Ineffective laundering mechanism of surgical scrubs: Potential source of healthcare-acquired infections.

The issue of surgical attire laundering and storage is not new. There have been several studies, which have looked at the laundering issue and drawn conflicting conclusions over the years. There remains a significant lack of organizational consensus, even in today’s highly infection-control conscious environment, as to where and how surgical attire is to be laundered and stored.

Numerous healthcare governing bodies and advisory organizations, including the Association for Professionals in Infection Control and Epidemiology (APIC), the Association for the Advancement of Medical Instrumentation (AAMI), the Association of periOperative Registered Nurses (AORN), the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA), agree that all surgical attire should be changed whenever it becomes visibly soiled, contaminated, or wet, or at least daily.It is generally accepted that healthcare workers’ uniforms get contaminated with bacteria during the administration of care, particularly during surgical procedures and wound care. Studies have repeatedly isolated bacteria from the uniforms of healthcare workers, including bacteria that were multi-drug resistant.The matter of concern, however, is that sometimes uniforms “enter” healthcare facilities already contaminated. A study found that 39 percent of healthcare workers’ uniforms tested were positive for VRE, MRSA, and C. difficile at the start of shift. These findings certainly suggest that the laundering mechanism is potentially failing to achieve uniform decontamination.

 The subject of where and how surgical attire is laundered becomes an extremely important issue. A survey of healthcare staff in the UK’s NHS trust revealed that 90 percent of that staff took responsibility for the laundering of their uniforms.There have been several studies which have raised troubling questions about the safety and efficacy of the home-laundering of surgical attire. A study of the typical home-laundering process (wash cycle with detergent alone, rinse cycle and a 28-minute permanent press drying cycle)  revealed that significant concentrations of viruses (adenovirus, rotavirus, and hepatitis A virus) survived the process and could also be transferred  to uncontaminated garments.Other studies have documented the presence of Vancomycin-resistant enterococcus (VRE), methicillin resistant Staphylococcus aureus (MRSA), and Clostridium difficile on home-laundered uniforms, suggesting the inadequacy of the home-laundering process in eradicating these organisms.

 Furthermore, while some data suggests that insufficient temperature control in home-laundering cannot guarantee uniform decontamination, other investigators suggest that, newer energy-saving domestic washing machines may actually provide lower wash temperatures than indicated and may also offer less vigorous washing cycles.

In light of the potential risks associated with home-laundering, a study was undertaken to provide additional insight into the subject. The aim was to compare the aerobic bacterial bioburden associated with surgical scrub attire separated into different categories based on their single-use/reusable status, use (worn versus clean) status, and, for the reusable scrubs, laundering mechanism (facility-laundered, third-party/commercial-laundered, and home-laundered). The  results demonstrated that the bioburden associated with “clean” home-laundered scrubs were significantly greater than those associated with all of the other “clean” scrubs facility-laundered, third party-laundered, and single-use, non-woven.

Further detailed study to identify the specific organisms comprised in these bioburden, whether they have a clinical significance and whether there is a relationship between this bioburden and surgical site infections (SSIs) or healthcare–acquired infection(HAIs) is under investigation. With SSIs being the most common nosocomial infection among surgical patients and accounting for 22 percent of all HAIs according to the CDC, these questions become quiet significant. It makes intuitive sense that bacterial exposure from surgical scrub garments could potentially contribute to the development of SSIs. Given the impact SSIs and other HAIs have on patient morbidity and mortality, healthcare expenditure and the significant issue of anti-microbial resistance, all healthcare practices with the potential to influence the development of these infections need to be carefully evaluated. This study also suggests that the home-laundering of surgical scrub attire cannot not be supported, and thus, should be re-evaluated by those healthcare organizations and recommending bodies currently allowing it.