TRUST POLICY AND PROCEDURES FOR THE MANAGEMENT AND PROVISION OF LINEN DECONTAMINATION

TRUST POLICY AND PROCEDURES FOR THE MANAGEMENT AND PROVISION OF LINEN DECONTAMINATION Reference Number FM 2013/002 Version: 2.2 Status: Review Author: Rob Ridge Job Title: General Manager - Facilities Management Version / Amendment History Version Date Author Reason 1 Oct 2009 Debbie Wild Original 2 Dec 2009 Helen Forrest Infection Control update 2.1 July 2013 Rob Ridge Policy Review 2.2 December 2016 Rob Ridge Policy Review Intended Recipients: All Trust staff Training and Dissemination: Essential to role, FM and Infection Control provide training and support for staff as and when requested/required To be read in conjunction with: Trust Policy and Procedures for Incident Reporting, Trust Policy and Procedures for Waste Management, Trust Policy and Procedures for Infection Control, Trust Policy for Radiation Protection. Trust Policy and Procedure for Personal Protective Equipment. Trust Policy and Procedures for Hand Hygiene In consultation with and Date: Premises Assurance Model - Linen and Laundry Services Statutory Working Group,Infection Control Committee EIRA stage One Completed Yes / Stage Two Completed - N/A Procedural Documentation Review Group Assurance and Date Yes June 2013 Approving Body and Date Approved Management Executive, 13.12.16 Date of Issue December 2016 Review Date and Frequency Contact for Review December 2019 (then every 3 years) Associate Director of Patient Experience and Facilities Management Director of Patient Experience and Chief Nurse Executive Lead Signature Director of Patient Experience and Chief Nurse Approving Executive Signature 1

Section 1 Introduction 2 Purpose and Outcomes 3 Definitions 4 Key Roles and Responsibilities 5 Implementing the Policy 6 Monitoring Compliance and Effectiveness 7 References APPENDIX 1 APPENDIX 2 APPENDIX 3 Best practice guidelines for frequency of change of hospital linen Means of segregation/specification of colour coded bags Quality Finish Standards 2

1.Introduction The Trust attaches the greatest importance to the health, safety and welfare of staff, patients and visitors. It is considered essential that management and staff should work together positively to achieve an environment compatible with the provision of the highest quality services to patients where health hazards to patients and others are minimised, so far as is reasonably practical. The Trust is committed to ensuring the safety and welfare of its employees and anyone else affected by its activities. This policy will ensure that the Trust meet requirements of the Health Act 2006 Code of Practice for the Prevention of Control of Healthcare Associated Infections, Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance, NHS Constitution Section 2a, patients have a right to expect care to be provided in a clean and safe environment that is fit for purpose, based upon national best practice. This includes the range of support services such as the provision of linen and laundry services that reduces the risk of cross-infection and enhances the patient experience. 2.Purpose and Outcomes Linen or clothing used by hospital patients or staff are a possible infection risk to staff handling these items on the ward, during transportation, or during the decontamination process. They may also pose a risk to other patients if not handled correctly. This document is aimed to give a clear understanding of the policy and procedures for the management and provision of linen decontamination within the Trust and to ensure all linen is handled safely and prevent contamination of the environment to prevent infection to patients and staff in light of the recently published Hospital Technical Memorandum HTM 01-04 Decontamination of Linen for Health and Social Care (June 2016). HTM 01-04 Decontamination of Linen for Health and Social Care (June 2016) supersedes the Choice Framework for local Policy and Procedures (CFPP) 01-04 Decontamination of Linen for Health and Social Care The purpose of HTM 01-04 is to provide a structure that will enable local decision making regarding the management, use and decontamination of healthcare and social care linen. The guidance is designed to ensure patient safety and enhanced outcomes at controlled cost using risk control. This best practice guidance will be of direct interest to providers of care and those working in laundry management and linen decontamination. Management and technical information is also provided for care providers and linen services providers. The guidance provided promotes a principle of continuous improvement in linen processing performance at all levels. It provides options that allow laundries, launderette operators and local linen processors (hereafter referred to as linen processors ) to choose how to meet Essential Quality Requirements (EQR) and how to progress to Best Practice (BP). The Trust is required to comply with its preferred linen processor s proposals to achieve EQR and BP. Every employee will be encouraged to co-operate with the Trust to implement this policy. 3.Definitions The definition of terms used and their meaning within the context of the document is to clarify interpretation and is not an exhaustive list 3

Linen means articles or garments made from linen or a similar textile, such as cotton or manmade fibres Used Linen all linen (including rental night wear) except that which is defined as infectious Infectious linen - all linen (including rental night wear) from known or suspected infectious/isolation patients, patients with diarrhoea or blood or body fluids from patients with blood-borne viruses Condemned Linen means rejected linen that is no longer fit for purpose i.e. torn or stained 4.Key Roles and Responsibilities 4.1 Chief Executive The Chief Executive has overall responsibility for the management and provision of linen decontamination. 4.2 Director of Patient Experience and Chief Nurse The Director of Patient Experience and Chief Nurse is the nominated Executive Director for Risk Management and has board level responsibility for ensuring that there is clear and effective monitoring of all aspects of Risk Management. 4.3 Associate Director of Patient Experience and Facilities Management The Associate Director of Facilities Management is responsible for overseeing the management and monitoring of the Facilities Services contracts, which includes the provision of linen decontamination. 4.4 Linen Processor A linen processor is the person or organisation designated by management to be responsible for the supply, delivery and decontamination of linen. 4.5 Clinical and Executive Directors/Divisional Directors Clinical and Executive Directors/Divisional Directors have responsibility for the management of Trust policies and procedures within their Division. 4.6 Premises Assurance Model (PAM) Statutory Working Group This team of appropriate professionals shall provide the Trust with advice and assistance on all matters relating to linen decontamination including the requirements for the ongoing review and completion of the Premises Assurance Model (PAM) submission with regard to Linen and Laundry Decontamination Services. Members of the group include General Manager Facilities Management, Facilities Contracts Monitoring Officer, Lead Nurse, Risk & Clinical Governance and Linen Processor Customer Liaison Manager. 4

4.7 Strategic Health and Safety Committee This committee is responsible for the monitoring and reporting to the Quality Review Committee of any issues arising from incidents involving the management and provision of linen decontamination. 4.8 All Staff All employees have duties and responsibilities in respect to the decontamination of linen and conduct their duties in accordance with the Trust Policy and Procedures for the management and provision of linen decontamination. Disciplinary action may be taken if a member of staff does not follow these. 5 Implementing the Policy Linen used on Trust sites can be categorised into one of the following: Flat Linen Drawer sheets Counterpanes/thermal spreads Blankets Gowns Baby linen cot sheets, cot blankets Nightwear Dressing gowns Theatre Linen drapes & gowns Pool Uniform white coats/theatre scrubs/surgical gowns Single use/disposable Curtains & Blinds Slings Transfer sheets Domestic cloths and mops Return to sender items (RTS) Cytotoxic Linen Radioactive Linen Active Mattresses Maternity monitoring belts Other any such items required to be laundered for patient use 5.1 Best practice guidelines for frequency of change of hospital linen Hospital linen or clothing must be changed and laundered between patients. The frequency of change will depend upon the individual case e.g. Daily for patients nursed in isolation or immediately if fouled. For further best practice guidelines for frequency of change of Hospital linen see Appendix 1. 5.2 Means of segregation/specification of colour coded bags Used (soiled and fouled) linen This applies to all used linen, irrespective of state, but on occasions contaminated by body fluids or blood. It does not apply to: 5

Linen from known or suspected infectious/isolation patients Other linen covered by the following paragraph on infectious linen Used (soiled and foul) linen must be placed in a WHITE impermeable polythene bag and tied Infectious Linen This applies to all used linen from: Known or suspected infectious/isolation patients Patients with diarrhoea Blood or body fluids from patients with blood-borne viruses Other conditions as specified by local policy (e.g. varicella zoster and measles) Infectious linen must be placed into a RED soluble (alginate) bag and tied, then into a WHITE impermeable polythene bag. The outer bag must be tied and attach tape around the neck of the bag which indicates Infected Linen For further advice regarding segregation into colour coded bags. See Appendix 2 Means of segregation/specification of colour coded bags. Sorting of linen should be done at ward level, i.e. continent pads, wipes etc., should be disposed through the correct waste stream and not left in the linen. Special care should be taken to ensure that sharps and other foreign objects are not left in the linen. 5.3 Condemned linen All staff have a responsibility in ensuring that linen is clean and fit for purpose. Any item of linen that is deemed not fit for purpose should be rejected prior to use and placed in a green bag (See Appendix 2) and left in the designated waste hold for collection. Reasons for rejecting linen may include: Staining Holes or tears Foreign objects body hair, tissues, dressing tape Dampness For further information see Appendix 3 Quality Finish Standards 5.4 Handling of Used/Infectious Linen It is the responsibility of the person disposing of the linen to ensure that it is segregated properly (see Appendix 2). Appropriate PPE should be worn when handling/disposing of used/infectious linen. All used/infectious linen should be handled with care to prevent environmental contamination. 6

To reduce the risk of cross infection, a linen bag skip must be taken to the patient s bedside and the used/infectious linen carefully removed, avoiding any unnecessary agitation and directly placed into the appropriate bag. Dirty linen must not be carried from the bedside. Staff must take correct coloured bag into an isolation room without using a linen skip to prevent cross contamination. Staff must wear the appropriate Personal Protective Equipment when handling used/soiled linen. The linen bags should be no more than ¾ full and appropriately sealed/labelled using adhesive tape roll marked infected linen where applicable. Staff handling and moving linen bags should be trained in safe moving and handling principles. The person moving the linen has a responsibility to assess the activity and tell someone (your employer, supervisor, or health and safety representative) if they think moving and handling of linen is putting anyone s health and safety at serious risk. Sealed/labelled bags must be placed in the designated waste hold for collection and must be kept separate from clean linen at all times. Hands must be washed thoroughly with soap and water after handling any used/infectious linen. 5.5 Storage of Clean Linen and Prevention of Recontamination Clean linen should be stored at ward/department level in a closed designated dedicated storage area. The storage area must be appropriately designed to prevent damage to linen and to allow for the rotation of stocks. Shelving must be easily cleanable and linen should not be stored on the floor. Frequency of cleaning of the linen cupboard must form part of the ward/department s scheduled cleaning programme. A small amount of non-linen related clean consumable items such as incontinence pads and toiletries may be stored in the designated dedicated storage area, so long as these are clearly segregated and do not present a risk of recontamination of linen. The storage of medical equipment such as monitors and other non patient care related items e.g. Christmas trees is not permitted. Pillows Pillows must be kept clean and decontaminated following patient use before storing in the linen cupboard. Pillows must have an impermeable cover, should the impermeable cover be faulty, cut or broken the pillow should be condemned and placed in a green bag (See Appendix 2) and left in the designated waste hold for collection. Linen Trolleys If linen trolleys are used during bed making these must be suitably covered to prevent recontamination and contain the minimum stock of linen possible. Linen trolleys must not be taken into bays or side rooms. Any unused or surplus linen must not be returned to the linen storage area. It must be laundered again. 7

5.6 Internal Transit of Clean and Used Linen Dedicated trucks and cages shall be used for the transportation of clean and used linen from collection points to the dedicated storage areas. Clean linen in transit must be protected with a washable or disposable cover. 5.7 Transportation of Linen On/Off-Site The Linen Processor responsible for delivery and collection of linen should have a safe system of work in operation to ensure that: Collectors, drivers and others are aware of and trained in the nature of the linen being carried. Vehicles are decontaminated after collection of used linen. There should be a physical barrier between clean and used linen when carried on a vehicle at the same time. Linen Processors are familiar with the procedures to be followed in the event of spillage or accidents and that written instructions, safety and protective clothing are provided on the vehicle where required. 5.8 Training All staff that are required to handle and move linen should be adequately trained in the safe procedures including moving and handling training. Records of such training shall be kept. Written local procedures should be available at all times. 5.9 Risk Assessment Risk associated with the segregation, handling, storage and transport of linen will be identified, documented and prioritised as part of the Trust Risk Register as required. Linen management control measures will be implemented and continually reviewed (see Section 7 Monitoring Compliance and Effectiveness). Procedures for handling linen shall be established within the Trust. Specialist departments will require specific procedures based on individual risk assessments, for example: Cytotoxic/Cytostatic Hazardous Linen. Radioactive Linen see Trust Policy for Radiation Protection for further guidance. 5.10 Personal Protective Equipment (PPE) Where a risk assessment has identified the need for personal, protective equipment (PPE) to be used, adequate supervision shall ensure that these items are provided, used and maintained. 5.11 Accidents and Incident Investigation Reporting The Trust s Policy on accident and incident reporting should be followed in relation to any incident involving linen. Close liaison between Facilities Management, Infection Prevention and Control and Risk Services shall ensure all incidents are properly investigated to prevent recurrence. 8

5.12 Spillages The procedure for dealing with spillages from all types of linen shall be agreed and circulated to all staff to which the spillage may affect. Spillage kits shall be available in areas at risk for use by the cleaning team. If a spillage occurs, staff should place wet floor signs at the area and call the Facilities Management Helpdesk. 5.13 Decontamination Process All linen must go through a thermal disinfection cycle in accordance with HTM 01-04. In addition, Linen Processors used by the Trust are required to be independently certified BS EN 14065 Textiles, Laundry Processed Textiles Bio Contamination Control System. 5.14 Specific Policy Areas 5.14.1 Heat-labile Items This category includes fabrics damaged by the normal heat disinfection process and those likely to be damaged at thermal disinfection temperatures. These fabrics should be washed at the highest temperature possible for the item as agreed with Infection Prevention and Control. These items must be clearly marked and placed in a NAVY BLUE bag - Return to Sender (see Appendix 2, Means of Segregation/Specification of Colour Coded Bags). 5.14.2 Laundering of Staff Uniforms The Trust does not provide a staff uniform laundering service. The Trust Policy relating to uniform/dress code Section 5.23 - Laundry of Uniforms states On the advice of the Microbiologists, clinical staff are advised that uniforms worn at work should be suitable for washing at 40 C in a domestic washing machine and should be tumble dried and/or ironed. Uniforms can be mixed with other items being washed, unless soiled, when they should be laundered alone. Staff can contact their local HMRC Office for advice regarding claiming personal tax relief on laundering of uniforms. 5.14.3 Laundering of Patient Personal Clothing Patients and their relatives/carers must be informed that Derby Teaching Hospitals NHS Foundation Trust does not routinely provide a patient personal clothing laundry service. Soiled clothing must be placed in an appropriate bag. Tie the bag and apply an adhesive label stating Soiled Clothing. Inform the patient s relative/carer that the patient has soiled clothing which requires laundering at home. Advise the relative/carer to empty the bag directly into the washing machine as soon as possible and to avoid handling the contents. Provide gloves if required and instruct on a sluice cycle before proceeding to wash cycle. Also, advise not to wash with other non-soiled items and to avoid over-filling the drum. Where an on-site patient personal clothing laundry service is provided section 5.14.4 must be adhered to. 9

NB: Staff must not launder items for patients in their own homes. 5.14.4 On-Site Laundrettes - Washing Machine/Dryers An authorised Linen Processor should be used wherever possible for the decontamination of linen and other healthcare associated items, which require decontamination e.g. patients slings. No washing machines/dryers must be purchased, installed or operated without authorisation from Infection Prevention and Control and Facilities Management. On site laundry facilities must comply with the following minimum requirements: 1) A full options appraisal and risk evaluation should be undertaken. 2) Washing machines and dryers must be of an industrial specification with a sluice cycle, capable of achieving thermal disinfection or equivalent. 3) Water Supply (Water Fittings) Regulations 1999 approved. 4) Suitable mechanism for the recording and validation of temperature/thermal disinfection for each wash cycle. 5) Appropriate planned preventative maintenance, inspection and call out contracts. 6) A service/repair log book. 7) Appropriate hand washing facilities. 8) Appropriate segregation for clean/dirty linen. 9) Provision of appropriate PPE. 10) Standard operating procedures and appropriate management structure. 11) Staff training. For further advice contact Infection Prevention and Control or Facilities Management. 5.14.5 Single Use Clothing on Discharge Wherever possible, patients should be discharged in their own clothes. However, should the need arise to provide a patient with clothing to wear on discharge, staff should use the single use clothing supplied to wards and departments, instead of hospital rental nightwear or gowns. If you require assistance in accessing single use clothing, please contact the Discharge Lounge, Linen Room or Facilities Management. 5.14.6 Stolen or Defaced Linen Hospital linen or clothing must not be removed from the premises by staff or patients without permission. Similarly, linen or clothing must not be wilfully defaced, cut or used for other purposes than for that it is intended for e.g. use of towels to clean a dirty floor. 5.14.7 Active Mattresses (Dynamic Pressure Redistributing Mattress) Used (soiled and fouled) Active Mattresses This applies to all used active mattresses, irrespective of state but on contaminated by body fluids or blood. It does not apply to; occasions Linen from known or suspected infectious/isolation patients. 10

Other linen covered by the following paragraph on infectious linen. Used (soiled and foul) Active Mattresses must be placed in a WHITE impermeable polythene bag and tied. Infectious Active Mattresses This applies to all used active mattresses from: Known or suspected infectious/isolation patients. Patients with diarrhoea. Blood or body fluids from patients with blood-borne viruses. Other conditions as specified by local policy (e.g. Varicella Zoster and Measles) Infectious active mattresses must be placed into a RED impermeable bag and tied and attach tape round the neck of the bag which indicates Infected Linen. 6 Monitoring Compliance and Effectiveness Audit arrangements will be implemented to support the continuing practise of effective segregation of linen. Audits will focus on the correct segregation, handling, storage and transport of Linen and inspection of laundry facilities and processes (annual due diligence inspections undertaken). Monthly reports on the Linen Decontamination Service are presented to the Facilities Management team during the performance monitoring meeting by the Linen processor. This policy will be regularly monitored to ensure that objectives are being achieved. It will be reviewed, and where necessary amended, in the light of legislative or organisational change. Monitoring Requirement: Monitoring Method: Monthly compliance through the Contract Performance Monitoring System. 6 monthly formal linen processor contract review meetings Annual due diligence inspection of Linen processor premises Report Prepared By: Monitoring Report presented to: Frequency of Report: Premises Assurance Model Statutory Working Group (SS5 Linen & Laundry Services) Paul Brooks Infection Control Operational Group Estates and Facilities Management Committee Annually 11

7. References a. Health & Safety at Work Act 1974 b. The Management of Health and Safety at Work Regulations 1992 c. Choice Framework for local Policy and Procedures (CfPP) 01-04 Decontamination of linen for health and social care d. BS EN 14065 Textiles. Laundry processed textiles bio-contamination control system e. Duty 4g The Health Act 2006 Code of Practice for the prevention & Control of Health Care Associated Infections f. Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance g. NHS Constitution Section 2a h. Control of Substances Hazardous to health (COSHH) Regulations 2002 (amended) i. Personal Protective Equipment at work regulations 1992 (as amended) j. Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2009 (known as the Carriage regulations) k. The Consumer Protection Act 1987 l. The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995 m. Safe management of healthcare waste (updated 2011) n. CfPP 01-01: management and decontamination of surgical instruments (medical devices) used in acute care o. Water Supply (water fittings) Regulations 1999 p. SHLSLM: Society of Hospital Linen Services & Laundry managers q. Premises Assurance Model updated 2016 r. Hospital Technical Memorandum HTM 01-04 Decontamination of linen for health and social care (June 2016) s. Hospital technical Memorandum - HTM 01-01 Decontamination of surgical instruments (July 2016) 12

Appendix 1 Best Practice Guidelines for frequency of change of Hospital Linen Sheets and Pillow Cases Thermal Spread/Blankets Nightwear and Towels Always change when visibly soiled Infected/Isolated Patients Must be changed DAILY Bed Bound Patients Change when visibly soiled or up to a maximum of 3 days Always change when visibly soiled All thermal spreads or blankets remain with patients for a maximum of 5 days or until discharge Patients wherever possible should be encouraged to bring in their own nightwear and towels Hospital nightwear and towels should be used for emergency admissions or as a last resort All Other Patients Can remain up to a maximum of 3 days Should a patient or patient s relative request a linen change this should be undertaken by staff as requested. 13

Appendix 2 Means of segregation/specification of colour coded bags CATEGORY DESCRIPTION SPECIAL NOTES COLOUR PICTURE A B C Used (soiled and fouled) linen Infectious linen Return to Sender items (RTS) All used (soiled and fouled linen (including patient wear) for example nightwear, patient gowns etc. NB Curtains must be bagged separately All used and soiled linen including patient wear from patients with known or suspected infections/isolation patients NB Curtains must be bagged separately Items owned by the Trust / Hospital / ward, for example laboratory coats, uniforms, slide sheets, baby sleeping bags, heat-labile items Place into a white polythene bag; this now includes linen and patient wear that is soiled with blood, faeces, vomit and urine. Do not place soiled linen in white bags if it s known as infected linen. Put in to a red soluble (alginate) bag and tie, then into a WHITE polythene bag. The outer bag must be tied and attach tape round the neck of the bag which indicates Infected linen All items must be labeled, with Dept, Hospital name. Any items sent not labeled may not be returned. If you have any Return to Sender items that are infected, follow instruction B White Polythene Bags Red Soluble Bag Inside a White Polythene Bag Navy Blue Polythene Bag D Theatre linen, drapes and gowns All theatre linen except that which is known to be infected (category B). Use only Synergy blue provider bags Light Blue Polythene Bag Printed drapes and gowns E Rejected clean linen (unused) Any clean linen which is found to be unusable (i.e. torn, stained, etc. not fit for purpose) All rejected linen must be placed in a green polythene bag for returned through the specific process agreed with the Trust. Green Polythene Bag Important Notes The linen bags should be no more than ¾ full and appropriately sealed/labelled using adhesive tape roll marked infected linen where applicable. The person moving the linen has a responsibility to assess the activity and tell someone (your employer, supervisor, or health and safety representative) if they think moving and handling of linen is putting anyone s health and safety at serious risk. 14

Appendix 3 Quality Finish Standards The required quality finish standards are based mainly on what area of the product the patient is likely to come in contact with. For example, the outside area of a sheet will be under the mattress and is unlikely to come in contact with the patient, therefore, the criteria is more lenient in this area. Staining Major Stain A fresh stain is clearly visible and greater than 2 cm in diameter in any area of the article. Minor Stain A stain of less intensity but still fairly visible to the naked eye and greater than 4 cm in diameter. Permanent Stain A stain which is embedded on to the weave of the material and which has been washed twice through the normal wash process. Likely types of staining will be mildew, iron or rust, concrete or floor marking and medical products. Transfer these products to the rewash process. Products which are stained with a medical consumable will normally pass, seek authorisation from your section manager before doing so. Unacceptable Stain Any stain which falls in to the definition of a major, minor or permanent stain. Medical stains may pass. See your Manager. Holes / Tears A hole or a tear in an article greater than 2 cm in diameter or length is not permissible except where defined below. Foreign Objects All products should be observed wherever possible for foreign objects and removed. This may be objects like body hair, tissues, dressing tape, ECG electrodes. Products where objects that cannot be removed easily, should be rejected and placed in the repair reject barrow for further assessment. Dampness All products must feel dry to touch. Further detailed criteria by article Sheets Slight creasing allowed along any edges but must not exceed 15 cm from edge of the sheet. No creasing allowed in any other area. Holes are only permitted within 15 cm from the edge but must not exceed 2 cm in diameter. Folding should be 2 primary and 3 secondary folds. Draw Sheets Slight creasing is allowed within 15 cm of the hemmed edges. Slight creasing allowed towards both ends of the selvedge edges but no creasing allowed within the centre section 15

of the selvedge. Holes or tears are permitted within 15 cm from the hemmed edge but must not exceed 2 cm in diameter or length. Folding should be 2 primary and 2 secondary folds. Counterpanes Slight creasing is allowed along any edges but must not exceed 15 cm from the edge. No creasing allowed in any other area. Folding should be 2 primary and 3 secondary folds. Duvet Covers Slight creasing is allowed near to the seamed edges and around the opening end of the duvet cover. No creasing allowed in any other area. Folding should be 2 primary and 3 secondary folds. Pillow Cases Creasing allowed around the opening end and the internal flaps. Slight creasing allowed near to seamed edges. No creasing allowed in any other areas. Folding should be 2 primary only. Bath Towels Slight creasing / wrinkling allowed in all areas of the article. Folding should be 2 primary and 1 secondary. Blankets Slight creasing / wrinkling allowed in all areas of the article. Folding should be 2 primary and 3 secondary. 16