In recent years, healthcare-associated infections (HCAIs) have become better understood. Awareness has grown partly due to the exhaustive investigations carried out by the estates community, and the continuing engagement of the wider water systems community after a number of well-documented cases.
We know patients are more vulnerable to infections because of illness, age or the treatment of their condition, but it’s worrying to think that the very place you go to make you better can, at times, make you worse despite the best efforts of those caring for you.
The financial and resource demands this can place on a health service that’s already under considerable pressure are significant. Yet, I’m sure we can all agree that it’s the more pressing human cost and emotional strain on those infected and their families that are incalculable.
The NHS is taking clear action to address the challenge and is determined to see HCAIs reduced and, ultimately, prevented. Water systems are one area the NHS has identified as critical in succeeding in this mission.
Why? We know hospital water systems can become a source of pathogens and bacteria and a probable source of nosocomial infections.
Of the multiple Gram-negative bacteria that persist in healthcare, Pseudomonas aeruginosa is one of the most well understood. Legionella pneumophila is another well-documented waterborne pathogen. Legionella bacteria grow in many water systems.
It naturally follows, therefore, that combating Legionella and Pseudomonas aeruginosa is a crucial part of managing, operating and maintaining a healthy water system.
The latest guidelines have brought this into clear focus. Last year, the UK’s DH updated and re-launched its existing documents relating to guidance for safe water in healthcare premises – HTM 04:01 (Parts A-C) 2016. What these revisions and amendments show is that effectively managing the microbial quality of a hospital’s water system as a contribution to better patient outcomes is a clear priority for the DH to fight back against HCAIs.
But what do these disciplines and control regimes look like for healthcare professionals on the frontline?
As outlined in HTM 04-01 Part A 2016, the risk of a waterborne infection outbreak developing can be reduced by storing water at a temperature of at least 60°C and distributing it so that it reaches outlets at 55°C within one minute. For example, Legionella bacteria multiply at temperatures between 20 and 45°C but are killed at higher temperatures.
Thermal disinfection requires a raising of water temperature to above 60°C and duty flushing each affected outlet for at least five minutes, ensuring that the temperature is maintained throughout the process.
But because of the complexity of water distribution systems and the difficulty of maintaining high-temperature levels through the system, thermal disinfection may not always be effective. As such, the guidance suggests that additional chemical, physical and other water control methods may be required.
The cleaning, duty flushing and disinfection of hot and cold water services will be necessary when an outlet is not being frequently used or when control measures have not been effective. Cleaning and disinfection are also required following evidence of microbial contamination of the water system as a result of an outbreak, or suspected outbreak, of Legionella linked to the water system.
Although subject to a risk assessment, HTM 04-01 recommends for healthcare premises that duty flushing “should form part of the daily cleaning process” and that the “procedure for such practice should be fully documented and covered by written instruction”. This is, of course, good practice and important, but the requirement of detailed record-keeping introduces additional cost and resource implications for healthcare settings.
Since Legionella is widespread in the environment, it is almost impossible to prevent it from entering water systems. However, as outlined above, the risk of an outbreak developing can be reduced by storing water at a temperature of at least 60°C. While an effective control method, this does present a scalding risk to users. In any healthcare facility, excessively hot water at the point of use is a real concern for safety.
Healthcare facilities have a duty of care that requires hot water temperature to be controlled. As adults, we’ve all pulled back from water that was too hot at some point but vulnerable patients, such as the very young, elderly and people with disabilities, often don’t have the reaction times to do this and often have more sensitive skin – making them more susceptible to scalding.
Guidance on reducing the risk of scalding recommends the “use of thermostatic mixing valves for specific hot water outlets”, although it should also be acknowledged that there is an increased emphasis on undertaking risk assessments to determine the “need and type to be installed”.
Advances in design and technology
So how do healthcare premises maintain patient safety and prevent potentially life-changing injuries such as scalding, while still achieving the exacting and essential requirements of controlling HCAIs?
HTM 04-01 recognises the benefits of thermostatic mixing valves (TMVs) because of their value in accurately controlling temperature.
Such is the value TMVs can bring in healthcare settings, the guidelines even specify some applications where they should be used such as showers and hair-washing facilities, unassisted baths, baths for assisted bathing and bidets.
Digital TMVs are the latest innovation in this area and offer estate and facilities mangers even further levels of functionality and control. Digital control offers precise temperature control, the ability to set a wide range of flow times, as well as a range of hygiene flushing options, such as duty flushing.
As it is not possible to determine which taps and showers will require duty flushing, the default for most hospitals is to manually duty flush all taps and showers and, importantly, to manually log that this flushing has been undertaken.
This can introduce the possibility of inadvertent human error and can often mean many high-use outlets are flushed unnecessarily as there is no way to tell which outlets are used regularly and which are not.
While typically these functions are undertaken by cleaning staff, that may not be the case in every healthcare setting, where care staff may also be called upon. In such instances, this could potentially result in resources being directed away from other valuable forms of patient care, and represents a significant annual cost.
Digital valves not only allow the duty flushing to be automatically programmed, according to the specific requirements, they are also capable of recording the event and creating a log, which can be downloaded to demonstrate compliance with guideline requirements – saving both time and money associated with manual record-keeping.