Best Practices for Maintaining Clean Healthcare Linen Using Exchange Carts

From the Association for Linen Management.

There has been concern of late regarding the integrity of healthcare textiles when utilizing an exchange cart system. There is no need for alarm given that “Outbreaks of infectious diseases associated with laundered textiles are rare; during the past 43 years there have been 12 reported cases globally. To date, there have been no published reports of patient-to-patient transmission of infection associated with hygienically clean textiles (HCT).” 1  The use of exchange carts in healthcare linen services has been in place since the early 1960’s and to-date there has not been a single incident where a patient illness/infection has been associated with this practice.


There are no regulations (federal or state) that mandate a change in current practice for exchange carts. However these concerns do provide an opportunity to remind both laundry processors and linen distribution personnel of the current recommended practices for maintaining clean healthcare linen:

 When transporting, (in trucks/vehicles) clean linens should be packaged in a manner to prevent inadvertent contamination from dust and dirt during loading, delivery and unloading.2

 Linen packaging recommendations include (a) placing linen in a clean hamper/cart with a clean liner that is closed or covered; (b) clean linen in a clean cart covered with a disposable cover or a reusable cover that is properly cleaned and secured to the cart; or (c) wrapping individual bundles in plastic or other suitable materials. 3

 Clean (sterile) textiles and contaminated textiles may be transported in the same vehicle, provided that the use of physical barriers and/or space separation can be verified to be effective in protecting the clean/sterile items from contamination. 4 It should be noted that in a few states the hospital licensing authorities require more stringent measures.

 Clean, uncovered/unwrapped textiles stored in a clean location for short periods of time (e.g., uncovered and used within a few hours) have not been demonstrated to contribute to increased levels of health-care-acquired infection. Such textiles can be maintained dry and free from soil and body substance contamination. 5

 All clean or sterile items being transported in uncontrolled environments should be in a covered or enclosed cart with a solid bottom shelf. 6

 Vehicles used to contain and transport surgical textiles should be cleaned on a regular basis or when visibly soiled. However, if the containment systems used for transport of the soiled items do not prevent contamination of the vehicles, the truck should be cleaned after each use. If the same operator is loading or moving soiled textiles and clean/sterile textiles in the same truck, the operator should use appropriate hand hygiene (e.g., waterless hand sanitizers) to prevent cross-contamination. 7

 Proper hand hygiene practices should be followed after handling contaminated textiles. [i.e., soap and water, antiseptic hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes.] Hands should be washed immediately or as soon as feasible after removal of gloves or other PPE. 8

 Textiles should be rotated and used on a first-in first-out (FIFO) basis. 9

 Clean textiles should be handled as little as possible and with clean hands. Clean textiles that come in contact with unclean surfaces (e.g., the floor) should be relaundered. 10 The Joint Commission has long held that once textiles enter an occupied patient room, even if not used by the patient, the textiles must be reprocessed upon patient discharge.

 Closed or covered cabinets are recommended for the storage of clean/sterile surgical textile items. Open shelving or carts may be used, provided that traffic is restricted to authorized personnel, the area is properly ventilated (the air exchange rate and air flow are correct), and the area is cleaned to ensure that it is free of dust and other visible soil. Shelving or carts used for storage should be maintained in a clean and dry condition. If shelving is used, the bottom shelf should be solid or lined with plastic, or items stored on the bottom shelf should be placed in containers. 11

 Depending on where and how clean/sterile surgical textiles are transported and stored within each facility, procedures should be developed for laundry cart cleaning and disinfection. Carts used to transport clean/sterile surgical textiles outside the facility should be cleaned and disinfected upon return to the facility. Carts used to transport soiled textiles should be cleaned and disinfected after the cart has been emptied and before use for the transport of clean/sterile surgical textiles. Reusable cart covers and liners should be cleaned and disinfected after each use. 12

 Linen delivery personnel, including route representatives, should maintain a clean and professional appearance. 13

 When returning clean/unused textiles to the laundry on an exchange chart – it would only make sense that the same measures taken to initially deliver the textiles to the hospital are also maintained when returning them to the off-site laundry processor in order to maintain their hygienic integrity.


Reviewing practice is never a bad thing and often brings improvement, yet we must be mindful that change in industry-wide practice should be developed from evidence based measures that can be documented and consistently provide improved outcomes when applied. The Institute of Medicine (IOM) in their blueprint for healthcare redesign identified evidence-based practice (EBP) to be
a key recommendation for improving outcomes. “Evidence-based practice holds great promise for moving care to a high level of likelihood for producing the intended health outcome” 14 said Kathleen R. Stevens, EdD, RN, ANEF, FAAN. “It expresses an underlying belief that research produces the most reliable knowledge about the likelihood that a given strategy will change a patient’s current health status into desired outcomes” she continues. ALM believes that broad-reaching change in textile care services practice should be driven by evidence based research. ALM is engaged with a multi-disciplinary task force to provide an analysis of healthcare linen handling practices from the processor to the patient bedside. The resulting evidence will be used to identify problematic areas and improve upon linen handling practices to ensure the hygienically clean textiles produced by quality laundry providers are maintained to the patient bedside. Results from this research should be available in the first quarter of 2017.

1 APIC Text of Infection Control and Epidemiology, Healthcare Textiles, r 2016_March_10
2 Centers for Disease Control and Prevention, Guidelines for Environmental Control in Health-Care Facilities, 2003
3 ibid
4 ibid
5 ibid
6 Association for the Advancement of Medical Instrumentation, ANSI/AAMI ST79:2010 §8.10.2 (General) Distribution containers
7 Association for the Advancement of Medical Instrumentation, ANSI/AAMI ST65:2008/(R)2013 9.5.5
8 Occupational Safety and Health Administration 29 CFR 1910.1030 (d)(2)(iv-v)
9 ANSI/AAMI ST65:2008/(R)2013 9.6.3
10 ANSI/AAMI ST65:2008/(R)2013 9.4
11 ANSI/AAMI ST65:2008/(R)2013 9.6.2
12 ANSI/AAMI ST65:2008/(R)2013
13ANSI/AAMI ST65:2008/(R)2013 9.3
14 Stevens, K., (May 31, 2013) “The Impact of Evidence-Based Practice in Nursing and the Next Big Ideas” OJIN: The Online Journal of Issues in Nursing Vol. 18, No. 2, Manuscript 4; accessed 4/12/2016.