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PAI – Waterborne Infection Transcript
Professor Kevin Rooney
Hello. I’m Professor Kevin Rooney, professor of care improvement and
consultant in intensive care medicine.
Today, we are in a simulated environment but did you know that in 2011 – 12,
five babies died from outbreaks of Pseudomonas aeruginosa in neo-natal
units in Northern Ireland?
The source of the infection was tap water, and contaminated wash-hand
stations. Some of the units where the outbreaks happened were recently
refurbished.
The scientific literature is also littered with outbreak reports
where water used directly on patients, or splashed from contaminated hand
wash stations, has been the source of the infection.
These outbreaks were mainly in ICUs.
We therefore need to understand how to minimise risk and protect patients
from contamination.
So where does contamination come from?
Low level numbers of organisms in the incoming water contaminates the
pipes - the contamination risk increases if the water is not regularly pulled
through the system.
Biofilm then builds up on the pipe-work and periodically sloughs off to
contaminate the water.
Biofilm develops on any surface that comes into contact with water; it contains
millions of different bacteria – after biofilm has built up, some organisms
periodically float off to contaminate the water used on our patients. It is not
possible to remove the biofilm by flushing, or by the use of disinfectants.
Effective management of incoming water and waste water is therefore
essential.
Discarding of waste water for example bed bath water and humidifier water
contaminates the wash-hand stations and the surrounding environment .
Pseudomonas aeruginosa and other similar organisms grow rapidly in any
water source or on anything wet, for example an intravenous drug with splash
contamination can cause a Catheter Related Blood Stream Infection.
It is not possible to detect when water or a tap is contaminated; therefore we
need to take actions that will minimise risks.
Pseudomonas aeruginosa is the most pathogenic of the water borne bacteria
and that is why the guidance is aimed at this organism.
It, by no mean is the only one.
Others include much rarer organisms such as Stenotrophomonas, and
Burkholderia.
But actions to prevent Pseudomonas contamination will also prevent
contamination by other water born organisms.
All ICU patients whether adults or children are vulnerable to infection because
the invasive devices used to save their lives are also entry points for bacteria.
These water born bacteria can form biofilm on these devices in a similar way
to handwash stations and pipes.
The transmission pathway can be complicated:
Bacteria can be transmitted from the pipe to the tap to the patient .
Water landing on aseptic surfaces can lead to contaminated drug infusions
and catheters even prior to their insertion.
Disposing waste water in wash-hand stations contaminates the hand wash
station and makes it a reservoir for Infection.
Using Tap water for humidification will cause a pneumonia.
Any waste fluids can provide nutrients for bacteria to grow.
As a result, there are 3 key actions to prevent patients becoming sick from
water:
Keep the water in the system moving by regular flushing – this minimises
biofilm formation
Never discard waste fluids (mouth hygiene, bed bath, ventilator exudate) in a
wash hand station.
Make sure there is no splash contamination when you prepare drugs or set up
for invasive procedures
So what guidance is available?
Health Protection Scotland working in
partnership with clinicians have produced guidance:
In this guidance 6 critical control points have been identified to reduce the risk
of waterborne infections.
One control point is for estates to ensure the water up to the tap is of good
quality.
There are further two control points for Infection Prevention & Control teams
to monitor for outbreaks and mange incidents.
This leaves us with a further 3 control points that are our responsibility.
These are
Flush taps to reduce the risk of pipe contamination
Prevent direct water usage colonising & infecting vulnerable patients.
Prevent indirect water usage from colonising & infecting patients
Adult ICU Nurse
Let’s look at practice, and see what we should do?
Critical Control Point 2 is about flushing taps to reduce the risk of pipe-work
contamination
Most importantly we must
Run all taps (both hot and cold) at maximum flow first thing every morning for a
period of 1 minute and keep a record of when they were flushed.
It is easy to miss taps around empty rooms– these are the areas which are most
vital. Stagnation of water will increases the contamination risk.
It does not need to be nurses who run the taps - but it is the responsibility of the SCN
to see that it’s done.
Running of the taps should not create a splash on the surrounding environment,
If there are any problems or concerns related to the safety, maintenance or usage of
any outlets please contact your Estates departments.
In our ICU we run the taps daily and sign to say that we have done it by the hand
wash station
NICU Nurse
Critical Control Point 3 is about preventing direct water usage from colonising or
infecting vulnerable patients and there is specific guidance for Neonatal Units. This
includes guidance for washing babies, defrosting and warming milk and for the use of
ice.
Provided there are no ongoing clinical incidents related to water and that the
guidance in the other critical control points is being followed, tap water can be used
for washing babies.
Small volumes of water should be used for most procedures as the water can be
absorbed by cotton wool before disposal in to a clinical waste bag.
In Neonatal Units, breast milk is stored in designated fridges and freezers. You can
defrost breast milk by placing it in a designated fridge or outside the fridge at room
temperature if it is to be used immediately after defrosting. A dry warming device
designed for this purpose can also be used.
Breast and formula milk can warmed by removing it from the fridge one hour prior to
use or by using a dry warming device.
Milk should never be defrosted or warmed using tap water.
Ice should never be used for the direct care of neonates.
Adult ICU Nurse
There is no restriction in the national guidance on using tap water for washing,
drinking or oral hygiene in adults or paediatric ICU patients. However, in our ICU we
use sterile water for mouth care.
ICE for use by severely immunocompromised patients should be made from sterile
water.
Critical Control Point 4 is about Preventing indirect contact with Pseduomonas
In all intensive care environments…
You should only use hand wash stations for hand washing – if this is not possible in
your area contact your IPCT / Estates dept for advice
Do not dispose of any bodily fluids or waste water in a hand wash station!
Small volumes of fluids can be emptied directly into a clinical waste bag, or paper
towels can be used to soak up fluids before disposal.
Larger volumes of water should be discarded in the dirty utility area or a designated
sink.
Suction bottles or chest drain contents should be sealed and discarded as clinical
waste.
Don’t wash any patient equipment in hand wash stations and don’t use the stations
for storing used equipment awaiting decontamination.
Aseptic procedures shouldn’t be performed in areas where there are other
procedures taking place that could create splash and contaminate an aseptic
surface.
Decontaminate all surfaces on which aseptic procedures are to be performed – using
a detergent or alcohol wipe.
Stored equipment should not be exposed to splash contamination.
Use pre-filled single-use bottles for all hand hygiene products.
Don’t top-up hand hygiene dispensers or any cleaning sprays/bottles, If you do, you
are likely to spread Pseudomonas around your unit.
NICU Nurse
In Neonatal Units, incubators can be washed with tap water and all surfaces must be
thoroughly dried to prevent microbial growth.
Sterile water should be used for all humidifiers.
The key point to remember is that you can’t see contamination;
and contamination can happen very easily.
The first you may know of it is when it causes infection in one of your patients.
Professor Kevin Rooney
Finally, if you ever change the use of a clinical area, e.g. turn a bed space into an
office – you must ask the estates to remove the wash-hand station! It is stagnation
that causes problems!
So what sort of information should be communicated by the clinical teams?
Key messages from this podcast are
All Patients (whether adults or children) in ICUs, and Haematology / Oncology
units are very vulnerable to infection.
Water arriving in clinically areas will periodically be contaminated with very
low levels of micro-organisms, like pseudomonas.
We must prevent this periodic low level contamination by flushing water and
avoiding stagnation.
We must discard fluid safely so that we do not create a source of
contamination that, colonise and subsequently infect our patients.
Splashes from water can contaminate drugs and lines during their
preparation.
Find out how to you keep patients safe from water pathogens in your area –
and make sure you understand your role in preventing infections from tap
water.
If you see any problems or concerns relating to safety, maintenance and cleanliness
of the hand wash station for example cracked sinks, taps not functioning, or there are
water outlets that are no longer required contact your Estates Department
Challenge colleagues, if you a hand wash station or if the national cleaning
specification for wash hand station being used inappropriately.
If in doubt, contact your Infection Prevention & Control Team.