Guidance on the Management of Linen - Lincolnshire Community ...

 
Guidance on the Management of Linen

Reference:                                  G_IPC_06
Version:                                    5
Ratified by:                                LCHS NHS Trust Board
Date ratified:                              13th February 2018
Name of responsible committee/individual:   Infection Prevention Committee, LCHS
Date approved:                              31st January 2018
Date issued:                                February 2018
Review date:                                January 2020
Target audience:                            All Staff
Distributed via:                            Website

                                                                                Chair: Elaine Baylis QPM
                                                                         Chief Executive: Andrew Morgan
Guidance on the Management of Linen
                                                   Version Control Sheet

               Section/Para/A     Version/Description of
 Version                                                       Date                  Author/Amended by
               ppendix            Amendments
 1                                Review of Guidance           May 2009              S Silvester, IPCNS, LCHS
 2                                Review & update              March 2012            L Roberts, Infection Control
                                  Added Equality Analysis                            Adviser, LCHS
                                  monitoring
 3             Whole              Complete Review              March 2014            L Roberts
               document
 4             Whole              Complete      review    -    Feb 2016              L Roberts
               document           Amend footer, Amended
                                  Workforce development
                                  to     Education      and
                                  Workforce development.
                                  Infection Control Link
                                  champions to Infection
                                  Prevention           Link
                                  Champions.
                                  Amended          updated
                                  Health and Social care
                                  Act 2012
                                  Updated CFPP 01-14
 5             Whole              Amend footer and             October 2017          S Fixter
               document           headers
                                  Amended updated
                                  Health and Social care
                                  Act 2005
                                  Incorporated in section 5
                                  training
                                  Amended storage of
                                  linen paragraph
                                  Infection prevention and
                                  Control team changed to
                                  infection prevention
                                  team
                                  Clinell wipes and
                                  sporicidal wipes added
 6

 7

 8

 9

 10

Copyright © 2018 Lincolnshire Community Health Services NHS Trust, All Rights Reserved. Not to be reproduced in whole or in part
without the permission of the copyright owner.

                                                                                                  Chair: Elaine Baylis QPM
                                                                                          Chief Executive: Andrew Morgan
Page 2 of 14
Guidance on the Management of Linen
                                                                         Contents
Version Control Sheet ....................................................................................................................................... 2
Guidance Statement ......................................................................................................................................... 4
1. Introduction ................................................................................................................................................... 5
2. Background................................................................................................................................................... 5
3. Scope of guidance ........................................................................................................................................ 5
4. Key personnel responsibilities ....................................................................................................................... 5
   4.1 Trust Board.............................................................................................................................................. 5
   4.2 Commissioners........................................................................................................................................ 5
   4.3 The Infection Prevention Team (IP) ......................................................................................................... 6
   4.4 Managers ................................................................................................................................................ 6
   4.5 Infection Prevention Link Champions....................................................................................................... 6
   4.6 Employees............................................................................................................................................... 6
5. Training......................................................................................................................................................... 6
   5.1 Training Provided .................................................................................................................................... 6
7. Monitoring and Audit ..................................................................................................................................... 7
8. Categories of linen ........................................................................................................................................ 7
   8.1. Used linen (soiled).................................................................................................................................. 7
   8.2 Infected/ Foul Linen ................................................................................................................................. 7
   8.3 Water Soluble Bags................................................................................................................................. 7
   8.4 Heat Labile Linen..................................................................................................................................... 8
9. General handling of linen .............................................................................................................................. 8
10. Storage of linen........................................................................................................................................... 8
11. Frequency of linen change .......................................................................................................................... 8
12. Management of linen in Community Hospitals............................................................................................. 9
   12.1 Return to sender items .......................................................................................................................... 9
   12.2 Condemning of Linen............................................................................................................................. 9
   12.3 Items of linen that must NOT be sent to the LAUNDRY ......................................................................... 9
   12.4 Marking patients’ own clothing............................................................................................................... 9
13. Pillows & duvets ........................................................................................................................................ 10
14. Curtains and soft furnishings..................................................................................................................... 10
15. Staff Uniforms ........................................................................................................................................... 10
16. Patients’ own clothing and linen ................................................................................................................ 10
17. Best Evidence ........................................................................................................................................... 11
18. Associated policies.................................................................................................................................... 11
19. Appendices ............................................................................................................................................... 11
Appendix A: Categories of linen and associated colour coding ....................................................................... 12
Appendix B: Guidance to carer/patient............................................................................................................ 13
Appendix C: Equality analysis ......................................................................................................................... 14

                                                                                                                              Chair: Elaine Baylis QPM
                                                                                                                      Chief Executive: Andrew Morgan
Page 3 of 14
Guidance on the Management of Linen

                                       Guidance Statement

       Background             The purpose of this guidance is to advise on the precautions and
                              control measures that are needed in the management of linen, thus
                              minimising the risk of healthcare associated infections to patients,
                              visitors and staff in health care settings.

       Statement              This guidance is comprehensive, formally approved, ratified and
                              disseminated through appropriate channels. It will be implemented
                              for all staff within Lincolnshire Community Health Services NHS
                              Trust.

       Responsibilities       Compliance with this guidance will be the responsibility of all
                              Lincolnshire Community Health Services NHS Trust staff and invited
                              contractors.
                              Education and Workforce development, Infection Prevention Link
       Training               Champions, Clinical Educators and Infection Prevention Team will
                              support/deliver any training associated with this guidance.

       Dissemination          Via Lincolnshire Community Health Services NHS Trust Website

       Resource implication   This guidance has been developed in line with the NHS Litigation
                              Authority guidelines to provide a framework for staff within the
                              organisation to ensure appropriate production, management and
                              review of organisation–wide policies.

                                                                                  Chair: Elaine Baylis QPM
                                                                          Chief Executive: Andrew Morgan
Page 4 of 14
Guidance on the Management of Linen

1. Introduction
All NHS organisations must ensure that they have effective systems in place to prevent healthcare associated
infections. Statutory requirements pertaining to laundering of healthcare linen outline the measures to be taken
in order to render safe the handling, transport and storage of linen (Choice Framework For local Policy and
Procedure (CFPP) 01-04).
The Trust has a duty of care to ensure no risk is posed to staff in the management of linen.

2. Background
Clothing and/or linen used by patients can pose a potential infection risk to others within a ward, primary care
setting or care home during handling, transportation and storage.

As healthcare is delivered in a variety of settings e.g. healthcare premises, hospitals,surgeries, domestic
residences and care homes, each setting may have different arrangements for the management of linen.
Nonetheless the procedures and principles of this guidance should be adhered to.

This guidance should be used in conjunction with the following:
       Hand Hygiene Guidance G_IPC_17
       Management of inoculation injuries G_IPC_18
       IPC Standard Precautions Guidance G_IPC_26
       Blood and body spillage guidelines G_IPC_31
       Uniform and dress code policy P_HS_15

3. Scope of guidance

The principles contained within the guideline reflect best practices and apply to those members of staff who
are directly employed by Lincolnshire Community Health Services NHS Trust.

However, it is recognised that the management of linen requires a countywide approach and this guideline
may be used and adapted by other organisations as appropriate.

4. Key personnel responsibilities

4.1 Trust Board
      Will ensure compliance with the Health & Social Care Act (2005), of which this guidance is integral.
      Will have close and regular liaison with designated members of the Infection Prevention Team /
       Director Infection Prevention and Control
      Ensure the provision of a safe environment in which the management of linen can take place, in
       accordance to statute.

4.2 Commissioners
They are responsible for ensuring that the Linen Management Organisations are complying to statute and any
deviations from this are reported as soon as practicably possible with resulting corrections.

                                                                                        Chair: Elaine Baylis QPM
                                                                                Chief Executive: Andrew Morgan
Page 5 of 14
4.3 The Infection Prevention Team (IP)
      Will act as a resource for guidance and support on the management of linen.
      Will review the guidance in response to the publication of any urgent communications from the
       Department of Health.
      Will support the Managers / Infection Prevention Link Champions in the audit and monitoring of the
       guidance.
      Will liaise with external organisations where deemed appropriate.

4.4 Managers
Have a responsibility to:
     Ensure all staff and new starters are aware of and comply with this guidance with particular reference
      to:
             hand hygiene
             personal protective clothing
             communications with the Infection Prevention Team
             supporting the Infection Prevention Link Champions to undertake their role.

       Inform new employees of their responsibilities under this guidance.
       Ensure that within 8 weeks of staff commencement with LCHS NHS Trust, staff members attend the
        corporate mandatory induction.
       Ensure that their staff are available to attend annual mandatory training according to their specific job
        role
       Follow up non-attendance or non-compliance of their staff where this has been identified by the
        Education and Workforce Development Team Administrator.

4.5 Infection Prevention Link Champions
Trusts should ensure through their Head of Clinical Services/ Head of Clinical Quality leads that each
neighbourhood team is covered by an Infection Prevention Link Champion (DH 2008), whose role and job
description should include training, auditing and feeding back to staff on:
     isolation
     hand hygiene
     “cleanyourhands” campaign
     environmental and practice issues.

4.6 Employees
All employees (providing direct care in a health or social care setting including patient/clients own home) have
a responsibility to abide by this guidance and any decisions arising from the implementation of them. Any
decision to vary from this guidance must be fully documented with the associated rationale stated.

Employees have a responsibility to attend mandatory training/update training as identified within the
Organisation’s Mandatory Training Matrix.

5. Training

5.1 Training Provided
Education and Workforce Development Team, provide education as appropriate to all staff on corporate
mandatory induction, clinical and non clinical mandatory update sessions.

                                                                                          Chair: Elaine Baylis QPM
                                                                                  Chief Executive: Andrew Morgan
Page 6 of 14
The Education and Workforce Development Team has a responsibility to ensure the coordination of the
  learning and development of staff, as identified within the Education and Workforce Development Policy. In
  relation to this guidance they will:
   Facilitate education sessions to staff groups supported by Infection Prevention Team
   Identify and follow-up non-attendance at mandatory training sessions with Line Managers

  7. Monitoring and Audit
  It is the responsibility of the manager to ensure that audit is conducted noting both facilities and practice on a
  biennial basis.

  As a contracted service, arrangements must be in place to ensure that the commissioners are assured that the
  guidance is in place and being monitored and audited formally on a regular basis.

Minimum          Process      Responsible Frequency     of         Responsible            Responsible           Responsible
requirement      for          individuals/ monitoring/audit        individuals/           individuals/          individuals/
to       be      monitoring   group/                               group/ committee       group/                group/
monitored        e.g. audit   committee                            (multidisciplinary)    committee             committee
                                                                   for    review    of    for                   for
                                                                   results                development           monitoring
                                                                                          of     action         of     action
                                                                                          plan                  plan

Compliance       Audit        Manager/ IP Biennially               IPC Committee          IPC                   IPC
                              team                                                        Committee             Committee

  8. Categories of linen
  At present the United Kingdom guidance (CFPP 01-04) places laundry into three categories (Appendix A):
                Used
                Infected
                Heat labile

  8.1. Used linen (soiled)
  This category includes all used linen irrespective of current state (not contaminated with blood/bodily fluids).

  8.2 Infected/ Foul Linen
         This category pertains to linen from patients with suspected or confirmed infections.
         Linen that is heavily contaminated with blood and/or body fluids is also included in this category.
         Linen must be initially contained in a water soluble bag.

  8.3 Water Soluble Bags
  The purpose of water soluble bags is to prevent handling of potentially hazardous linen by laundry personnel.
  In order to ensure effective use of water soluble bags the following instructions must be adhered to.
        Prior to use, store unused bags in their original packaging or in sealed plastic bag, in a dry area.
        Where possible, linen items that are wet should be wrapped inside dry used linen.
                                                                                            Chair: Elaine Baylis QPM
                                                                                    Chief Executive: Andrew Morgan
  Page 7 of 14
       Bags must be sealed when no more than ¾ full.
       Seal the bag using the tie provided. Do not seal the bag by knotting as this prevents the proper
        opening of the bag at the start of the laundry process.
       Place bag into infected linen category.

8.4 Heat Labile Linen
These include fabrics damaged by thermal disinfection e.g. wool, synthetics.

9. General handling of linen
It is the responsibility of the person disposing of the linen to ensure that it is segregated properly.
        Soiled / infected / foul linen must be stored in an appropriate container and in an environment away
         from clean stock etc
        Soiled/ infected / foul linen must only be transported around the environment within an appropriate
         coded bag/container.
        Containers for storing soiled/ infected/ foul linen must be kept clean
        To reduce the risk of cross infection, a linen skip must be taken to the patient bedside and the used
         linen carefully removed, avoiding any unnecessary agitation, and directly placed into the appropriate
         bag.
        Appropriate personal protective equipment (PPE) must be worn by all staff handling and bagging linen
         any used linen.
        The linen bags should only be used for linen and never for waste.
        The linen bags must be stored in a clean dry environment i.e. not under sinks
        The exposure of susceptible wounds should be avoided within 30 minutes of bed making and during
         patient’s mealtimes.

N.B. Ensure all items that pose a risk to staff such as discarded needles, dressings or items used in
the management of incontinence are disposed of appropriately.

10. Storage of linen
      Clean linen storage cupboards doors should be kept closed when not in use. The storage
       cupboards/shelving must also be kept dry and free from any debris/dust /pests
      Clean linen must not be stored on open trolleys.
      Clean and dirty linen must be kept separately.
      Linen trolleys, where used, must be cleaned on a weekly basis to prevent build up of dust/dirt /debris.
      If linen is removed from linen cupboard and not used, it must be classed as used linen, it should
       therefore be discarded and not returned to the linen cupboard.
      The dirty linen storage areas must be separate from clean linen storage, patient care areas, food
       preparation areas and clean supply and equipment storage areas.
      Dirty linen areas must be on a programmed cleaning regime.

11. Frequency of linen change
      Linen or clothing must be changed and laundered between patients.
      The frequency of the change will depend on the individual case e.g. daily for patients nursed in
       isolation or immediately if soiled.
      In other healthcare settings, e.g. GP surgeries, disposable linen must be considered e.g. paper couch
       rolls, disposable pillow cases and sheets. These must be discarded after each patient use.

These principles are to be applied to handling linen in all healthcare settings.

                                                                                           Chair: Elaine Baylis QPM
                                                                                   Chief Executive: Andrew Morgan
Page 8 of 14
12. Management of linen in Community Hospitals

In addition to the above guidance the following is also applicable:

12.1 Return to sender items
A ‘Return to Sender Service’ is available for the laundering of the Trust’s own linen which include items such
as uniforms, white coats, curtains, slide sheets and special bed linen.

All items to be laundered by this method must be clearly marked with the Trust Logo and then labelled with the
ward/user name and site. The laundry cannot be held responsible for any linen items sent to the laundry
which are unmarked.

The items should then be placed inside a Blue plastic bag. For each bag of laundry there must be an
accompanying “Laundry List” placed in the bag which should be completed in full.

If any item you send has not been returned within six working days, please contact the Support Services
Manager.

12.2 Condemning of Linen
All linen purchased and owned by the ward / department which is deemed unsuitable for further use should be
condemned and replaced by the ward / department. It is not the laundry’s responsibility to identify or replace
these items.

All damaged / condemned linen as produced by the Laundry provider must be returned to them.

Replacement of this category of linen and maintenance of satisfactory stock levels is the Manager’s and the
Support Services Manager’s responsibility.

12.3 Items of linen that must NOT be sent to the LAUNDRY
Items of linen used by patients with the following confirmed or suspected infections MUST NOT be sent to the
laundry:
        Anthrax
        Lassa fever/other viral haemorrhagic fever
        Plague
        Rabies

All items of used linen from patients with the above infections should be dealt with in the following manner:

              Enhanced Personal Protective Equipment must be used in all cases.
              All linen must be double bagged in hazardous waste bags and sealed.
              These bags would be clearly marked FOR INCINERATION ONLY.
              Staff should arrange for immediate disposal from the ward by designated individual(s).
              The designated individual(s) should personally and directly remove these bags and place into
               the incinerator/hazardous waste bin.
              If cased of highly infectious microorganisms e.g. Ebola. Follow PHE advice

Further advice if needed can be sought from the Consultant Microbiologist or the Infection Prevention Team.

12.4 Marking patients’ own clothing
It is essential in order that the item is returned to the correct area that all patients’ clothing sent to the Laundry
for laundering is marked clearly with the name of the patient and the location i.e. ward/department/hospital. If
garments have a detachable belt, that too should also be labelled/marked. Please ensure that the marking will
withstand numerous washes.
                                                                                            Chair: Elaine Baylis QPM
                                                                                    Chief Executive: Andrew Morgan
Page 9 of 14
13. Pillows & duvets
 The interior filling for pillows and duvets are efficient incubators of microorganisms if contamination occurs.
 All pillows and duvets should be made from a polyurethane coated fabric with welded seams.
 Pillows and duvets must be cleaned at a local level.
 Pillows and duvets should be routinely wiped clean between patients with hot water and detergent /
    detergent wipes e.g. Clinell
 During an outbreak if surface contamination with blood occurs, clean with hypochlorite solution (for blood
    1000ppm), all other times use Clinell or Sporicidal wipes.
 If decontamination cannot be carried out effectively then pillow or duvet must be incinerated (see section
    12.3).

14. Curtains and soft furnishings
Curtains in ward / clinical areas / departments must be laundered on a 6 monthly basis and when potentially
contaminated by an infected patient and /or blood/body fluids.

Non Clinical areas must have a routine of cleaning/recycling in place.

The curtains must be contained in the appropriate colour coded bag / container.

Disposable curtains must be changed six monthly and marked with the date they were changed.

Where a laundry contract is not in place disposable curtains must be considered. These can be discarded at 6
months or when soiled.

Soft furnishings such as chairs must have fluid repellent upholstery.

Stained and /or soiled chairs can be cleaned with Clinell wipes, if heavily soiled with blood and bodily fluids
can be steam cleaned, if too soiled to clean to be discarded following local guidance.

15. Staff Uniforms

Please refer to the local Uniform Policy P_HS_15

16. Patients’ own clothing and linen
Relatives can launder patients’ own clothes following the recommended guidelines (Appendix B).

Patients’ own clothes that become contaminated should not be sluiced in the ward/department. Remove overt
faecal matter first before placing into a secure bag for the relatives to take home to wash.

Within the patient’s own home, used / infected linen may be:

               Washed separately,
               Washed at the hottest temperature the fabric will allow,
               Tumble dried (where possible) or air dry,
               Ironed where possible.

It is at the discretion of the patient / relatives if items are to be discarded.

In community hospitals dissolvable patients’ laundry bags which contain instructions printed on them can be
used e.g. dissolve patient bags.

                                                                                           Chair: Elaine Baylis QPM
                                                                                   Chief Executive: Andrew Morgan
Page 10 of 14
17. Best Evidence
Ayliffe G.A.J., Fraise A.P., Geddes A.M. and Mitchell K. (2000) Control of Hospital Infection - A Practical
Handbook. 4th ed. Arnold. London.
Department of Health 2005 Saving Lives: a delivery programme to reduce Healthcare Associated Infection
including MRSA.
Department of Health2006: Infection Control Guidance for Nursing Homes.
Department of Health 2007: Essential Steps to safe clean care.
Department of Health2007: Uniforms and Work wear.
Department of Health 2007; Essential steps to safe clean care
Department of Health 2012; The Health Act - Code of Practice for the Prevention and Control of Health Care
Associated Infections
Department of Health 2013: Choice Framework for local Policy and Procedures 01-04 – Decontamination of
linen for health and social care: Guidance for linen processors implementing BS EN 14065
Healthcare Commission, Standards for Better Health July 2004.
McCulloch, J 2000. Infection Control: Science, Management and Practice, London.
NHS Executive Hospital Laundry Arrangements for Used and Infected Linen (HSG (95) 18). London: NHSE,
1995.
NHSLA Risk Management Standards for NHS Trusts, April 2009.
ULHT Management of Linen Guidance 2009

18. Associated policies
          Hand Hygiene Guidance G_IPC_17
          Management of inoculation injuries G_IPC_18
          IPC Standard Precautions Guidance G_IPC_26
          Blood and body spillage guidelines G_IPC_31
          Uniform and dress code policy P_HS_15

19. Appendices
Appendix A. Categories of linen and associated colour coding
Appendix B. Guidance for carer/patient
Appendix C. Equality analysis

                                                                                     Chair: Elaine Baylis QPM
                                                                             Chief Executive: Andrew Morgan
Page 11 of 14
Appendix A: Categories of linen and associated colour coding
    CATEGORY OF     INNER BAG   OUTER BAG              EXAMPLES
       LINEN

     USED LINEN       NONE        WHITE              All soiled patient
                                                  linen from Wards and
                                                        Departments
                                                 Theatre scrub suits
                                                    Lifting sheets
                                                      Canvasses

  FOUL/INFECTED/    RED WATER      RED               Infected & heavily
    INFESTED         SOLUBLE                           soiled linen only
                                                       For further
                                                     information refer to
                                                        Trust Infection
                                                        Control Policy

   THEATRE ITEMS    RED WATER     GREEN            Drapes & Gowns from
                     SOLUBLE                              Theatres

 SPECIALIST ITEMS                                   Return to sender
                                                  items, curtains, duvet
     SOILED ONLY      NONE         BLUE                 covers, all
                                                   launderable manual
                                                   handling equipment.
                                                  White Coats and
                                                      Uniforms (non-
                                                         Theatre)

                                                             Chair: Elaine Baylis QPM
                                                     Chief Executive: Andrew Morgan
Page 12 of 14
Appendix B: Guidance to carer/patient
Linen used by patients in their own home is normally laundered using a domestic washing machine.

The following considerations will reduce the risk of contamination of the environment and promote safety to
carers and staff.

Staff must not launder items for patients in their own home.

Used linen in the patient‘s home:

        Do not soak any items in solutions.
        Use household gloves for handling soiled linen.
        Faecal soiling should be sluiced down the toilet before machine washing.
        A pre-wash programme should be used for soiled items.
        Items should be washed at the hottest temperature suitable for the fabric (60oC or above)
OR      Dry cleaned at high temperature


Items heavily soiled with blood/bodily fluids should be:

        Use household gloves for handling soiled linen
        Washed separately (washing machines should not be overloaded),
        A pre-wash programme should be used for heavily soiled items,
        Washed at the hottest temperature the fabric will allow (over 71oC if possible)
        Tumble dried (where possible) or air dry,
        Ironed where possible.
OR      Dry cleaned at high temperature

It is up to the discretion of the patient / relatives if items are to be discarded.

If a dissolvable patient laundry bag is used, remind relatives to read the instructions on the bag.

                                                                                              Chair: Elaine Baylis QPM
                                                                                      Chief Executive: Andrew Morgan
Page 13 of 14
Appendix C: Equality analysis

            A.   Briefly give an outline of the key
                 objectives of the policy; what it’s The purpose of this guidance is to implement a
                 intended outcome is and who the co-ordinated approach to the management of
                 intended beneficiaries are expected to line
                 be

            B.   Does the policy have an impact on This document is relevant to all staff
                 patients, carers or staff, or the wider employed by LCHS NHS Trust
                 community that we have links with?
                 Please give details
            C.   Is there is any evidence that the
                 policy\service relates to an area with None known
                 known inequalities? Please give
                 details
            D.   Will/Does the implementation of the
                 policy\service result in different
                 impacts for protected characteristics?

                                                        Yes    No
                 Disability                                    x
                 Sexual Orientation                            x
                 Sex                                           x
                 Gender Reassignment                           x
                 Race                                          x
                 Marriage/Civil Partnership                    x
                 Maternity/Pregnancy                           x
                 Age                                           x
                 Religion or Belief                            x
                 Carers                                        x
                 If you have answered ‘Yes’ to any of the questions then you are required to carry
                 out a full Equality Analysis which should be approved by the Equality and Human
                 Rights Lead – please go to section 2
        The above named policy has been considered and does not require a full equality analysis
        Equality Analysis Carried out by:         S Fixter
        Date:                                     24th October 2017

                                                                                     Chair: Elaine Baylis QPM
                                                                             Chief Executive: Andrew Morgan
Page 14 of 14
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