Linen Handling and Laundry Policy

Version

Name of responsible (ratifying) committee

Infection Prevention Management Committee

Date ratified

1st March 2013

Document Manager (job title)

Consultant Infection Prevention

Date issued

4th March 2013

Review date

March 2015

Electronic location

Corporate policies

Related Procedural Documents

See section 8 of policy

Key Words (to aid with searching)

Linen, infected linen, contaminated linen, linen

handling

Linen handling and laundry policy. Version 3

Issue Date:4th March 2013
(Review date March 2015 (unless requirements change)
Page 1 of 13

CONTENTS
QUICK REFERENCE GUIDE.......................................................................................................3
1. INTRODUCTION........................................................................................................................... 4
2. PURPOSE.................................................................................................................................... 4
3. SCOPE......................................................................................................................................... 4
4. DEFINITIONS............................................................................................................................... 4
5. DUTIES AND RESPONSIBILITIES...............................................................................................4
6. PROCESS.................................................................................................................................... 5
7. TRAINING REQUIREMENTS.......................................................................................................9
8. REFERENCES AND ASSOCIATED DOCUMENTATION..............................................................9
Appendix A
9. EQUALITY IMPACT STATEMENT...............................................................................................11
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS.........................................12

Linen handling and laundry policy. Version 3

Issue Date:4th March 2013
(Review date: March 2015 (unless requirements change)

QUICK REFERENCE GUIDE

This policy must be followed in full when developing or reviewing and amending Trust procedural
documents.
For quick reference the guide below is a summary of actions required. This does not negate the need
for the document author and others involved in the process to be aware of and follow the detail of this
policy.
1. It is the responsibility of the person disposing of the linen to ensure that it is segregated in to
the 3 correct categories
2. It is the responsibility of both laundry contractor and PHT staff to ensure linen is clean and in
a good state of repair
3. Linen must be stored in a dedicated closed cupboard or fully enclosed mobile linen trolley
secured from unauthorized persons
4. Specific ward items must be appropriately labeled before sending to contracted laundry
service
5. It is staff responsibility to ensure instruments, sharps and non laundry items are not disposed
of with linen
6. Patients relatives and carers should be encouraged to wash all personal laundry at home and
correct washing instructions provided
7. Advice should be requested from Infection Prevention and Control team regarding infected
linen being placed in the hazards waste stream
8. Infection Prevention and Control policy must be adhered to when handling both clean and
soiled linen

Linen handling and laundry policy. Version 3

Issue Date:4th March 2013
(Review date: March 2015 (unless requirements change)

1. INTRODUCTION
The provision of clean linen is a fundamental requirement for patient care. Incorrect procedures
for handling or processing of linen can present an infection risk both to staff handling and
laundering linen, and to patients who subsequently use it.

2. PURPOSE
This Policy defines the responsibility of managers and staff to ensure correct, safe handling and
disposal of contaminated laundry, and the correct, safe distribution and storage of clean linen to
minimise infection risk throughout Portsmouth Hospitals NHS Trust.

3. SCOPE
This Policy applies to all staff, both clinical and non-clinical, employed by Portsmouth Hospitals
NHS Trust, who handle linen and also to all visiting staff including tutors, students and
agency/locum staff, who handle linen
In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety

4. DEFINITIONS
Clean / Unused Linen:
Any linen that has not been used since it was last laundered and that has not been in close
proximity to a patient or stored in a contaminated environment.
Dirty / Used Linen:
All used linen other than infected linen that remains dry.
Soiled / Infected linen:
Any used linen that is soiled with blood or any other body fluid or any linen used by a patient
with a known infection (whether soiled or not).
Cohort Area:
A geographically distinct area allocated to a group of patients with a disease or infection who
need to be separated from patients who do not harbour the disease or infection.
Isolation Room / Cubicle:
A single room, with its own hand washing facilities and preferably separate toilet facilities used
to reduce the risk of transmission of infection to or from patients, visitors or staff.

5. DUTIES AND RESPONSIBILITIES

Healthcare Workers (HCW):
Follow this policy
Report to their managers and/or the Infection Control Team if they are unable to do so.
Managers:
Ensure that HCWs follow this policy
Linen handling and laundry policy. Version 3
Issue Date:4th March 2013
(Review date: March 2015 (unless requirements change)

 Ensure that HCWs have the resources to follow this policy.

Infection Prevention & Control Team:
Maintain the policy
Provide educational opportunities on this policy.

6. PROCESS
6.1 Segregation of Linen:
It is the responsibility of the person disposing of the linen to ensure that it is segregated
appropriately. All linen may be segregated into the following three categories:
Clean / Unused Linen
Dirty / Used Linen
Soiled / Infected Linen
Clean / Unused Linen:
Clean linen must be in a state of good repair, as tearing or roughness can damage the patients
skin. The condition of the linen in use should be monitored by the laundry contractor and by
PHT staff. Linen should also be free from stains and excessive creasing and should be usually
acceptable to both patients and staff.
Handling of Clean Linen:
Once laundry has been decontaminated, every effort must be made to maintain its quality and
cleanliness.
Delivery:
Laundry should be delivered to the wards in clean covered containers. Clean laundry should
not be transported in containers used for used / soiled laundry.
Storage:
All clean linen must be:
stored in a clean, closed cupboard (either a dedicated linen cupboard or dedicated, fully
enclosed mobile linen trolley)
stored off the floor
stored with the linen cupboard/trolley doors closed to prevent airborne contamination
stored in a clean, dust free environment
segregated from used / soiled linen
Clean linen must not be stored in unsuitable areas e.g. the sluice, bathrooms, in bed spaces.
Local Use:
Clean linen should not be decanted onto open trolleys unless for immediate use
Linen taken into an isolation room/cohort area and not used must be treated as used linen
and laundered before use
Dirty / Used Linen:
Linen which is used but dry: Dirty / Used linen must not have been:
visibly soiled with blood or bodily fluids
used on source isolated patients
Dirty / Used linen should be placed directly into a clear plastic laundry bag.
Linen bags should be no more than 2/3 full.
Soiled / Infected Linen:
Any used linen that is soiled with blood or any other body fluid or any linen used by a patient
with a known infection (whether soiled or not).
This includes patients with or suspected:
Linen handling and laundry policy. Version 3
Issue Date:4th March 2013
(Review date: March 2015 (unless requirements change)

MRSA, gram positives or gram negative infections.

Human Immunodeficiency Virus (HIV)
Hepatitis A, B or C
1. Draining Tuberculosis (TB) lesions and open pulmonary TB
Enteric Fever
Dysentry (Shigella spp)
Salmonella
Norovirus
Clostridium difficile
Chickenpox
Head or body lice, scabies
Other notifiable diseases
Soiled / Infected linen should be placed directly into a clear water-soluble alginate bag and
secured, then placed into a red outer bag.
Linen bags should be no more than 2/3 full.
Dirty or soiled linen bags should be stored in dirty linen cages and not on floors or
obstructing public thoroughfares or the ward environment.
6.2 Trust Owned Return to Sender Items:
Return to Sender items that belong to specific wards (e.g. slings, slide sheets, duvets,
neonatal/paediatric blankets, posy mitts, dressing gowns etc) must be placed in a brown
bag
All items must have the hospital and ward name on them
All return to sender items should be listed on the laundry triplicate tickets (supplied by
Linen Rooms). The sender should keep the bottom copy of the ticket and send the top 2
copies to the laundry in the bag. The laundry will then return the item with a copy of the
ticket for matching
Soiled / Infected return to sender items should be placed as normal directly into a clear
water-soluble alginate bag and secured, then placed into a brown bag
6.3 Theatre Linen:
Dirty / Used Operating Theatre staff clothing should be placed into a clear plastic laundry
bag
Soiled / Infected Operating Theatre linen and staff clothing should be placed into a red
water-soluble alginate bag, then placed into a red outer bag
Care should be taken to ensure that theatre instruments and sharps are not accidentally
disposed of in linen
6.4 Patients Personal Laundry:
Safe return of personal laundry processed off site cannot be guaranteed
Patients / Relatives / Carers should be encourage to wash personal laundry at home
Many micro-organisms will be physically removed from linen by detergent and water, and
most are destroyed by a high temperature wash. Any remaining micro-organisms are
likely to be destroyed by tumble drying and ironing.
Patients personal laundry should be placed in a clear plastic bag, not a water-soluble
alginate bag (as private laundry facilities will not reach the required temperature to melt
the bag, which may lead to damage or blocking of the domestic washing machine). The
clear plastic bag should then be placed into a patients property bag to protect the
patients dignity
Laundry should be taken home and placed directly into a washing machine
Clothes should be processed at the hottest wash recommended by the manufacturers
instructions
Persons handling the laundry must be advised to wash their hands after handling the prewashed laundry
Linen handling and laundry policy. Version 3
Issue Date:4th March 2013
(Review date: March 2015 (unless requirements change)

Relatives / carers must be advised before they take home personal laundry if it is heavily
contaminated

6.5 Infested Laundry:

Laundry that is potentially infested with parasites (e.g. bed or body lice, scabies).
Place into a clear water-soluble alginate bag and secure, then place the alginate bag into
a red plastic bag
Marking of laundry as infested is not required.
6.6 Laundry which would remain hazardous following normal processing or for which
additional precautions are required:
Laundry thought to be contaminated with any of the following micro-organisms must be placed
in the hazardous waste stream and incinerated and not sent to the laundry service. Advice
should be requested from the Infection Control Team.

Bacillus anthracis (Anthrax)

Viral Haemorrhagic Fevers (e.g. Lassa fever, Marbug disease, Ebola fever)
Rabies
Tropical pyrexia of unknown origin
Lepromatous Leprosy
Bioterrorism agents e.g. Smallpox
CJD where CSF or other body fluids have leaked onto laundry items

6.7 Condemned or Unfit Linen:

Linen deemed not fit for purpose (heavily stained, torn, rough) should be placed in a separate
clear plastic bag, labelled as unfit for use and returned to the hospital laundry contractor
(Sunlight). Linen deemed not fit for purpose should not be placed in the same bag as other
linen for laundry as it will remain in general use and the Trust will be recharged for its handling.
Complaints about laundry or linen quality should be made to the Carillion helpdesk x6321
6.8 Procedure for Water-soluble Alginate Bags:
This procedure is to be used in all situations where linen is placed in water-soluble alginate
bags.
1.
2.
3.
4.
5.

Place the linen inside the alginate bag

Items that are soaking wet should be wrapped inside drier dirty laundry
Do not overfill the water-soluble alginate bag
Seal the alginate bag using the neck tie do not knot the bag
Place the water-soluble alginate bag inside the appropriate coloured linen bag.

6.9 General Principles:

These general principles should be adhered to when handling all linen and laundry.
Handling Linen:
All dirty linen must be handled with care, to minimise transmission of micro-organisms via dust
and skin scales.

All dirty linen must be placed carefully and directly into the appropriate laundry bag on
removal from the bed or patient
The used linen skip should be at the bedside. Used linen should not be carried to avoid
contamination of uniforms
Dirty linen must never be transported around the care environment unless within an
appropriately colour coded linen bag
Vigorous, enthusiastic bed stripping and changing of curtains is microbiologically
hazardous as large numbers of organisms (mainly skin flora) are dispersed. Care should
be taken to minimise contamination of equipment and the near patient environment.

Linen handling and laundry policy. Version 3

Issue Date:4th March 2013
(Review date: March 2015 (unless requirements change)

When beds or curtains are changed all open wounds/drains etc need to be temporarily
covered during linen changes.
Do not shake linen into the environment
Do not change linen during wound dressings in the same area
Use PPE when handling dirty linen

Care must be taken to ensure that no sharps or non-laundry items are included with dirty linen
before it is placed ready for laundering. Such items are potentially dangerous to staff handling
the laundry.
Hand Hygiene:
Hand hygiene is a term that incorporates the decontamination of the hands by methods
including routine hand washing and the use of alcohol hand rubs and gels.
Hands should be decontaminated before handling clean linen and after handling used
laundry.
Personal Protective Equipment:
Plastic aprons should be worn by all HCWs for all bed making this includes beds
where the patient has been discharged and patient occupied beds. Plastic aprons must
be changed between beds. The Standard Precautions Policy can be found here
Gloves must be worn when handling laundry from an infected patient or laundry
contaminated with blood and body fluids
Face protection / eye protection must be worn where there is significant contamination
with blood and body flushes likely to cause a splash injury.
Accidental Spillage from Used Linen:
Gloves and apron must be worn
Re-bag into the appropriate bag. If the appropriate bag is not obvious then the linen
should be treated as infected and placed in a clear alginate bag, then into a red outer bag
and tied securely.
Clean area with appropriate disinfectant (Actichlor plus) if necessary.
If advice is required contact the Infection Prevention & Control Department. x6261
Local Cleaning:
All hospital linen should be laundered by an external laundry contractor (with the
exception of specific wards authorised to have industrial washing machines)
Manual soaking / washing of soiled items must never be carried out in the clinical areas by
staff. This is a contamination and splash injury risk. Solid contaminants should be
disposed of in the appropriate clinical waste stream and laundry bagged as per policy
Patients personal clothing should be bagged and sent home for cleaning
Storage and Removal:
All dirty/used linen should be removed from clinical areas as frequently as circumstances
demand
Soiled linen must be kept away from public areas
Storage areas must remain closed and kept secure from unauthorised persons
Curtains:
Curtains require washing when visibly dirty, or at least every six months.
Curtains should be routinely changed when discharging or transferring a patient with
MRSA from the area or during outbreaks
Removal and changing of curtains results in aerosolisation of ingrained organisms
which may be harmful to patients and contaminate the near patient environment. For
this reason curtains should not be changed at key times e.g. during wound dressing
changes etc.
Linen handling and laundry policy. Version 3
Issue Date:4th March 2013
(Review date: March 2015 (unless requirements change)

Pillows:
All pillows used in clinical areas must have sealed intact impermeable covers.
Any pillow torn, split or stained must be discarded.
New pillows can be ordered from the Carillion helpdesk x6321.
Spare pillows must be returned to the pillow store in Emergency Department

7. TRAINING REQUIREMENTS
It is individual wards responsibility to ensure all staff have read and adhere to the linen handling
and laundry policy

8. REFERENCES AND ASSOCIATED DOCUMENTATION

Hospital Laundry Arrangements for Used and Infected Linen.
Health Service Guidelines. NHS Executive. HSG (95) 18; 1995.
An Organisation-Wide Policy for the Development and Management of Procedural Documents:
NHSLA, May 2007. www.nhsla.com/Publications/

Linen handling and laundry policy. Version 3

Issue Date:4th March 2013
(Review date: March 2015 (unless requirements change)

Appendix A

PORTSMOUTH
COLOUR CODING OF LAUNDRY BAGS
USED LINEN
I.E. SHEETS, BLANKETS
P/CASES, SCRUB SUITS ETC
Scrub suits should go inside a
CLEAR bag unless contaminated
with blood / body fluids

CLEAR Plastic
Bags

FOUL/INFECTED LINEN

MUST BE PUT INTO SOLUBLE

CLEAR BAG BEFORE PUTTING
INTO OUTER RED PLASTIC
BAG

Inner - Clear Alginate Bag

Outer - Red Sunlight plastic Bags
TRUST OWNED ITEMS
R.T.S
ALL ITEMS MUST HAVE
HOSPITAL/WARD NAME ON THEM

All laundry related requests should be made via the Carillion

Linen handling and laundry policy. Version 3

Issue Date:4th March 2013
Helpdesk
xt 6321
or linen room on xt 6324
(Review date: March 2015 (unless
requirements
change)

9. EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly

Linen handling and laundry policy. Version 3

Issue Date:4th March 2013
(Review date: March 2015 (unless requirements change)

10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

This document will be monitored to ensure it is effective and to assurance compliance.

Minimum requirement to be
monitored
Duty of care visit to laundry provider

Policy to be reviewed bi-annually

Lead

Carillion

Tool

Personal visit to
laundry provider
premises

Consultant
Infection
Prevention

Linen handling and laundry policy. Version 3

Issue Date:4th March 2013
(Review date: March 2015 (unless requirements change)

Frequency of
Report of
Compliance
Annually

Bi-annually

Lead(s) for acting on Recommendations

Carillion

Soft FM

Infection Prevention & Control team

Infection Prevention Management Committee

Linen handling and laundry policy. Version 3

Issue Date:4th March 2013
(Review date: March 2015 (unless requirements change)