Publicity surrounding the Textile Services Association’s report on nurses’ uniforms was succinct.
Allowing uniforms to be washed at home and worn to and from work is a risk to public health.
The practice is nearly universal in UK NHS trusts but this is well behind the hygiene standards in the UK food industry. “A dog-food factory is safer than the health service in this respect.”
TSA published investigative journalist Phil Cain’s report at the end of June. It puts such “soundbites” in context but the message is the same. The UK is out of step with practices in most European countries and the Department of Health must stop ignoring the risks of home washing and review its rules.
TSA CEO Murray Simpson says the UK’s current practice is “essentially playing a game of Russian Roulette with infection control.
Cain’s research is far ranging and includes interviews with laundries serving the UK food industry and with those serving the healthcare sector here and in mainland Europe, the views of industry associations and reviews of past research.
Thomas Krautschneider, chairman of the board of Austrian textile rental firm Salesainer Miettex explains that nurses in Austria are not allowed to leave the hospital in uniform. He argues that if there are rules governing the washing of healthcare bed linen, then it makes sense to apply the same rules to clothes worn by people in daily contact with patients. Home washing is a rough and ready process but professional laundering is precise, with much less chance of chemical residues in the clothes.
Cain has also interviewed Robert Long, secretary general of the European Textile Services Association, who says that the UK stands apart from most of the rest of the EU. “Does this mean everyone else in Europe has got it wrong? In Germany people are absolutely horrified when they hear that nurses in the UK are allowed to wear uniforms on public transport.”
Cain’s research finds that in Germany strict hygiene in cleaning uniforms is seen as an essential preventative measure, a lack of hard evidence on the link between uniforms and infection is irrelevant.
While the UK healthcare sector still allows home washing, other industry sectors have already considered the risks and imposed stringent hygiene rules.
Simon Fry, managing director of Fenland Laundries, says that following several problems with food contamination in the 1980s the food industry cleaned up its act by adopting an approach known as Hazard Analysis at Critical Control Points. HACCP flowcharts the whole production process and assesses the risks of contaminating the product throughout the process and then puts controls and monitoring systems in place at critical points to minimise risks.
“Nobody has conclusively proved that wearing a garment, which has been used in the area processing raw meat, in the cooked food area has caused contamination but it is recognised that there is a reasonable risk that it could,“ says Fry. So a factory processing both types would devise a system to bar garments from a raw food area being worn in the cooked meats’ section.
While Department of Health guidance on healthcare uniforms has remained unchanged, there have been several relevant studies.
The Watt report, which followed salmonella outbreak in a Glasgow hospital (2001), concluded that the risk of a similar occurrence would be reduced if the NHS took responsibility for the laundering of staff uniforms, stopped allowing potentially contaminated uniforms to be worn outside and provided adequate changing rooms and decontamination services.
The report also considers some research that has been less conclusive. In dismissing the potential risks of home washing, the Department of Health (DH) has relied on two studies, one by Thames Valley University (TVU) and the other by University College London Hospitals (UCLH). The DH 2007 guidance to local Trusts said there was no hard evidence either of a link between uniforms or work clothes and infection or that domestic washing was less effective than commercial laundering in removing micro-organisms.
It also dismissed the case for applying the same hygiene rules to both uniforms and other hospital textiles as nurses’ uniforms “were not in intimate contact with the patient, unlike bed linen or patient gowns”. Last year DH re-issued this guidance. Cain gives TSA’s reply to such arguments. Technical advisor Mike Palin says that the lack of hard evidence does not justify
a lack of action.
He also points out that ethical constraints prevent experiments that would deliberately infect people and this has been one of the reasons why direct studies have been ruled out. Indirect studies draw conclusions but cannot form the basis for statistical analysis.
The next question is “where does the TSA take its case from here?”
There have been some positive moves within the NHS. Since 2010 Belfast Health and Social Care Trust has been outsourcing uniform launderering for key departments in four of its eight hospitals. These trials involve around 350 staff.
Lilliput laundry has provided a daily delivery of uniforms to staff in A&E, burns and critical care units.
The uniforms are modified scrub suits. They are sorted by size and tracked by RFID. Using a pooled system has reduced the investment needed. Staff do not get personal garments back each time but it still avoids any risks associated with washing uniforms at home. A changing room has been provided.
TSA has also adapted its approach, partly in recognition that in a period of Government spending cuts, an immediate switch to a policy similar to those in mainland Europe is not practical. Trusts would have to bear not only the cost of the laundry service itself but also in many cases the substantial cost of installing suitable changing rooms.
So TSA has two main aims.
Government guidelines should recognise that using a professional service to clean uniforms and prohibiting staff from wearing uniforms outside the hospital should be the eventual goal for all NHS Trusts.
To start the process, TSA wants to extend the offer of accelerated trials with NHS Trusts to support research into garment hygiene. This should be viewed as an investment in protecting, the NHS, its staff and the general public.
TSA’s Murray Simpson says that members are prepared to put a fully managed uniform service in place in Trusts on a trial basis to show what the service can achieve.
He rejects the idea that changing room provision is an unsolvable problem. If the authorities feel that cost of providing changing rooms is the real reason for refusing change, they should say so and stop insisting that home washing is safe. TSA’s textile rental members could find a solution to the changing room problem if asked to do so.
Simpson reports that the campaign has had a good response so far. Cain’s report was sent to members, consumer journalists and the healthcare press. This produced some serious articles, notably in the healthcare press.
TSA also wrote directly to 350 chief executives of NHS Trusts and sent a copy to the House of Commons’ Health Select Committee. Simpson and TSA representatives will be meeting the committee chair, Stephen Dorrell.