Safe Water in Healthcare: A Practical and Clinical Guide

By James T. Walker, Susanne Surman-Lee, Paul J. McDermott and Michael Weinbren

Safe Water in Healthcare: A Practical and Clinical Guide enables users from different disciplines to understand all types of waterborne hazards that can pose a risk to those who might be exposed, the events which cause them to be present, what may precipitate an increase in their levels that may cause harm, and how they can be avoided or managed to reduce risk. The handbook highlights microorganisms that can cause infections, modes of transmission, the infections they cause, and risks. The book's authors draw from their extensive practical experience assisting with day-to-day problems that range from minor issues to outbreaks.

The book includes case studies on the growth of biofilms and where they cause problems in water systems as well as providing practical answers to a majority of issues that arise in healthcare water and drainage systems. This is an accessible handbook that fills the gaps for those without technical knowledge for a complex but important area of infection control. It provides practical guidance for professionals who are required to design, manage and maintain water systems and help them manage associated infection outbreaks.

• Discusses waterborne pathogens, their detection, identification and surveillance and describes the extent and range of recognized and emerging waterborne microorganisms as well as the diseases that occur and consequences to patients and staff
• Covers hazards that can cause harm within water systems and associated equipment, the circumstances or factors that increase the risks, and the multiple modes of transmission of waterborne pathogens
• Explains the importance of good design, including the type of design, management, hardware and software that can help manage and control the presence of waterborne pathogens.
• Highlights who needs to be involved at each stage to ensure that patients are kept safe from waterborne pathogens, taking into account current legislation and best practices guidance

• Language: English
• Publisher: Academic Press
• Release date: Mar 20, 2023
• ISBN: 9780323904933

James T. Walker

Dr Jimmy Walker worked as a Scientific Leader in water microbiology and decontamination at Public Health England (PHE), Porton UK. He has 30 years’ experience in public health microbiology with an extensive publication record, and regularly attended national and international scientific conferences. His particular interests were the presence of opportunistic pathogens in hospital water systems and advised hospitals on incidents and outbreaks associated with waterborne pathogens such as Legionella spp., Pseudomonas aeruginosa and Mycobacteria spp. He worked closely with the Department of Health (DH England) and Health and Safety Executive in writing and developing national and international guidance on the microbiology of water and decontamination in healthcare.

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1: Importance of leadership and governance

Abstract

Thousands of staff work across healthcare organizations. Clearly, safety in healthcare is everyone’s business, and we can all play a role in ensuring that vulnerable patients are safe. Water is a product that we may actually take for granted and assume that whatever is delivered from an outlet is actually safe for vulnerable patients. Yet countless water-related outbreaks and fatalities occur on an annual basis. NHS organizations should strive to continuously improve the quality of their services and safeguard high standards of care by creating an environment in which excellence in clinical care will flourish. One way of doing this is through excellent leadership and governance, which is how an organization directs, manages, and monitors its activities to ensure compliance with legislative requirements while ensuring that the safety of its patients, visitors, and staff is not compromised. In terms of water, the implementation of a water safety group and water safety plans can be important in the delivery of appropriate governance. However, the Chief Executive Officer (CEO) and the Board of Directors can oversee and delegate responsibility for delivering the water safety plan to the water safety group, the duty to ensure the safe provision of water and that patients are safe remains with them. This may involve the use of safety performance indicators, which have been agreed and set by the senior managers themselves and reports on their current status are provided regularly. Communication is key to good governance, which must be enshrined at all levels within the organization and continuously applied. It is the duty of all of us to ensure that vulnerable patients are safe from preventable waterborne infections.

Keywords

Leadership; Governance; Water safety groups; Water safety plans; Waterborne infections; Water transmission routes; NHS trust; Executive; NHS boards; Responsibility; Empowerment; Patient safety

Overview

This book sets out to provide an understanding of water systems for those whose work involves water and wastewater in hospitals and healthcare buildings but may have had limited access to training. One of the important concepts of the book is the incorporation of diagrams and case studies for the reader to understand the implication of unsafe water in healthcare and how ease it is to contaminate water that will then come into contact with vulnerable patients.

Water as delivered by the water supplier has to meet particular standards to ensure that the product delivered to you the customer is wholesome (DWI, 2015).

Once the water is delivered to the your site, the quality of that water becomes your responsibility, and it is once the water enters your building that the quality of the water will start to deteriorate and present a risk to vulnerable patients.

Through the book, we have described a wide range of scenarios where the quality of the water may pose a risk to vulnerable patients. The engineering aspect of water systems is clearly important in controlling the growth or microorganisms and biofilm. There are numerous guidance and standard documents that provide advice on how water systems should be built, commissioned, and operated and these are cited through the book.

Cooling towers have not been included in this edition, and further information is available from the HSE (2013a).

Outbreaks still occur, and there is no doubt that waterborne infections such Legionnaires’ disease are seen by the Health and safety Executive as being preventable (HSE, 2013b, 2014).

Leadership

The consequence of microbially contaminated water can result in infections that may be fatal. Where fatalities that have involved water occur, there may be subsequent investigations and even court proceedings. Such investigations will want to understand the contamination of the water, the transmission route, the nature of the infection and how the organization has managed the water system, its staff, and how it has responded to waterborne acquired infections. Does an organization have leadership and policies in place to manage waterborne outbreaks and to implement strategies that will ensure the safety of vulnerable, such as those in oncology units (Inkster and Cuddihy, 2021)?

Such policies and leadership could be referred to as clinical governance, i.e., a system through which NHS organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish (NHS England, 2022).

Governance

Governance is defined variously but, in the healthcare setting, a useful definition is provided in the English Health Technical Memorandum (HTM) 04-01 Part B (DHSC, 2016). Here, it is explained that governance is concerned with how an organization directs, manages, and monitors its activities to ensure compliance with legislative requirements while ensuring that the safety of its patients, visitors, and staff is not compromised. It goes on to highlight the importance of ensuring safe processes, working practices, and risk management strategies are in place and supported by sufficient resources and suitably qualified and competent staff.

This can be achieved by appointing a water safety group with sufficient expertise and developing and implementing a suitable water safety plan. Key to successful governance is effective communication with and active support from senior management, for example, the Chief Executive Officer (CEO) and the Board of Directors. This requires senior managers to delegate responsibility for delivering the water safety plan to the water safety group, while at the same time acknowledging that the duty to ensure the safe provision of water remains with them.

CEO’s and Board members are busy people, so the means by which important water safety issues are communicated to them needs to be clearly defined and efficient. There must be effective communication pathways between the water safety group and Board level, e.g., via other forums such as the Infection Prevention and Control Committees and Health and Safety Committee, and it is important that key water safety concerns are communicated in an agreed and unambiguous way (Fig. 1). In other high-risk industry sectors (e.g., chemical, oil, and gas), safety performance indicators have proved to be useful in this respect (HSE, 2011). Where they work best is in organizations where these key indicators have been agreed and set by the senior managers themselves and reports on their current status are provided regularly.

Fig. 1

Fig. 1 Importance of communication in governance.

Safety performance indicators can vary from organization to organization but might include metrics on specific elements of risk management, such as planned preventive maintenance, reactive maintenance activities, out-of-specification monitoring data, positive microbiological testing results, progress with risk assessments, staffing levels, and training requirements. Senior management should set the tolerance parameters for each safety performance indicator and performance can be communicated by means of a red/amber/green dashboard or similar. Safety performance indicators that are red require immediate action at Board level, those that are amber provide an alert that should prompt some form of further investigation by the Board, and green safety performance indicators provide assurances that safety is being successfully maintained.

Ultimately, good governance is evidenced by its outcomes. It is best achieved where there is effective upward communication to Board level, so that senior managers can be assured when water safety is being controlled, and so that they can be informed when it is not and take appropriate measures to regain control. There are responsibilities at all levels, but important decisions regarding allocation of budgets and other resources are made at the top of the management hierarchy, and these decisions need to be supported by evidence-based information (Fig. 2).

Fig. 2

Fig. 2 Levels of responsibility required for appropriate and effective governance.

Where standards of performance are clearly defined and set by senior management, and performance levels are communicated effectively to those individuals, the likelihood of good governance and the continued operation of water systems safely in healthcare premises is increased.

However, good leadership must ensure that governance is enshrined at all levels and continuously applied.

In summary

If we are to learn anything, then we must learn from history. Florence Nightingale stated in 1859 that The very first requirement in a hospital is that it should do the sick no harm.

Those who work in healthcare are dedicated to their patients and organizations need to ensure that they provide leadership and governance that ensures that staff are educated, supported, and empowered to act when situations and environments are not safe for patients.

References

DHSC. HTM 04-01: Safe Water in Healthcare Premises. 2016.

DWI. The Water Supply (Water Quality) Regulations 2016. 2015.

HSE. Development of Suitable Safety Performance Indicators for Level 4 Bio-containment Facilities: Phase 2. 2011.

HSE. Legionnaires’ Disease: Technical Guidance Part 1: The Control of Legionella Bacteria in Evaporative Cooling Systems. 2013.

HSE. Legionnaires’ Disease. The Control of Legionella Bacteria in Water Systems. Approved Code of Practice Legionnaires’ Disease. ACOP https://www.hse.gov.uk/pubns/books/l8.htm. 2013.

HSE. HSG 274 Legionnaires’ Disease—Technical Guidance Part 2: The Control of Legionella Bacteria in Hot and Cold Water Systems Technical Guidance.http://www.hse.gov.uk/pubns/books/hsg274.htm. 2014.

Inkster T., Cuddihy J. Duty of candour and communication during an infection control incident in a paediatric ward of a Scottish hospital: how can we do better?. J. Med. Ethics. 2021;doi:10.1136/medethics-2020-106862.

NHS England. Governance, Patient Safety and Quality. 2022.

2: Design, construction, and commissioning of healthcare water systems

Abstract

Design and commissioning of new healthcare premises are essential components to ensure that safe water is delivered at every stage of any major healthcare project and that the water is safe for all users and all uses right up to the handover stage. The client must make suitable arrangements to manage their project by forming a project water safety group to encompass a range of skills to understand the design, build, commission, and handover stages. Such groups must interact with the principal designer, principal contractor, contractors, and subcontractors. The water safety group may wish to engage with all parties at an early stage to provide supported learning such that the potential risks and harm caused by unsafe practices related to water and associated equipment that use water are understood. Commissioning plans should include monitoring the water quality during the build phase, particularly following filling and potential water stagnation, and addressing any adverse microbiological results. Check lists should be used and evidence provided to assure the water safety group that the design and build specification have been followed up to the handover stage as previously agreed. The water delivered by all parts of the water system should be safe, and contractual agreements should be in place to ensure that all issues that may put patients at risk are addressed within a timely manner.

Keywords

Water safety plan; Water safety group; Governance; Accountability; Design; Build; Commissioning; Handover; Safe water

Introduction to designing safe water systems

The requirement to protect patients from any harm caused by water should be the primary aim of those designing and specifying water systems and associated equipment. National guidance in England states that "Where new healthcare premises are planned or existing premises are to be altered or refurbished, the water safety group should be consulted at the earliest possible opportunity and water risk assessments be completed for all projects. This will enable the total water hygiene requirements to be assessed in the planning stages, and appropriate action taken, including ensuring that any pressure testing, flushing and cleaning does not lead to stagnation or contamination before being placed into service. The risk assessment should be reviewed once the system is operational. At all stages of the design, installation and commissioning of new or extended water systems, the design team should liaise and consult with the local water safety group in a timely manner, give consideration to HTM 04-01 Parts B and C and incorporate all operational managements requirement into their design. requirement into their design."

Choosing the right contractors for each stage of the project is fundamental to ensuring the project delivers safe systems. Requiring evidence that contractors have fulfilled their role successfully before and been prepared to work with the client at each stage including water safety groups. This evidence that can help make an informed choice may include reviewing examples of previous project consultations, how the commissioning was undertaken, handover process, sampling strategy, plans, and ongoing safety of the water.

At the concept stage of each capital build or major refurbishment, before the brief for the design architect is completed, the multidisciplinary WSG should carry out an assessment to identify the intended patient groups and the quality of water needed for each group. This should take account of all potential routes of exposure to all types of hazards and their associated risks to ensure all water systems in healthcare buildings are designed, constructed, installed, commissioned, operated, and maintained. The water supplied should be safe for all uses and all users from all potential water-associated hazards based on the susceptibilities of the intended population.

For the most neutropenic patients, it may be necessary to ensure they are protected from any exposure to water and rooms should then be designed without any water installations; taking account of data from the Netherlands, which has shown that removing the potential for patient exposure to water in ICUs reduced the overall levels of Gram-negative infections (Hopman et al., 2017).

It is important to understand that once design and build contracts have gone out to tender, it is too late to make substantive changes as each contractor will be basing their costings on the information provided. Hence, the team must ensure that all those who will be involved in the project development as well as those who will be providing or managing water-related services have input before the tender stage is essential for a successful outcome.

Project water safety plan

Developing a project plan (see BS 8680) that takes account of all uses of water and the vulnerabilities and susceptibilities of intended users will help the architect/design engineer/construction/installation/commissioning teams deliver safe water (BSI, 2020, p. 86). Relevant standards and guidance need to be incorporated with the WSG agreeing derogations where these are out of date or not appropriate.

No contractor wishes to deliver a project that is going to cause harm so involving preferred/shortlisted contractors at an early stage and providing a supported learning (training) environment will help to ensure contractors understand the potential risks of causing harm. The death of patients from poorly designed, installed, and/or commissioned systems and any associated equipment has major impacts on hospitals and staff (Francis, n.d.; Inkster and Cuddihy, 2021). Potential risks from poor system design and construction could include litigation (including from corporate manslaughter or corporate killing depending on location), financial losses as well as losses of organizational and contractor reputation (HSE, 2014).

Project duty holders and water safety groups should hold workshops with all those involved in the design, engineering, and purchasing prior to the tender stage so everyone is aware of the absolute requirement to put patient safety first. There needs to be project oversight and adherence to governance and policies together with a lessons learnt exercise from previous projects and includes the time built into the project for risk assessment and review at each stage of the system development to handover and occupation (RIBA, 2020). In a large development, where it is anticipated that the building will be occupied in stages, the water safety plan should include processes for monitored staged filling and commissioning with a sampling strategy to minimize the risk of stagnation such that wholesome water is delivered.

Project governance and accountability

To avoid the many historical errors that have led to outbreaks and cases following poor design and construction of new healthcare premises, it is imperative that the water safety plan ensures there is effective governance and oversight at Trust or Board level (i.e., the client) throughout the project. This is necessary to ensure that the safety of the patients remains at the core of every decision made regarding water systems design through all stages to handover and normal operation and maintenance, for any new healthcare building, or major refurbishment. A designated Project lead needs to be appointed to take day-to-day responsibility for the safe delivery of the project on behalf of the Duty Holder supported by a project-specific water safety group. The water safety plan (BS 8680:2020) needs to be developed to ensure that the water will be delivered at each point of use so that the water and its delivery mechanism are safe (reduced splashing and aerosols) for its intended uses and users. The water safety plan also has to include the associated waste water systems, which should be appropriately sized and compartmentalized to avoid backflow and spread of waterborne pathogens (Jamal et al., 2019).

Where there is an existing water safety group, they should ensure that their existing water safety plan contains sufficient organizational governance and policies, which have been agreed at Board level and implemented to make sure that there is a chain of accountability responsibility, communication, competency, and training from the top down. It is recommended that WSGs include the processes for how new projects should be managed within the WSP, whether or not they are aware of any plans. Leaving it until a decision has been communicated could well mean that it is too late to ensure there are the right competencies and governance structures in place.

Project WSG skills and competencies

The skills needed for the project water safety groups to function effectively include personnel with the skills needed to understand architects and design engineers’ drawings, specifications for materials and components, and the impact of poor design. The water safety group needs to ensure the architect/design engineers, commissioning engineers, contractors understand and carry out all the requirements relating to safe water provision taking account of the intended range of uses, quality requirements for each use, and the susceptibilities and vulnerabilities of the intended patient groups. It is essential for the completion and handover of safe water systems, and any associated equipment, that the project water safety group is empowered to make decisions. Where skills are not available in-house, then adequate checks should be made to ensure the competencies of consultants/(sub)contractors to deliver a safe project and ensure water safety (HSE, 2014).

For a large healthcare builds such as general hospitals, the project water safety group could include:

●Board representative with responsibility and accountability for project water safety.

●Infection prevention and control with appropriate knowledge of the built environment.

●Estates and facilities management personnel responsible for managing and maintaining the systems.

●Relevant specialist clinical service providers and those with water quality requirements including or ex aquatic physiotherapists, dialysis providers, decontamination, intensive care, transplant and hematology oncology units.

●Water specialist Advisor/Authorizing engineer (water) (DHSC, 2016).

●Architects and design engineers.

●Microbiologist with expertise in water microbiology.

●Contractors

●Principal contractor and principal designer (GOV.UK, 2015).

The range of competencies required includes:

1.Knowledge of regulatory, standards, and guidelines relating to water chemistry and water microbiology.

2.Experience of previous new build projects to understand the potential impact on patient health and well-being from poor water system design; specification, construction, installation, commissioning; operation, usage, and maintenance taking into account the susceptibility of the users.

3.How to develop and implement a comprehensive water safety plan to BS 8680:2020, based on risk assessments for Legionella as well as Pseudomonas aeruginosa and other waterborne pathogens as appropriate including (BSI, 2019, 2020, 2022):

(a)How to interpret proposed water system and drainage plans and schematics and their impact on patients, staff, and visitors.

(b)Knowledge of all applicable hazards, hazardous events, and risks associated with water systems and equipment within the proposed healthcare environment to be able to critically review risk assessments at each stage of the project.

(c)Knowledge of different water system methods used to control microbial risks and the relative pros and cons and contraindications.

(d)Knowledge of health and safety legislation, approved codes of practice and best practice guidance applicable to construction projects (including in the United Kingdom: The Construction (Design and Management) Regulations 2015, the Health and Safety at Work Act 1974 and associated regulations (as amended), e.g., The Management of Health and Safety at Work Regulations 1999, The Control of Substances Hazardous to Health Regulations 2002) (GOV.UK, 2015; HSE, 1974, 1999, 2020).

(e)Be able to develop and manage a team for implementation of a soft landings approach.

(f)A knowledge of all applicable legislation, guidance, and standards applicable to the project and where derogations may be required.

4.Effective communication, motivating and negotiating skills.

5.Ability to interpret architects and design engineers’ drawings.

6.An understanding of the governance and accountability required to ensure the project proceeds and is delivered as required for each use and each user.

7.Ability to determine and manage key stage assurance markers.

8.Ability to audit and risk assess each stage of the project for compliance with the project key stage assurance markers.

9.Be able to manage the development and implementation of quality systems to ensure appropriate documentation and best practice is implemented through all stages of the project.

An understanding of the stages of a new build project may help the project water safety group be prepared (BSRIA, 2018; RIBA, 2020). There are a number of examples where stages are important for project water safety groups (Table 1).

Table 1

Consultation

It is essential for the safety of patients, particularly those at increased risk of infection, that those responsible for designing, engineering, and advising on the quality of water required within healthcare buildings should make sure that there is adequate consultation with the building owners and all stakeholders. This will ensure that when the building is completed, water delivered at each point of use meets the required water quality standards, i.e., wholesome; conforms to all applicable legislation, national guidance and standards to protect patients at increased risk of harm from hazards related to water use or damp environments (DHSC, 2016; HSE,