INFECTION PREVENTION AND CONTROL
Figure 6: Showers are increasingly recognised as a source of acquisition of highly drug-resistant organisms. A number of features of shower design predispose to this. Water from the shower head often directly impacts on the drain – in any setting water from an outlet directly hitting a drain poses a high risk of dispersal of wastewater organisms. Secondly, the placement of the drain is such that the patient often makes contact with it, again exposing them to wastewater organisms. The design of the drain is often such that blockages/ impairment of flow are likely to happen, as even small amounts of hair can impede flow. Blockage of any drain anywhere increases the risk of dispersal of wastewater organisms. Blockages of wastewater systems are currently often not recorded, even though they may exceed several hundred per year.
Figure 7: The Medicines and Healthcare products Regulatory Agency (MHRA) oversees and regulates medicines and medical devices. If a medical device caused a patient harm this would be investigated by the MHRA. Whilst sanitaryware can result in patient harm, including dispersal of AMR, this is not seen as a medical device, and therefore is not under the same regulation or scrutiny.
extends further, as many of these drugs are very stable in the environment, and will have an impact on the municipal wastewater systems and sewage treatment areas. One company has developed a system which removes
drugs and microbial resistance from the healthcare facility wastewater system before it enters the municipal system. Although people in their own homes may be taking antibiotics which enter the municipal wastewater system, there is a major difference between the types of antibiotics used in hospital, and those in a home environment. In hospitals, our last-line antibiotics, which retain effectiveness against AMR, are administered to sick patients and then excreted in the urine, making their way to hospital wastewater. Mixing our last line of antibiotic defence with gut bacteria in hospital wastewater seems imprudent, but we do not understand the consequences of this set-up, and if it drives AMR, the consequences are devastating. A previous article in Health Estate Journal addressed the topic of wastewater systems in greater detail.7
The
Table 1: Some of the key product types requiring improved design or innovation.
INTERVENTION
Improved ease of cleaning for reusable and shared equipment Sinks
Drainage systems
purpose of this article is to provide a glimpse into some of the issues being encountered, hopefully to stimulate the dialogue and the multidisciplinary approach required between the NHS and stakeholders. Water and wastewater are leading to dispersal of AMR and infections on a daily basis within healthcare facilities. These infections result in avoidable use of antibiotics, prolonged stay length, increased healthcare costs, and patient mortality. The extent of the problem is highlighted by the extreme lengths some units have had to adopt to terminate outbreaks. What is becoming apparent is that
WHY?
n Constant staffing crisis in the NHS – healthcare worker time is a precious resource n Ineffective cleaning runs a real risk of transmission of infection and AMR pathogens
n No sink design currently exists that does not contaminate the environment with drain organisms n Right now sinks are considered so dangerous they are being removed from some clinical areas to mitigate this risk
n Blocked drains bring wastewater and drain organisms to the surface, and patients are thus more likely to be splashed or to come into contact with them
n These systems have not been designed to cope with operational use in healthcare 42 Health Estate Journal October 2024
routine hospital defences, such as Standard Infection Control Precautions (SICP), designed as a ‘catch all’ to prevent the spread of infection between patients and staff, are largely ineffective in preventing transmission events from water and wastewater systems. Therefore, units are adopting ‘water-free’ patient care, whereby most of the plumbed in water and drainage services are removed to control the outbreak. It is the risk from the wastewater system which predominantly drives this approach. The term ‘water-free’ is a misnomer, as water is still used in these areas.
The water system’s periphery Most water transmission events originate from the periphery of the water system – this is arbitrarily defined as the last two metres of pipework, connected device (e.g. basin or ice machine), and associated wastewater system. The design, placement, maintenance, and how staff interact with these services, fundamentally affect whether these plumbed in services are safe, or represent a risk to patient safety. Up until now there has been a significant missing part
of the jigsaw when it comes to the design and choice of equipment, where it is installed, and how it is maintained and used. This likely stems from the difficulty individuals have in trying to envisage how these items can adversely impact patient care. Thus it is not uncommon for a contractor to decide on a choice of sanitaryware for a healthcare facility, as no one sees the risk. Unless it is recognised and acknowledged at all levels that these
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