Policy No: IC10 Version: 6.0 Name of Policy: Linen Services Policy Effective From: 18/08/2015 Date Ratified 15/07/2015 Ratified Infection Prevention and Control Committee Review Date 01/07/2017 Sponsor Director of Nursing, Midwifery and Infection Prevention and Control Expiry Date 14/07/2018 Withdrawn Date Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that this is the most up to date version This policy supersedes all previous issues
Version Control Version Release Author/Reviewer Ratified by/authorised by 1.0 Jan 2006 Trust Policy Forum Infection Prevention and Control 2.0 February 2006 3.0 Feb 2008 Central Team Committee Infection Prevention and Control Committee Date January 2006 Changes (Please identify page no.) 4.0 28/02/2012 S Philipson V Atkinson 5.0 25/07/2013 S Philipson V Atkinson Infection Prevention and Control Committee Infection Prevention and Control Committee Reviewed and updated whole document into standard policy format 30/05/2013 Section 10 Monitoring now part of PLACE Assessment Change in lead Director highlighted in Duties and Responsibilities and Section 12 Update Appendix 1 Sunlight Bagging Policy 6.0 18/08/2015 S Philipson Infection Prevention and Control Committee July 2015 Section 7 Change Operational Hours Out of hours service Delivery Days Section 8 On site Laundry Appendix 1 Undated bagging policy Linen Services Policy v6 2
Contents Section Page 1 Introduction... 4 2. Policy scope... 4 3. Aim of policy... 4 4 Duties (Roles and responsibilities)... 4 5 Definitions... 5 6 Good Practice Guidelines... 5 6.1 Clean Linen... 5 6.2 Used Linen... 5 6.3 Patients Clothing... 5 7 Linen Services Department... 6 8 On Site laundry... 6 9 Training... 7 10 Equality and diversity... 7 11 Monitoring compliance with the policy... 7 12 Consultation and review... 8 13 Implementation of policy (including raising awareness)... 8 14 References... 8 15 Associated documentation (polices)... 8 Appendices Appendix 1 Soiled Linen Bagging System... 9 Appendix 2 Patient personal clothing... 10 Linen Services Policy v6 3
1 Introduction The provision of clean linen is a fundamental requirement for good patient care. It promotes dignity and respects the human rights of patients. In addition, incorrect procedures used during the handling or processing of linen can present an infection risk both to staff handling linen and to the service users who subsequently use it. The Trust policy reflects the guidelines within HSG (95)18, and Decontamination of linen for Health and Social Care (CFPP) 01-04 and aims to promote practices, which will ensure best practice in the use of linen within the patient environment. 2 Policy scope This is an Infection Prevention and Control policy for use of Gateshead Health NHS Foundation Trust in the management of Linen Services. 3 Aim of policy The Aim of the Policy is to ensure that all employees of Gateshead Health NHS Foundation Trust understand the process involved in the receipt, storage, correct use of clean linen and disposal of dirty linen to the linen service provider. 4 Duties (Roles and responsibilities) Designation Trust Board Chief Executive Director of Infection Prevention and Control Director Estates and Facilities Infection Prevention & Control Team Matrons All Staff Roles and Responsibilities The Trust Board has a responsibility to ensure that the risk of infection to patients, staff and visitors is minimised to its lowest potential and therefore supports the full implementation of this policy. The Chief Executive has ultimate responsibility for ensuring that effective systems and processes are in place to minimise the risk of infection to patients, staff and visitors. The Director of Nursing, Midwifery and Infection Prevention and Control has delegated responsibility for ensuring that effective systems and processes are in place to minimise the risk of infection to patients, staff and visitors Management of external contract and Trust Linen Services staff to support the requirements of this policy Support Hotel Service Manager to review and update the Linen Policy Give additional advice regarding the management of linen where required. Promote good practice and challenge poor practice Matrons are responsible for supporting this policy, providing clinical leadership improving and spreading best practice as identified in this policy. All Trust staff has a responsibility to adhere to Trust policy and ensure that appropriate measures are taken to reduce risks associated with infection. Linen Services Policy v6 4
5 Definitions Soiled Linen Used dry linen. Used dry linen from non-infected patients Fouled/Infected Linen Used linen contaminated with body fluids and/or from an infected patient Special Linen Used linen from highly infected patients i.e. smallpox handling and disposal of this type of linen would be advised by Infection Prevention and Control Leads and would not be returned to the laundry. 6 Good Practice Guidelines 6.1 Handling Clean Linen Clean linen should always be stored in a clean designated area with the door closed. Remove clean linen in sufficient quantities to undertake the required task. Surplus linen must not be returned to the clean linen store. Do not store clean linen on open trolleys/shelves within the patient environment 6.2 Handling used linen PPE - A disposable plastic apron should always be worn when handling used linen Wear a disposable plastic apron and gloves (non-sterile) when handling foul/infected linen PPE should be removed on completion of each task and hand hygiene performed Used linen must be handled with care to prevent environmental contamination with excretion or secretions, skin scales or bacteria. Used linen must be bagged at the bedside, never shaken or allowed to touch the floor or other surfaces. Linen must be held away from the body to prevent contamination of clothing. Ensure appropriate clean bags/receptacles e.g. linen skips, are available as close to the point of use as possible. 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. All used linen must be placed in the correct colour bag, securely tied and stored in a room or area designated for the purpose, which is safe and separate from patient areas. 6.3 Patient s Clothing Patient s personal items of clothing will normally be sent home with the relative/carer. Patient s personal items of clothing that are soiled or infected will be placed in a sealed bag and returned to the relative/carer. (Guidance notes for home laundering are available Appendix 2) Patient personal items to be processed through the Trust linen services provider - Ward s must ensure all clothing is marked before laundering. Clothing that is sent for marking must be clean. Purchases of textiles which can withstand industrial processes are recommended (avoiding 100% woollens for example). Linen Services Policy v6 5
7 Linen Services Department Staff within the Linen Services Department are responsible for the provision and maintenance of linen supplied and utilised within the Trust, which includes sewing room services, contact details are attached in appendix 1. Operational Hours 8am-4pm Monday Friday. Outside normal working hours emergency supplies are available via Portering Services. 7.1 Receipt of clean linen Delivered on a pack to ward basis ensuring a daily (Monday-Friday) just in time service maintaining supply to the optimum level. Deliveries are checked within the linen room area to ensure stocks have been correctly transported quantities supplied meet the specification and requirement audit the quality of linen items supplied 7.2 Handling and transport of used linen 8 On-site Laundry PPE should be worn appropriately to protect those transporting linen, e.g. aprons & gloves. Bags containing used/infected linen that have not been properly secured should not be uplifted; all incidents should be reported to the area manager. Used linen must be collected onto an empty linen cage once ⅔ rds full this should be returned to the designated area for collection. No other receptacle can be used and no additional items can be transported within the cage. Hand hygiene should be performed after handling used linen bags/receptacles/cages & on removing aprons & gloves. Vehicle s used in the transport of clean and dirty linen will be designated for each use with regular cleaning programmes in place to ensure these are clean. The workflow within the Linen Services area has been designed to ensure there is clear separation of clean and dirty linen stocks. Laundry equipment must not be purchased without the involvement of Estates and the Infection Prevention Control Team. All procurement of such equipment must be to the Trust s agreed standard and via the Procurement Department. Washers must have a sluice and disinfection cycle, and dryers must be vented to the outside. The disinfection cycle is achieved when the water has reached 65ºC and held at this temperature for not less than 10 minutes or at 71ºC for 3 minutes. Infection Prevention Control advice should be sought when setting up on site laundry facilities for in-patients. The area must be specifically designated as a laundry and not used for other purposes. Appropriate PPE should be available for staff use. The work should flow from clean and dirty areas with careful segregation to avoid recontamination of clean personal clothing. Hand sluicing of contaminated personal clothing by staff should not be allowed as there is a high risk of releasing aerosols of body fluids with potential infection risks for staff. Heavily soiled items should also have a pre-wash/sluice cycle selected. Linen Services Policy v6 6
Machines should only be used for laundering patient s personal clothing Alginate bags for infected and body fluid contaminated clothing items are available, if used these must be laundered in a disinfection cycle to ensure disposal of the alginate bag. Processed linen should be stored in a clean area above floor level and should not be kept in the laundry area. Separate washers and dryers to industrial standards must be purchased, as domestic machines have a small rinse cycle. Alginate bags must never be placed in driers. The machines should be fitted on a plinth to avoid the use of pumps which can be a source of cross infection. Effluent must be sealed in drains (closed pipes) from machine to manhole to prevent cross infection. Departments should retain a log book detailing regular visual checks of the equipment and any service or repair. Washing machines must be regularly maintained, kept in good working order and calibrated to ensure they reach the minimum temperatures. Departments should have local written policies which ensure Staff using the equipment are trained in the correct use of this equipment including loading and correct dosing of detergent. A hand wash basin should be available in the area. 9 Training All staff that are required within their role to handle clean linen or dispose of used linen at Ward or Department level should receive education and training at a local induction in the safe: 1. Storage of clean linen 2. Categorisation of used linen (see definitions above) 3. Disposal of used linen (see Appendix 1 for guide) 4. Storage until collection by the porters The ward/department must retain training records which should be reviewed during staff appraisal. 10 Equality and diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This policy has been appropriately assessed. 11 Monitoring compliance with the policy This policy will be monitored for effectiveness on a quarterly basis by PEAG Compliance will be monitored during routine Infection Prevention and Control visits/audits Annually as part of the PLACE Inspection programme Included as part of the PEAG reporting to Trust Board Staff at Ward/Department level are responsible for alerting the Linen Services Department if they experience shortages of linen or quality issues i.e. staining Monitoring of complaints and compliments. Linen Services Policy v6 7
12 Consultation and review This policy has been reviewed in consultation with PEAG group and Infection Prevention and Control Committee 13 Implementation of policy (including raising awareness) The Director of Infection Prevention and Control is responsible for overseeing the implementation of this policy. Operational responsibility belongs to the Director of Estates and Facilities for providing services and Linen Service Management The policy will be implemented and disseminated via local induction and training programmes. 14 References National Framework Laundry and Linen Services Contract Decontamination of linen for Health and Social Care (CFPP) 01-04 NHS Executive. Health Service Guidelines HSG (95)18 Hospital Laundry Arrangements for Used and Infected Linen 1995 Health Act 2006 Code of Practice for Prevention and Control of Health Care Associated Infections (Department of Health 2006) revised January 2008 Health Protection Scotland (2009) Safe Management of Linen Policy and Procedure 15 Associated documentation This policy should be ready in conjunction with the following policies as a minimum. Sharps Waste Disposal Hand Hygiene Work Attire & Appearance Personal Protective Equipment Cleaning and Disinfection Policy Linen Services Policy v6 8
Appendix 1 CFPP01:04 - COLOUR CODING BAGGING POLICY Bags should be filled two-thirds full (approximately 2.5 beds) LINEN HIRE ITEMS REJECTED LINEN INFECTED LINEN HIRE ITEMS White Berendsen Bag Rejected/Return Items Only Inner Dissolvable Red Bag Pink Berendsen Bag Outer- White Berendsen Bag Inner- Dissolvable Bag Blue Berendsen Bag Outer Blue Berendsen Bag This bagging policy immediately supersedes all previous linen bagging policies in adherence with DoH document CFPP01:04 Contact Details Linen Services Linen Room Telephone Extension 3410 Sewing Room Telephone Extension 2136 Linen Services Supervisor Bleep 3140 Linen Services Policy v6 9
Appendix 2 Patients Personal Clothing Guidance Notes for Relatives Patient s personal items of clothing may only be washed through the hospital laundry system if the clean items are marked and identified to the Patient and Ward area. The Trust cannot accept responsibility for items sent to the laundry without the appropriate ID or fabrics, which may be liable to damage as a result of thermal disinfection. Advice for patient s personal items taken home for laundering Dispose of plastic bag(s) used to carry items. Alginate bags must never be placed within a domestic washing machine. Remove items from the bag and place them directly into the washing machine, if possible, without sorting them. If you have to sort them wear rubber gloves and wash these with soap and water afterwards. Wash the clothing separately from your other home laundry. Always hold the clothing away from you to avoid spreading germs. Do not shake the clothing. Hand hygiene should be undertaken following handling of items. Launder items using at as high a temperature as possible as per washing instructions on the care label. Use normal washing powder or detergent. Tumble dry where possible (following manufacturers guidance). Iron according to manufacturers instructions. A hot iron with steam is best if possible. Where hand rinsing of heavily soiled items is absolutely necessary, this should be carried out by fully submersing the items to avoid potential aerosolisation/splashes while rinsing. Ensure splashing is minimised particularly when discarding used water. Linen Services Policy v6 10