WATER HYGIENE AND SAFETY – SPECIAL REPORT


Don’t assume that others understand your system


Dr Susanne Surman-Lee, a State Registered Consultant Clinical Scientist, and director at independent public health consultancy, Leegionella Ltd, and George McCracken, head of Estates Risk and Environment at Belfast Health and Social Care Trust, take an in-depth look at some of the challenges and complexities of maintaining safe and hygienic healthcare water systems. They argue that many of the problems surrounding poor quality of water in healthcare are ‘due to a lack of ownership, lack of detail in contracts, and poor understanding and training of those involved in the design, specification, build, installation, and commissioning’.


Funding promised by the government for new hospitals is to be accompanied by new standards to revolutionise design and speed up construction. This raises some concerns that in the rush to complete the buildings by 2030, the safeguards built into existing good practice guidance, and adequate time to develop Water Safety plans to prevent mistakes in water system design and specification, through to commissioning and handover, will not be factored in. This has the potential to pose risks to health – and even cause death – for the most vulnerable of patients. Many of the problems surrounding poor quality of water in healthcare are because of a lack of ownership, detail in contracts, and poor understanding and training of those involved in the design, specification, build, installation, and commissioning. In addition, the communication between the project teams and those who have to operate water systems on a daily basis must be improved.


There is no dispute that poor design, poor specification, build, installation, commissioning, and operation of water systems have all played a role in causing avoidable hospital-acquired infections and deaths from an increasingly wide range of opportunistic waterborne pathogens (OWPs).


Risk in the supply not reflected


Clinical washbasins should neither be used as a repository for random items, nor as a means of disposing of fluids or other solutions which could heighten infection risk.


estate is welcomed, recent events surrounding the safety of water systems in flagship new hospitals3


raise concerns that


A press release on the www.gov.uk website on 2 October this year, entitled ‘PM confirms £3.7 billion for 40 hospitals in biggest hospital building programme in a generation’, noted ‘Funding confirmed for 40 hospitals, with a further eight schemes invited to bid for future funding to deliver 48 hospitals by 2030’. It also referred to the development of new standards ‘to help revolutionise design and speed-up construction’.1


A need to prevent future mistakes Whether or not, as The Guardian highlighted on the same day, this money is a gross underestimate of the amount needed, and includes hospitals already in the pipeline, eight new sites are to be invited to make a bid for a new hospital.2 While the promise of funding for the NHS


in the rush to spend the money and complete the buildings by the target year of 2030, adequate time and checks to prevent future mistakes will not be factored into the timetable. A further concern is that the ‘new standards’ should not dilute the good safety guidance for water systems we already have, e.g. the HSE’s ACoP L84


and HSG 274,5 and the Department of Health’s HTM 04-01,6 the


latter put together with a panel of experts, taking account of the increased susceptibility of those who might be exposed within healthcare premises. In 2002, Anaissie,7


following a review of


hospital-acquired waterborne infections, made a plea for action. Eighteen years later, the true burden of hospital-acquired waterborne illness is still under- recognised, and his plea has largely been ignored.


While water quality at the point of entry must meet drinking water quality standards, the parameters used to demonstrate compliance do not reflect the risk from OWPs present in the supply. These OWPs, including legionellae and Pseudomonas aeruginosa, do not normally cause harm to the general population at the levels present in cold water (<20˚C). However, in the journey from the point of supply to the point of use, deterioration in water quality may occur due to temperature gain, low use, and the presence of nutrients resulting in the growth of OWPs, as well as increases in metal ions, and other substances derived from the materials of construction and components of the system. Good design and specification of water systems, fittings, and components, is therefore a major factor in reducing risk.


There are many factors which need to be considered to ensure that all water within healthcare premises is safe for all intended uses, and that users take account of the susceptibility of the users. While we cannot cover all of these in this article, we will highlight some of the major problems in achieving this goal.


Patient safety versus the patient ‘experience’


There are some fundamental discussions that need to take place before pen is even put to the drawing board, and these


December 2020 Health Estate Journal 23


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