|Year : 2014 | Volume
| Issue : 1 | Page : 13-20
A study of occupational health and safety measures in the Laundry Department of a private tertiary care teaching hospital, Bengaluru
M. Shashi Kumar, B. Ramakrishna Goud, Bobby Joseph
Division of Occupational Health Services, Department of Community Medicine, St. John's Medial College, Bengaluru, Karnataka, India
|Date of Web Publication||21-Jun-2014|
M. Shashi Kumar
#620, Raghava Nilaya, 6th Cross, Bhuvaneshwari Nagar, T. Dasarahalli, Bengaluru 560 057, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: The Laundry Department plays an important role in preventing the spread of infection and continuously supplying clean linen to various departments in any hospital. Objectives of the Study: To identify existing practices and occupational safety and health (OSH) measures in the Laundry Department and to assess the use of personal protective equipments (PPEs) among health care workers. Materials and Methods: A cross-sectional study was carried out in a private tertiary care teaching hospital. An observation checklist was developed, which was partially based on occupational hazard checklist of OSHA for Laundry Department. This was field tested and validated for applicability for this study. Results: The potential biological hazards are infections through exposure to aerosols, spills and splashes during various activities, fungal infection due to wet clothes and environment and infections through fomites. The potential physical hazards are injuries due to slips and falls, exposure to heat, humidity, dust, noise, and vibration. The potential chemical hazards are contact dermatitis and allergic asthma due to exposure to detergents, phenyl solution, bleaching powder, and soap oil solution. The potential ergonomic hazards are musculoskeletal diseases and repetitive stress injuries at the shoulder, elbow, and small joints of the hands. PPEs were not used consistently in most areas of the department.
Keywords: Hazards, laundry department, personal
|How to cite this article:|
Kumar MS, Goud BR, Joseph B. A study of occupational health and safety measures in the Laundry Department of a private tertiary care teaching hospital, Bengaluru. Indian J Occup Environ Med 2014;18:13-20
|How to cite this URL:|
Kumar MS, Goud BR, Joseph B. A study of occupational health and safety measures in the Laundry Department of a private tertiary care teaching hospital, Bengaluru. Indian J Occup Environ Med [serial online] 2014 [cited 2019 Jun 16];18:13-20. Available from: http://www.ijoem.com/text.asp?2014/18/1/13/134951
| Introduction|| |
Any person indulging in an occupation, whether working for a big enterprise or self-employed, studying, earning, retired or a housewife, is exposed to occupational health hazards. These hazards, if ignored, may lead to an occupational disease. Awareness of hazards and appropriate preventive measures mitigate or prevent most occupational diseases. 
Occupational health and safety (OHS) is defined by the OHS advisory services 18001 (OHSAS 18001) as "conditions and factors that affect, or could affect, the health and safety of employees, temporary workers, contractor personnel, visitors or any other persons in the workplace.  "According to the US National Safety Council "effective occupational safety efforts involves the control and elimination of recognized workplace hazards to attain an acceptable level of risk and to promote the wellness of workers. Optimal occupational safety results from a continuous proactive process of anticipating, identifying, designing, implementing, and evaluating risk-reduction practices. "
Occupational safety and health (OSH) is as important in the health care setting as it is in any industrial or agricultural setting.  Health care workers (HCWs) are at risk from exposure to hazardous biological, chemical and physical agents as well as repetitive strains, violence and fatigue, many of these maybe life-threatening in nature. Exposure to hazardous agents depends upon the job category and the work environment of the HCW. 
Occupational safety and health is as important in the health care setting as it is in any industrial or agricultural setting.  HCWs are at risk from exposure to hazardous biological, chemical and physical agents as well as repetitive strains, violence and fatigue, many of these maybe life-threatening in nature. Exposure to hazardous agents depends upon the job category and the work environment of the HCW. 
According to World Health Organisation estimates, there are 59.8 million HCWs worldwide. About two-thirds of them (39.5 million) provide health services; the other one-third (19.8 million) are management and support workers, which includes those working in ancillary Departments such as Laundry, Dietary, CSSD, Laboratory, Mortuary, Ambulance Services and Administrative Departments. 
Studies documenting the incidence of needle stick injuries among HCWs are available the same is not the case with respect to Laundry Department's personnel. [7-13] This ancillary department plays a vital role in preventing infection by supplying linen.
Objectives of the study
The objectives of this study were:
- To identify existing practices and occupational safety measures in Laundry Department of a tertiary health care institution, and
- To assess the use of personal protective equipments (PPEs) by various categories of HCWs in this department.
| Materials and methods|| |
This was a cross-sectional study.
The study setting was a private tertiary care teaching hospital located in Bengaluru city with bed strength of 1200 beds and bed occupancy of approximately 85%. The hospital provides super specialty and sub-specialty services at out- and in-patient departments and at outreach areas. Laundry Department that is integral to the optimum functioning of the clinical services that are provided.
Selection of the study population
Currently working individuals who consented to participate in the study.
Currently working individuals who could not be met at work place even after three attempts.
The survey was undertaken between September 2009 and August 2010.
Instruments used for the study
An observation checklist was developed by the investigator. This observation checklist was partly based on:
- Occupational hazard checklist by the OSHA 
- And partly self-developed (based on interactions and observation of activities at the department)
The questions were based on the literature review on hazards for the workers involved in these activities.
Validation of the observation checklist
The checklists were face validated by three experts in the field of occupational health working in large tertiary care hospitals in Bengaluru city and their comments and suggestions were incorporated.
Methods of data collection
Multiple visits (at least five visits) were made and the activities were observed in order to document the work processes and occupational safety measures in place therein. An unannounced visit was also made to observe the practice of use of PPE.
Interviews with workers
Informed consent was obtained from the workers before the factors determining the appropriate use of PPEs were identified by administering a pretested schedule to them.
The qualitative data were documented by the following methods:
- On site interaction with the workers during the visits were undertaken to determine the reasons for not utilizing the PPEs
- Key informant interviews were conducted using a semi-structured questionnaire. The key informants for the study were:
- The in-charge of the department
- The activity supervisor
- Selected workers in the department.
Analysis of data
The data collected were entered into Excel Spreadsheets and analyzed using Microsoft Excel. Frequency tables were used to describe the distribution of study variables in the population.
| Results|| |
The findings are described under following headings:
- Description of physical structure of the department
- Schematic representation of areas of the department and the activities under each area
- Description of hazards into biological, physical, chemical, and ergonomic hazards
- Characteristics of the workers
- Use of PPEs among the workers.
Description of physical structure [Figure 1]
The laundry has been divided into many areas based on the activities. The list of areas is as follows:
|Figure 1: Schematic representation of the area of the department and the activities under Laundry Department|
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- The linen receiving area: This is an area where the linen from various departments are received and segregated
- Common hall: This is a large hall where the activity of collection of unwashed clothes takes place. In addition in another area of this hall, washing, drying and pressing takes place
- Dirty linen washing area: The area where soiled/dirty linen are rinsed with the water before transferring to the washing area. This activity is carried out by a washer woman
- Washing area: The area where clothes are washed. Steam is used for the washing the clothes and also to disinfect them
- Linen squeezing area: This is an area where water from the washed clothes is extracted using "hydro extractor" machine
- Drying/spreading area: There are three different sheds for sun drying the clothes
- Folding room: This is the area where the washed clothes are folded and arranged
- Store room: In this room, the washed and pressed clothes are collected by the staff of the operation theater (OT) and CSSD
- Tailoring section: In this room, the damaged clothes are stitched.
Description of hazards into biological, physical, chemical, and ergonomic hazards
Biological hazard sat the Laundry Department
- At the linen receiving area, the workers involved in counting and segregating linen are at potential risk of infections due to: (a) Contact of the skin to the linen soiled with body fluids and (b) inhalation of aerosols generated due to handling of the wet linen. The supervisor was not consistently wearing PPEs
- During the transportation of the dirty linen from receiving area to the dirty linen washing area, it was observed that the worker's clothes and forearm were in contact with the body fluids present on the clothes
- At the dirty linen washing area, the workers were involved in rinsing of the soiled linen (blood clots, vomitus, cerebrospinal fluid and fecal matter) used in different in-patient wards, emergency departments, intensive care units (ICUs) and OT. Here, the worker manually removes the contaminants by placing the linen against a powerful stream of water. This activity generates a lot of aerosols and splashes that drench the clothes and body of the worker, as well as the floor. The worker is also exposed to the feces and body fluids, while transferring the linen from the trolley into the disinfectant tank used for the activity
- The worker at the dirty linen washing area used all the appropriate PPEs before starting the washing process except the gloves, which are ill-fitting. The gloves were found to be of substandard quality in addition to being damaged. The worker continued to work with the same gloves, which lead to hands coming in contact with body fluids (and thereby pathogens therein)
- The workers at the washing area are also exposed to aerosols generated during the washing process and also possibly by the ingestion of droplets generated due to splashes.
Physical and environmental hazards
- On an average, the department receives linen in the range of 9000-11000 clothes/day. Most of them are manually counted by the worker at the receiving counter. The helper is at risk of musculoskeletal injury of the back muscles especially at the lumbar region as he flexes and extends the back, while counting the linen and at the shoulder joint due to repetitive movements
- In the washing area, the workers had a potential risk of fall. The floor at this area was slippery due to spillage of soap oil solution and drained water. It was reported that one of the workers sustained fracture femur due to slip and fall in the washing area. This fall happened while loading the linen into the washing machine
- It was observed and also reported by the workers that linen in the washing machine got entangled after washing is completed and was difficult for the workers to unload them. Here, the worker is exposed to physical hazards of musculoskeletal injury (of muscles of hand, chest and shoulder) while in the process of extracting the clothes from the machine. The workers also reported pain at these sites after the activity
- The workers reported injuries to the elbow and hands when they hit the machine surfaces due to the slipping of the entangled wet linen using gloves. Hence, none of them used gloves
- The workers were exposed to the continuous noise at the washing area and linen squeezing area. The lid of the "hydro extractor machine" was loose and generated noise. To reduce the noise workers usually put pressure on the lid by using their hands which in turn exposes them to vibration hazards
- At the spreading area, the worker bends to pick the linen and lift it above his head and spread the clothes over the string. These can potentially cause musculoskeletal disorders (MSDs)
- The worker at the pressing area is exposed to the hazards of burns and scalds, heat and humidity.
- The Laundry Department is involved in preparation of soap oil, detergent powder and bleaching solution and phenyl solutions and supplying it for the entire hospital. Each of these activities lasted for 4-6 h a day and happens 4 days a month. During the preparation, the workers complained of severe irritation and burning sensation of the eyes, nose, mouth, throat, and face after the activity. They also reported burning sensation in the stomach. During the visit, one of the workers reported of contact dermatitis of upper and lower limbs. Workers collecting the linen from the wards are exposed to hypochlorite solution
- The workers are exposed to cotton dust, especially in the linen collection area and tailoring unit and folding area. They are exposed to dust during the activity of collecting of the dried clothes from the spreading area and linen folding area.
- The trolley used by the worker for transportation of linen from the linen storage area to the receiving counter was overloaded and the worker was straining his body to push the trolley. The load of clothes blocked the vision of the worker resulting in him bending to one side to visualize the path. This makes him prone for MSD like back strain
- The workers in the washing areas (both dirty washing area and the washing area) adopted abnormal posture and body positions, while transferring the linen from the trolley to the washing area and vice versa
- The height of the hydro extractor machines used for drying of the washed linen is at the mid-thigh level, due to which the workers repeatedly bend and extend the back while loading and unloading the machine hence straining lumbar spinal region. They are also more prone for the MSDs, especially low back ache and side strain while pulling the entangled linen out of the extractor. The workers are at risk of MSDs due to repetitive bending and standing while drying clothes in Linen Drying area [Figure 2].
|Figure 2: The worker raising the hands above his head to spread the washed clothes in washing and drying area|
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Personal protective equipments
- [Table 1] and [Table 2] show the use of PPEs in various areas of the Laundry Department
- At the linen receiving area, the workers were not wearing gloves or mask. The reasons reported were (a) The workers said that they felt that it is not necessary for them to wear gloves for these activities as they rarely come in contact with linen. (b) The worker said that it is uncomfortable to use the mask because it caused some amount of breathing difficult "TumbaHimsaehakolloke, usiradokkekasta" - very uncomfortable to wear and difficult to breathe
- At the dirty linen washing area, it was noted that the worker used recommended PPEs during the activity; however, the gloves used were re-sterilized gloves from CSSD, which are not durable and got damaged easily, while working. Many of these were ill-fitting to the worker and exposed him/her to hazards
- The boots used by the worker were ill-fitting (large) and made the worker uncomfortable and slowed movements during the activity. Hence, to overcome this difficulty the worker used to throw the linen into the water tank from a distance generating splashes and spills. This process also released aerosols. At the same time, the worker is prone for MSDs
- The workers at the washing area and the squeezing area used waterproof aprons and boots for the activities. They did not wear gloves, mask, and goggles. The reasons for this practice of not using these PPEs were as follows:
- Gloves: The gloves used by the workers were made of either latex or rubber; hence, it was difficult for them to grip and pull the entangled wet washed linen from the machines. As mentioned earlier few of the workers had also experienced injuries when they used gloves during the activity
- It was also observed that workers used gloves only to load linen received in the morning batch because most of the linen received were from OT, ICU, and pediatric ICU. They also receive linen used for caring people infected with HIV and methicillin-resistant Staphylococcus aureus. The workers considered them more infectious than the linen received in other batches
- Mask: The workers reported not using mask in this area because the activity of loading and unloading the linen into and from the machines is strenuous and mask makes it difficult for them to breathe. The sweat secreted during the activity also caused irritation to the face. They also reported that on most days the workers suffer from cold and cough and the phlegm produced makes the mask wet, messy and sticky. Few also reported that they felt more heat in the face when they wore the mask. It was reported that they use the mask only when the smell of linen is bad or when the linen is visibly soiled with blood and feces
- Boots: They use these regularly because the floor is slippery and it is difficult to walk on the surface. However, in the afternoon and when the load of linen is less a few workers did not wear boots
- Apron: All the workers were observed to be using the aprons at the washing area and the linen squeezing area
- Ear plugs: The workers did not use ear plugs as they were not provided to them. At the folding area the workers used mask inconsistently. The reasons were that it was difficult to breathe and to communicate with other workers during work.
|Table 1: Distribution of workers based on experience and compliance to the PPEs|
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Characteristics of the workers in the Laundry Department
77% of the workers in the Laundry Department were males [Table 3]. Among them 67% were <35 years of age 23% of all employees were permanent employees and 77% were contractual employees. There were equal number of males and females among permanent employees; however, among contractual employees 85% were males [Table 4].
|Table 3: Age and gender distribution of the workers in Laundry Department|
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|Table 4: Gender distribution of the workers based on their employment status and years of experience|
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Twenty employees (65.5%) had work experience of <10 years and 15 workers have >10 years of work experience. [Table 5] summarizes the distribution of workers according to their designation and gender. All the ward boy and supervisors were males, while department in-charge and tailors were by females.
|Table 5: Distribution of the workers based on gender and work designation|
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Personal protective equipments
In the Laundry Department, only the workers at the dirty linen washing area used all the appropriate PPEs for their activities; however, they were not consistent with the usage. The workers in other areas did not use PPEs consistently. Even though, the need for the various PPEs varied from area to area, the factors affecting the noncompliance of the PPEs usage depend on the type of PPEs and activities they were involved and most of them were similar irrespective of the difference in areas of work in the department. The factors affecting the usage of PPEs are as follows:
- Mask: Difficulty to breathe, communicate; irritation due to sweat secreted during the activity; feeling of more heat in the face when they wore the mask; and medical conditions like rhinitis
- Gloves: The gloves used by the workers were made of either latex or rubber; hence, it was difficult for them to grip and pull the entangled wet washed linen from the machines
- Boots: Ill-fitting (large) boots especially for the female workers; uncomfortable and slowed her movements during the activity. However, they used these regularly
- Ear plugs: The workers did not use ear plugs as they were not available to them
- The workers did not wear masks or goggles while spreading the washed clothes as most of them thought it is not necessary as the linen was washed and clean.
Characteristics of the Laundry Department
- Of the 35 workers studied in the Laundry Department, males comprised around 77% and females around 23%. This difference was because the activities in the Laundry Department demanded more physical activity such as lifting clothes, pushing linen in trolleys, and handling machines
- 77% of the males were contractual laborers and as already discussed the workers could not access the medical and social security schemes in the hospital. However, all workers did have a periodic health appraisal during which they were examined and referred to respective specialties for free consultations.
| Discussion|| |
The workers at the receiving area, dirty linen washing area, and washing area are more at risk of biological hazards of infections as they come in contact with the linen soiled with body fluids and may also inhale the aerosols generated due to activities in these areas [Figure 3]. The ventilation and lighting in the dirty linen washing area was not satisfactory. Therefore, the chance of infection due to aerosols is more. However, only the worker at the dirty linen washing area used appropriate PPEs, rest of the workers who do not use PPEs. The reasons for the same are explained later. The workers are administered hepatitis B vaccine. Three of the workers reported hepatitis B infection.
|Figure 3: The worker involved in rinsing the dirty linen for removing the blood stains, blood clots and faeces and other stains at the dirty|
linen washing area
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Physical and environmental hazards
- In the washing area, dirty linen washing area, and at the linen squeezing area the floor was slippery due to spillage of soap oil solution and waste water. Even though, major injuries are documented it was seen that minor events were not registered in the department. Fitting the job to the person and specific person to specific jobs may prevent the accidents periodic inspection and maintenance of the machines will prevent the hazards due to vibration and noise.
Ergonomic hazards at the Laundry Department
- Some of the workers overloaded the trolley and strained their back while pushing it. This was practiced to speed up the work and save time. The height of the hydro extractor machines were less hence the workers had to bend at the lumbar spine region to while loading and unloading the machine. This may cause MSD
- A study done by Lloyd et al.  (1988) listed that postural stress and work that approach the limit of a work strength are two out of three most common causes of back pain of all work related back pain. A survey done in Australia has reported that in laundry, 19% of OHS managers and 24% of workers agreed that moving and sorting linen was the most hazardous task with respect to manual tasks. 
| Conclusions|| |
- This study documented that the Laundry Department had Occupational Health and Safety Hazards. This is despite the hospital management having very good policies for the welfare of the HCWs in all the departments. The workers in this department are not aware of the hazards. It is hoped that the findings of this study will trigger the need for other hospitals with similar facilities to plan and execute interventions that will protect and promote the health of this vulnerable group of hospital employees
- The HCWs were exposed to the physical, chemical, biological, and ergonomic hazards. The same hazards are prevalent in the Laundry Department as well. Here too, the exposure to biological hazards varied depending upon the type of activity. This being the case the consistent use of PPEs following a change in behavior and attitude of the workers is to be expected. Regular education sessions, motivation, and monitoring will help improve compliant use of PPEs
- The physical and environmental hazards were common in linen washing area and linen squeezing area. Proper housekeeping will prevent the stagnation of soap oil solution and may reduce the hazards. Proper and regular maintenance of the machines may prevent the hazards of noise and vibration.
| Acknowledgment|| |
Faculty, Department of Community Health, St. Johns Medical College and workers of Laundry Department.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]