BEST PRACTICE
components, e.g. solenoids and thermostatic mixer valves, and there may also be flexible hoses connecting the solid pipe to the tap and sieves to trap harmful debris. n Solenoids have large rubber EPDM diagrams, and flexible hoses EPDM internal linings on which bacterial biofilms containing Legionella and P. aeruginosa will form. (Note: Flexible EPDM should not be used – see Estates and Facilities Alert DH (2010) 03 – ‘Flexible water supply hoses’).
n Thermostatic mixer valves ensure that water hotter than 44˚C is not discharged from outlets. This water, at 44˚C, will provide a breeding ground for the growth of microorganisms.
n Many components contain sieves engineered to trap debris, but by their nature they become biofilm breeding grounds, where sloughing leads to contamination downstream.
n Water tap outlet components (or flow straighteners or other such devices) can be complicated with a range of different components providing a high surface area for biofilm to grow; where this is at the periphery of the outlet, there will be sufficient oxygen for microbial growth. (Fig 4).
n Washhand basins are used to clean hands, and those hands occasionally accidentally contact with the outlet, and may lead to retrograde contamination.
n Poor design, where water directly hitting a drain can disperse organisms over a range of at least two metres.
The human element
The science, technical details, and components exist to ensure that water systems are safe. Unfortunately, hospital-
Figure 6: An example of a handwash station drain trap full of debris, which will create nutrients for the biofilm.
acquired cases of Legionella still occur, and this is invariably due to failure to manage the water system/poor training.20 Thus the HSE regards Legionella as a preventable disease, and on these grounds will purse prosecutions.3,20 The true burden of waterborne disease in the healthcare setting is vastly underestimated. There is no national surveillance of waterborne infections, but perhaps the biggest hindrance is our inability to recognise transmission events. The adult literature on healthcare waterborne infections is predominated by antibiotic-resistant organisms, which possess no extra attributes enabling waterborne transmission. Rather they are using the well-trodden pathways used by ‘sensitive’ organisms, but are detected because they draw the attention of
clinicians and infection control teams. ‘Sensitive’ organisms blend into the background, allowing them to go largely undetected. In Holland, where water service removal on an intensive care unit successfully stopped an outbreak with a highly resistant organism, there was also a significant reduction in all Gram-negative organisms.24
This supports the theory that
transmission of many organisms (especially if sensitive) goes undetected. Ensuring water safety requires governance, a water safety committee, and correct composition of members appropriately trained and interested in the topic. Chief executives are busy people, and are unlikely to know or understand their responsibility. Spending 20 minutes meeting with the CEO to explain water safety, their role, and that of the Water Safety Group, is likely to be time well spent, opening channels and understanding within the organisation.
Guidance documents and training Guidance documentation is available (HSE, HTM, British Standards etc),3,4,20
and
appropriate competency-based training and auditing are key components. However, guidance documents and standards can often be difficult to interpret if you are not a specialist in the area, and this article has been designed to assist in providing such information. While no one would argue over the need for good training, it may not always be on offer. For example, responsibility for water safety nationally was directed towards infection control teams without any prior water safety training. Attending a one- day course is unlikely to provide adequate knowledge, especially if returning to an environment where such knowledge is
November 2020 Health Estate Journal 67
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