The Society of Hospital Linen Service and Laundry Managers (SHLSLM) has published its long-awaited linen standards for the healthcare sector.

Introducing the Best Practice Guide for Linen Services at the society’s annual conference in Blackpool, Lancashire, on April 24, Ian Hargreaves said the society wants to establish minimum standards for the purchase, processing and storage of linen used within the NHS and healthcare sector.

The guide is aimed at three distinct groups – those based at ward and department level; those employed within a laundry by a linen services provider; and those responsible for monitoring and agreeing service provision.

The guide will provide a basis for developing specifications for a contract or service level agreement and a standard against which services can be benchmarked. It will be part of an ongoing performance management process and provide a framework for auditing.

Hargreaves acknowledged that the guide “had been a long time arriving”. Discussions started in 2003, but the Department of Health had only agreed that the Society could progress these last year.

The best practice principles are underpinned by six factors that provide a context within which to ensure that linen services are appropriately resourced and deployed. They are:

• a focus on patient and customer needs;

• clarity for staff responsible for linen service standards;

• compatibility with linen services quality assurance systems;

• consistency with infection control standards and requirements;

• setting clear outcome statements, which can be used as benchmarks and output indicators; and

• monitoring to ensure compliance.

The guide highlights three areas for improving the provision of linen services – the design of the end product; linen stocks and usage; and the elimination of sources of cross-infection or re-infection within the linen processing and storage areas.

Hargreaves said that linen services providers must ask whether changes could be made to the size, weight or colour, or to the delivery pattern of a specific item, and whether the item is still required.

Is a hospital-based linen room still required, or could deliveries be made directly to wards? Is there a bed change policy, and are all purchases of linen co-ordinated? Is protective clothing worn at all times by sorting staff or outside the working environment?

The linen services provider should have a formal quality control system such as ISO 9001 and/or EN 14065 Laundry Processed Textiles: Bio-Contamination Standards, or an acceptable alternative. Its best practice principles should be incorporated into existing quality systems and cover the following:

• infection control procedures;

• transport and distribution procedures;

• delivery schedules;

• delivery quantities;

• collection procedures;

• textile specifications;

• wash quality;

• finish quality; and

• presentation quality.

Minimum standards and procedures for the handling and disinfection of linen are set out in HSG (95)18. Infection control committees should be aware of these practices and be able to endorse or upgrade them before implementation. Handling and packaging methods must be designed to prevent re-infection.

These best practice guidelines provide a framework within which to make comparisons that will help benchmarking and peer review programmes.

The guide sets out allowable percentages for specific attributes in laundered linen, including levels of whiteness (reflectance); levels of staining; levels of repair; and quality of finish. These are set out as minimum and target values and the figures should be used to form an action plan to improve on the results.

With regard to infection control, the guide says that all linen must be laundered in accordance with the latest guidance and legislation, including HSG (95)18, to ensure that all linen is clean, disinfected and fit for purpose. Trusts should provide the appropriate uniforms, protective clothing, changing and storage facilities.

If trusts do not provide a laundering service for uniforms, or where staff choose not to use such services, there should be a clear policy on the laundering of uniforms at home that is approved by the local infection control committee and/or the director of infection prevention and control. This should cover the wearing of uniforms outside the workplace; the correct method of transporting soiled and clean uniforms to and from the home; and the correct procedures to be used in home laundering.

Dr Elizabeth Jones, head of patient environment for the Department of Health also heads the uniform working party. Speaking on the “Need for standards within the NHS”, she told delegates how the service is responding to the challenge of improving the healthcare environment. She explained that the standards for better health had two prinicipal objectives.

There should be a common set of requirements that applies across all healthcare organisations to ensure that the health services provided are both safe and of an acceptable quality. There should also be a framework for continuous improvement in the overall quality of care people receive, so that NHS resources are used to help raise the level of performance measurably year-on-year.

Her words come at a time when the Healthcare Commission has launched (on 24 April 2008) a thorough inspection of NHS acute trusts to determine whether they are meeting standards on infection control. It will inspect all 172 acute trusts annually as part of a drive to reduce death and illness from healthcare-associated infections (HCAIs), and has called on trusts to ensure that they have the necessary systems in place to minimise the risk to patients of catching a HCAI such as MRSA or Clostridium difficile.

In particular, trusts will need to check they are meeting the 11 mandatory duties outlined in the government’s hygiene code, which came into force as part of The Health Act 2006. The code pays particular attention to cleanliness, isolation facilities and management systems. The hygiene code applies across all of the NHS.

The code’s 11 mandatory duties, include a duty “to provide and maintain a clean and appropriate environment for healthcare”. As part of the criteria for assessing core standards for primary care trusts (PCT), the code says that “with a view to minimising the risk of HCAI… trusts must make sure that the supply and provision of linen and laundry supplies reflects Health Service Guidance HSG (95)18, Hospital Laundry Arrangements for Used and Infected Linen. In addition, the trust must make sure that clothing worn by staff when carrying out their duties (including uniforms) is clean and fit for purpose.

Jones said that to make the Best Practice Guide a reality, high level standards need to be enforced locally. “The expertise is out there so now it is up to you to make these standards work,” she concluded.

Ken Holmes, who was chairman of the healthcare laundry group until leaving the Department of Health, explained how the HSG (95)18 guidelines are being rewritten as part of a much greater revision of health service standards.

Holmes explained that HTM01-04 were a series of documents that looked at decontamination procedures across NHS services, and laundry processing forms part of the National Decontamination Programme. Originally launched in by the NHS in England, the National Decontamination Programme has increasingly addressed broader issues of infection control in healthcare premises.

Prevention of infection and control needs to be embedded into everyday practice, and this includes the provision of linen services. Effective prevention and control places greater emphasis upon high standards of hygiene and cleanliness, and on ensuring that the handling, transport and disposal of waste is properly managed.

In reviewing HSG (95)18 it was found that certain key components were missing – there was no reference to standards, for example.

A working group was set up in January 2007, and a first report made in December. The research stage is now complete and a full report is expected this summer (2008).

The document will cover management – policy, regulation, roles and responsibility, including biocontamination control systems; environment and system design; and equipment and validation.

Likely changes would include use of batch process machines (tunnel washers) for infected linen; the extension of venting and safety arrangements to tunnel washers used for processing infected linen; minimum instrumentation requirements; and a disinfection process validation regime.

Discussing how a good practice guide can save pounds, David Peat, chief executive of East Lancashire Primary Care Trust talked about the operating framework for the NHS in England 2008/09. This principally revolves around Lord Darzi’s interim report on NHS reform, which contains a set of guiding principles for a fair, effective, personal, safe and locally accountable NHS.

PCTs will be expected to deliver local priorities alongside new public service agreements (for example, reduction in HCAIs). NHS chief executive David Nicholson’s call for trusts to “look out, not up” was intended to ensure they put patient care first and listen to ward managers’ advice on the resources they need to provide that care. There are five key areas for attention. These are:

• improving cleanliness and reducing HCAIs;

• improving access (the 18-week referral to treatment pledge) and improving access (including at evenings and weekends) to GP services;

• keeping adults and children well;

• improving patient experience; and

• preparing to respond in a state of emergency.

An increasingly diverse range of suppliers means the procurement and contract management systems must be of a very high standard.

He said the challenge being posed nationally is for PCTs to become “world class commissioners”, to enhance wellbeing, healthcare and value for money, and use the world-class commissioning programme to build PCT capability.

Rosie Bricas, of the Health and Safety Executive discussed health and safety issues of processing linen from healthcare establishments. This was particularly timely, considering her department’s “Shattered Lives” national safety campaign. She said there was an obligation on establishments handling linen to ensure that staff were safe. She pointed out that the TSA had published “extensive guidelines” on the safe use of laundry machinery.

In his presentation on “Beds, bugs and burns…a holistic approach to textiles in the healthcare sector”, Brian Wilkinson of Linen Connect spoke about the Armourtex range of products. These use a Japanese-developed range of fibres that have proven antimicrobial and flame retardancy features. He stressed that the fibres were not chemically treated, but that the properties are inherent in the fibre.

Paul Roberts, a risk management advisor for the Department of Health, asked, “Are your curtains safe?”. He described two incidents in 2005 in which a supposedly fire-resistant cotton curtain/bed screen was set alight by an in-patient in a mental health ward. The fires prompted an alert by the Department of Health in 2007.

Tests by Scottish Healthcare Supplies found the screen could be set alight with a cigarette lighter relatively easily. The curtains were made by Gatoc, which is no longer trading. The cotton material had been treated with the fire-resistant chemical Pyrovatex. Both incidents involved material from the same batch, manufactured in 2000.

The Department alert recommended that all areas where curtains/bed screens are in use should be included as part of the fire risk assessment undertaken in compliance with the Regulatory Reform (Fire Safety) Order 2005.

Roberts said that in areas considered to be higher risk, such as mental health wards or emergency departments, the replacement of all cotton curtains (regardless of manufacturer) with polyester, should be considered. Polyester is an inherently flame retardant material that melts away from the flame, allowing it to pass the BS 5867-21 flammability test without the need for fire-resistance treatment.

Polyester can be ignited eventually, producing hot molten droplets. This should be taken into account as part of the fire risk assessment when choosing curtain materials.