Dh Htm 0401 Part c Acc

7/25/2019 Dh Htm 0401 Part c Acc

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Departmentof Health

Health Technical Memorandum04-01: Safe water in healthcarepremisesPart C: Pseudomonasaeruginosa advice for

augmented care units


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Health Technical Memorandum

04-01: Safe water in healthcarepremises

Part C:Pseudomonas

aeruginosa advice foraugmented care units


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Health Technical Memorandum 04-01: Safe water in healthcare premises: Part C Pseudomonas aeruginosa advice for


iiii

Crown copyright 2016

You may re-use this information (not including logos) free of charge in any format or medium underthe terms of the Open Government Licence.

To view this licence, visit www.nationalarchives.gov.uk/doc/open-government-licence/or write tothe Information Policy Team, The National Archives, Kew, London TW9 4DU, oremail: [email protected].

This document is available from our website at

https://www.gov.uk/government/collections/health-technical-memorandum-disinfection-and-sterilization
http://www.nationalarchives.gov.uk/doc/open-government-licence/mailto:psi%40nationalarchives.gsi.gov.uk?subject=https://www.gov.uk/government/collections/health-technical-memorandum-disinfection-and-sterilizationhttps://www.gov.uk/government/collections/health-technical-memorandum-disinfection-and-sterilizationhttps://www.gov.uk/government/collections/health-technical-memorandum-disinfection-and-sterilizationhttps://www.gov.uk/government/collections/health-technical-memorandum-disinfection-and-sterilizationmailto:psi%40nationalarchives.gsi.gov.uk?subject=http://www.nationalarchives.gov.uk/doc/open-government-licence/


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Contents

iii

Contents

Executive summary ...................................................................................................................iv

Glossary and abbreviations ...................................................................................................... v

1.0 Introduction ....................................................................................................................... 1

2.0 Hot and cold water services: overview ............................................................................ 23.0 Protecting augmented care patients ............................................................................... 4

Appendix A Example of a typical risk assessment to inform the WSP for augmentedcare units ................................................................................................................................... 7

Appendix B Exemplar P. aeruginosasample sheet................................................................10

References ................................................................................................................................11


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iv

Executive summary

Hospital water is a recognised potentialsource of Pseudomonas aeruginosa(hereafterP. aeruginosa), which is a microorganism

that can act as an opportunistic pathogenand colonise and infect vulnerable patients.Several outbreaks of P. aeruginosahave beenattributed to contaminated water systems inhospitals.

An addendum to Health TechnicalMemorandum (HTM) 04-01 published in 2013advised on how to deal with the presence ofP. aeruginosain augmented care units.

HTM 04-01 Part C (2016) supersedes the2013 addendum to HTM 04-01. The guidanceis directed towards healthcare organisationsproviding patient care in augmented caresettings, specifically aiming to inform estatesand facilities departments and infectionprevention and control (IPC) teams. As part ofthe 2016 revision of HTM 04-01, those sectionsof the addendum that introduced healthcareorganisations to the concept of Water SafetyGroups and Water Safety Plans are now a

fundamental part of HTM 04-01 Parts A andB. The HSE has also incorporated WSGs andWSPs in its technical guidance HSG274 Part 2(see the Referencessection).

For the purposes of this document, the patientgroups in augmented care settings include:

a. those patients who are severelyimmunosuppressed because ofdisease or treatment: this will include

transplant patients and similarlyheavily-immunosuppressed patientsduring high-risk periods in theirtherapy;

b. those cared for in units where organsupport is necessary, for examplecritical care (adult paediatric and

neonatal), renal, respiratory (mayinclude cystic fibrosis units) and otherintensive care situations;

c. those patients who have extensivebreaches in their dermal integrity andrequire contact with water as part oftheir continuing care, such as in thoseunits caring for burns.

This document identifies methodologies to

control and minimise the risks of morbidity andmortality due to P. aeruginosaassociated withwater outlets. It provides guidance on:

considerations for water outlets and hotand cold water services in augmentedcare settings;

protecting augmented care patients andensuring a safe environment;

methods of cleaning wash-hand basins

and other good hygiene practicesto minimise the risk of P. aeruginosacontamination.




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Glossary and abbreviations

v

Glossary and abbreviations

Alert organisms: Alert organisms aremicroorganisms that have the potential to causeharm and disease in individuals and which can

cause an outbreak of infection in a hospitalenvironment. An alert organism is identified bythe microbiology laboratory and referred to theinfection prevention and control (IPC) team forassessment of possible healthcare-associatedacquisition and to identify any possibleenvironmental/equipment sources.

Augmented care units/settings: There is nofixed definition of augmented care; individualproviders may wish to designate a particular

service as one where water quality must beof a higher microbiological standard than thatprovided by the supplier. While this documentprovides broad guidance, the water qualityrequired will be dependent on both the typeof patient and its intended use. Most carethat is designated as augmented will be thatwhere medical/nursing procedures render thepatients susceptible to invasive disease fromenvironmental and opportunistic pathogenssuch as Pseudomonas aeruginosaand other

alert organisms. In broad terms, these patientgroups will include:

a. those patients who are severelyimmunosuppressed because ofdisease or treatment: this will includetransplant patients and similar heavilyimmunosuppressed patients duringhigh-risk periods in their therapy;

b. those cared for in units where organsupport is necessary, for examplecritical care (adult paediatric and

neonatal), renal, respiratory (mayinclude cystic fibrosis units) or otherintensive care situations;

c. those patients who have extensivebreaches in their dermal integrity andrequire contact with water as part oftheir continuing care, such as in thoseunits caring for burns.

Biofilm: A biofilm is a complex layer of

microorganisms that have attached and grownon a surface. This form of growth providesa niche environment for a wide range ofmicroorganisms to interact and where thesecretion of exopolysaccharides by bacteriawill form an extracellular matrix for bothbacteria and other unicellular organisms suchas amoebae and flagellates to remain in aprotected state.

Dead-leg: A length of water system pipework

leading to a fitting through which water onlypasses infrequently when there is draw off fromthe fitting, providing the potential for stagnation.

Flow straightener: A device inserted into thespout outlet of a tap to modify flow, take outturbulence and create an even stream of water.

Point-of-use filter: A filter with a maximalpore size of 0.2 m applied at the outlet, whichremoves bacteria from the water flow.


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vivi

Water outlet: (In this document) refers mainlyto taps and showerheads, but other outlets,as indicated by risk assessments, may beconsidered important.

Water Safety Group (WSG): A multidisciplinarygroup formed to undertake the commissioningand development of the water safety plan(WSP). It also advises on the remedial actionrequired when water systems or outlets arefound to be contaminated and the risk tosusceptible patients is increased.

Water safety plan (WSP): A risk-managementapproach to the safety of water that establishesgood practices in local water distribution andsupply. It will identify potential hazards, considerpractical aspects, and detail appropriate controlmeasures.

Water supply [to the hospital]: The watersupplied can be via:

the mains water supply from the localwater undertaker (water company);

a borehole; a combination of mains water and

borehole supply;

emergency water provision (bulktankered water or bottled drinking water).

List of abbreviations

IPC: infection prevention and control

POU: point-of-use

TMV: thermostatic mixing valve

WSG: Water Safety Group

WSP: water safety plan




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1.0 Introduction

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1.0 Introduction

1.1 Part C of HTM 04-01 (2016) focuses onspecific additional measures that should betaken to control and minimise the risk of

P. aeruginosa. It is aimed at those involved withpatient safety and specifically aims to informand advise healthcare estates and facilitiesand infection prevention and control (IPC)teams. Although its main focus is control ofP. aeruginosa, the document may also haverelevance to other waterborne pathogens suchas Stenotrophomonas maltophilia, Burkholderiacepaciaand atypicalmycobacteria.

1.2 Part C should be read in conjunction with

HTM 04-01 Parts A and B and HTM 04-01:Supplement Performance specification D08: thermostatic mixing valves (healthcarepremises) as the recommendations given inthese documents for the control of Legionella,scalding risks, the testing of thermostaticmixing valves etc are also relevant.

An overview of P. aeruginosais given inChapter 5 of HTM 04-01 Part B. Guidance

on: testing for P. aeruginosais given in

Appendix D of HTM 04-01 Part B.

sampling for P. aeruginosais given inAppendix E of HTM 04-01 Part B.

the microbiological examination of P.aeruginosatest samples is given inAppendix F of HTM 04-01 Part B.

1.3 Additional general requirements for thequality assurance of water systems includingthose within healthcare facilities should be

followed (see the Health & Safety ExecutivesApproved Code of Practice and guidance onregulations Legionnaires disease: The controlof Legionellabacteria in water systems (L8)and the NHS Premises Assurance Model).


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2.0 Hot and cold water services: overview

For comprehensive guidance on the designand installation of hot and cold waterservices, see HTM 04-01 Part A.

2.1 With the change in focus towardsimproving the patient environment andminimising the risk of healthcare-associatedinfections, there has been an increase in theprovision of single-bed rooms with en-suitefacilities. Additionally, to promote good handhygiene, wash-hand basin provision hasincreased significantly in all clinical areas.However, in many situations this has led to

infrequently used water outlets and low waterthroughput. Such outlets form a greater risk ofcontamination by P. aeruginosathan those thatare used more frequently.

2.2 Water services have become morecomplex. Every effort should be made whenplanning, designing and installing new ormodified systems to minimise and removepotential hazards (for example oversized waterstorage tanks, flexible hoses, stagnant water,

poor temperature control, long branch pipesand dead-legs), as well as enabling access formonitoring and maintenance. Adapting existingsystems to improve safety is almost always themore expensive solution.

2.3 In new and existing premises, therefore,it is essential that the needs of individualpatient washing and bathing requirementsare carefully considered. In new premises,the provision, correct siting and installation of

showers and wash-hand basins, particularly

in accommodation where patients are unlikelyto make use of them, requires assessment.For existing premises, and subject to a risk

assessment, permanent removal of existingoutlets and their associated pipework shouldbe considered.

2.4 Tap design has evolved. In olderinstallations, thermostatic control of watertemperature was achieved by a separatethermostatic mixing valve (TMV) (commonlycalled a t-shaped TMV), typically locatedbehind the sanitary assembly panel to whicha wash-hand basin or other assembly was

fitted, which then supplied water to thehot connection of a manual mixing tap orseparate tap. Many new installations nowinclude taps of a modern design with integral

TMVs. They are usually manually controlled(on and off) and can be adjusted to furtherreduce outlet temperature to fully cold. Forsome applications, remote sensor-operatedtaps are available (many sensor taps alsohave the option of auto-flushing programmesand can be linked to the hospitals building

management system). In some instances thesedevelopments have led to a more complicatedinternal tap design which may increase theneed for additional routine maintenance(including decontamination) to mitigate the riskof contamination by P. aeruginosa.

2.5 There is some evidence that the morecomplex the design of the outlet assembly (forexample, some sensor-operated taps), themore prone to P. aeruginosacolonisation theoutlet may be (see Berthelot et al., 2006).




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2.0 Hot and cold water services: overview2.0 Hot and cold water services: overview

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2.6 The choice and type of water outletsfor the augmented care setting is thereforeimportant (see also Table 2 in HTM 04-01Part A). This choice should be based on a risk

assessment of infection-control and scaldingissues.

2.7 In intensive care and other critical careareas, where patients are unlikely to be ableto use the wash-hand basins, the installationof non-TMV mixing taps may be the preferredcontrol option following a risk assessment.

Note:

For clinical wash-hand basins, HealthBuilding Note 00-10 Part C Sanitaryassemblies (formerly Health TechnicalMemorandum 64) recommends integralthermostatically controlled water usingeither a single-lever tap or a sensor tapfor most applications and settings. Ifrisk assessment justifies a different tapassembly for clinical wash-hand basins inaugmented care settings, then derogation

from Health Building Note 00-10 Part C maybe considered so long as it is approved bythe Water Safety Group (WSG).

2.8 In accordance with Health TechnicalMemorandum 04-01 Part A, TMVs shouldbe fitted where risk assessment has shownvulnerable patients are at risk of scalding.

This should be considered when planning/designing new builds or refurbishments. A TMVthat is integral to the body of the tap/shower is

preferred, as it is designed to always draw coldwater through every time the outlet is used,thus helping to minimise the risk of stagnation(see also Table 2 in HTM 04-01 Part A).

Note:

Scalding risk assessments should form partof the water safety plan (WSP) before anydecision is made on the method of scalding

risk control (see also paragraphs 6.166.26in HTM 04-01 Part B).

2.9 Owing to their high surface-area-to-volume ratio and location at the tap outlet,certain designs of flow straightener maypresent a greater surface area for colonisation

and support the growth of organisms.Therefore, when selecting new taps, wherepossible flow straighteners should be avoided/not included. Health Building Note 00-09 alsoadvises against using aerators in outlets.

2.10 Sensors should be offset or positionedsuch as to reduce the risk of accidentalcontamination of the outlet and be positionedso that point-of-use (POU) filters can beused. Facilities for overriding the sensors will benecessary.

2.11 If retro-fitting new taps, it is important toensure that they are easy to use and practicalfor the existing space.

2.12 Taps, components and fittings should beremovable and easily dismantled for cleaningand disinfection. When replacing taps, alsoconsider fitting:

taps that are easy to use;

taps to which a filter can be attached tothe spout outlet. Note: Such taps canbe used for supplying water for cleaningincubators and other clinical equipment.


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3.0 Protecting augmented care patients

3.1 Management should ensure that all staffwith responsibility for cleaning should beadequately trained and made aware of the

importance of high standards of cleanliness(see also paragraphs 1.211.29 in HTM 04-01 Part A and paragraphs 6.296.30 in HTM04-01 Part B). Refresher training shouldbe given where a specific area does notmaintain the expected standard of cleanliness.

Visual monitoring of domestic staff shouldbe undertaken by means of regular audits.

The following paragraphs give examples ofbest practice advice aimed at protectingthe susceptible patient and ensuring a safe

environment:

a. For direct contact with augmentedcare patients, water of a knownsatisfactory quality should be used,that is, either:

i. water where testing has shownabsence of P. aeruginosa; or

ii. water supplied through a POU filter;

or

iii. sterile water (for example, for skincontact for babies in neonatalintensive care units).

b. Water outlets should be reviewedwhere there may be direct or non-direct contact with augmented carepatients. This may also includereviewing the need for the outlets/

showers and their potential removal.

c. Use of single-use cleaning wipesshould be considered for patienthygiene.

d. Rigorous reinforcement of standardinfection control practices should beimplemented. This includes regularrefresher training for relevant staff.

e. The cleaning of clinical wash-handbasins and the taps should beundertaken in a way that does notallow cross-contamination froma bacterial source to the tap (see

paragraph 3.2).

f. The cleaning of patient contactequipment (for example, tap handles,incubators, humidifiers, nebulisersand respiratory equipment) shouldbe reviewed. Options to minimise riskinclude the following measures:

i. use of single-use equipment;

ii. if locally reprocessed even ifused on the same patient cleanequipment with water of a knownsatisfactory quality (see (a) above);

iii. use of single-use detergentwipes for cleaning incubators.Manufacturers instructions shouldbe followed. If a disinfectant isused, it is important that it will notcause damage to the material of the

incubator. Disinfectants should notbe used to clean incubators whilethey are occupied.




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3.0 Protecting augmented care patients3.0 Protecting augmented care patients

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g. All other uses of water used inaugmented care units should beconsidered and appropriate action/changes to operational procedures

taken. Uses of water to be consideredinclude:

i. drinking water fountains;

ii. bottled water dispensers;

iii. wet shaving of patients who have acentral venous catheter inserted intothe jugular vein;

iv. washing patients with in-dwellingdevices.

Notes:

1. Tap water should not be used in neonatalunits for the process of defrosting frozenbreast milk.

2. Water features should not be installed inaugmented care units.

3. Chilled water and ice-making machinesshould not be installed in augmented careunits. Where ice is needed for treatmentpurposes, it should be made using waterobtained through a microbiological POUfilter or boiled water in sterile ice trays orice bags.

h. All patient equipment should be storedclean, dry and away from potentialsplashing with water.

i. All preparation areas for asepticprocedures and drug preparationand any associated sterile equipmentshould not be located where they areat risk of splashing/contamination fromwater outlets.

j. All taps that are used infrequently

on augmented care units should beflushed regularly (at least daily in themorning for one minute). If the outletis fitted with a POU filter, the filtershould not be removed in order to

flush the tap unless the manufacturersinstructions advise otherwise. Arecord should be kept of when theywere flushed. Some taps can be

programmed to flush automatically;such flushing may be recorded throughthe building management system(BMS).

k. Thermostatic mixing valves (TMVs)and associated components shouldbe serviced, including descaling anddecontamination, at recommendedintervals (see also Chapter 11 in HTM

04-01: Supplement Performancespecification D 08: thermostatic mixingvalves (healthcare premises)).

l. A TMV that is integral to the body ofthe tap/shower should be considered,as it will always draw cold waterthrough every time the outlet is used,thus helping to minimise the risk ofstagnation.

m. Where taps are designed to be easilyremoved for maintenance purposes,they should be periodically removed fordescaling and decontamination and/orplaced in a washer-disinfector (subjectto the tap manufacturers instructions).

n. It should be ensured that:

i. accurate records and drawingscover all the hot and cold water

systems and that they are updatedfollowing any modification;

ii. all services are properly labelled,such that the individual services canbe easily identified;

iii. staff who are engaged inthe installation, removal andreplacement of outlets andassociated pipework and fittings

are suitably trained to preventcontamination of the outlet andwater system.


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3.2 Clinical wash-hand basins are atparticularly high-risk of contamination. It istherefore important to ensure the cleaning ofthese basins and the taps is undertaken in a

way that does not allow cross-contaminationfrom a bacterial source to the tap. In particular:

a. During cleaning of basins and taps,there is a risk of contaminating tapoutlets with microorganisms if thesame cloth is used to clean the bowlof the basin or surrounding area beforethe tap.

b. Waste-water drain outlets areparticularly risky parts of the basin/system and are almost alwayscontaminated (see Peleg and Hooper,2010; Breathnach et al., 2012).Bacteria may be of patient origin, soit is possible that bacteria, includingantibiotic-resistant organisms, couldseed the outlet, become resident inany biofilm and have the potential to betransmitted to other patients.

c. If POU filters are fitted to taps, thesame cleaning regime applies to thewash-hand basin, but the filter itselfshould be cleaned according to themanufacturers instructions. Careshould be taken to avoid contaminatingthe external surface and outlet of thefilter.

Best practice advice relating toall clinical wash-hand basins in

healthcare facilities

3.3 Clinical wash-hand basins should beused solely for hand-washing. In particular, thefollowing dos and donts should be noted:

a. Do not dispose of body fluids at theclinical wash-hand basin. Use theslophopper or sluice in the dirty utility

area to dispose of body fluids.

b. Do not wash any patient equipment inclinical wash-hand basins.

c. Do not use clinical wash-hand basinsfor storing used equipment awaitingdecontamination.

d. Do not touch the spout outlet whenwashing hands.

e. Taps should be cleaned before the restof the clinical wash-hand basin. Careshould be taken to avoid transferringcontamination from wash-hand basinto wash-hand basin.

f. Do not dispose of used environmentalcleaning agents at clinical wash-hand

basins.

g. Make sure that reusable containerscontaining environmental cleaningagents are used in a manner that willprotect them from contamination withP. aeruginosa(see Aumeran et al.,2007; Ehrenkranz et al., 1980; Sautteret al., 1984).

h. Use non-fillable single-use bottles forantimicrobial hand-rub and soap.

i. Consider the appropriate positioningof soap and antimicrobial hand-rubdispensers. The compounds in theproducts can be a source of nutrientsto some microorganisms. Therefore,it is advisable to prevent soiling of thetap by drips from the dispensers orduring the movement of hands from

the dispensers to the basin whenbeginning hand-washing.

j. Identify and report any problemsor concerns relating to safety,maintenance and cleanliness ofwash-hand basins to the WSG.Escalate unresolved issues to highermanagement and/or the IPC asappropriate.




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Appendix A Example of a typical risk assessment to inform the WSP for augmented care units

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Appendix A Example of a typical riskassessment to inform the WSP

for augmented care units

Healthcare providers will assess risks identified for their units providing augmented care. Theexemplar risk assessment form below is included for illustrative purposes.


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Health Technical Memorandum 04-01: Safe water in healthcare premises: Part C Pseudomonas aeruginosa advice for augmented care units

Infection/colonisation withPseudomonas aeruginosafrom contaminated water

Susceptible patients withinaugmented care units

USE OF WATER:For direct contact with patients, water ofa known satisfactory quality is used: water where testing has shown absenceof P. aeruginosa; or

water supplied through a point-of-use(POU) filter; or

sterile water (for skin contact for babiesin neonatal intensive care units).

ENGINEERING ASSESSMENT OF WATERSYSTEMS: Correct installation and commissioningof water systems in in line with HTM04-01 is adhered to

Schematic drawings are available forwater systems.

FLUSHING: Flushing of water outlets is carried outand documented.

SAMPLING: Plans for the sampling and microbio-logical testing of water are in place

Description of the hazardsPersons affected by thework activity and how

Existing controls Likeli

Facility/ward/department: Assessment completed by:

Date: (Names/titles):

Brief description of activity, location or equipment: to determine the level of risk that Pseudomonas aeruginosafrom the wapatients in the unit

Note to reader: This is anexample risk assessment. Thecontrol measures outlined arenot exhaustive but are forillustrative purposes only.Each healthcare provider willhave its own risks and willneed to carry out a risk

assessment based on theserisks (see paragraphs6.236.26 in HTM 04-01 PartB for examples of other risksand further guidance).


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Appendix A Example of a typical risk assessment to inform the WSP for augmented care unitsAppendix A Example of a typical risk assessment to inform the WSP for augmented care units

99

Risk scoring: Use the grid below to achieve and overall score for the risk by measuring across for the impact and down for the

likelihood.

IMPACT

1 2 3 4 5

LIKELIHO

OD

1 1 2 3 4 5

2 2 4 6 8 10

3 3 6 9 12 15

4 4 8 12 16 20

5 5 10 15 20 25

KeyGreen Low

AmberMedium

RedHigh

The resulting action planshould include:

Sources of information/persons consulted Further action if necessary to control the risk

Person/s responsible for coordinating implementation of the action. Recommended timescales Date completed Revised risk rating

Risk scoring matrix


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Appendix B Exemplar P. aeruginosasamplesheet

[]

[]

Hospital/site: St Lukes

Building: East Wing

Faculty/department/ward: 12

Time sample taken: 07.00

Date: 20 February 2016

Name of sampler (print): J. JONESBacterial species:P. aeruginosa

Note: The tap should not be cleaned or disinfected by heat or chemicals immediately before sampling

RoomNo.

Roomname

Outlettype

OutletID No.

Pre-flushsample

Post-flushsample

Samples barcode (affixadjacent to sample details)

Refer to Appendix E in HTM 04-01 Part B (2016 edition) for detailed advice on obtainingsamples correctly

101 NeonatalICU:

WHB

WHB

Mixer

Mixer

001

002

Yes

Yes Yes

102 NeonatalICU clean

utility: WHB

Sink

Mixer

H/Clever-op

003

004

Yes

Yes

Notes

[]

[]

[]

[]

[]

[]

[]

[]

[]

[]




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References

11

References

Department of Health publications

NHS Premises Assurance Model (NHS PAM).https://www.gov.uk/government/publications/nhs-premises-assurance-model-launch

Health Building Notes

Health Building Note 00-09 Infection control in the built environment.https://www.gov.uk/government/publications/guidance-for-infection-control-in-the-built-environment

Health Building Note 00-10 Part C Sanitary assemblies.https://www.gov.uk/government/publications/guidance-on-flooring-walls-and-ceilings-and-sanitary-assemblies-in-healthcare-facilities

Health Technical Memoranda

Health Technical Memorandum 04-01 Safe water in healthcare premises. Part A: Design,installation and commissioning.2016.https://www.gov.uk/government/collections/health-technical-memorandum-disinfection-and-sterilization

Health Technical Memorandum 04-01 Safe water in healthcare premises. Part B:Operational management. 2016.https://www.gov.uk/government/collections/health-technical-memorandum-disinfection-and-sterilization

Health Technical Memorandum 04-01: Supplement. Performance specification D 08:thermostatic mixing valves (healthcare premises).https://www.gov.uk/government/publications/hot-and-cold-water-supply-storage-and-distribution-systems-for-healthcare-premises

Other publications

Aumeran, C., Paillard, C., Robin, F., Kanold, J., Baud, O., Bonnet, R., Souweine, B. and Traore, O.(2007). P. aeruginosaand Pseudomonas putida outbreak associated with contaminatedwater outlets in an oncohaematology paediatric unit.Journal of Hospital Infection. January.

Vol. 65 No. 1, pp. 4753.
https://www.gov.uk/government/publications/nhs-premises-assurance-model-launchhttps://www.gov.uk/government/publications/guidance-for-infection-control-in-the-built-environmenthttps://www.gov.uk/government/publications/guidance-for-infection-control-in-the-built-environmenthttps://www.gov.uk/government/publications/guidance-on-flooring-walls-and-ceilings-and-sanitary-assemblies-in-healthcare-facilitieshttps://www.gov.uk/government/publications/guidance-on-flooring-walls-and-ceilings-and-sanitary-assemblies-in-healthcare-facilitieshttps://www.gov.uk/government/collections/health-technical-memorandum-disinfection-and-sterilizationhttps://www.gov.uk/government/collections/health-technical-memorandum-disinfection-and-sterilizationhttps://www.gov.uk/government/collections/health-technical-memorandum-disinfection-and-sterilizationhttps://www.gov.uk/government/collections/health-technical-memorandum-disinfection-and-sterilizationhttps://www.gov.uk/government/publications/hot-and-cold-water-supply-storage-and-distribution-systems-for-healthcare-premiseshttps://www.gov.uk/government/publications/hot-and-cold-water-supply-storage-and-distribution-systems-for-healthcare-premiseshttps://www.gov.uk/government/publications/hot-and-cold-water-supply-storage-and-distribution-systems-for-healthcare-premiseshttps://www.gov.uk/government/publications/hot-and-cold-water-supply-storage-and-distribution-systems-for-healthcare-premiseshttps://www.gov.uk/government/collections/health-technical-memorandum-disinfection-and-sterilizationhttps://www.gov.uk/government/collections/health-technical-memorandum-disinfection-and-sterilizationhttps://www.gov.uk/government/collections/health-technical-memorandum-disinfection-and-sterilizationhttps://www.gov.uk/government/collections/health-technical-memorandum-disinfection-and-sterilizationhttps://www.gov.uk/government/publications/guidance-on-flooring-walls-and-ceilings-and-sanitary-assemblies-in-healthcare-facilitieshttps://www.gov.uk/government/publications/guidance-on-flooring-walls-and-ceilings-and-sanitary-assemblies-in-healthcare-facilitieshttps://www.gov.uk/government/publications/guidance-for-infection-control-in-the-built-environmenthttps://www.gov.uk/government/publications/guidance-for-infection-control-in-the-built-environmenthttps://www.gov.uk/government/publications/nhs-premises-assurance-model-launch


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Berthelot, P., Chord, F., Mallaval, F., Grattard, F., Brajon, D. and Pozzetto, B. (2006). Magneticvalves as a source of faucet contamination with P. aeruginosa?Intensive Care Medicine.

August. Vol. 32 No. 88, p. 1271.

Breathnach, A.S., Cubbon, M.D., Karunaharan, R.N., Pope, C.F. and Planche, T.D. (2012).Multidrug-resistant P. aeruginosaoutbreaks in two hospitals: association withcontaminated hospital waste-water systems.Journal of Hospital Infection. September. Vol. 82No. 1, pp. 1924.

Ehrenkranz, N.J., Bolyard, E.A., Wiener, M. and Cleary, T.J. (1980).Antibiotic-sensitiveSerratia marcescens infections complicating cardiopulmonary operations: contaminateddisinfectant as a reservoir. Lancet. Vol. 2 No. 8207, pp. 128992.

Health and Safety Executive (2013).Approved Code of Practice and guidance on regulations.Legionnaires disease: The control of Legionellabacteria in water systems (L8). (4th edition).

Health and Safety Executive, 2013.

Health and Safety Executive (2014). HSG274 Legionnaires disease technical guidance.Part 2: The control of Legionellabacteria in hot and cold water systems. Health and SafetyExecutive, 2014.

Peleg, A.Y. and Hooper, D.C. (2010). Hospital-acquired infections due to Gram-negativebacteria. New England Journal of Medicine. Vol. 362 No. 19, pp. 180413.

Sautter, R.L., Mattman, L.H. and Legaspi, R.C. (1984). Serratia marcescens meningitisassociated with a contaminated benzalkonium chloride solution. Infection Control. Vol. 5

No. 5, pp. 223225.


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