News - May 2018
Prevention is better than cure
In recent years, healthcare-associated infections (HCAIs) have become better understood because of exhaustive investigations, wider engagement within the water systems community, and a number of well-documented cases.
The World Health Organization (WHO) points to the scale of the challenge: with more than six million cases of HCAIs occurring in the US and Europe each year.
Around 136,000 of these cases will result in the death of a patient; with 5,000 lives lost every year in England and Wales.
In England alone this is estimated to cost the NHS £1billion a year, with infected patients costing three times more to treat than those who are uninfected.
We know hospital water systems can become a source of pathogens and bacteria, and are a probable source of nosocomial infections.
Of the multiple Gram-negative bacteria that persist in healthcare, Pseudomonas aeruginosa and Legionella are the best understood and most well documented.
It should come as no surprise, then, that combating these is a crucial part of managing, operating and maintaining a healthy water system; and the latest guidelines have brought this into sharp focus.
Last year, the Department of Health updated and relaunched its existing documents relating to guidance for safe water in healthcare premises - HTM 04:01 (Parts A-C) 2016.
The guidance distinguishes between control regimes to reduce the risk of Legionella and the growth and colonisation of other waterborne organisms within water systems, and control regimes for Pseudomonas aeruginosa and other waterborne pathogens.
Importantly, what the revised memorandum does do is move facilities towards a more-holistic management of water and promotes good practice in the design, commissioning, and operation of water services in healthcare premises.
But what do these guidelines 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°c-45°C, but are killed at higher temperatures.
Thermal disinfection requires raising water temperature to above 60°C and flushing each affected outlet for at least five minutes at that maintained temperature.
In some water systems, where temperature is difficult to maintain for example, additional chemical and physical methods may be required.
Cleaning, duty flushing, and disinfection of hot and cold water services will also be necessary when an outlet is not being frequently used, when control measures have not been effective, or when there is microbial contamination of the water system as a result of an outbreak, or suspected outbreak, of Legionella.
Further, HTM 04-01 recommends 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 instructions’.
This is, of course, good practice and important, but detailed record keeping, in particular, introduces additional cost and resource implications.
Advances in technology
Since Legionella is widespread in the environment, it’s almost impossible to prevent it from entering water systems.
The risk of an outbreak developing can be reduced by storing water at a temperature of at least 60°C. But, while an effective control method, this does present a scalding risk to users and this is on the Department of Health’s ‘never events’ list.
So, we’re faced with the question: how can you maintain patient safety and a rigorous infection control regime while preventing potentially-life-changing injuries such as scalding?
HTM 04-01 recognises the benefits of thermostatic mixing valves (TMVs) because of their value in accurately controlling temperature. TMVs guarantee water pressure between hot and cold water supplies is maintained, even if there are water pressure or temperature fluctuations.
Digital TMVs are the latest innovation in this area, offering precise temperature control, the ability to set flow times, and a range of hygiene flushing options, such as duty flushing and thermal disinfection.
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 this.
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.
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 digital log.
Arguably the most-significant advancements with digital controls have concerned the ability to network taps and showers. This is an exciting prospect for a healthcare facility.
In simple terms it means temperatures, flow times, and essential control measures can be set, managed and logged remotely.
With this information available on demand, estates and facility managers are able take informed action quickly.
Monitoring data from different outlets allows close comparison of water usage across a facility, for example, and staff can adjust flow times, temperatures and duty flush schedules appropriately.
This allows hospitals to adopt a more-sustainable water management programme while achieving a greater level of precision and accuracy.
Maintaining a safe and compliant hospital water system is understandably a complex challenge. However, the good news is we already have the technology at our fingertips to provide a more-effective and efficient way of water management in healthcare facilities.