WATER HYGIENE AND SAFETY – SPECIAL REPORT
should be centred around what the real function of a hospital is. Is its core remit to provide a safe environment for healthcare professionals to treat patients, or is its role to provide an enjoyable experience for the patient in hotel-like accommodation, resulting in extra costs (taking funds away from patient care), and increased risk of waterborne infections? While there are good arguments for single patient rooms – from an infection control perspective, to improve sleep, and provide privacy etc,8 there are counter arguments from both a nursing standpoint and as regards the mental wellbeing of patients compared with those housed in wards with multiple beds. The need for single rooms with full en-suite facilities is less convincing when you take into account the changes in the way many areas within hospitals are used, typified by shorter stay lengths, as patients are admitted on the day of a procedure, having showered before admission, and discharged the same day. Patients who stay in for any length of time may be too ill to get out of bed, let alone shower, and yet a shower which is not used poses a risk to patients, and can cost the hospital dearly operationally to ensure that it remains safe with flushing and ongoing maintenance. In addition, the rising number of elderly patients and those deemed to be immunocompromised mean that more patients are at risk from OWPs, especially from contaminated showers.
Ongoing lifecycle costs ignored? In 2008 NHS Scotland8
estimated that
there was little extra cost involved in single room provision, but did not appear to take into account that for every extra shower, ignoring the capital cost of the space and fitting out of the shower room, there are significant ongoing costs for the lifecycle of the building – including cleaning of the shower room and fittings, calibration of thermostatic mixing valves (TMVs), cleaning, descaling, and disinfecting TMVs (3-6 monthly, depending on water hardness), disinfection of shower heads and hoses on a quarterly basis, and their regular replacement, and flushing of the shower head and hose when the room is unoccupied or the patient is too ill to use the shower. In addition, there are costs associated with employing contractors, supervision, auditing, and monitoring, together with the cost of chemicals and cleaning products.
Budget separation Another major obstacle, and a disincentive to design teams to ensuring that the design will consistently supply safe water for all intended uses and users, is the separation of capital funding and the ongoing costs associated with remedial works, often needed post-
24 Health Estate Journal December 2020
into design and specification. There should be processes in place to ensure that all those involved in the development of the project understand that when they do not get it right people may die. All working on the project, from the design and specification point onwards, should have the training, experience, and competency, to avoid the life-threatening consequences to the most vulnerable of patients. This may sound harsh, but ensuring the safety of the most susceptible patients, and of staff, should be the main focus, rather than simply delivering a hospital early and under budget.
Poor location of the soap and towel dispensers leading to contamination of the outlet. Soap can support the growth of P. aeruginosa and similar microorganisms on the surfaces, potentially contaminating hands.
handover to rectify inherent problems, and the costs of ongoing maintenance and operation. Design engineering, a misnomer if ever there was one, is carried out mainly as a cost-cutting exercise to save money from the capital budget, often replacing safer features and enhanced quality fittings and components requested by operational staff. This is carried out with little consideration of whether the long-term management and operational costs will exceed the money saved at the outset. To improve both patient safety and save precious NHS funds, this ‘short termism’ must be addressed. An example which has been highlighted in the press recently is the Queen Elizabeth University Hospital in Glasgow, which, while being handed over under budget, has required a great deal of remedial work to put right problems associated with unsafe water systems.
Understanding the water safety concept
In addition, all too often Water Safety Groups are notified too late to have the time to have a significant input
While estates teams and specialist advisors/Authorising Engineers are all too aware of the problems associated with badly designed and constructed water systems, sadly, all too often those designing, building, and commissioning water systems do not understand the implications of poor water system design on patient and staff safety, and safe systems are not being delivered as a result. We should not assume that architects and planners are aware of and understand relevant guidance such as Health Technical Memoranda, Health Building Notes, Health and Safety legislation, and associated guidance, and other guidance prepared by professional bodies.9
Contracts are key Stockley9
also identifies the ‘lack of
experience in producing output specifications and in setting up contracts’. Contracts may run into hundreds of pages, while not addressing the issues around ensuring that the design and specifications meet the needs of the target users, and are able to meet the water quality needs for each individual type of use. A driver for improvement and adherence to specified guidance would be to put the onus on the contractors to ensure that water delivered at each point of use is of the specified water quality, i.e. meets standards required, and is demonstrated to be free from OWPs. At least one innovative Trust has developed a design guide which details the specification for the design and engineering aspects of projects involving water systems and associated equipment – which includes the processes to keep systems safe during the design, build, installation, and commissioning phases, including the types of fittings and components acceptable by the Trust. The intention is to support project teams to ensure that water systems and associated equipment are delivered safely.
Cold water provision
Investigations of cases and/or gross contamination associated with new builds, and failings in the design, specification, installation, and commissioning of both refurbishments and new builds, have highlighted many inherent system designs and build problems (see Table 1). A major issue found is the overprovision of cold water. The calculations used to determine how much water is required are out of date, and this, combined with the common problems due to the lack of outlet use, have a huge impact on maintaining systems safely. As an example, water sampling in a regional oncology building highlighted sporadic Legionella positives over several years. The installation of a proportionally dosed chlorine dioxide plant, together with local mechanical interventions, resulted in a temporary improvement. To try and
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