Uniform concerns30 April 2018
The results of a study by a team at De Montfort University has called into question the efficacy of home laundering of nurses uniforms. It is a problem that is ‘bugging’ healthcare decontamination experts, as Kathy Bowry reports
The Government made a decision in 2010 to allow nurses to wash their uniforms at home in order to offer tax breaks to financially strapped staff (and let’s be cynical, free up laundry and changing room space for an injection of cash into equally challenged Trust coffers from renting to Costa et al). However, there have been worries that this scheme, well- intentioned though it may have been, is not delivering on hygiene and infection control.
Dr Katie Laird, heading a team from De Montfort University undertook two studies making up two scientifically peer-reviewed Journal articles, and a review piece for Nursing Times. that highlight a number of factors that need consideration when assessing the safety of domestic laundering of nurses uniforms.
The study involved an initial survey in 2015 of three NHS hospital Trusts in England and Wales to investigate how effective home washing is at destroying dangerous bacteria followed in 2017 by practical experiments mimicking in a laboratory setting nurses’ most common laundering practices as defined by the 2015 study.
While in-house and contract laundries operate according to the Department of Health’s technical memorandum on the decontamination of linen for health and social care (DoH, 2016), things are very different when it comes to washing uniforms at home.
In 2010 the DoH issued guidance on domestic laundering of NHS nurses uniforms that determined: “A wash for 10 minutes at 60C removes almost all microorganisms. Washing with detergent at lower temperatures – down to 30C – eliminates meticillin-resistant Staphylococcus aureus and most other microorganisms.”
In the light of the rise of Hospital Acquired Infections (HAI) and antibiotic-resistant bacteria, “almost all” and “most other” are worrying terms. Also concernng is that the UK and Ireland are the only countries in the European Union and North America that have a home washing policy for hospital uniforms.
Not following Trust policy
The first study in four hospitals (Riley et al, 2015), showed that not all staff were following Trust policy on laundering and aftercare of uniforms (there are no national NHS guidelines and each Trust inteprets the guidelines individually). It also showed a variation between Trusts on recommended wash temperatures, and unclear guidance regarding the use of detergents; drying; and whether to wash uniforms on their own - that is, not with other items of normal laundry.
Results in the study were divided into two categories: infectious departments (clinical areas considered to have a high risk of infection) and non-infectious departments (considered to have a lower risk of infection). Infectious departments included surgical, critical care and isolation wards. Emergency departments and emergency assessment units were also considered infectious, since any patient could enter with an infection before being allocated a bed.
In all, 265 healthcare staff including nurses, healthcare assistants, ward clerks, housekeepers and physiotherapists responded to the 2015 study questionnaire which found:
- 43.7% laundered their uniforms below the 60C recom study mended by the DH
- 33% washed them at 40C
- 5% washed them at 30C
- 91% of all respondents said they used a detergent in the wash cycle with their uniforms
- 37% of respondents used a biological detergent
- 35% used a non-bio- logical detergent and 14% used a ‘two-in one’ detergent
- 26% of respondents wore their uniform for two or more shifts before washing it, longer than the recommended wash after every shift
- 78% of staff had their uniforms for more than 18 months before these were replaced by new ones
- 3% raised the issue of changing facilities, indicating that these were limited or located some distance away from the wards. (This could be one reason why staff wear uniforms to and from work place, suggests the report.)
In part two of the research, published in 2017, the most common laundering practices established by the study published in 2015 were mimicked in a laboratory setting to assess the survival of Staphylococcus aureus and Escherichia coli on cotton and polyester fibres. The data showed that both bacteria were able to survive on polyester for up to seven days and on cotton for up to 21 days. This raises questions on storage of dirty uniforms at home, especially with regard to potential cross-contamination with surfaces.
Mixed polyester and cotton (65%/35%) and 100% polyester fabric samples innoculated with high bacterial loads (108) – to take a worst-case scenario – were washed at 40C and 60C using biological detergent.
To determine whether cross-contamination could occur in the wash, sterile samples were included. Although the 40C wash did remove most microorganisms, the cells that remained were in excess of 1,000, with similar numbers transferred to the sterile items.
The findings show that most microorganisms are removed from textiles at lower washing temperatures but the risk that surviving microorganisms may be present needs to be fully quantified. When the samples were washed at 60C, no microorganisms were detected, which supports the DH’s recommendation that uniforms should be washed at a minimum temperature of 60C for 10 minutes. However, nurses’ worries about the cost of hot washing and concerns about being environmentally friendly by using a colder ‘eco-wash’ could be contributory factors to failure to do so, finds the report. Also add in the fact that domestic washing machines are extremely diverse in operation and not easy to regulate and, while they may heat up to 60C initially, they do not maintain that temperature through the wash. Older machines are also less likely to reach temperature at all.
Dr Laird summarises: “The potential risks associated with domestic laundering of nurses uniforms needs greater investigation. The research conducted at De Montfort University over the past few years has demonstrated that DH policies on the domestic laundering of nurses uniforms is often interpreted differently by individual NHS Trusts and that nurses then do not always adhere to these policies for a number of reasons.
“Scientific data has also shown that bacteria are able to survive on both cotton and polyester fibres for between 7-10 days and that a 40C wash with detergent not only does not kill/remove all of the bacteria from the textiles but also cross contaminates other textiles in the wash.
“Although no direct link has been made between nurses uniforms and a patient contracting a HAI, there may be a potential for this to happen and more evidence is required in order to take a proactive rather than an reactive approach.
“In the food processing industry the laundering of textiles and workwear is much more highly regulated due to the fact that contamination could occur. Should the laundering of uniforms return to industrial laundering there are a number of factors to consider including changing facilities for nurses, cost to NHS and capacity at laundries to take nurses uniforms back in house (or to a commercial outsourced operation).”