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Derogate to Improve In-Premise Water Hygiene

The new NHS England publication on “Processes for Managing & Reporting Derogations from Estates Technical Standards & Guidance” (https://www.england.nhs.uk/long-read/processes-for-managing-and-reporting-derogations-from-estates-technical-standards-and-guidance/) is welcomed. The publication acknowledges the importance for healthcare facilities to be designed and constructed to the highest and most appropriate level in order to deliver clean, safe and secure environments.  In addition it sets out the pathway for NHS organisations to complete derogations to improve patient care and outcomes through both evidence and cost-based assurance.  According to their process, derogations must involve all specialists to make an informed decision, be risk assessed, appropriately documented and submitted to a relevant senior person for approval.

Due to increasing age (some documents are a decade old) national water hygiene guidance is frequently no longer relevant, nor fit for purpose and some recommendations and statements within have been made without field-based evidence or efficacy.  Publications over the last decade have irrefutably demonstrated the link between water and wastewater services in patient care areas to healthcare-associated infections.  The concern surrounding Legionella pneumophila is overwhelmed by more sinister waterborne pathogens such as Pseudomonas aeruginosa, non-tuberculous Mycobacteria, Klebsiella spp, Stenotrophomonas maltophilia. Antibiotic resistance in these Gram-negative waterborne pathogens is already with us, and therefore installation and use of water outlets and drains in close proximity to patients must be viewed with caution and managed with robust procedures.

Where relevant guidance is lacking or its advice outdated, it is critical for the Water Safety Group to base their decisions on sound published evidence and not to repeatedly return to inadequate or ineffective guidance.  However, there is a reluctance to stray from “Code” or to step away from the perceived safety of being compliant to guidance.  Examples which are lacking or misguided include

  • understanding of stagnancy risks and ineffectiveness of flushing regimens
  • use of plate culture methods to prove effectiveness of control measures or remediation
  • implementation of control measures without adequate supporting engineering remediation
  • installation and use of water services in augmented/critical care patient areas
  • installation and use of equipment such as ice machines, drinking water coolers and mobile hand wash basins

Independent, peer reviewed published evidence has repeatedly supported the removal of water services from areas where there are critical care patients,  particularly in the “outbreak” scenario.  Last month a paper by Giovanni-Battista et al., published in the Journal of Hospital Infection confirmed that the presence of handwash basins significantly contribute to hospital-acquired infections, specifically hospital-acquired Pseudomonas aeruginosa respiratory infections, in non-outbreak periods within intensive care units1.  If there was a handwash basin in the room, the patient was significantly more likely to have a hospital-acquired infection.  After adjusting for the many variables, the presence of the basin was still found to be an independent risk factor for infection.  If this publication was a single siren, then it would be prudent to await further supporting evidence before implementing action.  Yet, within the past decade there has been a multitude of papers published from a variety of countries, all indicating the presence of a handwash basin, sink or shower, most commonly the drain or trap, being linked to hospital-acquired infection2-15. 

This evidence should be on the agenda of every hospital water safety group and every infection prevention team.  Discussions should be taking place regarding their facilities, the presence of water services in high risk patient care areas, their surveillance data for background Gram negative infection levels and how best to reduce water system exposure in patient areas. 

If guidance is followed, for example Health Building Note 00-09 Infection control in the built environment (2013)16, there would be water services aplenty – for example “In intensive care and high dependency units (critical care areas), a clinical wash hand basin should be available by each bed space.”; “Two clinical wash-hand basins in multi-bed rooms”; “In primary care and out-patient settings, where clinical procedures or examination of patients/clients is undertaken, a clinical wash-hand basin should be close to where the procedure is carried out”.  Such advice was driven to promote and support clinical personnel handwashing.  Yet in the last 10 years there have been multiple hand hygiene compliance papers which clearly indicate that the presence of a wash hand basin does not lead to either correct use17-19 or compliant handwashing with at best average 30-40% compliance20-22.  Today there is greater reliance on alcohol hand gel use within patient rooms.  The position that the presence of clinical handwash basins is required to support handwashing with soap and water due to the risk of Clostridium difficile transmission is overshadowed by the significant risk of waterborne pathogens via any water services present.

Healthcare water hygiene and safety is a constant challenge for infection prevention and engineering. As with other healthcare-associated infections, occurrence of waterborne infections erodes public confidence in healthcare facilities and patient care. Derogation from current national guidance is sometimes needed in order to improve patient outcomes and reduce hazards and risk through the application of more recent evidence-based data.  It is a sensible approach for robust water safety; however derogation is not a universally agreed opinion and adherence to guidance is considered to be a safety net for decision making.  What do you think?

If your water safety group want to discuss the NHS England derogation publication and its process, recent literature, make appropriate patient safety plans regarding water services for renovation or new build projects, or to future-proof decisions regarding patient care, please contact us.

References

  1. Giovanni-Battista F, Geffers C, Schwab F, Behnke M, Sunder W, Moellmann J, Gastmeier P. Sinks in patient rooms in the ICU are associated with higher rates of hospital-acquired infections. A retrospective analysis of 552 ICUs. J Hosp Infect. 2023 Jun 10:S0195-6701(23)00177-9. doi: 10.1016/j.jhin.2023.05.018. Epub ahead of print. PMID: 37308060.
  2. De-Las-Casas-Cámara G, Collados-Arroyo V, García-Torrejón MC, Muñoz-Egea MC, Martín-Ríos MD. Impact of sink removal from intensive care unit rooms on the consumption of antibiotics and on results of Zero Resistance Project. Med Clin (Barc). 2022 Jan 7;158(1):1-6. English, Spanish. doi: 10.1016/j.medcli.2020.10.019. Epub 2021 Feb 13. PMID: 33593639.
  3. de-Las-Casas-Cámara G, Giráldez-García C, Adillo-Montero MI, Muñoz-Egea MC, Martín-Ríos MD. Impact of removing sinks from an intensive care unit on isolations by gram-negative non-fermenting bacilli in patients with invasive mechanical ventilation. Med Clin (Barc). 2019 Apr 5;152(7):261-263. English, Spanish. doi: 10.1016/j.medcli.2018.06.023. Epub 2018 Aug 23. PMID: 30146354.
  4. Catho G, Martischang R, Boroli F, Chraïti MN, Martin Y, Koyluk Tomsuk Z, Renzi G, Schrenzel J, Pugin J, Nordmann P, Blanc DS, Harbarth S. Outbreak of Pseudomonas aeruginosa producing VIM carbapenemase in an intensive care unit and its termination by implementation of waterless patient care. Crit Care. 2021 Aug 19;25(1):301. doi: 10.1186/s13054-021-03726-y. PMID: 34412676; PMCID: PMC8376114.
  5. Kearney A, Boyle MA, Curley GF, Humphreys H. Preventing infections caused by carbapenemase-producing bacteria in the intensive care unit – Think about the sink. J Crit Care. 2021 Dec;66:52-59. doi: 10.1016/j.jcrc.2021.07.023. Epub 2021 Aug 24. PMID: 34438134.
  6. Feng Y, Wei L, Zhu S, Qiao F, Zhang X, Kang Y, Cai L, Kang M, McNally A, Zong Z. Handwashing sinks as the source of transmission of ST16 carbapenem-resistant Klebsiella pneumoniae, an international high-risk clone, in an intensive care unit. J Hosp Infect. 2020 Apr;104(4):492-496. doi: 10.1016/j.jhin.2019.10.006. Epub 2019 Oct 10. PMID: 31606433.

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