Safe water in healthcare premises

The Safe Water in Healthcare Premises guidance document HTM 04-01, first published in October 2006 by the UK Department of Health, received an update in May 2016. The author looks at what is new in this latest revision.

In summary, the main changes from the original 2006 edition are: l The addition of guidance on the risk posed by other waterborne pathogens, not just by Legionella.

l The acknowledgement that the temperature control regime is the traditional approach and no longer the preferred strategy.

l The guidance now advises the consideration of other controls, to minimise the risk of infection by all waterborne pathogens.

l The guidance also advises strict adherence to the recommendations in HSE’s guidance document covering the control of Legionella bacteria in hot and cold water systems (HSG274 Part 2).

l The document includes guidance on the remit and aims of a Water Safety Group (WSG) and Water Safety Plan (WSP).

l Issues associated with thermostatic mixing valves have been recognised, and a supplement has been introduced, outlining specifications for these to deliver non-scalding as well as microbially safe water.

What does this mean? It is now necessary to ensure the safety of all water used by patients, residents, staff and visitors, and to minimise the risk of infection associated with all waterborne pathogens. This approach, therefore, now

applies to other waterborne pathogens, not just to Legionella. Pseudomonas aeruginosa, Stenotrophomonas maltiphilia and Mycobacteria are now also covered. A temperature control

regime may no longer be sufficient to minimise the risks created by these waterborne pathogens, and other control measures should, therefore, be considered. It now also advises the strict


adherence to the recommendations in HSE’s HSG274 Part 2, which includes detailed advice on the available control programmes. A Water Safety Group (WSG) is also

required now. This group has to be multidisciplinary and should not only include representation from estates teams but also from infection control; medical microbiology; nursing; augmented care; housekeeping and support services; medical technical officers; specialist

Dr Birgitta Bedford

Dr Birgitta Bedford was the first person to earn a PhD degree in Legionella control

from Cranfield University, UK. She is currently the Research Director for ProEconomy Ltd.

users of water (such as Renal units and departments offering aquatic therapy); and sterile services departments (SSDs). This group should implement, develop and manage a Water Safety Plan (WSP) together, to ensure the safety of all water. A further addition states that the

performance of thermostatic mixing valves (TMVs) should now be carefully monitored, to ensure that the risk of scalding and microbial contamination is avoided.

How does this affect a healthcare organisation? The infection pathways of waterborne pathogens, such as P. aeruginosa, S. maltiphilia and Mycobacteria, are more varied than those of Legionella and are not limited solely to the inhalation or aspiration of water droplets (aerosols). As a result, minimising the risk of

infection is not only restricted to preventing growth in water systems but also includes avoiding growth outside water systems. Therefore, the updated guidance stresses the need for clean, hygienic environments and practices. In water systems, preventing growth

and gaining control of all waterborne pathogens is difficult because they all thrive and are protected in biofilms. The latest version of HTM 04-01 recognises that biofilms are particularly problematic in water systems that are complex, such as those in healthcare premises, where the risk of infection is higher. Control programmes should therefore

not only be capable of removing biofilms, but they should also be effective against the free-floating pathogens that are released from these biofilms. It is known that temperature and

oxidising chemicals do not penetrate established biofilms well, that pathogens survive in water temperatures lower than 20˚C and higher than 55˚C, and that, due to gassing-off, it’s hard to maintain adequate oxidising chemical biocidal levels at outlets, without overdosing the water system.


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