Environmental services and laundry hazards

Environmental services staff clean every room, corridor, bathroom and surface in the hospital, empty every bin, change every curtain and strip and make thousands of beds a year. Laundry staff wash, dry, iron and fold everything those beds and patients use. Both departments are essential to infection control, and both have injury rates as high as many clinical units. They also get less attention: their work is often done at night, out of sight, by staff who are not always included in unit huddles, training and committee work. This lesson looks at the hazards of both departments.

Environmental services at Northbridge

Northbridge's environmental services department has about 85 staff working across three shifts, plus a night lead. Marta and her colleagues are each assigned to a group of units, with a mix of daily cleaning, discharge cleaning when a patient leaves, isolation cleaning and responding to spills and requests. On a typical day the department completes about 60 discharge cleans and about 15 terminal cleans of isolation rooms.

Their hazards draw on almost every earlier lesson:

• Chemicals: disinfectants, sporicides, bowl cleaners, floor strippers and finishes, used many times a shift (Lesson 6).
• Sharps: needles and other sharps left in beds, linen, bins, under furniture and on floors, which are a common cause of needlesticks for staff who never use needles themselves.
• Body fluids and infection: blood, vomit, urine and stool on surfaces, in bathrooms and in waste, and rooms that held patients with C. difficile, norovirus, tuberculosis or drug-resistant organisms (Lesson 5).
• Slips and trips: wet floors they have just mopped, and floors other people have spilled on (Lesson 4).
• Lifting and repetitive work: mopping, wiping, bagging, carrying, high dusting and bed making (Lesson 8).
• Violence: patients who are confused, agitated or intoxicated do not distinguish between nurses and housekeepers.
• Working alone: night staff may be the only person in a part of the building.
• Equipment: floor machines, UV disinfection devices and hydrogen peroxide vapor systems.

Cleaning isolation rooms

When a patient on transmission-based precautions is discharged, their room gets a terminal clean: every surface, the bed, the mattress, the equipment, the bathroom and the curtains. Environmental services staff wear the same protection that the sign on the door calls for, and for some organisms more. A C. difficile room is cleaned with a sporicidal product, because ordinary disinfectants do not kill the spores, and hands are washed with soap and water afterwards. A room that held a patient on airborne precautions is left empty with the door closed until enough air changes have passed to clear it, which is usually set by the infection control team for each room, and staff who enter sooner wear an N95.

Two newer technologies need care. Ultraviolet (UV-C) disinfection robots are wheeled into an empty room after cleaning and run for several minutes. UV-C can burn the skin and eyes, so the devices must be run only in an empty room with the door closed and the motion sensors working, and the room must not be entered until the cycle is over. Hydrogen peroxide vapor systems fill a sealed room with a fine mist; the room must be sealed, signed and not entered until the vapor has been broken down to a safe level, which the device measures. Only trained staff run either device.

Sharps where they should not be

Marta has found needles in bed sheets, in a pillowcase, in a bag of regular garbage, on the floor under a bed and once inside a folded blanket on a chair. Each one was left by someone who was busy and meant to deal with it later. The person who finds it is rarely the person who left it, and environmental services and laundry staff find more stray sharps than anyone else.

The rules for sharps start with the person who uses them: dispose of every sharp at the point of use, in a sharps container within reach, and never leave one on a bed, tray or in a pocket. For environmental services staff, the rules are about not being the next victim:

• Never reach into a bin or bag with your hand, and never push waste down with your hands or feet.
• Hold bags away from your body by the top, and do not hug or carry them against your legs.
• Strip beds by rolling linen inward from the edges, never by gathering it in your arms.
• Look before you touch: under pillows, in folds and on the floor around the bed.
• Pick up a found sharp with tongs or forceps, not your fingers, and put it straight into a sharps container.
• Replace sharps containers when they reach the fill line, not when they are overflowing, and never push items down into a full container.
• Report every sharp found out of place, with where it was found, so the unit can find out how it got there.

Waste streams

A hospital produces several kinds of waste, each with its own container, labeling and handling rules. Regulated medical waste is defined by each state, and Minnesota regulates it as infectious waste under its own law, while hazardous waste is regulated under the federal Resource Conservation and Recovery Act. The main streams are:

• General waste, which is most of the volume: packaging, paper, food waste and most used gloves, gowns and dressings that are not soaked in blood.
• Regulated medical or infectious waste: blood and body fluids in amounts that could drip, pathological waste from surgery, microbiology lab waste and sharps. It goes in labeled red bags or containers and is treated before disposal.
• Sharps, in puncture-resistant containers, which are sealed and collected as infectious waste.
• Hazardous drug waste: trace chemotherapy waste in specially labeled containers, and bulk hazardous drug waste handled as hazardous waste. HSE-394 covers it.
• Pharmaceutical waste and chemical waste, collected separately and never poured down the drain.
• Recycling, confidential paper and electronic waste.

Putting waste in the wrong stream is a safety problem as well as a cost problem. A needle in a general waste bag can injure a housekeeper, a transporter or a worker at the waste contractor. Too much ordinary waste in biomedical bins costs money and fills the storage room. The waste rooms themselves need to be secure, ventilated, cool and easy to clean.

The laundry

Northbridge processes 4,200 lb (about 1,900 kg) of linen a day in its own laundry, for the hospital, Maple Court and a small contract with a clinic. The laundry runs two shifts with about 22 staff, and Marta works there one week in four. Linen moves through the building in one direction, from soiled to clean, so that clean linen never meets dirty linen or the air from the soiled side.

• Collection: soiled linen is bagged at the bedside in fluid-resistant bags, never shaken, sorted or carried against the body, and bags are filled only about two-thirds full so they can be closed and are not too heavy.
• Soiled sorting: this is the riskiest step for infection and sharps. The sorting room is kept under negative pressure so that air flows in, not out. Staff wear gowns, gloves and face protection, use sorting tables at a good height and never put their hands into the middle of a pile. Many hospitals now wash without sorting, or sort only after washing, which removes much of this hazard.
• Washing: wet linen is heavy, often three times its dry weight. Tunnel washers and washer-extractors that load and unload automatically, and spring-loaded carts, reduce lifting. Laundry chemicals are dosed automatically.
• Drying: dryers are hot and their lint is flammable. Lint screens are cleaned every shift, and dryers are never opened mid-cycle or overloaded.
• Ironing and folding: flatwork ironers and folding machines have rollers that can catch fingers, hands and hair. They must have guards and finger bars that stop the machine, an emergency stop within reach, and they are locked out before any clearing of jams or cleaning. HSE-210 covers lockout. Folding is also highly repetitive work.

Heat is a hazard throughout the laundry, especially in summer, when the area around the dryers and ironers can be several degrees warmer than the rest of the building. Ventilation, cool drinking water, breaks in a cooler area and rotation between hot and cooler tasks help. HSE-243 Heat and Cold Stress covers heat in detail. Noise from tunnel washers and dryers can also be high enough that hearing protection is needed in some areas.

Tracking sharps in linen

Every sharp found in linen in the sorting room is logged with the unit the bag came from. Joanne uses the log to see which units are sending sharps to the laundry, adjusting for how much linen each sends.

# Sharps found in soiled linen at the laundry, last 6 months
finds = {"Emergency": 7, "4 West": 5, "3 East (surgical)": 4, "ICU": 2,
         "Maple Court": 1, "Birthing": 1, "Mental health": 0}
linen_kg = {"Emergency": 31000, "4 West": 38000, "3 East (surgical)": 36000, "ICU": 14000,
            "Maple Court": 61000, "Birthing": 12000, "Mental health": 9000}

total_finds = sum(finds.values())
total_kg = sum(linen_kg.values())
overall = total_finds / total_kg * 10000
print(f"overall: {total_finds} sharps in {total_kg:,} kg = {overall:.2f} per 10,000 kg\n")

rates = sorted(((finds[u] / linen_kg[u] * 10000, u) for u in finds), reverse=True)
for rate, unit in rates:
    flag = "  <-- above twice the overall rate" if rate > 2 * overall else ""
    print(f"{unit:20} {finds[unit]:2} finds  {rate:4.2f} per 10,000 kg{flag}")

overall: 20 sharps in 201,000 kg = 1.00 per 10,000 kg

Emergency             7 finds  2.26 per 10,000 kg  <-- above twice the overall rate
ICU                   2 finds  1.43 per 10,000 kg
4 West                5 finds  1.32 per 10,000 kg
3 East (surgical)     4 finds  1.11 per 10,000 kg
Birthing              1 finds  0.83 per 10,000 kg
Maple Court           1 finds  0.16 per 10,000 kg
Mental health         0 finds  0.00 per 10,000 kg

The emergency department stands out: it sends less linen than 4 West or 3 East but more sharps, at more than twice the hospital's overall rate. The investigation finds that sharps containers in two emergency bays are mounted on the far wall, away from where staff work, so used sharps get put down on the stretcher for a moment and are wrapped up with the sheet. Moving the containers to the point of use cuts the finds. Without the log, the laundry staff would simply have kept finding needles.

For supervisors: the people nobody sees

Environmental services and laundry staff are often left out of the unit's safety conversations: they are not at the huddle, nobody tells them which patient is on airborne precautions or has a violence flag, and their reports go to a different manager. If you manage a clinical unit, make sure the housekeeper assigned to your unit gets the same safety information as your nursing staff, including isolation signs that are up to date and alerts about patients with a history of violence. If you manage environmental services or the laundry, make sure your staff are on the safety committee, in the training and in the injury reviews, and that their reports of sharps and spills go back to the units that caused them.

Working alone at night

At night, the environmental services department runs with a small crew spread across the whole building. Staff may be alone in basement corridors, waste rooms, the laundry or an empty clinic. Northbridge gives night staff a phone or radio, a check-in with the night lead every two hours, access to the security team and a rule that they do not enter a patient room alone where there is a violence flag. HSE-352 Working Alone and Late-Night Safety covers check-in systems in detail.