Clean and fit for the purpose

Hospitals in the UK face much tighter hygiene regulations under new health legislation currently before parliament. The proposals will bind hospitals, care homes and other national health services to a new hygiene code of conduct.

As well as setting standards for things such as hand washing and cleaning wards, the code seeks to establish a policy for the provision of laundry services, and for the provision of linen, including laundering nurses’ uniforms.

Jane Kennedy, the Minister of State for Delivery and Quality at the Department of Health, with responsibility for clinical quality, patient safety and clinical negligence, launched the legislative proposals last July for “Action on Health Care Associated Infections (HCAIs) In England”, to form part of the Health Improvement and Protection Bill.

The four key components of the HCAI legislation are:

a new code of practice

a new duty on NHS bodies providing healthcare to follow the code with a parallel duty on the Healthcare Commission (HC) to assess compliance with it

a new discretionary power available to the HC to issue an improvement notice

sanctions, which may be taken against those who, in the view of the Secretary Of State or Monitor, continue to breach the code.

Legislation will also cover private hospitals and care homes.

The draft policy on staff uniforms states: “Policies on provision of linen should be in line with national guidelines. These policies should include staff uniforms which should be clean, fit for the purpose and project a professional image”. It also states: “Policies on provision of laundry services should be in line with national guidelines”.

This is in line with a strong body of opinion within the industry that while professional laundering on its own might not solve HCAIs, it could be part of the solution.

Yet, frustratingly for the healthcare laundry lobby, there is still no revised official linen standard at present. The long-awaited standard failed to materialise last year because of the General Election. As a further complication, came the demise of the NHS Estates as part of a Department of Health reorganisation in September.

The Department of Health currently says laundering procedures should be carried out in accordance with Health Service Guidelines HSG (95)18 Hospital laundry Arrangements for used and infected Linen.

Phil Liversidge, president of the Society of Hospital Linen Services and Laundry Managers expresses disappointment that the proposed guidance still refers to guidelines issued 11 years ago. “We need to know how effective the current service guidelines HSG(95)18 on handling fouled and infected linen, still are,” he says. He points to the experiences of other European countries – Germany, for example, has been looking at wash temperatures as high as 90C.

He points out that the lack of any decision has “left the industry in a state of flux”.

HSG(95)18 sets a standard for decontamination of three minutes at 71C and 10 minutes at 65C, and Liversidge still firmly favours thermal disinfection rather than chemical as the thermal method does not allow mutation.

The HSG(95) 18 is being reviewed at the present time, he added and said that more investigation is needed into the temperature, hospital acquired infections, and into other developments that have occurred since the 1995 guidelines were published such as the antimicrobial fabrics and processes such as ozone injection.

all Antimicrobial fabrics are a recent development, but there is no guidance as to their effectiveness.

Murray Simpson at the Textile Services Association (TSA) welcomes the new proposals, as the Code of Practice represents a national policy on uniforms for the first time. TSA members process some 50% of the NHS laundry/linen service requirements.

The TSA’s hygiene review group is consulting with the Department of Health on the national guidelines for laundry and linen services, and infection control.

“We have again stressed the need for an urgent review of the national guidelines for laundry and linen services, particularly HSG(95)18 on arrangements for the processing of foul and infected linen. These guidelines do not follow best practice in terms of risk assessment nor do they recognise developments in equipment and detergent technology.”

He says a guiding principle for the revision of the Guidelines should be the European Standard EN14065 Risk Assessment/Biocontamination Control (RABC). “We understand that the National Patient Safety Agency has assumed policy responsibility for the revision of these guidelines which we welcome.”

On staff uniforms, Simpson says that this presents a particular problem for infection control that is not properly addressed.

In the UK most uniforms are currently laundered at home by staff. “This practice, almost unknown in the rest of Europe, presents the opportunity for cross infection since there is no guarantee that the uniforms have achieved thermal disinfection in the washing cycle, nor is there any control over re-infection, a particularly important point since most staff travel to work in their uniform,” says Simpson.

The TSA wants the new Code of Practice to forbid staff to launder uniforms at home and to require NHS trusts to make appropriate arrangements with either a hospital laundry or a commercial textile rental supplier which can provide uniforms that have been laundered and delivered by a validated process. Uniform selection, its fitness for purpose and laundering arrangements must be given greater attention from an infection control standpoint.

“The food industry requires this level of assurance to ensure no cross contamination in food preparation factories,” says Simpson. “Trusts should wish no less reassurance about staff uniforms being used in a healthcare environment.”

As part of the “Wipe it Out” campaign against MRSA, the Royal College of Nursing states in its “Guidance on uniforms and clothing worn in the delivery of patient care” that hospital laundries are much more effective than a home washing machine as they use thermal disinfection to remove pathogens and reliably reduce the “bio-burden” (number of organisms) to a safe limit.

The college has stated in the past that it would be in favour of uniforms being washed by, or under the control of, the NHS as long as the service is robust enough to ensure to maintain turnaround and cope with breakdowns.

The document also says that risk assessment within any health care setting “must consider clothing as a potential route for cross infection”. It offers the following minimum safety standards as guidance for risk management:

written guidelines for uniform laundering must be agreed and approved by the infection control team or director of infection prevention and control (DIPC)

the provision of sufficient uniforms to allow freshly laundered clothing for each shift or work session

fabric must be capable of withstanding water temperatures of at least 65C

access to spare clothing if staff clothing becomes contaminated;

access to a laundry disinfection service for visibly/excessively contaminated uniforms or agreement about safe alternative arrangement

and if routine laundering facilities are not available, the health authority must advise staff what it considers to be appropriate.

Dynamic sector

With a market that includes hospitals, medical centres and dentists, outpatient surgical, acute care facilities, clinics, nursing homes, assisted-living facilities and home care, the healthcare sector is a fast growing segment and one that, potentially, will benefit greatly from services provided by the textile rental industry.

As hospitals are pressured to cut costs, more and more hospital and healthcare administrators may weigh up the cost of outsourcing their linen and laundry services to textile rental companies against the cost-effectiveness of operating an on-premise laundry (OPLs).

However, the UK picture is not quite so straightforward. The contentious issue of HCAIs overshadows the whole sector, at a time when NHS funding, its future re-organisation and the quality of service it will provide, is being widely debated.

Traditionally, there is no centralised purchasing policy in the NHS, nor a national policy on uniforms and no checks on purchases. Trusts are taking their own initiatives in purchasing garments, particularly new style uniforms that clearly identify the role of staff.

According to Nikki Griffiths, marketing executive at leading workwear supplier Alexandra, some NHS Trusts and private medical customers choose to operate an in-house laundry and buy garments directly from the supplier. Others prefer a fully managed rental service where garments are supplied and laundered by a third party. “Alexandra is well placed with the appropriate products, account management and flexible service to meet the needs of all healthcare customers, whether directly or indirectly via a textile rental company,” says Griffiths.

The catalogue range offers healthcare customers a tried and tested choice of uniforms immediately available from stock.

Many of the styles have been developed with industrial laundry processes in mind, ensuring appropriate fabrics and fastenings are selected.

“All products suitable for industrial laundry are shown with an “industrially launderable” flag,” says Griffiths. “The design and development team works closely with the industry to ensure new technology is incorporated into product ranges.”

Alexandra’s bespoke design service offers an NHS Trust or private medical company the opportunity to introduce garments designed to their own specification.

Customers who want their own look and promote their own identity, adds Griffiths, increasingly request this service. Alternatively, customers can adapt one of the proven catalogue styles by changing style features or trim colours for a quick, cost effective way of giving uniforms a company identity. Continuous and fast development services are offered to all bespoke customers.

The Bioguard range of garments has been designed to give long-lasting antimicrobial protection using technologically advanced fabric. Bioguard incorporates an antimicrobial finish called Sanitized that actively fights bacteria and fungi that are a significant cause of cross-infection and contamination. The treated fabric is suitable for industrial laundering and can withstand washes at over 70C and tunnel drying process at over 150C.

Like Alexandra, Boyd Cooper is a PaSA (Purchasing and Supply Agency) NHS national contract holder. Christopher Cocks, NHS sales and marketing manager for Boyd Cooper, acknowledges that the whole issue of thermal disinfection is very topical at the moment. “All our garments exceed the present NHS guidelines on uniform care,” he says. A lot of new fabrics are emerging, particularly antimicrobial. However, uptake is slow.

“There is a downward pressure on price in the NHS,” says Cocks. “It is phenomenally price-driven. Trusts will look at cost alone.”

The company does lot of work with the NHS and with teaching hospitals and universities in the UK. Last year marked the 225th anniversary of Boyd Cooper and its acquisition by the Johnson Service Group, now the largest supplier of workwear and corporatewear in the UK. Johnson also owns CCM, one of Europe’s leading manufacturers of work apparel, currently supplying over 3million garments a year, and another supplier to the NHS.

Boyd Cooper’s manufacturing is based in Lithuania but takes place, all under supervision of Boyd Cooper staff, and the company’s core trade is nurses’ uniforms and textiles. It can offer healthcare customers its Unipack service where each uniform is individually packed and labelled with the correct staff name.

Cocks says the company typically deals with Trusts. Some have now merged into joint organisations in order to deal with suppliers as a single purchaser.

The demise of the Initial Workwear group is an indication of the way the market has gone, says Cocks. He says that his company does not see antimicrobials attracting huge sales, not because the demand isn’t there, but because a purchasing manager will order ordinary uniforms rather than treated garments purely on grounds of cost.

He says there is a strong case to show that by purchasing antimicrobial fabrics Trusts can make savings over time in terms of use and care. However, these savings won’t show up in the uniform budget, so if a microbial item is £2 dearer than the non-treated, the purchasing manager will have little option within the constraints of their budget.

Antimicrobial fabrics have been available in the Boyd Cooper range since 2003, but take-up in the NHS is slow, says Cocks. “However that is not to say that just because the NHS doesn’t want it at this particular time that we as a company should ignore it. We supply garments in standard as well as antimicrobial fabrics, and are also conducting trials of newer developments such as the use of silver to provide self-sterilising fabrics.”

As far as future changes in NHS purchasing policy are concerned, Cocks says the tie-up with Johnson will be of mutual benefit.

The company is in a good position if NHS continues to purchase and launder its own garments, as it has an established reputation as a preferred supplier. but if the NHS opts for rental, then the close links with Johnson, with its experience in the garment rental sector, also puts it in good position.

At Carringtons Workwear, which deals mainly with the laundries and their manufacturing companies, Graham McEneaney says that while there is always strong demand for garments that would stand up to the rigours of commercial laundering, they must be affordable.

“The market generally is very tight, mainly due to the NHS’s financial state.” So it is sticking to its current garments.” Few, if any of the new antimicrobial garments are breaking through into the NHS because of insufficient funding.

“There seems to be a feeling that the future may well be relying on Industrial laundry – washing at high temperatures which will sterilise the garments.

“But this leaves the garment vulnerable when it is being worn on the ward unless it has an antimicrobial finish.”

The company has successfully sold its Permagard antimicrobial fabric to NHS trusts in Ipswich and Airedale, and to the London Ambulance.

The Permagard treatment is said to keep the uniform fabric hygienically clean during use, protecting the wearer and patient.

Permagard can be laundered at sterilisation temperatures with proven durability to over 100 wash cycles and the bleaching of white goods enhances its antimicrobial performance.