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FAQ - Miscellaneous - 2016
FAQ - Miscellaneous - 2016

 

 

Could you possibly provide guidance and references regarding laundering of contaminated PPE or linens within the facility vs. commercial laundering? Thanks in advance for your help and resources. 

Ask OSAP has encountered this question as it pertains to dental office setting, and can offer some relevant general information. Some additional points can be made from the OSHA perspective.

Infection Control and Management of Hazardous Materials for the Dental Team states as follows:

Contaminated Laundry

Contaminated laundry (e.g., reusable protective clothing, towels, and patient drapes) is to be handled as little as possible with a minimum of agitation. Laundry is not to be bagged, containerized, sorted, or rinsed in the location of use. Contaminated laundry is to be placed and transported in bags or containers that are color-coded or labeled with a biohazard symbol. When a facility uses universal precautions in handling all laundry to be cleaned, alternative labeling is sufficient if it permits all employees to recognize the containers as requiring compliance with universal precautions. If the contaminated laundry is sent off site for cleaning, it must be placed in bags or containers that are color-coded or labeled with a biohazard symbol, unless the laundry uses universal precautions in handling all soiled laundry. 1

And,

The OSHA bloodborne pathogens standard also indicates that employees cannot take home contaminated clothing and linens for laundering. Laundering is the responsibility of the employer through laundering in the office or by contracting with a commercial laundering service. 1

The US Occupational Safety and Health Administration (OSHA) states the following regarding laundry in a Letter of Interpretation:

Question 1: Do "universal precautions" apply to the activities of medical and dental facilities (e. g., the handling of masks, goggles, gloves, lab coats or other personal protective equipment (PPE))?

Reply 1: Yes. According to the Bloodborne Pathogens Standard, "Universal precautions" is an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens." 29 CFR 1910.1030(b). 29 CFR 1910.1030(d)(1) requires that universal precautions be observed to prevent contact with blood or other potentially infectious materials. This would include the handling of PPE that has become contaminated with blood or other potentially infectious materials (OPIM) in medical and/or dental facilities.

Question 2: Would it be a violation of the Bloodborne Pathogens Standard if medical or dental facilities failed to adhere to universal precautions for the handling of blood, OPIM, or items, such as laundry contaminated with blood or OPIM?

Reply 2: Yes. Medical and dental facilities failing to adhere to universal precautions would be in violation of section 29 CFR 1910.1030(d)(1) unless the facility is observing a more stringent set of guidelines. According to the Centers for Disease Control and Prevention's (CDC's) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007: "Standard precautions combine the major features of Universal Precautions and Body Substance Isolation and are based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered. . ."1 These include hand hygiene; use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. Standard precautions are more stringent than universal precautions alone and would be acceptable.

Question 3: Would potential contact of textiles, such as linen or laundry, with unknown body fluids in medical or dental settings where universal precautions are practiced trigger coverage under OSHA's Bloodborne Pathogens Standard at that medical or dental facility? Also, would the contaminated textiles require special handling under the Bloodborne Pathogens Standard?

Reply 3: Pursuant to 29 CFR 1910.1030(a), the Bloodborne Pathogens standard is applicable to all occupational exposure to blood or other potentially infectious material (OPIM), as defined in 29 CFR 1910.1030(b). The definition of OPIM includes saliva in dental procedures, among other things. Occupational exposure is defined as "reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's duties." A determination of the duties, tasks, and scope of the employees' work must be done by the employer to assess whether employees have reasonably anticipated exposure to blood or OPIM [29 CFR 1910.1030(c)(2)]. Employers with employees who launder or otherwise handle linen contaminated with blood or OPIM (e.g., housekeeping staff in a healthcare setting; employees in a commercial laundry facility with a contract to launder contaminated linen from medical/dental settings) would be considered to have reasonably anticipated exposure and would be covered by the standard. Blood is often found on linen and laundry in medical facilities, and saliva is often found on such materials in dental offices. With respect to unknown fluids, 29 CFR 1910.1030(d)(1) provides in pertinent part: "Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials." The fact that the contaminated textiles are in a medical or dental facility where universal precautions are practiced would not preclude coverage under the Bloodborne Pathogens Standard.

With regard to the handling of contaminated laundry, 29 CFR 1910.1030(d)(4)(iv) sets forth the requirements for the handling and transport of laundry contaminated with blood or OPIM. For example, 1910.1030(d)(4)(iv)(A) and 1910.1030(d)(4)(iv)(A)(1) - 1910.1030(d)(4)(iv)(A)(3) cover the handling, containerization and transport of contaminated laundry, while sections 1910.1030(d)(4)(iv)(B) and 1910.1030(d)(4)(iv)(C) cover use of PPE while handling contaminated laundry and use of color-coded or labeled bags for transport to off-site facilities that do not use universal precautions in handling all laundry (e.g., transport to an off-site commercial laundry facility). Please refer to these sections of the standard for the specific requirements.

Question 4: Would an off-site facility (e.g., commercial laundry facility) which handles contaminated linen from healthcare settings be required to have a written exposure control plan?

Reply 4: Yes, as stated in the response to question #3, employers with employees who launder or otherwise handle linen contaminated with blood or OPIM (e.g., employees in a commercial laundry facility with a contract to launder contaminated linen from medical or dental settings) would be considered to have reasonably anticipated exposure to blood or OPIM and, thus, would be covered by the Bloodborne Pathogens Standard. Consequently, such employers are required to establish a written exposure control plan designed to e
liminate or minimize employee exposure. 29 CFR 1910.1030(c)(1).

Question 5: Does an employer need to also ensure the proper laundering of contaminated linen?

Reply 5: The Bloodborne Pathogens Standard covers the handling and transport of contaminated laundry for the protection of employees; however, OSHA regulations do not have specific requirements for actual laundering procedures for assuring patient-specific infection control. OSHA's authority is limited to the protection of workers. As you noted in your inquiry, there are existing infection control guidelines set by the CDC. In the 2003 Guidelines for Environmental Infection Control in Health-Care Facilities, the CDC provides guidance for the handling, cleaning, and disinfection of contaminated laundry. The document can be found at
http://www.osha.gov/pls/oshaweb/owaredirect.html?p_url=http:/www.cdc.gov/mmwr/preview/mmwrhtm/rr5210a1.htm.

Question 6: Is it permissible for employees to launder personal protective equipment like scrubs or other clothing worn next to the skin at home?

Reply 6: In your inquiry, you correctly note that it is unacceptable for contaminated PPE to be laundered at home by employees. However employees' uniforms or scrubs which are usually worn in a manner similar to street clothes are generally not intended to be PPE and are, therefore, not expected to be contaminated with blood or OPIM. These would not need to be handled in the same manner as contaminated laundry or contaminated PPE unless the uniforms or scrubs have not been properly protected and become contaminated.

Question 7: Is an employer in a dental office responsible for implementing an exposure control plan at the establishment if that employer launders the contaminated linen or PPE onsite?

Reply 7: Yes. Again, please see the response to question #3 above. Also, please be aware that dental offices would have other reasonably anticipated exposure scenarios other than the laundering of contaminated PPE that would make it necessary to develop and implement an exposure control plan. The exposure control plan should cover all job classifications and tasks in which employees have occupational exposure.

Question 8: Is that same employer responsible for following the CDC guidelines for laundering contaminated laundry?

Reply 8: The CDC guidelines are not mandatory. They are recommendations written with the intent of enhancing infection control measures in all healthcare facilities, including dental settings.

Question 9: How would OSHA regard an employer in a dental office who does not adhere to the requirements of the Bloodborne Pathogens Standard (e.g., use of universal precautions and establishment of an exposure control plan) and who does not use proper procedures for laundering contaminated laundry?

Reply 9: Again, please see the response to question #3 above. All employers having employees with occupational exposure must comply with the requirements of the Bloodborne Pathogens Standard and would be considered noncompliant for failing to do so. Please see the response to question #8 above with regard to the use of proper procedures for laundering contaminated linen. 2

OSHA states the following regarding laundry on its Website:

Contaminated Laundry


Potential Hazard

Contaminated Laundry as outlined in the Bloodborne Pathogen Standard definitions
Section (b) as: laundry which has been soiled with blood or other potentially infectious material
or may contain sharps.

Potential Hazard

Exposure to blood or other potentially infectious materials through contaminated laundry that was improperly labeled, or handled.

Possible Solutions

Follow the procedures outlined in the Bloodborne Pathogens Standard,
1910.1030(d)(4)(iv) handling contaminated laundry such as:

  • Handle contaminated laundry as little as possible with minimal agitation.
  • Bag contaminated laundry at the location of use. Do not sort or rinse laundry at the location where it was used [1910.1030(d)(4)(iv)(A)(1)].
  • Place wet contaminated laundry in leak-proof, and color-coded or labeled containers, at the location where it was used [1910.1030(d)(4)(iv)(A)(2)].
  • 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 or containers which prevent soak-through and/or leakage of fluids to the exterior [1910.1030(d)(4)(iv)(A)(3)].
  • Contaminated laundry must be placed and transported in bags or containers labeled with the biohazard symbol or put in red bags in accordance with 1910.1030(g)(1)(i).
    • In a facility that utilizes universal precautions in the handling of all soiled laundry-alternative labeling or color-coding is sufficient if it permits all employees to recognize the containers as requiring compliance with universal precautions [1910.1030(d)(4)(iv)(A)(2)].
    • 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 [1910.1030(d)(4)(iv)(C)].
  • For more information on labeling requirements see:
  • Contaminated laundry bags should not be held close to the body or squeezed when transporting to avoid punctures from improperly discarded syringes.

Under OSHA’s Most Frequently Asked Questions Concerning the Bloodborne Pathogens Standard, the following questions and answers can be found:

Q45. Are employees allowed to take their protective equipment home and launder it?

A45. Employees are not permitted to take their protective equipment home and launder it. It is the responsibility of the employer to provide, launder, clean, repair, replace, and dispose of personal protective equipment.

Q46. Do employers have to buy a washer and dryer to clean employees' personal protective equipment?

A46. There is no OSHA requirement stipulating that employers must purchase a washer and dryer to launder protective clothing. It is an option that employers may consider. Another option is to contract out the laundering of protective clothing. Finally, employers may choose to use disposable personal protective clothing and equipment.

Q47. Are there guidelines to be followed when laundering personal protective equipment? What water temperature and detergent types are acceptable?

A47. The decontamination and laundering of protective clothing are governed by the laundry provisions of the standard in paragraph (d)(4)(iv). Washing and drying the garments should be done according to the clothing manufacturer's instructions. 4

The 1993 CDC guidelines for infection control in dentistry states:

Protective clothing such as reusable or disposable gowns, laboratory coats, or uniforms should be worn when clothing is likely to be soiled with blood or other body fluids (2,5,6). Reusable protective clothing should be washed, using a normal laundry cycle, according to the instructions of detergent and machine manufacturers. Protective clothing should be changed at least daily or as soon as it becomes visibly soiled (9). Protective garments and devices (including gloves, masks, and eye and face protection) should be removed before personnel exit areas of the dental office used for laboratory or patient-care activities. 5

In summary, the cleaning of contaminated dental uniforms should be done in compliance with OSHA’s Bloodborne Pathogens Standard. As stated above: There is no OSHA requirement stipulating that employers must purchase a washer and dryer to launder protective clothing. It is an option that employers may consider. Another option is to contract out the laundering of protective clothing. Finally, employers may choose to use disposable personal protective clothing and equipment. 4  It is also recommended that the manufacturer’s instructions for laundering of a specific garment be followed.

 Resources

1)      Miller CH. Infection Control and Management of Hazardous Materials for the Dental Team, 5th edition. Elsevier/Mosby Publishers. Pages 84 & 116.

2)      US Department of Labor – Occupational Safety & Health Administration. Standard Interpretation Letter Dated February 18, 2016. http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=27008   Accessed on February 18, 2016.

3)      US Department of Labor – Occupational Safety & Health Administration. Hospital E-Tool – Laundry. http://www.osha.gov/SLTC/etools/hospital/laundry/laundry.html    Accessed on February 18, 2016.

4)      US Department of Labor – Occupational Safety & Health Administration. Most Frequently Asked Questions Concerning the Bloodborne Pathogens Standard. http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=21010    Accessed on February 18, 2016.

5)      US Centers for Disease Control and Prevention. Recommended infection-control practices for dentistry, 1993. MMWR 1993;42(No. RR-8). http://www.cdc.gov/MMWr/preview/mmwrhtml/00021095.htm   Accessed on February 18, 2016

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