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Water Management in Healthcare Estates

Importance of multidisciplinary approach to risk management on agenda at inaugural H&V News Water Management Conference.

The Health and Safety Executive says that as its new strategy puts greater emphasis on tackling the burden of work related ill-health, it will be raising awarenesss around the risk management and control of legionella in healthcare.

News of this focus, part of the Executive’s key stakeholder work, came as the Department for Health previewed its revised HTM 04-01 – launched on 20th May - at H&V News’s first conference on Water Management in Healthcare Estates.

John Newbold, Principal Specialist Inspector in HSE’s Biological Agents Unit told the audience at H&V News’s Water Management in Healthcare Estates conference that HSE’s recent Intervention Programme of evaporative cooling installations had uncovered poor practice in risk management to prevent and control legionella - results which he described as ‘scary.’

He said that of the 5000 sites originally notified to Local Authorities, some no longer had cooling towers, had changed use or had recently been inspected resulting in 2500 sites being visited by HSE and LA regulators (1906 by HSE). Of the 229 HSE sites were enforcement notices were served, 23% were for failings in their risk assessment, with 14% of those having no risk assessment at all. 23% were due to failings in the scheme of control, with 27% of those having no written control scheme. 54% were due to failings in the implementation of the control scheme, with 27% of those because of insufficient training.

Mr Newbold said: “Legionella is foreseeable and therefore it is preventable. In 2016 we shouldn’t be having outbreaks, but statistics confirm that it is not going away. The law doesn’t change, and the organisms involved don’t change, so something must have changed. I can’t emphasise enough the importance of getting the risk assessment in place, then getting the right people in place.”

He said that the emphasis on Water Safety Groups and Water Safety Plans in guidance, whilst not a legal requirement, was a great opportunity to create multi-disciplinary groups to provide for a holistic approach to risk management of water systems in healthcare - from infection control, to cleaning to engineering.

The overall message from the conference was that the spread of waterborne pathogens in healthcare estates can be kept at bay by a combination of robust systems, interdisciplinary teamwork, and attention to detail. But given that many different people have a role to play in managing the risks it is vital to take a holistic approach, prioritising good communication and ensuring competence of all parties.

The event was developed as a natural spin-off from the successful Combatting Legionella conferences, which have seen heating and plumbing experts work closely with the healthcare sector.

The close relationship saw the conference chosen as the place for an exclusive preview of the vital new HTM 04-01 which has been thoroughly revised to provide a comprehensive guide to management of water systems in the healthcare environment.

Philip Ashcroft, Principal Buildings & Facilities Management Services Engineer for NHS Estates and chair of the TM 04-01 working group, underlined how important it is for healthcare sites to have a robust management system in place. He said: “The Care Quality Commission may be asking questions about water systems, bringing the risk that a Trust may lose its registration if systems are not in place.”

Mr Ashcroft entitled his talk ‘Safe water in healthcare premises: putting policy into practice.’

Mr Ashcroft said the update of HTM 04-01 is intended ‘to move users of the document towards a holistic management of water systems via Water Safety Groups, Water Safety Plans and other initiatives’, drawing together and updating the previous guidance, and adding recommendations to ‘deliver safe water for all’.

Mr Ashcroft warned that there was a stronger emphasis on competence in the new TM 04-01 – an emphasis which applies to trades working with the systems.

He said: “The plumbers and installers should be approved, such as being registered with WaterSafe – you need to be certain that the trades coming to site are competent, as well as any in-house staff.”

He warned that strict protocols should apply to heating and water equipment. “We don’t want to see pipework left open for the dust to reach it and installation and storage of fittings should be hygienic. I was gobsmacked coming from the water industry to find that healthcare doesn’t have set water hygiene awareness programmes.

He drew attention to the importance of the WSG and WSPs noting that WSGs had been a fundamental part of the water industry delivering mains water to the healthcare sector at a 99.97% average conformity. He reminded the audience that it was their legal responsibility to maintain the water at this level of quality at point of use.

Mr Ashcroft said that the composition of the WSG should be given proper consideration, with the relevant disciplines impacting water represented, including nursing and cleaning staff as well as the expected infection control estates management and water-responsible person He said: “People may have skills you don’t know about and it may be composed of both daily workers and people from outside.”

He emphasised the importance of engineering guidance within the regulatory framework, including the new HTM and the Health and Social Care Act – reminding the audience that the latter requires all equipment and premises used must be: clean; secure; suitable for the purpose for which they are being used; properly used; properly maintained; and appropriately located for the purpose for which they are being used. He also stressed that poor practice on the water systems could actually threaten a hospital’s CQC registration.

He also emphasised that the guidance applies equally to new and existing sites and that the risk management should apply to more than simply management of legionella.

One of the key areas, he said, was to main control over changes to the water systems, which can too often occur because of changes required by clinical staff – such as closure of wards and changes to ward layouts.

He also stressed that Thermal Mixing Valves need to be properly managed, as a particular risk for harbouring bacteria. He conceded that hospitals had generally over-supplied them out of a concern for scald risks, rather than considering the waterborne pathogen risk.

He said: “TMVs need to be properly maintained and only specified for vulnerable patients… and I would like to see simple instructions on how to install and maintain them.

Public Health England Guidance

Dr Jimmy Walker, Scientific Lead for Water and Decontamination at Public Health England, described PHE’s recent guidance on response to the detection of Legionella. Dr Walker noted that there had been no improvement in keeping legionella outbreaks at bay since 2003, despite a range of new guidance and HTMs and asked ‘why are we not getting it right?’

He reiterated that appropriate expertise and monitoring needs to be in place, and he outlined a series of issues for heating and water engineers to address. These include: keeping clothing and tools for hot and cold systems separate from those used for drainage; ensuring all contractors have undertaken water hygiene courses; bagging all fittings; capping all pipes. Temperature and turnover of water is also essential he stressed – the guidance calls for flow temperature of hot water out of the calorifier to be a minimum of 60°C; then a minimum of 55°C on flow and returns to all outlets and at the start of the hot water return; and a minimum of 50°C at the final connection to the calorifier. In addition, turnover of water needs to be maximised to avoid stagnation.

He also stressed that some form of ongoing monitoring of the systems needs to be in place, including sampling, with the WSG being consulted whenever there is a change to the system or where refurbishment takes place.

“We often find minor changes to wards, but they seem to forget the water implications,” he said.

Dr Walker noted that certain plumbing infrastructure could be a problem for bacterial management unless properly managed. He said: “Flexible hoses should only be used where essential, and if they have to be used, they should be as short as possible and kink-free. Fittings should be bagged before being brought on site.”

He added that use of biocides also needs to be meticulously controlled and the WSG actively involved: “It cannot be a case of ‘fit and forget’” he said.

One of the key areas of the new guidance is the storage and turnover of water and Dr Walker stressed that even the supports for the tank needed particular focus, given that they could harbour bacteria, if the supports were internal and/or hollow.

Dr Walker recommended that the Water Safety Plans should include a full asset register with drawings ‘for every tap, sink or shower’. Showers, had particularly been shown to be a risk for stagnant water, because they can be used irregularly in high-dependency wards for instance. “They are often found to be a source of legionella, were there is lack of use,” he warned.

Another high-risk item of equipment were the heater/coolers used in operating theatres for heart bypass, he noted, with numerous incidents recorded in Europe of contamination, because the units contain water that is often left to stagnate.

Infection control

The extent of the risk being faced was revealed by a presentation by Dr Mike Weinbren, consultant microbiologist at Chesterfield Royal hospital NHS Trust.

Dr Weinbren noted that the ends of pipe runs were a real focus of bacterial growth. He said: “Most of Pseudomonas occurs in the last 2 m of a system – as much as 90%.”

He urged managers not simply to have a policy of testing for organisms, but to have an active strategy to block rates of transmission. He said: “It is not just about legionella and pseudomonas. There are lots of other organisms out there – are we missing something?”

Dr Weinbren also stressed the importance of a proper cleaning regime, given the high number of resistant organisms found in the bowel, which could find their way onto other surfaces. He revealed that wastewater systems were an increasing problem, particularly when blocked by non-degrading antiseptic wipes. “Have we unwittingly created a superhighway for micro-organisms in hospitals, with drainage systems?”

He recommended that the appropriate training and education was extended to architects and system designers, as well as operational staff.

Amongst advice was to remove the surfaces which might biofilm growth – such as aerators and flow straighteners. He also noted that shaving in wards had proved a particular risk.

In line with other speakers, he added that TMVs were problematic – noting that for a small NHS trust, the servicing of the devices was adding an extra 800 man-hours a year, compared to a Monobloc tap arrangement.

He warned that human issues such as not isolating sluices and splashing washing water were an added risk factor.

End Users panel

Such factors were reiterated by the end-user panel at the conference, where estates managers told how they were working to bring in mandatory hygiene courses for contractors, repositioning sinks to avoid splash contamination, and cutting out thermal mixing valves from estates, unless in areas for vulnerable patients.

They agreed that it was important to demonstrate competence among plumbers and engineers, such as by requiring a Water Safe card or similar approved scheme.

Use of TinyTags to monitor the use of basins and taps was also held up as good practice.

The panel agreed that there was a risk that there would not be enough suitably qualified for work with water hygiene.

Contractor Liaison

Caroline Vickers from Tetra Consulting described the importance of properly managed contractor handover in new buildings, in her talk entitled Brand New Problems. She cited the example of a new-build ITU which had suffered a Pseudomonas outbreak because the building had not been properly decontaminated, causing £100,000 of costs plus associated delays. Ms Vickers said that with new-build, it was essential to have correct procedures and particularly to have full records of work done. She said: “This is not just an ‘Estates problem’, it should have the involvement of Capital Projects too. It is important to risk assess and design stage, but then also at completion too and to have checklists at handover.”

She noted that the revised CDM regs (Construction Design and Management) enshrined the responsibility of the Principal Designer of the project, who should be appointed by the client. “If there is more than one contractor, under the CDM2015, there has to be a Principal Designer in charge of the health and safety of design and construction.” She emphasised that it was essential to have their involvement in the risk management, along with liaison with the Authorising Engineer for Water.

“The majority are not aware of the implications of water safety and biological contamination,” she said.

Elise Maynard, chair of the Water Management Society discussed the practicalities of testing and disinfection, with particular reference to ‘new’ waterborne pathogens such as Mycobacteria and Elizabethkingia meningosepticum which have recently been identified by more sensitive methods of detection. “I am convinced that if we looked more into our water in the UK, we would find Mycobacteria” she said.

Ms Maynard said that better communication with testing laboratories was essential to understand the implications of findings. She said: “’Not Detected’ does not mean there is a complete absence of the pathogen.”

She also pointed out a number of areas of potential risk – ranging from bottled water to endoscopy rinses – and emphasised that some pathogens survived on surfaces for long periods of time. Pseudomonas for instance, can survive for between 6 hours and 16 months.

Ms Maynard reviewed recent updates from the academic world, including one that concluded the use of copper surfaces ‘is not effective for directly controlling Legionella’ and suggested that the number of viable Legionella cells had been underestimated in previous studies, because of the difficulty in culturing them, throwing more doubt on copper’s biocidal effects.

She concluded that a holistic approach is essential. She said: “Water treatments shouldn’t be considered in isolation – many work better in conjunction with one another. This is the same for the management of water distribution systems – a team approach is vital.”

The research perspective was provided by Dr Elaine Cloutman-Green, Clinical Scientist in Infection Control at Great Ormond Street Hospital. She noted that hospital-acquired infections affect between 5 and 15% of all patients and that opportunistic pathogens such as Pseudomonas can severely impact on immune-compromised patients.

Dr Cloutman-Green highlighted the extent of the problems caused by hospital sinks, which are routinely used in contravention of the safety guidelines not only for hand-washing, but also to wash equipment, to store used equipment and, worse to dispose of bodily fluids. At the same time, the sinks are not decontaminated properly – not cleaning taps separately, or running the water while cleaning, which dilutes the effect. Taps were found to have organisms present in 10-50% of samples taken in a study of ITU paediatric sinks by Dr Cloutman-Green and colleagues.

The conference was brought to a conclusion with a series of workshop discussions. The prevailing theme, once more, was the need for an interdisciplinary approach to water management and the requirement for a competent, well-guided workforce in system design, capital works, maintenance and health management alike.

The specifics of Legionella management will be revisited in H&V News’s Combatting Legionella Conference on 22-23 September. More details from



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