Journal of Hospital Infection (1994) 27, 219-235

INFECTION CONTROL IN PRACTICE

How hospital linen and laundry services are

provided

D. Barrie

Department of Medical Microbiology, Charing Cross and Westminster

Medical School, Fulham Palace Road, London, Wt5 8RF, UK

Accepted for publication 3 March 1994

Summary: Hospitals provide clean linen for patients and staff. This article
describes the laundering process, laundry equipment, how used hospital
linen differs from that of other large organizations and the Department of
Health guidance on handling and laundering hospital linen. It reviews how
hospital linen contracts are awarded and the responsibilities of the team
which evaluates them. Methods of microbiological testing of laundered linen
and the interpretation of the results are considered. The properties of
different fabrics available for use in operating theatres are summarized.
Measures to prevent infection and injury to staff handling used linen are
given.

Keywords: Disinfection; laundries; prevention of infection.

Introduction

Hospitals are expected to provide clean linen for patients and staff,
including bed linen, towels, personal clothing, uniforms, scrub suits, gowns
and drapes for operating theatres. Hospital linen differs from that of other
large institutions in that some items are contaminated with blood, excreta or
secretions and others have been used for infected patients. Another major
difference is that laundries contracted to process hospital linen are expected
to comply with guidance laid down by the Department of Health (DoH).’
Linen is disinfected during laundering and rendered free of vegetative
pathogens but is not sterile. Although it has been incriminated in outbreaks
it is rarely considered as a possible source of hospital-acquired infection.
Linen was found to be heavily contaminated by Bacillus ceyeus in the course
of an investigation of two cases of meningitis following neurosurgery2 and
appeared to be responsible for an outbreak of neonatal umbilical infection
by B. ceYeUsin a maternity ward.3
019556701/94/070219+17$08.00/0 0 1994 The Hospstal Infection Soctety

219
220 D. Barrie

The laundering process

The laundering process is intended to remove soiling, contamination and
microorganisms from dirty linen. It consists of prewash, main wash and
rinse.

Pre-wash
During the pre-wash, larger particles of soiling matter are removed and
suspended in the water which is then drained to waste. Detergent is used to
reduce the surface tension and to aid the removal of soil and soluble stains.
Most protein stains are removed by maintaining the temperature below
38°C and a low alkalinity.

Main wash
In the main wash, a combination of mechanical action, time, temperature,
detergent, alkali and de-staining agents removes the remaining adherent soil
and stains. The thermal disinfection required for hospital linen’ is achieved
during the wash stage by holding the temperature for 3 min at 71°C or 10
min at 65°C. These are the minimum safe disinfection temperature time
combinations and it is essential that additional time is given to allow
adequate penetration of heat into the work load - usually an additional 2-5
min, is sufficient but will depend on the type and size of machinery
employed. It is preferable to employ the higher temperature range to ensure
correct and thorough disinfection.

Rinse
Rinsing removes alkali, detergent and other additives from the linen by
dilution. Following water extraction, by pressing or spinning,items may be
tumble dried, The majority are ironed in calenders in which heat and
pressure are applied by the action of heated rollers rotating in a heated bed.

Laundering machines

Laundries use two types of machine, washer extractors and continuous

batch tunnel washers.

Washer extractors
These machines operate on the same principle as a domestic washing
machine, taking in fresh water for each wash and rinse. The process can be
adjusted to launder different fabrics and colours, to remove various types of
stains and to cope with different weights or loads of linen. Complete cycles
take 35-65 min. Washer extractors can be used to process any type of linen,
including high volumes of bedding (i.e. sheets, pillowcases, blankets), most
articles of clothing, uniforms and heat-sensitive fabrics and ‘infected’ linen.
 Hospital linen and laundering services 221

The inherent flexibility of washer extractors is a major benefit for handling

the range of used linen produced in hospitals.

Continuous batch tunnel washers

The processing of large quantities of linen is normally achieved by a
continuous batch tunnel washer (CBTW). Pre-weighed loads of linen pass
through a number of compartments in which they are pre-washed, washed
and rinsed. A typical machine has two pre-wash, five main wash and three
rinse compartments. Depending on the capacity and make of machine, linen
is added to the machine in 50 kg or 36 kg increments. The CBTW uses a
counter-current flow principle in which linen moves forward through the
machine and water flows in the opposite direction. Fresh water from the
mains is introduced at a constant rate at the final rinse compartment, flows
counter-current to the linen until it reaches the first rinse compartment, and
then drains to a collection tank. Two-thirds of this water is pumped to the
pre-wash compartment, flows forwards with the linen to the second
pre-wash compartment, and is then drained to waste. The remaining
one-third of the rinse water is pumped from the collection tank and enters
the last main wash compartment, flows backwards to the first wash
compartment, and then drains to waste. In this way the fresh clean water
used in rinsing is re-used as relatively clean water for washing subsequent
loads of linen.
Linen is sorted into different categories, weighed and loaded
automatically into the first pre-wash compartment of the CBTW.
Detergent, alkali and de-staining agents are added automatically to the
appropriate compartments, and steam is injected into the main wash
compartments to achieve the required temperature levels. Wash
temperatures of up to 80°C are normally used, ensuring safe thermal
disinfection. The amount and timing of additives, the movement of linen
through the CBTW, and the times required for tumbling and drying
different types of linen are controlled by computer. If the temperature
required for thermal disinfection is not achieved and maintained for the
right length of time, or if the water levels in the pre-wash, wash and rinse
stages are incorrect, the CBTW will not proceed and complete the cycle
until remedial action has been taken. The complete wash and rinse cycle
takes about 30 min, with SO/36 kg load being held in each compartment for
about 2 min. The process is not interrupted by the processes of filling or
draining water, loading and unloading linen, heating or spinning, since the
CBTW runs continuously. CBTWs use water, additives and heat more
efficiently than washer extractors and can handle 7000-10 000 kg of linen
daily (Figure 1).

Hospital linen

Varying numbers of microorganisms, in particular, Gram-negative bacilli,

coagulase negative staphylococci and Bacillus species are present on linen
222 D. Barrie
f Prewash - Main wash Rinse e
1 2 3 4 5 6 7 8 9 10 11 12 PESS

Load 30°C 65% 75°C 80°C 82°C 80°C 75°C

Approximatelv i
Iii&d ” ’ I
water to Fresh softened
main wash water 7-10 1 kg-’

Recovered water

Approximately 2 filtered
f--+-h
I I
from press unit

water to pre-wash Centre recovery

tank with filter

Drain

Figure 1. Diagram of a continuous batch tunnel washer showing the water flow and the
temperature profile of the washing process.

before laundering. Greater numbers are found, although they are not
necessarily more pathogenic, on linen fouled with excreta. Dirty hospital
linen is therefore not usually an infection risk to laundry staff provided that
they wear protective aprons and gloves; however, linen contaminated with
secretions or excreta of patients with some gastrointestinal infections or
notifiable diseases is a potential infection risk to staff and is classified as
‘infected’ linen in the DoH guidance (Table 1).
Previous guidance from the DoH included the category of ‘foul and
infected’, which had to be handled as infected linen.’ This was discontinued
because hospital staff often failed to separate it from other used linen. In
some geriatric and psychiatric units up to 80% of linen was classified as foul
and required processing in designated washer extractors.‘s6 This volume of
foul/infected linen overloaded the area set aside for it. However, there is still
a difference of opinion as to whether or not foul linen should be grouped
with infected linen, and this is recognized within HC(87)30. From a
microbiological point of view bacteria are present in higher numbers on foul
than on used linen but do not present a greater infection risk to hospital and
laundry staff. Foul linen can be laundered in a CBTW which achieves
thermal disinfection. Nevertheless many laundry staff object to sorting
linen which is soiled with faeces or smells offensively of urine.
There are considerable differences between laundering linen for hospitals
and laundering linen for hotels and non-residential institutions. Measures
must be taken to protect staff from infection during the transport and
 Hospital linen and laundering services 223

Table I. Categories into which hospital linen should be sorted. (HC(87)30)’

Category Definition

Used linen Items soiled by use or fouled by excretions and secretions

Infected linen Linen from patients with, or suspected of suffering from,

enteric fever, and other salmonella infections, dysentry
(Shigella spp.), hepatitis A and B, and carriers, open
pulmonary tuberculosis, HIV infection, notifiable diseases
and other infections by hazard group 3 pathogens+*

Heat-labile linen Items made of synthetic material which cannot withstand

the temperatures used for the heat disinfection of other
categories.

*Hazard Group 3 pathogens: organisms that may cause severe human disease and present a serious
hazard to laboratory workers. They may present a risk of spread to the community but there is usually
effective prophylaxis or treatment available.*

laundering of infected linen, and all hospital linen must be disinfected

during laundering. The DoH guidance sets out the specific requirements
for the laundering of hospital linen (Table II).

Used linen
Over 90% of hospital linen falls in this category and amounts to about
30 000 items a week in a 600-bedded hospital. This requires a considerable
washing capacity for which many commercial and hospital laundries use a
continuous batch tunnel washer. The machine used must comply with DoH
guidance’ summarized in Table II.
A thermal disinfection cycle of all parts of the machine - including all
water collection tanks and transfer systems which do not normally reach
disinfection temperatures - is required at the beginning of each day, or if
the machine has been out of action for three or more hours.
It is worth considering the DoH requirement that CBTWs should be
emptied of linen at the end of the day, ‘to reduce contamination of the linen
by bacteria which have multiplied overnight’. It could be argued that
thermal disinfection at the start of each working day of the parts of the
machine which do not normally reach high temperatures and thermal
disinfection of linen during washing will eliminate vegetative bacteria.
However bacterial spores will survive, and though not the usual source of
infection, laundered linen has been incriminated in outbreaks of B. cereus
infection.2,3
Removal of bacterial spores appears to depend mostly on dilution during
rinsing after ‘lifting’ from linen during washing. In the author’s experience
contamination was not reduced when the practice of leaving linen in the
wash compartments overnight was changed to emptying the entire machine
224 D. Barrie

Table II. Summary of Department of Health guidance for handling and laundering hospital
linen’
Item Measures to be taken

Colour-coded containers Used linen-white or off-white. Infected linen-red or red and

for transport to laundry white. Heat-labile-white with orange stripe.

Requirements for infected Not be sorted after use. Double ‘bagging’ using an inner water
linen soluble bag or bag with a water soluble membrane. Not to be
sorted before laundering. Laundered in designated washer
extractor machines with vent pipes routed to atmosphere and
sealed drains and sumps.

Disinfection of linen Used and infected linen-thermally disinfected during

washing. Heat-labile-disinfected by chemical means, e.g.
using sodium hypochlorite in penultimate rinse, or by an
alternative chemical agreed by the local control of infection
committee.

Protection of laundry staff Waterproof aprons and gloves to be worn by staff when sorting
linen. Lesions on hands to be covered with waterproof
dressings. Handwashing and changing facilities to be provided.
Adequate training. Occupational health advice available.

Requirements for Thermal disinfection of rinse sections before production

continuous batch tunnel commences each working day and after machine has been out
washer of action for three hours or more. Thermal disinfection to be
under electronic or computer control. Linen to be removed
from all compartments at the end of each working day.

of linen and water, but it was eliminated after an increase in the water flow
to the CBTW. In the author’s opinion thermal disinfection is more
important than emptying the CBTW of linen overnight.

Infected linen
To reduce the risk of infection to hospital and laundry staff, infected linen is
placed directly into a bag which is either water soluble or has a water soluble
membrane. The bag is closed and placed in an outer red nylon or polyester
bag. At the laundry the outer bag is removed and both the closed inner bag
and the outer bag are transferred to a designated washer extractor. The bag
or water soluble membrane dissolves in the machine releasing the contents.
This procedure avoids direct contact of staff with the linen until it has been
thermally disinfected.
The temperatures of the wash process are the same as those for used
linen: i.e. the temperature and time must achieve thermal disinfection.
Wash extractors used for infected linen must meet other DoH
requirements. Vent pipes must be routed outside, and effluent from the
drain must be sealed from the machine to the manhole, which should
 Hospital linen and laundering services 225

preferably be situated outside the laundry. Any open sump or pit below the
machine drain valve must be covered to reduce bacterial spread by aerosol
when water is being removed from the machine. Temperature recording
and control equipment must be monitored and checked, with all gauges
being calibrated annually. Records must be maintained of all checks and
calibrations carried out.

Heat-labile linen
Items made of heat-labile synthetic materials cannot withstand the
temperatures used to process and heat disinfect other categories of linen.
They are normally laundered in washer extractors at a temperature of 4O”C,
and dried at 60°C. Calendering (a process of finishing by pressure) should
be avoided. Tumble drying and tunnel finishing systems are normally
employed.
The disinfection of heat-labile items is complicated by the fact that
thermal disinfection temperatures are not reached. Instead, chemical
methods can be employed. Chlorine bleach (sodium hypochlorite sufficient
to achieve a concentration of 150 ppm available chlorine) can be used in the
penultimate rinse. Hypochlorite bleach cannot be added earlier because it
will be used up by soiling matter, detergents and alkali used in the wash
process. It cannot be used for coloured items as it removes colour dyes from
fabric. It cannot be used at temperatures greater than 60°C as it will create
severe chemical damage to cotton fabrics or blended fabrics with a cotton
component. It must not be used for any textile with a fire retardant resin
finish. Other specific resin finishes can also be affected.

Destaining agents used in the laundering of hospital linen

Hydrogen peroxide or sodium hypochlorite can be used to remove stains

from linen. Hydrogen peroxide is effective at high temperatures, is added
during the wash stage and does not impair the flame retardancy finish of
linens but is more costly.
Sodium hypochlorite is added to the penultimate rinse at temperatures
below 60°C because above 60°C it is highly active and will cause very serious
chemical damage to cotton-based textiles. Laundry staff prefer hypochlorite
because it is cheaper and usually more effective as a destaining agent but it
has the disadvantage of destroying the flame retardance finish of cotton
fabric. Flame retardant finishes are normally organic phosphate resins
which coat cotton fibres and yarns and which, in the presence of heat (flame
field etc.), release an inert gas blanking off oxygen from the fibre and
therefore preventing combustion being supported. Some laundry staff
believe that the laundering process destroys the flame retardant finish after
between 10 and 200 washes and the effect of hypochlorite on flame
retardance is irrelevant. In fact, some laundries use it for all categories of
linen, others only for infected linen, for CBTWs or for heat-labile linen.
226 D. Barrie

Flame retardance can be reduced by the use of hard water together with
soap-based detergents, when fatty lime ‘soaps’ (scum) will be produced in
the wash process and deposited on the fabric. If the rinsing is inadequate the
deposit remains on the fabric, masking flame retardant finishes and
providing a fuel source to support flame spread. This will not normally
occur if wash processes are carried out with softened water or with non-soap
based detergents.

The laundry contract

Laundry contracts are usually awarded for a period of 3 to 7 years. The

contract is awarded by the Trust or Hospital Management Board on the
advice of an evaluation team. Members of the team should include the
Contracts or Supplies Manager, representatives of the finance and human
resource departments, Laundry or Support Services Manager, and the
Infection Control Doctor/medical microbiologist.
Invitation to tender
The invitation, conditions of tender, and the draft contract, are drawn up by
the local management team or Supplies Manager. The conditions of tender
require the tenderers to supply information about the company, its
partners/directors, the management structure, trading history, present
trading circumstances and audited accounts. It requests details of the
premises which the tenderer proposes to use, and the manufacturer, year of
manufacture and model type of the major items of laundering equipment.
The contract specification is drawn up by the local management team or
by the Laundry or Support Services Manager. It indicates the number of
articles to be laundered each week, the proportion which are classified as
infected, and the number of different types of articles. It requests an
assurance that the laundry is able to cope with variations in these numbers.
Quality assurance, quality control methods, the contractor’s health and
safety at work policy and ‘sharps’ injury procedures are also required. In
addition, independent quality evaluation or assessment carried out annually
are often specified. These are frequently carried out by the Fabric Care
Research Association, of which all health authorities are currently
members.
The tender documents are circulated to members of the evaluation team
for additions and modifications.
Submission to tender
The tender submissions received from contractors are sent to the evaluation
team. Each member has a brief to appraise the part of the submission for
which he or she has responsibility (Table III).

Laundry inspections

It takes at least a whole day to inspect and travel between the laundries
 Hospital linen and laundering services 227

Table III. Responsibilities of members of the evaluation team

Contracts or Supplies Manager Infection Control Doctor/medical microbiologist

Commercial aspects Handling procedure for different categories of linen
Terms and conditions of Laundering infected linen
contract
Commercial viability Thermal disinfection of linen
Quality control Thermal disinfection of continuous batch tunnel washer
Customer service Protection of staff from infection
Distribution Sharps policy
Operations

Finance representative Laundry or Support Services Manager

Cost of the contract Technical capability and on-site engineering support
How costs are calculated Work flows
Current expenditure Machinery, capacity, state of repair, maintenance programme
Comparison of costing of Quality control and assurance
rental and hospital-owned
linen (if appropriate)
Financial viability of the Cleaning procedures for equipment and buildings
supplier Company/laundry staff training policy and procedures

Human resources representative

Adequate staffing levels
Training of staff
Presence of good industrial
relations
Satisfactory disciplinary and
grievance procedures
Employment policy that
complies with statute
Provision of good rates of pay

which have submitted tenders. However, to see the laundering process in

operation from the reception of dirty linen to the dispatch of clean linen is
time well spent. The microbiologist, Contracts or Supplies Manager and
Laundry or Support Services Manager should take part, each person having
a different but complementary approach.

Reception
There must be enough space for all the loads received daily from several
hospitals and a system in place to segregate and launder infected linen in the
designated barrier washer extractors. Careful observation can often detect
fundamental problems in laundry procedures. For example, during one of
my visits it was obvious that the designated washer extractors were not
being used and senior laundry staff explained that ‘few bags of infected linen
come in because there isn’t much hepatitis about now’. More disturbing was
the added comment that staff had decided that linen should be considered
infected only if it looked infected during sorting!
228 D. Barrie

Sorting area
Used linen is sorted according to type (e.g. pillowcases, sheets, towels).
Staff handling used linen should be observed to wear appropriate protective
clothing (e.g. waterproof aprons and strong household gloves). At one
laundry, staff had been provided with thin plastic gloves which tore easily
and were quite useless. When CBTW machines are in operation, different
types of linen are weighed into bags. When they reach the required weight
they are transported, suspended from overhead tracks to the loading chute
and into the first pre-wash compartment. A bag is emptied into the machine
approximately every 2 min. In the interest of safety, the bags should not be
suspended or transported over the staff. Most overhead conveyor systems
normally operate with an overhead protection mesh over any working or
walkway area.

Laundering
To ensure a rapid turn round time there must be evidence of enough
machinery to process used and infected linen on the day it is received.
Designated washer extractors must be used for infected linen and there
must be sufficient capacity to process it. This will ensure minimum holding
time in the reception area and reduce overloading of machines to avoid
producing inferior work. The wash extractor designated for infected linen
must be checked to ensure that the vent pipe is routed outside, the drain
chamber or sump below the machine is efficiently sealed and that thermostat
and temperature recording devices are accurate, monitored and recalibrated
regularly.
The DoH’ stipulates that all compartments of the CBTW must be
emptied of linen at the end of each working day. It is worth ascertaining by
direct questioning that this advice is being followed. In some laundries,
linen is left in the wash compartments overnight to save time when work
begins the next day and this is not acceptable when a laundry (hospital or
commercial), is processing hospital work and is contracted to comply with
DoH guidance.
Bacteria contaminating in-use drums of additives could reach
considerable numbers if the drums are ‘topped-up’. Staff should be asked if
it is the laundry practice to discard empty drums and always use fresh ones.
Contaminants of any type can be reduced if drums are covered with suitable
lids or closures. This is in any event good practice and reduces waste and
spoilage.
The capacity of the CBTW depends on the load weight, number of
compartments, duration of the cycle, the number of machines and length of
working day. Thermal disinfection must be carried out at the beginning of
each working day and if the CBTW is out of action for three hours or more.

Tumble dryers
The capacity of the tumble dryers must match the laundering capacity for
 Hospital linen and laundering services 229

an effective work flow. The transfer of linen from the CBTW after water
extraction to a series of tumble driers is usually computer controlled as
different types of linen require different drying times.

Calendering
Processed linen should be inspected visually for stains as it is fed into the
calenders, and if necessary allocated for rewashing. The member of staff
responsible for this quality control must concentrate on this and not be
expected to carry out other duties at the same time.

Cleaning of premises
During tumble drying and other processing methods, considerable amounts
of lint are released and settle around and between equipment. This
produces a serious fire risk if not removed regularly. A build up of lint on
overhead beams and lamps at high levels indicates an ineffective cleaning
programme.

Adjudication
Each member of the evaluation team gives an assessment of the advantages
and disadvantages of each tender judged from his or her area of expertise.7
The importance of personnel arrangements are emphasized, and laundries
embarking on larger contracts should be assessed as to whether they can
recruit and train enough suitable staff in the area.

Interviews of tenderers
The contractor’s laundry manager and financial representative usually
attend for the interview. This is an opportunity for clarification of
conflicting or confusing points in the tender. Remedial actions which the
tenderer proposes to take are also investigated. Contingency arrangements
can be assessed. For example, what happens when the water supply dries
up, as occurred recently during a hot summer.

Awarding the contract

The team recommends which laundry should be awarded the contract and
submits the proposal to the Management Board for consideration.

Microbiological testing of laundered linen

It is essential that used and infected linen is thermally disinfected at the

temperatures/times recommended by the DoH. Higher temperatures than
those recommended are usually reached in most CBTWs and
washer extractors. It is most important that temperature recording
equipment is monitored and calibrated regularly. Therefore routine
microbiological sampling of laundered linen is not indicated. Periodic
sampling may be of value if contaminated linen is suspected of being the
230 D. Barrie

source of hospital-acquired infection, in particular outbreaks due to spore

bearing bacteria which survive thermal disinfection.
The most appropriate method of microbiological sampling of linen has
not been determined. Liquid extraction methods are complicated to
perform and involve destruction of the fabric to obtain test samples, but the
results are accurate. Impression plate methods are quickly and easily carried
out but are a less efficient sampling system.’ The methods were compared in
a recent study. 9 Samples of sterile fabric were inoculated with known
numbers of B. cereUSand pressed on culture plates, either while wet or after
drying; each sample was then liquid extracted and the bacteria counted.
Impression plates of dry linen detected 0.2% of the organisms recoverable
from the fabric, and 1.2% of wet linen, but the impression method was a
more practical method of sampling. B. cereUSwas used because it had been
the linen contaminant in an outbreak of postoperative meningitis.
There are no agreed standards for acceptable bacterial counts of
laundered linen. In this investigation the relevance of B. cereUS counts on
impressions of linen laundered in a suspect CBTW was judged by
comparison with those on linen processed by three other CBTWs. Greater
than 20 cfu B. cereus per impression plate on 36 of 57 items processed by the
suspect CBTW contrasted with O-5 cfu on 107 of 111 items processed by
the other CBTWs. Therefore < 5 B. cereUS cfu per impression plate was
considered to be an acceptable result.
A reduction of 90% in the number of bacteria on contract plates taken
from random items before and after laundering has been suggested as a
microbiological test of the laundering process.” This test is not sufficiently
exacting since vegetative bacteria can be eliminated at lower temperatures
than the DoH requirements. An alternative method, the reduction of
Streptococcus faecalis in sealed tubing,” measures the effect of temperature
but does not take into account removal of bacteria by dilution.
Some laundry contracts specify that at 6-monthly intervals linen
impression plates should be taken after laundering by CBTW and washer
extractors or if there is reason to believe that linen is contaminated. The
difficulty of interpreting the results remains. A practical approach would be
that the isolation of vegetative bacteria should lead to immediate checks that
thermal disinfection requirements are being adhered to and the isolation of
B. ceretis might indicate low water to linen ratios.

Rental of linen for hospital use

A contract for hospital laundry services can be provided for laundering

linen owned by the hospital or for laundering items used by the hospital but
rented from the laundry. The usual reason for considering a rental system is
that a hospital has an insufficient supply of linen in circulation due to
inadequate replacement of old and worn items. An advantage of a rental
system is the superior quality of the linen provided, good stock control, and
 Hospital linen and laundering services 231

the guarantee of agreed levels of linen at ward level each day. The cost of
renting is 1520% higher than the cost of laundering hospital-owned linen.
This must be balanced against the cost of replacing old, torn, or stained
items, which amounts to approximately &2000 a month for an average
district general hospital. A ward delivery service can be a part of a rental
contract. This is favoured by nursing staff since the laundry is responsible
for stocks at ward level, better quality linen is usually provided, the supply
appears to be more reliable, and savings may be made on linen room and
delivery staff.
Before submitting a tender, the contractor is invited to discuss the
requirements of each ward with the Ward Sister/Charge Nurse. Nursing
staff and laundry can agree on the different requirements of particular
wards; for example, surgical wards with a high turnover of patients need a
plentiful supply of bed linen, whereas care of the elderly wards may require
laundering of patients’ personal clothing.

Fabrics for operating theatre wear

Air borne bacteria on skin particles dispersed from personnel in theatrer2 are
a source of wound contamination’3 and sepsis during surgery.14 Surgeons,
surgical assistants and scrubbed nurses wear sterile gowns to protect the
operation site. However, cotton, the traditional fabric used for theatre
clothing does not prevent the passage of skin scales as the diameter of the
pores of the material is usually greater than 80 urn.” Ventile, a closely
woven cotton, is more effective in this respect but it is uncomfortable, more
expensive and little used now.

Re-usable fabrics
Cotton/polyester mixtures are now the most commonly used fabric for
scrub suits, gowns and drapes but do not present a barrier to airborne
particles, and, like cotton, do not protect the wearer from the blood and
body fluids of patients. ‘Barrier’ fabrics are less permeable to airborne
particles and provide some protection against blood and body fluids. Barrier
is a general descriptive term used by manufacturers, but there are no agreed
British or European bacterial barrier tests for fabrics. Many are made of
tightly woven microfilament polyester with a special finish. They are more
expensive: e.g. a surgeon’s gown is two to five times the cost of a cotton one.
Laminated polyester (the laminate is the middle of three layers), is the most
impervious material available for gowns and drapes. Air and bacteria cannot
pass through the plastic laminate, and there is no ‘strike through’ of blood.
Thus patient and staff are protected. Gowns made entirely of laminated
fabric are uncomfortably hot; consequently the fabric is used for the front or
a front panel, for all or the lower half of the sleeves, and polyester or a
‘barrier’ fabric is usually used for the rest of the garment. These fabrics are
summarized in Table IV.
232 D. Barrie

Table IV. Properties of ye-usable fabrics available for operating theatres

Cotton Barrier type fabrics Laminated polyester

Withstands laundering at 73°C Yes Yes Yes

Withstands autoclaving Yes Yes Yes
Permeability to bacteria High Moderate/low Very low
Permeability to fluids High Moderate/low Very low
Linting High/ Low Low
moderate
cost Low Moderate/high* High*
Comfort High High Low?
Draping quality Good Good Moderate

*Barrier fabrics are more expensive than cotton or cotton/polyester mixtures. Surgeons’ gowns, for
instance, are between two and almost five times dearer than cotton. Laminated gowns are approximately
five times the cost of cotton.
t As laminated fabric does not ‘breathe’ it is used for the front and sleeves of gowns and polyester/cotton
or barrier material used for the rest of the garment.

Single-use fabrics
Non-woven single-use gowns and drapes are available for theatres and are
used in some hospitals. There is no risk from contamination from previous
use. Those laminated with a plastic layer are impervious to blood and body
fluids. It is worth noting in the present climate of cost consciousness that
single-use items are more expensive than re-usable items, but savings are
made on laundry costs, linen repairs and replenishing linen stocks.

Theatre gowns for surgery

Impermeable gowns
The increasing incidence of HIV and other blood-borne viral infections has
caused theatre staff to consider the infection risks from blood and body
fluids when ‘strike through’ occurs. Although the risk of acquiring HIV
infection through blood contamination of intact skin is considered to be
negligible,i6 surgeons increasingly expect that impermeable gowns will be
available when there is a definite risk of blood or body fluids reaching their
skin. Guidelines for surgeons and health care workers on the prevention of
HIV and hepatatis suggest that gowns impermeable to fluid should be worn
for surgery associated with a high risk of blood contamination.i6-‘s High risk
operations include major abdominal surgery, gynaecological and
cardiovascular operations, brthopaedic surgery especially involving the use
of power tools, obstetric procedures and trauma and burns.
Advice from one source recommends that if impermeable gowns are not
available, a plastic disposable apron should be worn beneath the gown.”
Not all surgeons will agree to use plastic aprons under their gowns, which
 Hospital linen and laundering services 233

are uncomfortable and do not cover the arms, the most likely areas of the
body to be exposed to blood and to have damaged skin.”
The spectrum of surgical operations ranges from complex cases
associated with substantial blood loss to minor procedures with minimal or
no blood loss. Between these extremes is a wide range of surgical
procedures. It is virtually impossible to be absolutely certain before each
operation begins and gowns are being donned, that some unforeseen
complication will not develop which will result in exposure of staff to blood.
It is then too late to change into a different gown. The most practical and
safest, albeit expensive, policy is to provide impervious gowns routinely for
all but the most minor operations.

Laundering of theatre linen

Linen from patients with hepatitis B infection from carriers of hepatitis B
and from patients with HIV virus, or linen potentially contaminated with
blood borne viruses should be classed as ‘infected’.‘,‘7,20 In some hospitals,
all theatre linen is bagged as ‘infected’ on the grounds that a high proportion
will be blood-stained and not all patients with blood-borne viruses are
identified, and also because it is disagreeable and time consuming for the
theatre staff to separate it from other linen.
With this arrangement there are practical advantages for laundry staff.
Hazardous extraneous items are inadvertently but frequently enclosed with
theatre linen. 2’ Every laundry manager can produce a collection of surgical
instruments which have arrived in this way! Although some are discovered
when the linen is sorted into different categories before it is put through the
CBTW, others escape detection. Forceps may be caught in the internal
perforations of the CBTW and towel clips can puncture the membrane of
the hydraulic press. If, however, theatre linen is classified as ‘infected’ it will
be laundered in washer extractors which may not be damaged to the same
extent. However, such instruments can and do cause severe damage to linen
items being processed, whether in a CBTW or a washer extractor.
Tissues left in the pockets of scrub suits cause problems because they
disintegrate into countless fragments during laundering. In a CBTW these
are deposited on many other articles in the same compartment and are
carried by the water to other compartments. Those who have experienced a
similar situation in the domestic setting will know how tedious it is to
remove them.

Prevention of infection in laundry staff

DoH guidance includes measures to prevent infection in hospital and
laundry staff handling and processing dirty linen’ (Table II). Active
immunization against hepatitis B is recommended for staff who are at risk of
injury from blood-stained sharp instruments or contamination of skin
lesions by blood or blood-stained body fluids.22,23 Laundry staff are
234 D. Barrie

regularly sent a variety of surgical instruments, used syringes with needles

attached, placentae and blood-stained dressings.*l The incidence of injury
may be less than among other health care workers24 but they should be
vaccinated as they are at risk. 25Staff working in laundries based in hospitals
are generally looked after by the hospital occupational health department
and offered a course of the vaccine. Staff in other laundries should also be
protected.
An important objective of the infection control team should be teaching
staff what problems the thoughtless and careless of disposal of sharp and
blood-stained items can cause to others.

I should like to thank the DoH Medical Devices Directorate for information on the
properties of re-usable fabrics, Mr N. Gill, Technical Consultant, Fabric Care Research
Association for helpful discussions about various aspects of laundering equipment and
processes, and details about de-staining agents and Mrs P. Wilson for secretarial assistance.

This is an invited article in the series that provides guidelines on infection control practice.

References
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 Hospital linen and laundering services 235

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