development of new uk guidance for the delivery and

Development of new UK guidance for the delivery and management of safe water in healthcare premises for the control of legionella

Dr. Jimmy Walker Biosafety, Air and Water Group 11.40 – 12.00 ESGLI, Amsterdam [email protected] Views expressed are those of the presenter

2 Revision process of HTM 04-01

The background 2006 - 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 0401 - Safe water in healthcare premises

3 Development of guidance for safe water in healthcare

Legionnaires’ disease


No improvement in mortality from 2003-2014

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Pseudomonas aeruginosa From recent research (recent unpublished) Up to 60% of outlets in augmented care may be contaminated by P. aeruginosa In one trust up to 19% of P. aeruginosa infections were due to water borne transmissions in augmented care This would indicate that WSG still needs to address the issue of water as a vector of transmission


Two samples from the siphon and the tap aerator of the water outlet yielded Kp OXA-48

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Statutory Requirements Health 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 of Practice L8 2013

British and European Standards


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

Align with the Health and Safety Executive’s (HSE’s) recently revised Approved Code of Practice for Legionella (L8) and the series of HSG274 guidance documents.

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

Advice:

• Hygienic storing and installation of fittings and components

• Any person working on water distribution systems or cleaning water outlets needs to have completed a water hygiene awareness training course.

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


Management of your water system Formation and implementation of WSG Multidisciplinary group Identified lines of accountability Appropriate expertise to fulfil the WSP and RA Participation of nursing, clinical, estates and facilities

providers Chaired by a person who has appropriate management responsibility, knowledge, competence and experience. Where required, it may appoint in writing an independent professional adviser/Authorising Engineer (Water) with a brief to provide services in accordance with this HTM and the HSE’s technical guidance HSG274 Part 2. 11 Development of guidance for safe water in healthcare

Design, installation, commissioning

Decisions affecting the safety and integrity of the water systems and associated equipment including procurement, design, installation and commissioning of water services, equipment and associated treatment processes should not go ahead without being agreed by the WSG. The WSG need to ensure that appropriate expertise and competence is available to ensure the delivery of safe water for all uses throughout the organisation


Design and Refurbishment WSG should be consulted at the earliest possible opportunity and water risk assessments be completed for all projects for all new premises or refurbishments

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

WSG should discuss and agree a sampling regime and appropriate parameters (physical, chemical and microbiological) depending on the intended use of the system and vulnerability of the patients which should be included in the contract

Sampling should be carried out prior to any construction/refurbishment works and immediately prior to handover, but no sooner than 48 hours after disinfection. It is recommended that sampling is undertaken by an accredited organisation independent of the contractor.


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 the lifecycle of the installation. WSG should be actively involved in the decision-making process

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

Showers - most effective management of showers will be achieved by the removal of unnecessary ones and the regular use of others.

Summary checklist for hot and cold system water systems - updated


Components Flexible hoses should be kept as short as possible and kink free and only used to:

• allow for vibration of equipment;

• accommodate vertical displacement of high and low baths and sinks;

• facilitate essential maintenance and access of bespoke equipment when no alternative is available.

All pipes, fittings, valves, sub-assemblies, calorifiers, cisterns should be supplied to site cleaned, free from waterborne pathogens, particulate matter and other residues.

Pipes should be capped at both ends and pipe joint fittings should be suitably 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 medical quality compressed air or oil-free dry compressed air. Where water is used for test purposes, it should be supplied from a wholesome source.


Components and risks Where not integral to the fitting, in-line strainers should be fitted within the water pipework system to protect vulnerable valves and fittings (pressure-reducing, safety-relief and stop valves, terminal fittings including thermostats and solenoid valves etc) against ingress of particulate matter.

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


Components and risks New systems should not include legs of pipework for potential future extensions to the system as these will create stagnant legs. Any alterations to existing systems – or where redundant pipework is found – should be cut back to the connection point; this includes replacing the branch ‘T’ with a straight coupling.

The risk of scalding for vulnerable patients (young children and older people, disabled people and those with neuropathy) is of particular concern in healthcare premises caring for such individuals, and therefore thermostatic mixing devices could be needed for hot water outlets. A risk assessment for scalding risk versus the risk of infection from waterborne pathogens should be undertaken by the WSG.


Competencies of risk assessors Those engaged to carry out any risk assessments associated with water safety should be able to demonstrate to the WSG their experience and competence in assessing specific risks from microbiological, chemical and physical hazards on the specific healthcare population. • accredited training • 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, BSRIA BG 57/2015


The risk assessment should demonstrate to the WSG

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

• effective corrective or preventive action has been implemented,

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


Installers and training Installers should adopt practices that reduce the likelihood of cross-contamination from tools, clothing or the environment. Separate clothing and tools used for other non-wholesome services such as sewerage and drainage systems should be kept separate and not used when working on hot and cold water systems.

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

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

NB Contractor’s responsibility to ensure that all operatives intending to work on the water system have completed water hygiene training covering associated risks 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 and is information appropriate for the target audience.


Water treatment and control When control of the microbiological safety of water systems cannot be achieved throughout the system by maintaining temperatures, additional control strategies should be considered to reduce the risk of waterborne infection. Commonly used strategies include the use of filtration, pasteurisation or the use of biocides.

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

The WSG should:

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

• be satisfied that the design, specification and commissioning will enable the water treatment systems to achieve the required biocide concentrations throughout the system to minimise microbial risk.

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


Development of guidance for safe water in healthcare

MDR Pseudomonas aeruginosa contaminated outlet

Storage Storage 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


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

Government guidance to the Water Supply (Water Fittings) Regulations recommends that as far as is reasonably practical cold water temperatures should not exceed 20±2ºC

Further cooling of cold water should only be considered in specialist units where people are at particular risk as a result of immunological deficiency, for example bone marrow transplant units. For other accommodation, the aim should be to promote turnover of cold water by means of the design of the distribution circuitry.


Hot water services Hot water is required in healthcare premises at various delivery temperatures for particular needs. The highest temperature, 55°C, is required typically in main kitchens, laundries, dirty utilities and food preparation areas. Elsewhere the delivery temperature for personal hygiene will depend on individual preference for comfort and safety of patients who require assistance. In circulating hot water systems, the highest temperature will be required at all draw-offs on a loop.

The flow temperature of hot water out of the calorifier should be a minimum of 60°C. It should be a minimum of 55°C on flow and returns to all outlets and at the start of the hot water return. It should be a minimum of 50°C at the final connection to the calorifier.

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

Instantaneous hot water heating should be considered only for smaller premises.


Management of control Requires surveillance and maintenance of control measures including temperature control, usage, cleaning and disinfection measures as identified within 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 the layout 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 is compliance with national evidence-based guidelines for preventing healthcare-associated infections.

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


Water safety plan Documentation - 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 intelligent use of data to easily monitor trends and analyse chemical and microbiological parameters.


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

Summary Dashboard – examining the detail per asset

Legionella Graphical Report with Schematic

Remedial Actions

Figure 4


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 – what else is in the hospital

Vending, chilled-water and ice-making machines

Portable/room humidifiers

Non-wholesome water storage - fire system

Deluge showers

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

• 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 water supply, 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


development of new uk guidance for the delivery and

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