CHICAGO — A tragic event that happened several years back at a children’s hospital in New Orleans recently grabbed the attention of the general public and gained national media headlines.
Between August 2008 and July 2009, five children who were patients at Children’s Hospital in New Orleans died after an outbreak of mucormycosis, a fungal infection that can be fatal only in rare situations, such as in the case of patients with severely compromised immune systems.
What caused renewed concern about the case was an article published in the Pediatric Infectious Disease Journal summarizing an investigation of the circumstances of the outbreak and of several areas within the hospital and its contracted launderer’s facility. In their report, the authors ultimately identify what they believe is the main transmission vehicle for the fungus: the hospital’s linens.
The authors of Mucormycosis Outbreak Associated with Hospital Linens, some of whom represented the Centers for Disease Control and Prevention, tested linens processed by an outsourced laundry provider and found cases of the fungus in the linen, exposure to which was the only common factor to all of the patients, who occupied several different wards in the hospital.
In the article, the authors state: “In this outbreak, we suspect the contamination of clean linen occurred at the laundry facility or during delivery, after the linen had been washed and dried. The movement of clean linens from the end of the laundry process to the hospital is the time during which the chance of contamination is greatest.”
The report highlighted several opportunities for transmission, pointing to incidents during transport and storage of the clean linens where they were uncovered and exposed to outside air and potentially to construction dust. Rhizopus, a form of mold that causes mucormycosis, is found abundantly in dirt and soil.
While Children’s Hospital has insisted that mucormycosis was “not the primary cause of death in any of the patients,” authors of the journal article say that the hospital has since made major changes to its linen processing and handling protocols, switching to a new laundry vendor, getting rid of old linens, and cleaning and disinfecting linen storage areas.
According to various news reports, civil lawsuits filed against Children's Hospital by families of the victims are pending. The hospital did not respond to requests from American Laundry News for comment.
FOLLOWING PROCEDURES
Industry experts interviewed by American Laundry News had specific suggestions for actions that laundry operators can take to make sure they are following tried-and-true procedures.
Gregory Gicewicz, president of the Healthcare Laundry Accreditation Council (HLAC), says laundries that serve healthcare institutions need to follow HLAC standards and best practices (accreditation by the organization is voluntary).
“Quite simply put, had they followed the standards or had they been accredited, the likelihood of this happening would have been severely minimized,” he says, adding that HLAC’s standards cover processes beyond the washing and drying of linens—including the cleaning of delivery trucks, the covering and disinfecting of carts, proper loading and unloading procedures, and separation on loading docks—all in a process-based approach.
“So what we really preach with this process approach is make sure that you have really well-established, well-defined processes in your laundry, before and after; make sure that your people are trained in those processes; and make sure that you’re constantly, as part of executing these processes, doing your validations of them,” says Gicewicz.
Joseph Ricci, president and CEO of the Textile Rental Services Association (TRSA), reports that its member operators have been receiving an influx of calls from their customers, who want to ensure that the laundries are using proper procedures.
“One thing we’ve been talking to our members about is [that] there certainly are best practices in place that would have helped to avoid this kind of situation,” he says.
Sometimes this means that laundries serving as suppliers to healthcare facilities need to put their foot down when it comes to sticking to those established procedures.
“I think you have to sort of insist as a provider—and sometimes that’s difficult to insist that your customer do something they don’t necessarily want to do—but I think you have to do that,” says Ricci.
He adds that accreditation and certification for laundries are an “extra step” toward making sure proper protocols are followed. A statement released by TRSA addressed an article in The New York Times titled A Deadly Fungus and Questions at a Hospital, which highlighted the incident at Children’s Hospital. The association outlined several recommendations and standards, such as the Centers for Disease Control and Prevention (CDC) standards for packaging, transporting and storing clean textiles. TRSA also listed its Healthcare Service Operations Manual and Hygienically Clean – Healthcare certification as resources for related guidelines.
But Ricci has a word of warning about relying too heavily on certification and accreditation.
“[W]hile the certification process … shows your commitment to the hygienically clean process, and can help ensure that you’re taking the right steps, there’s no guarantee, because there’s not somebody there monitoring every day from any of the certification programs, [ensuring] that you’re doing it right every day,” he says. “So it really becomes incumbent upon the launderer and their customer to work together and really be diligent about these protocols.”
Lisa Waldowski, infection control specialist at the Joint Commission, an organization that accredits healthcare organizations and programs, says its accreditation manual doesn’t specifically refer to laundry or linens, but that it can be identified as a risk factor and assessed by an infection prevention professional as needed. She says one of the Joint Commission’s leadership standards involves monitoring contracted service agreements “to make sure they’re provided safely and effectively.”
In its own response to The New York Times article, the Association for Linen Managment (ALM) outlined its suggestions for oversight of laundry services: accreditation by the Joint Commission, Det Norske Veritas or the Healthcare Facilities Accreditation Program (HFAP); use of hospital licensing authorities that inspect for compliance with Centers for Medicare & Medicaid Services (CMS) standards and any state-specific statutes; and following CMS standards regarding the responsibility of a hospital’s governing body to ensure that contractors comply with regulations and standards.
According to ALM’s statement, “Adherence to sound practice such as the OSHA Bloodborne Pathogens regulations and voluntary standards such as the Association for the Advancement of Medical Instrumentation’s AAMI/ANSI ST65 contributes to the industry’s longstanding reputation for quality.”
“Being aware is half the battle—you’ve still got to follow all the guidelines,” warns Linda Fairbanks, ALM executive director. She says accreditation can help laundries get reacquainted with standards and regulations and be a good check-and-balance system, but it’s not an “end-all, be-all.”
“The laundry [for Children’s Hospital] should have known. The standards are out there,” she says.
Check back Wednesday for the conclusion!
Have a question or comment? E-mail our editor Matt Poe at [email protected].