Introduction

The linen and laundry service is an important utility service which not only helps contain the hospital infections but also contributes to the image of the hospital. Clean and crisp linen has a very soothing and assuring effect on the patient’s psyche while dirty linen is bound to cause patients’ dissatisfaction and negative impressions about the entire hospital. It is, therefore, essential for every hospital to maintain high standards of linen and laundry service so as to ensure full satisfaction of clients, both external (patients/relatives) and internal (doctors/nurses/technicians).

Depending upon the policy, the hospital may have its own laundry service, outsource it or have their own facility run by a contractor on contractual basis. In any situation, the responsibility of quality of services lies with the hospital management.

 

Objectives of Laundry Services

1. To provide comfortable and pleasing environment to the patients and visitors of the hospital by supplying clean linen.
2. To control hospital infections.
3. To make uninterrupted supply of the linen to the user department: as break down of linen supply result into 3% to 4% cancellation of operations schedule.
4. 3% to 4% of hospital infection is due to mishandling of the infected linen.
5. Improved efficiency and productivity.
6. Improve image of the hospital.

 

Types of Linen

Hospital linen can be classified as follows:

1. Patient’s Linen

a. i.  Hospital linen

ii. Body Linen

iii. OT Linen

b. Staff Linen

c. Linen for housekeeping of offices like curtains etc. for departments and wards

2. Laundry Linen

a.Infected Linen

b. Soiled Linen

c. Foul Linen

d. Radioactive Linen

 

Policies

1. To pre-treat soiled linen such as removal of bloodstain, faeces
2. To process soiled linen five, six, or seven days weekly
3. To mark linen and other clothes with hospital and department identification
4. To undertake stitching of minor tears
5. To maintain inventory
6. To prevent delays in collection and delivery
7. To receive the items from all the departments
8. To maintain entry in the receiving register
9. To follow all safety rules and procedures
10. To follow standardized washing processes and methods of cleaning
11. To follow instruction manuals for safe main tenance and operating of laundry machinery
12. To follow proper washing and pressing techniques
13. To maintain a good accounting and inventory system
14. To follow fire and safety policy in the department strictly
15. To formulate a daily/weekly/monthly schedule for supplies of washed items to the, operation theatres, critical care unit, intensive care unit, accident and emergency department, wards, blood bank, diagnostic departments and outpatient department.

 

Procedures

Counting and sorting soiled linen by processing type:

1. Stain removal
2. Preparing washing solutions
3. Processing infected linen
4. Correct loading of washer machine
5. Feeding sheets into flat work ironer
6. Folding and packing clean linen.

 

Rules

1. Indicating nature of stains to assist removal
2. Linen examined for dentures, surgical instruments, jewellery, and other items inside pockets
3. Clean linen withdrawn on first-in-first-out basis
4. Soiled linen and clean linen need separate carts.

 

Standards

1. Ironed items being wrinkle-free, folded correctly, looking fresh and repaired where torn
2. Washing solutions need to kill bacteria without destroying the material.

Organization flow chart of laundry management

 

 

 

In many hospitals, laundry is attached to the house keeping department or CSSD. In large hospitals, it functions independently.

 

Records

1. Quantity of linen: received-processed-clean linen issued
2. Requisition for linen
3. Manufacturer’s directions for operating machines
4. Materials and utility supplies used Administration department records common to other departments.

 

Quality of Service

1. Processed linen being free from stains, wrinkles, and fraying, and delivered punctually to users. Correct strength of detergents.
2. Linens not being damaged by improperly maintained machines
3. Linens stored correctly to obviate damage and deterioration.

 

 

Infection Control

Fouled or infected linen and normally soiled linen should be separately handled and washed. This area should be separated from the rest of the reception area and from the post wash clean area of the laundry. The infection control unit should focus its attention on laundry services at par with CSSD to ensure infection control measures are observed meticulously.

 

 

Types of Laundry Services

The various types of laundry services can be classified as under:

1. Rental system: Especially for hospital of small size, where it will not be economical to have their own laundry system, the hospital hires laundered items from contractor on rental basis.
2. Contractual system: In this system the hospital linen is collected by the contractor and laundered items are supplied to the hospital. The hospital may provide space and physical facilities to the contractor for laundry. In some cases, the hospital may own the plant and may give on lease to the contractor for operations. Outsourcing is the need of the hour and the students are advised to refer chapter on contracting in health care in the same book.

 

 

3. In plant system: The hospitals have their own laundry plant. It is one of the best methods for hospital laundry, but sometimes the operating cost is the limiting factor. This type of laundry is more suitable for hospital of big size.

4. Cooperative system: A group of hospitals may utilize the laundry services of one plant on cooperative basis. It is suitable for hospital of small size or nursing homes. The disadvantage of mixing of the hospital linen and cross infection is inherent.

 

 

Methods of Distribution / Supply of Linen

The following systems are prevalent:

1. Topping up system
2. Exchange trolley system
3. Requisition system
4. Quota system.

 

1. Topping up system: The quota of linen is fixed for each ward/department or user unit and same is supplied to replenish the exhausted stock. This is based upon imprest system. It requires a detailed work up to be done to determine the quota for each unit or ward.
2. Exchange trolley system: A full quota in form of a trolley of clean linen is supplied to the user unit or ward in exchange of the old trolley, irrespective of the quantity utilized at the time of exchange of fresh for old trolley. It saves manpower, and time.

 

3. Requisition system: This is based upon the indenting system. A written requirement is submitted to the central linen supply department and on the basis of requisition the linen is supplied to the demanding units as on when required basis.

4. Quota system: It is usually a daily quota system, there is predetermined, prefixed requirement for each unit, the linen is supplied directly from the central linen store. The only disadvantage in this system is; if the imprest has not been determined realistically, the linen may accumulate at the user units.

 

Requirement of Linen

The requirement of the linen is calculated on the basis of actual performance of the user units like:

1. OT, Labour rooms
2. ICU, Wards, Pvt. Wards, etc..
3. OPD and departments of hospital
4. Staff requirement

 

As a rough guide 2 to 3.5 kg of dry linen per patient per day is required. If we presume bed occupancy rate is 100% six sets of linen are required as:

1. One set in patient’s bed
2. One set ready for use of next time
3. One set in process at laundry
4. One set en route to laundry
5. Two sets for work and exigency in stock.

 

Physical Facilities

Location

It is conveniently located in the ground floor. It should be closer to the user units. Close proximity to CSSD and Dietary services is desirable, due to common requirement of steam from boiler plant.

Space Requirement: The space requirement is 10 sq. feet/bed.

Physical Layout: It depends upon work flow; it can be “U” shaped or rectangular type.

 

Workflow

Ancillary Facilities

The following ancillary facilities are requisites of the laundry services:

1. Laundry manager’s office cum room
2. Tailoring area
3. Worker’s rest room
4. Toilets
5. Boiler room
6. stores

 

Materials and Décor

1. Flooring should be non-slippery and washable.
2. Walls should be washable, free from crevices, corners and edges or ridges.
3. Ceiling should be smooth, washable with a clear head room of 14 feet.
4. Doors should be wide.

 

Lighting

1. Day light should be used, wherever possible.
2. Good lighting is an important consideration for improved efficiency and increasing productivity.

 

Ventilation

10 air changes per hour are the recommended air changes for proper ventilation.

 

Power Supply

There should be three phase connections. The distribution panel should be easily accessible. There should be stand by generator. For motorized equipment’s 3 kW hour per 45 kg of dry laundry and for laundering, it is recommended as 3 Watts per 1/ 3 sq. meter of floor area.

 

Water

There should be provision of adequate supply of water. Approximately 15 litre of hot water and 10 litres of cold water are required per 0.5 kg of linen processed. If there is supply of hard water then softening of water is done with the help of softening plants.

 

 Steam Supply

The steam supply system must deliver steam to the equipment’s at the required temperature. A temperature of 170°C is obtained from steam at 45 kg per 6 sq. cm pressure. All steam lines should be properly insulated for protection of the workers.

 

Fire System

There should be provision of fire detection system with alarm and system of fire extinguishing in place, to prevent fire hazards.

 

Staffing

The hospital laundry must have a well-trained laundry manager as he has to supervise the work of very technical nature and at the same time, most of the work is carried out by the non-technical personnel like Dhobis who do not know the importance of hospital infection control.

S. No.	Staff	Number
1	Laundry manger	1
2	Laundry supervisor	1
3	Store keeper	2
4	Orderlies	6
5	Tailors	1
6	Safaiwala	1
7	Operators	17

 

As a rough guide 1 man per 30 beds in hospital. As per the recommendation of U.S. Department of health, approximate number of personnel required as:

Operational Aspects of Washing in Laundry

 

 

 

 

 

Working Formula

		Types of linen
Cleaning Agent	Cotton white 100-pound dry weight	Cotton white 100-pound dry weight	Woollen pounds weight
Washing soap	1.5	1	1.5
Washing soda	1	0.5	–
Bleaching powder	0.5	–	–
Whitener	0.05	–	–
Starch	–	1	–
Temp.	140 – 160 °F	150 °F	60 °F

 

 

Equipment’s

The laundry service in hospital is heavily depended upon the equipment’s. Every day some new equipment is being added to the list or some up gradation of equipment is being done. There is need of judicious equipment procurement planning and above that preventive planned maintenance program of the equipment. The number and types of the equipment’s will depend upon various factors. The important one are:

1. Type of hospital
2. Size of hospital
3. Linen load
4. Capacity and ability of the laundry manager to supervise the work and equipment’s.
5. Type of the laundry system in existence.

Some of the equipment’s are being enlisted as follows:

1. Boilers
2. Washing machines
3. Hydro extraction
4. Sluice machine
5. Driers.
6. Calendaring machine
7. Steam bed press
8. Electric hand press
9. Sewing machine
10. Table for ironing
11. Weighing scale
12. Fire extinguishers
13. Air compressor
14. Trolleys.

 

Managerial Issue

1. Control of Pilferages and theft
2. Cost control
3. Occupational safety of the worker

The contaminated laundry can be defined as “laundry which has been soiled with blood or other potentially infectious material or may contain sharps.” Potential hazards: Exposure to blood or other potentially infectious materials through contaminated laundry that was improperly labelled, or handled.

 

 

Solution

1. Handle contaminated laundry as little. Possible with minimal agitation.
2. Bag contaminated laundry at the location of use.
3. Do not sort or rinse the laundry at the location where it was used.
4. Place wet contaminated laundry in leak proof, and colour coded containers at the location where it was used.
5. Whenever contaminated laundry is wet and presents a reasonable likelihood of soak through of or leakage from the bag or container, the laundry shall be placed and transported in bags which prevent soak-through and/ or leakage of fluids to the exterior.
6. Contaminated laundry must be placed and transported in bags or containers labelled with the biohazard symbol or put in red bags.
7. In a facility that utilizes universal precautions in the handling of all soiled laundry-alternative labelling or color-coding is sufficient if it permits all employees to recognize the containers as requiring compliance with universal precautions.
8. Use red bags or bags marked with the biohazard symbol, if the facility where items are laundered does not use universal precautions for all laundry.
9. Sharp handling:

a. Potential Handling: Exposure to blood borne pathogens from contaminated laundry; that contains sharps.

b.Possible solutions: A safety and health program that includes procedures for appropriate disposal and handling of sharps and follows required practices outlined in the Blood borne Pathogens Standard.

c.Contaminated needles and sharps: Shall not be bent, recapped or removed. No shearing or breaking permitted.

d. Sharps Containerization: Immediately or as soon as feasible. Contaminated sharps need to be discarded in appropriate containers. Needle containers need to be available, and in close proximity to areas where needles may be found, including laundries.

10. Ergonomics

11. Quality assurance in laundry

12. Staffing functions: Clarity in roles and responsibility among the supervisors and staff, training of staff, schedule of working hours, occupational safety measures for staff.

13. Physical facilities and plant: Location of laundry. In relation to boiler room, source of hot water, steam, electric supply, noise control, ventilation, lighting, and vibrations. 13. Linen handling: System of handling of dirty, soiled, infected and contaminated laundry. System of control of accounting of linen sent to laundry and when it leaves the laundry.

14. Laundering process: Sorting, segregating, washing formula, steps taken to remove stains, laundering process of special linen, control of damaged linen etc.

15. Linen control: Linen control program through linen control committee. Right from the procurement procedure to the final disposal, that is inventory control of the linen. The students are advised to consult chapter on material management in the same book and to go into the details of inventory control techniques.

16. Sewing room: Location of sewing room, items to be stitched, sewing machines in use, marking method of new linen.

17 . Cost: The total cost of laundry, distribution of laundering costs to various user units, the factors determining the cost of the laundering, the present valuation of laundry, the depreciation costs of various equipment’s installed in the laundry.

18. Quality assurance program: Through quality circles and by application of “5 S” technique of sorting, segregating, shine, standardize and control. These 5 ‘S’ have been derived from Japanese literature, as this technique of control is very popular in Japan.

19. Hospital infection control: Contaminated linen must be disinfected before issuing to dhobis. Both contaminated and clean contaminated should be transported to laundry, separately. Handling, separating, and counting of even clean contaminated linen is hazardous, hence there should be minimum handling. Drying of linen in the sun after washing should be discouraged as it usually spreads on road side or other contaminated area, poses risk to the general public.

a. Decontamination of blankets: Cotton and acrylic blankets are preferred to woollen blankets. They can be handled like linen; contaminated soiled woollen blankets can be decontaminated either by exposing to formaldehyde vapours or autoclaving. Liquid disinfectants may damage woollen blankets. The woollen blankets can be dry-cleaned but it does not inactivate HIV/ AIDS.

b. Decontamination of mattress: It is advisable to cover all mattresses with water proof synthetic material like raxine or plastic. Big autoclaves are available for disinfection of mattresses. Washing can be done manually.

 

Criteria For Evaluation Of Quality Of Services

1. Patients’ Feedback: Number of complaints/comments received from patients about the quality of linen or the quality of wash.
2. Number of complaints received from clinicians/nursing staff/ technicians (internal customers) about:

a. The timeliness of linen supply

b. The quality of linen supplied (worn out/faded, stained, patched, smelling or poorly ironed)

c. The quantity of linen supplied

3. Average monthly cost of linen replacement

4. Losses due to thefts, pilferage or damage in process.

 

Summary

Linen service in a hospital plays an important role in providing an infection free, clean and fresh environment to the patients. Unclean, stained, patched and smelly linen, like bad quality food, can be a major source of dissatisfaction of the patients. It conveys a poor impression about the entire hospital. Not only that, it adds to the chances of cross infection. A good, patient focused service must eliminate all such deficiencies. High quality linen and laundry services, however, require a well planned mechanized laundry with adequate supply of the right quality water and consumables as well as adequate and well trained staff. It also requires a sustained effort at process control and improvement through standardized procedures covering all the activities, as a part of a continuous program of quality management.