machines should be fitted with accurate heat sensors that are
correctly positioned. These must be tested at least 6 weekly and calibrated.
Records must be kept of this and of regular monitoring of wash temperatures.

Washing machines that are used for fouled and infected linen will have vent
pipes routed outside. Effluent must be sealed from the machine to the
manhole outside the laundry. Any open sump or pit below the machine drain
valve must be covered.

Batch continuous washing machines must have any linen removed overnight
and the rinse sections must be thermally disinfected at the beginning of each
day and after the machine has been out of action for 3 hours or more. The
disinfection cycle must be under electronic or computer control.

                                 Page 14 of 17
Audit checklist

      There will be systems in place for the audit of this policy. Audit should
      be carried out no less than annually.

Standard Statement                                                   Y    N*      N/A

1.   # 3.4 Uniforms contaminated with body fluids are sent to
     the laundry.

2.   # 4.0 There is a poster available explaining colour coding
     of laundry bags.

3.   # 5.1 Linen is bagged at the bedside.

4.   # 5.3 Linen is placed in correct bag (see # 4.0 Colour
     Coding of Laundry Bags).

5.   # 5.4 Linen bags are less than 2/3 full.

6.   # 6.1 Linen bags are securely tied.

7.   # 10.2 Items which are contaminated with blood or other
     body fluids are sent to the laundry.

8.   # 10.3 Items are washed at the highest temperature the
     fabric can withstand.

9.   # 10.4 All items are dried using a tumble dryer.

10   # 13.0 All staff are aware of this Policy.

                      Score:        Y
                                   Y+N x 100 =            %
*Action Plan

Document below actions to be undertaken, with timescale, to achieve
compliance with policy, following liaison with Infection Control Team.

Review undertaken by:                                             Date

                                 Page 15 of 17
          Linen Segregation Guidance
  Used linen from non-infected patients
  should be placed directly into a white                                      White plastic
                                                                              laundry bag
          plastic laundry bag.

All linen which has been in contact with infected   first place in
 patients, or heavily contaminated with blood.      alginate bag, these
                                                                                        Red                  Red
                                                    are water soluble
This linen is required to be double bagged, first                                     alginate              plastic
                                                    and MUST NOT
                                                                                        bag                  bag
 in a red alginate bag and then a red plastic       be used as outer
                        bag.                        bags

Used theatre linen must be double bagged,           first place in alginate
                                                    bag, these are water
first in a red alginate bag and then a green        soluble and MUST
                  plastic bag.                      NOT be used as                       bag                 plastic
                                                    outer bags                                                bag

                                                           Please note:
   • Slings and sliding sheets should be marked with ward area and placed in clear plastic bags and taken to the linen room
             • Ensure all extraneous material (patients teeth, books etc..) is removed prior to placing linen into bags
                                   • Do not overfill bags – bags must not be more than 2/3 full
                                 • Mop-heads need to be placed separately in clear plastic bags

                                                          Page 16 of 17

Author, please attach this to each copy of the policy being sent to a
meeting for comments.
Dear Chairman, please would you review this policy at your committee and return
any amendments / comments to ____________________________ by
 _____ / _____ / _____

Title of meeting               ______________________________________

Date of meeting                 ______________________________________

Name of policy                  ______________________________________

Name of author                 ______________________________________

                                                                   Yes      No        N/A
Are there any elements of this policy which present operational
issues that require further discussion? If yes, please provide a
contact name for the author.

Is the policy referenced?
Does the policy include a training plan?
If you are the appropriate forum, have the necessary
resources been agreed to implement this policy?
Is there a plan for policy implementation?
Does your meeting recommend further consultation with
groups or staff other than listed at the front of the policy?
Other comments
from meeting.

Policy accepted without further comment. (Please circle)                  Yes / No
Policy needs further amendment. (Please circle)                           Yes / No

Name of Chair __________________________
Signature ______________________________                 Date _____ / _____ / _____
For Human Resources Policies only
Name of Staff Side ______________________
Signature ______________________________                 Date _____ / _____ / _____

                                   Page 17 of 17

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