Whats Left Behind:

Why Hygienically Clean Isnt Clean Enough

This white paper issued by ImageFIRSTTM Healthcare Laundry Specialists 2013 All rights Reserved.

What is Hygienically Clean?

Many commercial laundries, especially those in the healthcare industry, now claim that they offer services that will get laundry hygienically clean. What does that mean, exactly? The truth is, no one really knows. Although many people cite the Association for the Advancement of Medical Instrumentations definition, which is free of pathogens in sufficient numbers to cause human illness, there is no clear and universal definition for the term 1 hygienically clean. Moreover, at this moment in time, there is no scientific or quantitative definition that states explicitly what sufficient numbers 2 means. For the Textile Rental Services Association, for example, this means that the product must have less than or equal to 20 colony forming units (cfu),3 but not all organizations are so clear and explicit. In essence, then, what hygienically clean really means is that the product has been cleaned thoroughly enough to remove most of the pathogens, and the remaining pathogens arent enough to make anyone sick.

measured? Is a hygienically clean product really clean enough, and how can you tell?

Why Does It Matter?

The Healthcare Laundry Accreditation Council (HLAC) best summed it up in a 2010 paper: Laundry plays a vital role in every healthcare facilitys integrated infection prevention and control program. During a hospital stay, patients are literally surrounded and exposed to yards of healthcare textiles, including hospital staff work attire, sheets, blankets, towels, gowns, privacy curtains and more. The need for surgery or longterm care can increase textile exposure significantly for patients.4 While HLACs paper focuses more on hospital stays, the same logic applies to outpatient surgery centers as well as to any doctors office that uses linens for its staff or its patients. If those products havent been cleaned correctly, each exposure is another chance to spread infection. Textiles, including staff work attire, bed and bath linens, patient gowns and privacy curtains, are considered fomites, or objects capable of carrying an organism and serving as a reservoir that can be involved in transmission. In one study, Neely and Maley showed that bacteria such as VRE and MRSA injected into sterile textiles can survive anywhere from one to 90 days, provided that textile has not been cleaned, laundered, or otherwise decontaminated during that time.4

Whats Wrong with Hygienically Clean?

The problem with trusting the hygienically clean claim lies in its ambiguous nature. If theres no real definition as to what hygienically clean is, then how can it be

This white paper issued by ImageFIRSTTM Healthcare Laundry Specialists 2013 All rights Reserved.

 The Association of Perioperative Nurses (AORN) also looked at textiles as fomites when formulating their Recommended Practices for Surgical Attire (2010). While the studies they reviewed were focused more on comparing home laundering to commercial laundering, the results have significance here as well. When uniforms were cultured at the beginning of a shift, thirty-nine percent of the uniforms identified as clean had one or more microorganisms (e.g., vancomycin-resistant enterococci, MRSA, Clostridium difficile) identified. Uniforms were tested again at the end of the shift and 54% had one or more microorganisms; some that were positive at the beginning of the shift were negative at the end of the shift. In one demonstration, bacillus spores were transferred from health care providers aprons and cotton uniforms to a mock patient.5 AORN also quotes another study that involved taking surveillance cultures from five patients, in which results showed that three of the patients were colonized with the same strain of microorganism as that cultured from the health care providers uniforms.5 As these studies show, the evidence bears out quite clearly that healthcare textiles can be a transmission source for HAIs, or healthcare-associated infections, so the priority becomes reducing this potential as much as possible.

Ensuring Patients Safety

When using or considering using a commercial laundry that prides itself on delivering hygienically clean laundry, there are several things that healthcare professionals should look for several things to ensure that their patients safety will be protected. Ask for documentation. Because hygienically clean is a somewhat nebulous term, ask the provider how they define it and how they can prove that they meet their definition. If they provide test results, ascertain if the results were obtained internally or if the tests were conducted by an external, independent laboratory. Check for industry certifications. Right now, there are two main industry certifications from two very different entities: TRSAs Hygienically Clean - Healthcare certification and HLACs Accreditation. A laundry can attain TRSAs Hygienically Clean Healthcare certification by deploying best management practices (BMPs) to pass bacteriological testing and facility inspections. TRSA does not dictate the BMPs, washing processes or chemicals used

This white paper issued by ImageFIRSTTM Healthcare Laundry Specialists 2013 All rights Reserved.

 to meet its Minimum Performance Specifications for bacteriological testing, but it does require that whatever protocols the laundry has decided to implement are both documented and practiced, including written quality control procedures.2 In contrast, HLACs Accreditation Standards cover the complete textile processing cycle, from handling and transporting soiled healthcare textiles, to in-plant processing and delivery back to the customer. The Standards also cover many basic considerations, such as facility layout, personnel training, and customer service. Special attention has been directed to OSHA required practices, including Bloodborne Pathogen Exposure Control Standards as well as to the American National Standards Institute (ANSI) / Association for Advancement of Medical Instrumentation (AAMI) standards for processing of reusable surgical textiles for healthcare use.6 The pros and cons of these certifications or accreditations is largely immaterial to this paper, except for one salient point: achieving one of these accreditations means that an outside agency has examined a particular laundrys practices to see if they meet that agencys standards. If the laundry provides confirmation of its hygienically clean claim from an independent laboratory, these credentials may not be strictly necessary, but they can serve to provide additional peace of mind. Get familiar with the entire process. Laundering is only half of the equation when it comes to safe textiles. As the CDCs Lynne Sehulster states, The weak link in the whole thing is what happens after the process is done and the cleaned textile comes of the ironers, folded, packaged, stored and transported.7 While local or state regulations may set higher standards, healthcare providers should always check to make sure that their clean textiles have been transported using barrier methods to keep them separated from soiled textiles and free from dust, dirt and other contaminants during transport.

Better Than Hygienically Clean

The previous point about transport reveals another weakness of the hygienically clean claim: textiles are only hygienically clean until they are contaminated, whether through poor transport procedures or through pathogen contact in the healthcare setting. This may seem obvious and unavoidable, but new technology has provided ways to keep textiles safer both before and after pathogen introduction. For example, Ecolab has introduced EPA-registered products that can elevate treated textiles

This white paper issued by ImageFIRSTTM Healthcare Laundry Specialists 2013 All rights Reserved.

 from the ambiguous hygienically clean to sanitized, which means that a 99.9% reduction of bacteria has been achieved.8 This is a clear, concise and measureable definition that is set by the EPA and can be used universally throughout the industry. Ecolab also offers an EPA-registered product designed to provide residual bacteriostatic activity against Gram Positive and Gram Negative bacteria.9 In laymans terms, what this means is that there is a zone of inhibition that will isolate any bacteria that is introduced to the textile and it will slow its growth,9 thereby minimizing the transmission of infection diseases even while the textiles are in use. will look good and feel good while also providing superior protection.

Conclusion
In the lack of a clear and quantitative definition of hygienically clean, end users may make their own assumptions about its meaning and overvalue its importance. Although fabrics, textiles, and clothing used in health-care settings are disinfected during laundering and generally rendered free of vegetative pathogens (i.e., hygienically clean), they are not sterile10 and they shouldnt be considered as such. Even the most commonly used definition of hygienically clean allows up to 20 colony-forming units (cfu) per item, and many hygienically clean claims dont quantify the remaining pathogens. For a clear understanding of how clean your textiles really are, make sure you get independently-verified documentation and/or choose a laundry provider that delivers sanitized products.

Setting Higher Standards

As a laundry provider that only services healthcare facilities, ImageFIRSTTM Healthcare Laundry Specialists has a clear understanding of the needs and concerns of its healthcare partners. This is why ImageFIRST goes beyond the hygienically clean designation and introduces EPAregistered sanitizers and bacteriostatic products into its laundry cycles to increase the infection prevention properties of the treated textiles. ImageFIRST products also go through rigorous and routine quality assurance testing that is backed up by independent lab evaluations and the HLAC accreditations that many ImageFIRST hold. Moreover, all ImageFIRST products are wrapped for delivery to minimize contamination. This ensures that the textiles surrounding your patients and staff

This white paper issued by ImageFIRSTTM Healthcare Laundry Specialists 2013 All rights Reserved.

References
1

Healthcare Laundry Accreditation Council (HLAC). Hygienically Clean Textiles. Available at www.hlacnet.org/clean_textiles.php. March 2011. Textile Rental Services Association (TRSA). Standard for Producing Hygienically Clean Reusable Textiles. May 2013. Textile Rental Services Association (TRSA). Hygienically Clean. Available at www.trsa.org/hc. 2013. Tinker K. Moment of Truth: Proper Air Flow Critical to Healthcare Laundries. White paper from the Healthcare Laundry Accreditation Council. July 2010. Association of Perioperative Nurses (AORN). Recommended Practices for Surgical Attire. November 2010. Healthcare Laundry Accreditation Council (HLAC). Hygienically Clean Textiles. Available at www.hlacnet.org/standards.php. January 2012. Pyrek K. Trends in Infection Prevention and Control: Healthcare Textiles: Laundry Science and Infection Prevention. Infection Control Today. March 2011. Polarine J. Disinfectant Regulation, Technologies, Sterility and Validation. Steris. Available at http://www.pda.org/Chapters/ North-America-cont/New-England/ Presentations/Disinfectant-RegulationTechnologies-Sterility-and-Validtion.aspx. Ecolab. Advacare Residual Bacstat.

10

Centers for Disease Control and Prevention (CDC). Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for Environmental Infection Control in Health-Care Facilities. 2003.

This white paper issued by ImageFIRSTTM Healthcare Laundry Specialists 2013 All rights Reserved.