POLICY NAME LINEN POLICY AND PROCEDURE

DOCUMENT TYPE POLICY AND PROCEDURAL MANUAL

DEPARTMENT DOCUMENT NO. ADM-HSKG-P-2023-008
ISSUE DATE 03-27-2023 REVISION 0

1. PURPOSE

1.1 To provide guidance in correct linen handling and management so that the risk of infection
transmission is minimized
1.2 To ensure that all healthcare workers are aware of the actions and precautions require to
minimize the risk of transmission of infection between patients, staff and visitors.

2. SCOPE

This policy applies to all hospital staff both clinical and non-clinical, employed by MHMC who handle linen.

3. DEFINITION OF TERMS
3.1 CLEAN OR UNUSED LINEN
Any linen that has not been used since it was laundered and that has not been in close proximity
to a patient or stored in a contaminated environment.

3.2 DRY USED LINEN

All used linen other than infected linen that remains dry.

3.3 WET USED LINEN - INFECTED LINEN

Any used linen that is soiled with blood or any other body fluid or any linen used by patient with
known infection (whether soiled or not). this includes patients with or suspected: Methicillin-resistant
Staphylococcus Aureus (MRSA), Human Immunodeficiency Virus (HIV), Hepatitis A B C, Active
Pulmonary Tuberculosis, Multidrug-Resistant Tuberculosis, Enteric Fever, Dysentery, Salmonella,
Norovirus and other notifiable disease

4. RESPONSIBILITIES
4.1 Engineering and Environmental Services Head
4.1.1 Ensure that healthcare workers follow this policy.
4.1.2 Promote good practice and challenge poor practice
4.1.3 Directly supervise Institutional worker who is in-charge of linens
4.1.4 Ensuring that Infectious Waste Staff or the housekeeping is aware of their responsibilities,
including the requirement to attend Infection Control Training regarding infection control.
4.1.5 Taking appropriate action should any breach of this policy arise.

4.2 Infection Control Officer

4.2.1 Review and update policy
4.2.2 Give additional advice regarding the management of linen where required.
4.2.3 Responsible fo the implementation of this policy into practice and taking appropriate
action should any breach of this policy arise.
4.2.4 Providing clinical leadership with the policy implementation

4.3 All Healthcare staff and Linen In-charge Hospital Worker

4.3.1 Responsible for adhering to this policy, regardless of role, discipline or service area
4.3.2 Perform risk assessment when handling linen and use appropriate personal protective
equipment.
4.3.3 Observe standard precautions of infection control.

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4.3.4 Report any breach of this policy to immediate head and inform Infection Control Officer
for appropriate action.
4.3.5 Must be familiar and adhere to the relevant infection control policies to reduce the risk
of cross infection
5. POLICIES
5.1 Clean linen must be in a state of good repair, as tearing or roughness can damage the patient’s
skin. The condition of the linen in use should be monitored by the laundry contractor and the
hospital staff incharge of linen. Any tear damage of the linen must be reported to the head of
engineering and environmental services.
5.2 Clean linen must be packed per set in a clean plastic bag and stored in a clean, closed container
to prevent airborne contamination. Stored in a clean, dust free environment and segregated
from used linen.
5.3 Appropriate personal protective equipment (PPE) must be worn by all staff handling and bagging
any used linen. PPE must be removed and disposed of as clinical waste once the task is
completed and hands washed as per Hand Hygiene Policy.
5.4 Bed linen shall be changed routinely and when soiled. Proper schedule should be follow.
5.5 All used linen other than infected linen that remains dry should be placed directly into the plastic
container with label DRY USED LINEN. Linen bag should be no more than 2/3 full.
5.6 All used linen that is soiled with blood or any other body fluid or any linen used by patient with
known infection must be place immediately into the plastic container with label WET USED LINEN.
Linen bag should be no more than 2/3 full.
5.7 Wet and infected linen should be doubled bagged in the event that it is grossly soiled and is
leaking through the single plastic bag. The double bagging can be done by a single individual
inside the room.
5.8 Linen used by/on patient with known infection (MRSA, HIV, Hepatitis A B C, Active Pulmonary
Tuberculosis, and Multidrug-Resistant Tuberculosis, Enteric Fever, Dysentery, Salmonella,
Norovirus and other notifiable diseases) whether wet or dry should be put in a separate plastic
bag, labeled before putting it in WET USED LINEN.
5.9 The linens on tables, wheelchairs and stretchers are used for treatment or transport must be
changed between each patient.
5.10 When removing linen from bed or table, vigorous movements shall be avoided to prevent aerosis
of microorganisms. The linen shall be carefully inspected to insure that all hazardous instruments
have been removed. Fold the linen to the middle of the bed or table and remove it carefully so
that clothing is not contaminated. Contain the linen in a linen bag prior to transport to the
laundry pick up area.
5.11 After the linen container bag is 2/3 full, it shall be tied shut and should be regularly removed from
the wards and transported to the laundry pick-up area for processing as soon as possible to
reduce smell, staining and development of molds.
5.12 The laundry pick-up area must be free of vermin.
5.13 Trolleys for transporting linen must not be used for other purposes and should not pass through
food processing areas. They should be cleaned regularly after use.

6. PROCEDURE
6.1 MANAGEMENT OF LINEN
6.1.1 Handling and storage of used linen in ward.
6.1.2 All dirty linen must be placed carefully and directly into the appropriate laundry
container bag on removal from the bed or patient.
6.1.3 Used and dirty linen must be handled with care to prevent environmental contamination
with excretion or secretion, skin scales or bacteria. Linen must be bagged at the bedside,
never shaken or allowed to touch the floor.
6.1.4 No extraneous items must be place in the laundry bags, especially sharp objects. This
may contribute to a health and safety risk for laundry workers.

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 LINEN POLICY AND PROCEDURE ADM-P-2023-008

6.1.5 Linen must be held away from the body to prevent contamination of clothing.
6.1.6 Linen bags should be no more than 3/4 full.
6.1.7 HANDWASHING AFTER HANDLING USED LINEN IS IMPERATIVE.

6.2 HANDLING AND STORAGE OF USED LINEN IN OR COMPLEX, ICU AND HEMODIALYSIS
6.2.1 Infectious Waste Staff must wear proper PPE before handling linens.
6.2.2 Care must be taken that other objects such as sharps, patient’s personal items etc. are
not discarded with the linen.
6.2.3 All used linen (dry, wet, infected) must be placed carefully and directly in the appropriate
laundry container bag on removal from patient.
6.2.4 Linen should be doubled bagged in the event that it is grossly soiled and is leaking before
placing it in WET USED LINEN CONTAINER.
6.2.5 Linen used by/on patient with known infection (MRSA, HIV, Hepatitis A B C, Active
Pulmonary Tuberculosis, and Multidrug-Resistant Tuberculosis, Enteric Fever, Dysentery,
Salmonella, Norovirus and other notifiable diseases) whether wet or not should be put in
separate plastic bag, labeled before placing it in WET USED LINEN container.
6.2.6 After the linen container bag is 2/3 full it shall be tied by yellow color knot and should be
regularly removed and transported to the laundry pick-up area for processing as soon as
possible to reduce smell, staining and development of mold.
6.2.7 HANDWASHING AFTER HANDLING USED LINENS IS IMPERATIVE.

6.3 TRANSPORTING USED LINEN FROM WARD OR DEPARTMENT TO PICK UP POINT

6.3.1 Laundry bags must be securely tied.
6.3.2 The pick up place must be dry, clean, secure and separate from the clean linen area.
6.3.3 Collection time is every morning and afternoon
6.3.4 Linen handlers must have heavy duty rubber gloves available. Guidance on hand washing
techniques and frequency must be given.

6.4 TRANSPORTING USED LINEN FROM PICK UP TO THE LAUNDRY

6.4.1 the outsource linen provider is responsible for cleaning and disinfecting the container or
vehicle in order to prevent contamination of clean linen; (a) after any spillage, (b) after
transportation of dirty laundry, if it is next to be used for clean laundry, (c) at least
weekly.
6.4.2 There must be no contact between clean and soiled linen at anytime. If clean linen and
soiled or fouled linen are to be carried in the vehicle at the same time there must be a
waterproof barrier present or a rigid container of the used linen.

6.5 RETURN OF CLEAN LINEN FROM THE LAUNDRY TO THE LINEN DEPARTMENT
6.5.1 Contamination of clean linen must be prevented by:
6.5.1.1 Ensuring that linen is packed on a clean plastic bag and adequately covered while on
transport.
6.5.1.2 Vehicle used in carrying linen must be cleaned on a regular basis.
6.5.1.3 Storage in a clean, dry area.
6.5.1.4 Transport in a clean, dry container or vehicle which is cleaned and disinfected prior to
loading with clean linen.
6.6 MONITORING COMPLIANCE WITH AND THE EFFECTIVENESS OF THE POLICY
6.6.1 Process for monitoring compliance and effectiveness
6.6.1.1 Compliance with this policy will be monitored by the infection control officer,
Engineering and Environment Head in liaison with the heads of evey clinical
department.

SAFE MANAGEMENT OF LINEN ALGORITHM

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LINEN POLICY AND PROCEDURE ADM-P-2023-008

PREPARATION AND STAFF PROTECTION

 Ensure appropriate and clean plastic bags or receptacles are available as close to the point of use as possible.
 Personal protective equipment (PPE) should be worn appropriately to ensure contamination from used linen
does not occur.

ALL LINEN

DRY USED WET / INFECTED

 Do not separate linen. Place each item
LINEN LINEN
directly in the designated plastic
container.
 Never place or drop linen on the floor
 Place used linen or on other surfaces which mayy be  Should be placed
immediately into a touched as this could lead to directly into the
designated container. contamination, especially during care containere to prevent
 Used linen should not be delivery. any further handling.
rehandled.  Staff should avoid shaking linen as this The bag should be
 Use linen container may result in the dispersal or secured by using a
should never be potentially pathogenic microorganisms yellow tie.
overfilled and should be and/or skin scales into the  Containter should
appropriately tagged for environment. never be overfilled.
identification  After handling linen, staff should
ensure they dispose of any PPE
appropriately.
 Hand hygiene should be performed
following handling linen,

PREPARED BY: REVIEWED BY: APPROVED BY: NOTED BY:

Jhoanne Monteclaro Jerome Angelo Lascano Lucita Maybituin Subia Atty. Glenn Subia
Admitting Staff Administrative Officer Hospital Administrator President
Note: Please input Name and Signature with Date.

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