Dealing with water shortages

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Charles Pierce
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Director Infection Prevention and Control Southern Health & Social

1 5 th ICAN Conference 5 th November 2014 Room 3: 10:30-12:00 Dealing with water shortages Dr Nizam Damani Associate Medical Director Infection Prevention and Control Southern Health & Social Care Trust, Portadown, UK Senior Lecturer, Queen s University, Belfast, UK 1

2 Outline Setting the scene Use of water in healthcare facility Infections caused by contaminated water How to deal with water shortages in health care facilities Conclusions 2

3 Water borne infections or outbreaks in healthcare facilities Water in healthcare institutions can be a source of various outbreaks from contaminated water: Legionella spp. (esp. L.pneumophlia ) Other Gram negative bacteria: Pseudomonas spp, (esp. Pseudomonas aeruginosa, Burkholderia cepacia, Ralstonia picketii, Stenotrophomonas maltophila, Sphingomonas sp, Acinetobacter sp, Enterobacter sp, Serratia sp. Nontuberculous mycobacteria Aspergillus fumigatus & other fungi Poor quality of water may also interfere with the microbial activities of antiseptics and disinfectants 4

4 Various types of scarcity of water 5

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6 Use of water in health care facility 1 Medical equipment Renal dialysis Clean steam used in the heating and sterilisers Ultrasonic baths Final rinse water of surgical washer disinfectors Water used in the Automated Endoscope Reprocessors (AER) Laboratory Clinical analysers Preparation of microbiological media 7

7 Use of water in health care facility 2 Environment Facility for cooling towers Humidification and air-conditioning units Eyewash and shower station Fire hoses Others Taps for hand washing and surgical scrub Baths and showers Therapy tanks for physical therapy Birthing pool Suctioning and ventilator care Ice machines and ice storage tanks Water bath for thawing plasma and for warming dialysis fluids Dental unit water line 8

8 Water Use in Healthcare Facilities 9

9 Intermittency in piped water supplies in six countries Bull World Health Organ 2014;92:

10 Supply of water in Low-middle income countries Supply of water is usually of poor quality as intermittent water supply often has higher levels of microbial contamination As leaks in buried water pipes are unavoidable (even with active programmes of maintenance and repair pipes) Positive pressure cannot be maintained and water from outside the pipes which is often highly contaminated, especially where sanitary improvements are lacking may then contaminate the piped supply 11

Supply of water in Low-middle income countries Healthcare facilities are responsible for the quality of water once it enters the building Healthcare facilities and household have who have only

11 Supply of water in Low-middle income countries Healthcare facilities are responsible for the quality of water once it enters the building Healthcare facilities and household have who have only intermittent access to piped water have to rely on storage of water which lead to formation of biofilms and multiplication of microbes leading to even higher microbial count Formation of biofilms 12

12 Water Storage tank! Source: 13

13 Water Storage Tank Source: 14

14 Maintenance of water storage facilities is an essential part of preventative measure Regular cleaning and disinfection of your coldwater storage to ensure that : Water supply is clean, hygienic and free from visible contaminants Maintain storage tank properly to reduce the risk of healthcare associated water borne diseases Tank and its cover are fit for purpose and free from the need for refurbishment or replacement. 15

15 Maintenance of water storage facilities Combine a robust physical clean with chemical disinfection for a thorough job: Physical scrubbing and hoovering to remove the calcium carbonate scale, sediment and biofilms that accumulates naturally. Chemical disinfection (with permitted substances) to reduce high bacteria counts 16

16 Examples of common water contaminants and their effects From: McDonnell. Antisepsis, disinfection and sterilization. AMS Press,

17 Quality of water in healthcare facilities Endoscopy: This is an area where water efficiency is unlikely to be acceptable from a clinical perspective and where water reuse may pose an infection threat Sterile services departments: It is very difficult to improve water efficiency in essential support services such as sterile services. 18

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19 Outbreak of Pseudomonas aeruginosa in N. Ireland Neonatal Units Outbreak occurred between November 2011 to January 2012 From colonization to blood stream infections leading to death of babies Independent review was carried out and outbreaks were linked to contaminated water 20

20 Outbreak of P.aeruginosa in N. Ireland Neonatal Units: Lessons learnt Water Safety Group Review location and need of wash hand basin Remove hand wash basin which are not used frequently to avoid stagnation of water and formation of biofilms in pipe work Regular testing of water in for P.aeruginosa in Augmented care : Critical Care areas (Adult ICU, Paediatric ICU, Neonatal ICU), High Dependency units, Burns units, Transplant Units, Haematology & Oncology wards and Renal units / wards Use of point-of-use filter if the count is high and carried out pipe work Remove Thermostatic mixing valve (TMV) except in certain area Remove all non-touch sensor taps for hand washing 21

21 Sensor (non-touch) taps for hand washing Sensor (non-touch) taps conserve water Powered by electricity or by batteries Increase the risk of HCAIs esp. Pseudomonas infections 22

22 Unused sink can caused dead leg From: 23

No storing of used equipment awaiting decontamination Taps should be cleaned before the rest of

23 Hand wash stations Best practice Hand wash basin should only for hand washing No disposal of body fluids No disposal of used environmental cleaning fluids No washing of patient equipment No storing of used equipment awaiting decontamination Taps should be cleaned before the rest of the hand basin (NHS Cleaning manual) Washing patients with water from outlets demonstrated to be safe

Thermostatic mixing valve (TMV) TMV valve blends hot water with cold water to ensure constant outlet temperatures, preventing scalding To prevent growth of Legionella, it is

24 Thermostatic mixing valve (TMV) TMV valve blends hot water with cold water to ensure constant outlet temperatures, preventing scalding To prevent growth of Legionella, it is increasingly common practice around the world to regulate the storage water temperature to above 60 C (140 F), and to circulate or distribute water at a temperature less than 50 C (122 F). 25

25 Thermostatic mixing valve (TMV) TMV 26

26 Water management and water efficiency 27

27 Dealing with water shortages 1 PROBLEM: Taps are prone to leakage and it is estimated that a dripping tap may consume around 15 L per day Solution: Staff should be informed of the importance of reporting leakage and a reporting system should be put in place PROBLEM: Taps typically use about 9 Litres of water per minute, but may use as much as 18 Litres per minute Solution: Staff should be informed of the importance of using taps appropriately 28

28 Consumption of water during bathing and using WC PROBLEM: Flushing of toilet: Older models may use as much as 12 Litres per flush, newer models consume around 4 6 Litres Solution: Minimize unnecessary flushing Replace WCs with newer models 29

29 Hydrotherapy Pool Hydrotherapy is a therapeutic wholebody treatment that involves moving and exercising in water physiotherapy in a pool. ACTION: Size of the pool Pool covers can reduce evaporation losses Filtration units can be used to recirculate water 30

30 Water for Hand hygiene In many developing countries, tap water may not be fit for drinking. While drinking water may be ideal for hand washing, available evidence does not support the need for potable water. If the water is considered potentially unsafe for hand washing, the use of antibacterial soap may not be adequate Guidelines on Hand Hygiene in Health Care, WHO: Geneva,

Water for Hand hygiene CDC has developed guidelines for safe water systems and hand hygiene in healthcare settings in developing countries Field tests were carried out in Kenya and have been

31 Water for Hand hygiene CDC has developed guidelines for safe water systems and hand hygiene in healthcare settings in developing countries Field tests were carried out in Kenya and have been adapted in Africa and in Asia The document recommend that for hand washing, water should be of drinking quality 32

32 Hand hygiene using Tippy Taps Tippy Taps are designed for simple, economical, and effective hand washing stations in countries with resource-poor settings and in settings with lack of access to piped water supply. How to make Tippy Taps is available from 33

33 Hand hygiene Save water and prompt use of Alcohol-based hand rub [ABHRs] on physically clean hands as they are more effective in decontaminating hands than hand washing with soap and water. If the hands are visibly dirty and/or contaminated with blood and/or body fluids, then they must be washed thoroughly with soap and water and dried on a clean paper towel or single-use clean cloth towel. 34

34 Application time of hand hygiene (handwashing and handrubbing) and reduction of bacterial contamination Hand rubbing is: More effective Faster Better tolerated Pittet and Boyce, Lancet Infectious Diseases

35 EM of surface of skin showimg keratined cell filled with lipid rich material. LIPID 36

36 Damage of the stratum corneum in the electron-microscope Trockene Hornschicht 37

37 Surgical Scrub Study compared hand bacterial counts after 3 minute and 5 minute scrubs with seven different formulations. Results showed that the 3 minute scrub could be as effective as the 5 minute scrub, depending on the formula of the scrub agent. Hingst V et al. J Hosp infect 1992;20:

Surgical Hand Disinfection 4,823,373 operations in Germany (1991) 2 more minutes hand disinfection of 1 person of the operating team: 160,778 hours =

38 Surgical Hand Disinfection 4,823,373 operations in Germany (1991) 2 more minutes hand disinfection of 1 person of the operating team: 160,778 hours = 104 years (working 7 h/day) Water consumption for 1 min/2 min hand washing: 8/16 liters million liters (365 swimming pools) From : F.D. Daschner 39

39 Surgical hand preparation technique with an alcohol-based hand rub formulation Alcohol-based: 1.5 to 3 min Guidelines on Hand Hygiene in Health Care, WHO: Geneva,

40 Conclusions Use water prudently and safely Regularly clean and disinfect cold-water storage tank Encourage use of Alcohol-based hand rub products on physically clean hands ( hand hygiene & surgical hand disinfection) Use hand wash basin for hand washing only Carry out risk assessment on the quality of water needed for each units/wards Avoid contact with contaminated water in Augmented care areas (esp. preterm babies, ICU, transplant, burns, renal, patients) Carry out through investigation if the HCAI is related to contaminated water and take remedial actions 41

41 Thank You 42

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