WATER SYSTEM SAFETY
essential element of the early identification of water outlet contamination to prevent HCAIs, so the frequency of routine sampling for PA and other waterborne pathogens should be based on risk assessment, and agreed with the WSG. The frequency of microbiological sampling, where there are high-risk patients, should be sufficient for trend analysis to establish evidence-based confidence that control measures remain effective. Assessors should decide whether they
have sufficient available information to assess the risk successfully. If they conclude that it is insufficient, for example due to the absence of ‘as-fitted’ drawings or schematic diagrams, or any other critical information, they should decline to issue the assessment, or issue it in draft or otherwise qualified format, identifying any omissions and the effect they might have on its validity. As part of the site survey, assessors should also speak to management and staff to determine whether the organisation’s management culture and work practices are adding to, or reducing, the risk.
Systems assessment Assessors should also review the operation and condition of each system and its components, to assess whether they would support the proliferation and dissemination of Pseudomonas aeruginosa by all potential modes of exposure. All parts of each system should be assessed – including any discrete plant, associated equipment, fitting, or component, and the existence and location of sentinel
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To verify that a risk assessment for PA is valid in a healthcare setting, it should be undertaken by a multidisciplinary team to ensure that all relevant hazards, hazardous events, and all systems and relevant equipment, are considered
points. However, with the greatest risk for PA growth close to and within outlets, particular attention should be paid to assessing the configuration, management, and maintenance, of outlets and any component parts – such as tap inserts, including those close to the outlet, e.g. TMTs, TMVs, isolation valves, and any associated systems or equipment, and the potential for cross-contamination from within drains.
Risks from flow-straighteners Inserts such as flow-straighteners and water-saving devices in taps have been shown to increase colonisation risk significantly and transmission of PA infection. These should not be present in augmented care areas, and if not needed, should be removed from any other areas. Health Building Note 00-09: Infection control in the built environment advises that soap dispensers should be mounted, sited, and designed, to prevent cross- contamination from users, but it does not consider that often these are placed above the washbasin, allowing the soap to drip down into it, and providing nutrients for bacteria such as Pseudomonas aeruginosa to thrive.
An HSE response on specific
In response to an enquiry from the author asking if the HSE is considering publishing guidance on Pseudomonas aeruginosa, a spokesman said this was ‘not currently under consideration’. He added: “The Advisory Committee for Dangerous Pathogens does provide independent scientific advice to HSE and other Government departments on all aspects of hazards and risks to workers and others from exposure to pathogens. However, I am unsighted on their workplans, as UKHSA has the Secretariat function for this Committee, and most Group 2 pathogens do not have their own specific guidance. “It is our understanding that those
Inappropriate materials The assessor should be aware of the risk of colonisation due to inappropriate materials, fittings, components, and equipment. For example, plastic pipework can leach nutrients into cold water systems, and support PA and other bacteria colonising the pipework. This risk is increased in new systems. Section 14.2 of the new BS 8580-2:
2022 standard, Engineering control measures, provides several photographs that demonstrate issues of concern and the associated risks. These include: a tap insert showing biofilm; debris on a TMV protective strainer; example of poor design of a washhand basin; example of an incorrectly fitted tap; example of poor siting of soap and towel dispensers; slime from an ultrasonic humidifier; and a scaled fountain.
Pseudomonas guidance the control of risks from Pseudomonas. HSE is not the lead regulator for patient safety in England, and a Memorandum of Understanding was signed with the Care Quality Commission after the Stafford Inquiry. “Other risk systems, such as
most at risk from Pseudomonas infections would be highly susceptible patients in hospitals, particularly those with burns or open wounds, and especially the immunocompromised. As such, HSE may not be the appropriate regulatory body to provide guidance on
28 Health Estate Journal June 2022
swimming pools and hot tubs, have been known to cause self-limiting skin infections from Pseudomonas. However, adherence to current published guidance, i.e. HSG282 or industry guidance such as PWTAG, should also control risks from Pseudomonas in those environments. “Legionella technical guidance and the Approved Code of Practice are for a much broader audience than solely for healthcare, and HTM 04-01 (and its devolved equivalents) guidance give good practical advice to the healthcare sector on controlling the risks from a range of waterborne pathogens, including Legionella and Pseudomonas.”
Clinical hygiene control measures The control measures in Annex A (see below) should be considered and implemented as appropriate, following discussion with the WSG, with the following taken into account: a) the cleaning regime for sinks, showers etc, and audits undertaken to minimise the risk of cross-contamination from drains to outlets. b) all those using outlets should be aware of the risk of cross-contamination, including ensuring that personal items (e.g., cloths, toothbrushes, and shaving equipment) which could be colonised or splashed, are not in stored close to sinks, showers etc. c) there is suitable management and storage of cleaning equipment (damp mops and cloths are also likely to become colonised), and the make-up and use of cleaning and sanitising agents are managed effectively. d) there is suitable advice to limit the introduction of contaminated water and drinking vessels to minimise the risk of PA being brought in from outside sources; and e) there is surveillance to verify that any potential cases of infection are identified, and investigations instigated promptly to prevent further transmission.
Various annexes Annex A (informative) of BS 8580-2: 2022 details waterborne microbial hazards and hazardous events in healthcare settings. Table A.1 goes on to use the CATES principles to allow an evaluation of the risk from 13 microorganisms found in
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