Safe water in healthcare premises

Safe water in healthcare premises - why is Pseudomonas aeruginosa such a problem?

Dr. Jimmy WalkerBiosafety, Air and Water Group08:30h Friday December 9th

Water & Health Symposium; Water Use in Public Buildings [email protected] expressed are those of the presenter

2Source: Sedighi et al Detection and Determination of the Antibiotic Resistance Patterns in Pseudomonas aeruginosa Strains Isolated From Clinical Specimens in Hospitals of Isfahan, Iran, 2012 IJMS

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4Source: Sedighi et al Detection and Determination of the Antibiotic Resistance Patterns in Pseudomonas aeruginosa Strains Isolated From Clinical Specimens in Hospitals of Isfahan, Iran, 2012 IJMS

• 4 neonatal units

• 25 infected babies

• 4 fatalities

Northern Ireland incidents 2011-2012

6 Why is Pseudomonas aeruginosa such a problem?


26%

60%

7%

4%

Outlet fitting

Impact of outlets that are positive in the last two metres?

Trautmann et al AJIC 2005


The background2006 - HTM 04-01 The control of Legionella, hygiene, safe hot water,

cold water and drinking water systems.

2013 - Health Technical Memorandum 04-01: Addendum Pseudomonas aeruginosa – advice for augmented care units

2013 - HSG 274

Part 1 The control of legionella bacteria in evaporative cooling systems and

Part 3 The control of legionella bacteria in other risk systems

2014 - HSG 274

Part 2 The control of legionella bacteria in hot and cold water systems

2016 - HTM 04-01 - Safe water in healthcare premises


13 Revision process of HTM 04-01

Caroline WillisGinny MooreSamuel CollinsChloe HutchinsMarc Raymond

Statutory RequirementsHealth and Safety at Work etc. Act 1974

The Management of Health and Safety at Work Regulations 1999

Control of Substances Hazardous to Health (COSHH) Regulations 2002

Public Health (Infectious Diseases) Regulations 1988

Water Supply (Water Fittings) Regulations 1999

Water Supply (Water Quality) Regulations 2000

Private Water Supplies Regulations 2009

Food Safety Act 1990

The Health and Safety Executive’s (4th edition) Approved Code ofPractice L8 2013

British and European Standards


Main Changes to HTM 04-01Provide comprehensive guidance on measures to control waterbornepathogens such as Pseudomonas aeruginosa, Stenotrophomonasmaltophilia, Mycobacteria as well as Legionella (not an exhaustive list)

Align with the Health and Safety Executive’s (HSE’s) recently revisedApproved Code of Practice for Legionella (L8) and the series of HSG274guidance documents.

Updated guidance on the remit and aims of the Water Safety Group andWater Safety Plans.

Advice:

• Hygienic storing and installation of fittings and components

• Any person working on water distribution systems or cleaning wateroutlets needs to have completed a water hygiene awareness trainingcourse.

• Sampling and testing for Pseudomonas aeruginosa now included in PartB to complement similar guidance on Legionella.


16 Why won’t bacteria behave themselves?

Management of your water systemFormation and implementation of Water safety group (WSG)Multidisciplinary groupIdentified lines of accountabilityAppropriate expertise to deliver the Water Plans and Risk

assessmentsParticipation of nursing, clinical, estates and facilities

providersChaired by a person who has appropriate managementresponsibility, knowledge, competence and experience.WSG may appoint an independent professionaladviser/Authorising Engineer (Water) to provide services inaccordance with HTM 04-01.



Présentateur

Commentaires de présentation

Detailed minutes of the group meetings should be recorded, distributed promptly and retained in accordance with the management policy to demonstrate governance. Act in an appropriate and timely manner. Individual responsibilities should not be restricted by the need to hold formal meetings. IPC team should refer episodes of colonisation or infection of patients that could be related to the water system to the chair of the WSG Review any proposed or existing developments associated with the water supply and distribution system to ensure that they minimise risk to patients/service-users Ensure that decisions affecting the safety and integrity of the water system do not proceed without its agreement. All systems and equipment that use water to which patients, staff and visitors could be exposed should be approved by the WSG The WSG should ensure that appropriate expertise and competence is available to ensure the delivery of safe water for all uses throughout the organisation and should have clearly identified lines of accountability up to the CEO and board. Ensure that decisions affecting the safety and integrity of the water system do not proceed without its agreement. IPC team should refer episodes of colonisation or infection of patients that could be related to the water system to the chair of the WSG

Design, installation, commissioning

Decisions affecting the safety and integrity of thewater systems and associated equipment includingprocurement, design, installation andcommissioning of water services, equipment andassociated treatment processes should not goahead without being agreed by the WSG.The WSG need to ensure that appropriate expertiseand competence is available to ensure the deliveryof safe water for all uses throughout theorganisation


Design and RefurbishmentWSG should be consulted at the earliest possible opportunity and waterrisk assessments be completed for all projects for all new premises orrefurbishments

At all stages of the design, installation and commissioning of new orextended water systems, the design team should liaise and consult withthe local WSG in a timely manner

WSG should discuss and agree a sampling regime and appropriateparameters (physical, chemical and microbiological) depending on theintended use of the system and vulnerability of the patients which shouldbe included in the contract

Sampling should be carried out prior to any construction/refurbishmentworks and immediately prior to handover, but no sooner than 48 hoursafter disinfection. It is recommended that sampling is undertaken by anaccredited organisation independent of the contractor.


At what point does the water need to be wholesome?


Description of systems, operational considerations and requirements

Source of supply - public or private supply

Cold water distribution system - good insulation and water turnover

Temperature control regime - require monitoring on a regular basis.

Biocide regimes - Any biocidal treatment is likely to adversely affect thelifecycle of the installation. WSG should be actively involved in thedecision-making process

Pressurisation/supply pumps - ensure all pumps are brought intooperation at a regular frequency (for example, weekly)

Showers - most effective management of showers will be achieved bythe removal of those not used and the regular use of others.

Summary checklist for hot and cold system water systems - updated


ComponentsFlexible hoses - short and kink free and only used to:

• allow for vibration of equipment;

• vertically displace high and low baths and sinks;

• facilitate essential maintenance and access of bespoke equipment whenno alternative is available.

All pipes, fittings, valves, sub-assemblies, calorifiers, cisterns should besupplied to site cleaned, free from waterborne pathogens, particulate matterand other residues.

Pipes should be capped at both ends and pipe joint fittings should besuitably bagged or capped and boxed. Larger items of plant such as pumps,calorifiers etc should have connections blanked with plugs or flanges.

Where possible, leak-testing should be carried out using nitrogen or medicalquality compressed air or oil-free dry compressed air. Where water is usedfor test purposes, it should be supplied from a wholesome source.

Do not accept components that are already contaminated with P. aeruginosa24 Why is Pseudomonas aeruginosa such a problem? (image courtesy of Wendy Claaasen)

Components and risksWhere not integral to the fitting, in-line strainers should be fitted withinthe water pipework system to protect vulnerable valves and fittings(pressure-reducing, safety-relief and stop valves, terminal fittingsincluding thermostats and solenoid valves etc) against ingress ofparticulate matter. THESE WILL REQUIRE SERVICING!

When selecting new taps, HBN 00-09 advises against using aerators,strainers and flow restrictors at the point of discharge.


Components and risksNew systems should not include legs of pipework for potential futureextensions to the system as these will create stagnant legs. Anyalterations to existing systems – or where redundant pipework is found –should be cut back to the connection point; this includes replacing thebranch ‘T’ with a straight coupling.



Outlet fitting

What about the relationship of the hot flow and return?

If 3-5m?Sensor or percussion tap

Components and risksThe risk of scalding for vulnerable patients (young children and olderpeople, disabled people and those with neuropathy) is of particularconcern in healthcare premises caring for such individuals, and thereforethermostatic mixing devices could be needed for hot water outlets.

A risk assessment for scalding risk versus the risk of infection fromwaterborne pathogens should be undertaken by the WSG.


Competencies of risk assessorsThose engaged to carry out any risk assessmentsassociated with water safety should be able todemonstrate to the WSG their experience andcompetence in assessing specific risks frommicrobiological, chemical and physical hazards on thespecific healthcare population.• accredited training (TRAINING MANUAL?)• personal examples of recent water safety risk

assessments in the healthcare sector• Information presented orally and/or by interview• familiarity with statutory regulations including HSG

274, BS 8580 (RA), BSRIA BG 57/2015 (LD RA)29 Why is Pseudomonas aeruginosa such a problem? (LD – Legionaires disease; RA - risk assessment)

The risk assessment should demonstrate to the WSG

• all the relevant factors that may pose a riskof waterborne infection,

• effective corrective or preventive action hasbeen implemented,

• monitoring is in place to ensure the plansare effective in controlling the risk.


Installers (plumbers) and trainingInstallers should adopt practices that reduce the likelihood of cross-contamination from tools, clothing or the environment. Separate clothing andtools used for other non-wholesome services such as sewerage and drainagesystems (blocked toilet) should be kept separate and not used when working onhot and cold water systems.

Only use components and sub-assemblies that have been hygienically stored(for example, wrapped in bags and or original packaging)

Any person who works on hot and cold water systems or who is responsible forcleaning water outlets should have completed a water hygiene training course

NB Contractor’s responsibility to ensure that all operatives intending to work onthe water system have completed water hygiene training covering associatedrisks of working practices and local requirements.

Healthcare organisations should implement a water hygiene training scheme(and health screening element) which utilises local content where possible andis information appropriate for the target audience.


StorageStorage should be designed to minimise residence time in the cistern and maximise turnover of water to avoid stagnation and deterioration of water quality - a nominal 12 hours’ on-site storage is recommended.

Ensure cistern roof supports are of a type that do not retain water within the support, cause pockets of stagnation, or prevent the free flow of water throughout the cistern, as these have been shown to cause degradation of the stored water quality


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Cold Water SystemCold water pipework runs should be designed and installed to reduce therisk of heat gain and should not be above or near heat sources includingceiling-mounted radiant heating panels. Cold water service mains shouldbe run within a different ceiling space, riser or zone from other heatsources. This includes the hot water service distribution system andsteam supply. If not possible, the cold water service and hot waterservices should be run apart as far as practicable and preferably with thehot water at a higher level than the cold.

Government guidance to the Water Supply (Water Fittings) Regulationsrecommends that as far as is reasonably practical cold watertemperatures should not exceed 20±2ºC

Further cooling of cold water should only be considered in specialistunits where people are at particular risk as a result of immunologicaldeficiency, for example bone marrow transplant units. For otheraccommodation, the aim should be to promote turnover of cold water bymeans of the design of the distribution circuitry.


Hot water services Hot water is required in healthcare premises at various delivery temperaturesfor particular needs. The highest temperature, 55°C, is required typically inmain kitchens, laundries, dirty utilities and food preparation areas. Elsewherethe delivery temperature for personal hygiene will depend on individualpreference for comfort and safety of patients who require assistance. Incirculating hot water systems, the highest temperature will be required at alldraw-offs on a loop.

The flow temperature of hot water out of the calorifier should be a minimum of60°C. It should be a minimum of 55°C on flow and returns to all outlets and atthe start of the hot water return. It should be a minimum of 50°C at the finalconnection to the calorifier.

Water system design should negate the need for trace heating in healthcarepremises.

Instantaneous hot water heating should be considered only for smallerpremises.


Thermal Control?The decision whether to install aTMV in areas not normallyaccessible to patients should bebased on a risk assessment

E to

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Thermal control


Areas of biofilm detected(even with thermal flushing andKemper system on the cold)

Courtesy of Chloe Hutchins and Howard Tolley, PHE


Outlet fitting

What about the relationship of the hot flow and return?

If 3-5m?Sensor or percussion (push) tap

55-60C hot flow pipe

Cold water supply

Why is Pseudomonas aeruginosa such a problem? (Garvey et 2016. JHI)

MDR Pseudomonas aeruginosa contaminated outlet filter

Garvey et al., JHI 2016.

Retrograde contaminationAttachment/drips PositioningSufficient activity space (for handwashing)

41 Water Safety IHEEM Cardiff 8th September

Retrograde contamination

Pragmatic issues - water flows

42 New fundamental research on presence and control of water borne pathogens

44 Water Safety IHEEM Cardiff 8th September

Management of controlRequires surveillance and maintenance of control measures includingtemperature control, usage, cleaning and disinfection measures as identifiedwithin the risk assessment and WSP for both hot and cold water systems.

WSG should ensure that estates and facilities staff :

• have up-to-date accurate records and drawings/diagrams showing thelayout and operational manuals of the whole water system.

• should have received adequate hygiene training

• And that IPC teams have received adequate training and that there iscompliance with national evidence-based guidelines for preventinghealthcare-associated infections.

Infection prevention & control teams and WSGs should continue to monitorclinical isolates of waterborne pathogens including the presence of P.aeruginosa in risk-assessed augmented care units as an alert organism andbe aware of possible outbreaks or clusters of infection with thismicroorganism.


Water treatment and controlWhen control of the microbiological safety of water systems cannot beachieved throughout the system by maintaining temperatures, additionalcontrol strategies should be considered to reduce the risk of waterborneinfection. Commonly used strategies include the use of filtration,pasteurisation or the use of biocides.

Where biocides are used as with the temperature regimen, meticulouscontrol and monitoring programmes should be in place if they are to beeffective.

The WSG should:

• be actively involved in the decision-making process to ensure thesuitability of biocidal products for their intended application.

• be satisfied that the design, specification and commissioning willenable the water treatment systems to achieve the required biocideconcentrations throughout the system to minimise microbial risk.

• ensure that measures are taken to protect vulnerable patients such asthose in dialysis units


Water safety planDocumentation - up to date and continually reviewed

Safe hot water temperature - microbiology/scalding risk

Utilisation - stagnation

closure of rooms/units/wards

Maintenance of water supply

contingency

alternative supplies

Performance monitoring

to inform the WSG regarding compliance

Electronic data management tools - to facilitate the intelligentuse of data to easily monitor trends and analyse chemical andmicrobiological parameters.


How much data do you collect?What do you do with the data?

Présentateur


In a large hospital trust monitoring water systems generates a lot of data, where there have been cases of Legionnaires’ disease the amount of monitoring is onerous, costly and if the data is to be used effectively takes a lot of time wading through spreadsheets, looking at the relationships between biocide levels, temperatures, positive microbiology, flushing records, room usage etc. to determine why three is a positive result from a particular outlet or outlets. If there is an patient with Legionnaires’ disease or pseudomonas infections it can take a long time to interrogate the data checking the interrelationships particularly in the light of patient movements. I have been in many an incident meeting where there have been reams of written monitoring data and spreadsheets to go through.

Présentateur


If we look at the data in other ways

Summary Dashboard – examining the detail per asset

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Another advantage of datasabre is the ability to drill down into the individual results and result history for a particular outlet

Legionella Graphical Report with Schematic

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If you then layer these over the positive results you can see the rooms and pipework together

Remedial Actions

Présentateur


Other advantages are the ability to interrogate the data and look at interventions in detail – what makes the biggest difference? Can we take retest out of slide 18 as that in itself is not an intervention – is it possible to see the results following an intervention then following a retest? What does other cover??

P. aeruginosa decision diagram


Other operational considerations that the WSG may need to consider

The WSG need to identify other waterborne hazards

Spa Pools (HSG 282)

Heater Cooler Units – Mycobacteria chimera

Vending, chilled-water and ice-making machines

Portable/room humidifiers

Non-wholesome water storage - fire system

Washand basin outlets (antimicrobial resistance)

Lawn sprinklers and garden (or similar) hoses

Trolley wash systems

Vehicle washing facilities

Internal and external decorative water features

Respiratory nebulisers and humidifiers


Summary• HTM 0401 has been updated to reflect other published guidance and to

reflect the risks from waterborne infections and in particular P. aeruginosa

• A wide range of experts were involved in this process

• The role of the water safety group is pivotal to

• design, installation, commissioning and testing of the hot and cold watersupply, and storage and distribution systems for healthcare premises.

• operational management, including the control of Legionella, P.aeruginosa and other important waterborne pathogens.

• water safety in augmented care settings

• Documentation underwent extensive review process prior to publication

• Many thanks to everyone that participated in the process

• And of course many to Aquatools for this excellent conference and for yourattention this morning.

• Merci beaucoup, abientot!59 Why is Pseudomonas aeruginosa such a problem?

Safe water in healthcare premises

Healthcare

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