Water supply is critical to the smooth running of hospitals and other health and care settings.

But, for estates and facilities management (EFM) teams, this creates a huge demand as they are charged with ensuring supplies are consistent and, most importantly, that systems are protected from potentially-harmful bacteria such as legionella and Pseudomonas aeruginosa.

Legionnaires’ disease was first identified in 1976 when there was a large outbreak of pneumonia at a hotel in Philadelphia.

Since then, knowledge of the bacterium has developed, including details of its ecology and means of control.

So too has our understanding of Pseudomonas aeruginosa, which became familiar to hospital EFM professionals after three premature babies died due to infections from water systems at a Belfast hospital in 2012.

Under pressure

Chris Potts, marketing director at ANT Telecom, explains: “Organisations across the UK are held accountable by the UK’s Health and Safety Executive (HSE) to prevent the growth of legionella and other known pathogens in freshwater systems.

“Health estates professionals face understandable pressure here as, aside from protecting people’s health, if legionella is detected, or suspected, this would require intensive and costly treatment and testing, which can last for months.

“It also has the potential to cause all sorts of operational issues if areas need to be sealed off while treatments takes place. This could have a further impact on patient care, but also has wider implications across the entire hospital facility.”

Daniel Pitcher, managing director at the Water Hygiene Centre, adds: “Within healthcare settings invariably individuals are unwell, immunosuppressed, elderly, or have underlying medical conditions which makes then susceptible to bacteria which may be present.”

While water pipes are a key consideration as there are often ‘deadlegs’ and hard-to-reach areas that routine flushing may bypass; taps also pose a hazard.

The root of infection

The average hospital can have more than 2,000 taps – or outlets – and each one of these can harbour legionella which, if not properly controlled, can enter the lungs, leading to Legionnaires’ disease.

Pitcher said: “Outlets can include many constituent parts and components that could allow biofilm to thrive. Coupled with the infrequent use of some outlets, particularly during the COVID pandemic when there was a reduction in the number of people in hospitals, this results in favourable conditions which allow legionella to grow.

“When individuals then operate the outlet, water is released and there will be water atomised which the individual can breathe in. This contains the legionella bacteria and is the root of infection.”

As well as reducing outlet use significantly, the Coronavirus pandemic also put routine flushing of water systems on the backburner in some hospitals, further increasing the likelihood of infection. Stuart Skinner, marketing manager at Rada (a Kohler company), added: “Waterborne pathogens such as legionella present a particular risk to patient safety, and mortality rates for immunocompromised patients with Legionnaires’ disease can be as high as 80%. “We found that during the pandemic, understandably, estates teams and frontline staff were primarily focused on managing surges in patient numbers over anything else.

 The impact of COVID

 “While infection control was a huge focus, the usual high standards for routine water safety measures were no longer the priority during COVID. This meant that regular testing perhaps slipped as managing duty flushing requirements and water testing can often take up huge staff resource.” As a result of this, he reports increased interest in digital systems that enable these measures to be programmed and automated. And, to support EFM teams, manufacturers have, over the past decade, been redesigning outlets so they require less maintenance and have inbuilt protection against a host of harmful bugs. Skinner said: “Poorly-designed or maintained taps could pose a risk as legionella thrives in stagnant water. “While this can be managed by effective maintenance and infection control regimes, such as duty flushing, this can be very time consuming and resource intensive for facilities and clinical teams. “It’s important, therefore, that estates and facilities teams carefully consider how best to reduce the risks of bacterial growth, right from the specification stage, and that means choosing products that have been designed and built with infection prevention in mind.” Modern tap designs focus on ease of use, infection prevention, and must support intensive handwashing regimes.

 Flexibility and precision

Skinner said: “What is particularly challenging about healthcare is that every section of a hospital will have its own exacting demands for water delivery. “Acute care wards and operating theatres will require the most stringent of handwashing protocols and non- touch tap operation. Other areas, such as inpatient wards, will see outlets used frequently by multiple patients, so ease of operation and maintenance is important here. “Flexibility and precision are also key and digital products offer this, as they can be programmed to meet every exacting demand. For example, clinical taps with run times set to surgeons’ specific handwashing protocols, or automated duty flushing, which frees up the staff resource needed to carry out this task manually.” Zip Water’s HydroTap UltraCare solution delivers instant chilled and boiling water and has been specifically developed and proven to reduce legionella and other bacteria in water. It has been designed with four protective barriers: • A MicroPurity UV-C module, which disinfects water as it is dispensed • MicroPurity carbon-free filtration, which retains chlorine in filtered drinking water, helping to prevent infection from spreading and removing dirt, lead, microplastics, and microbiological cysts • SteriTouch antimicrobial treatment which is incorporated both externally and internally in components to reduce surface bacteria by 99.99% • A HydroCare service plan, which ensures the taps always perform to the highest levels of hygiene, efficiency, and reliability with tailored service plans, filter replacement, and a bespoke sanitisation regime Mark Brindley, product manager at Zip Water, said: “The key consideration in providing a product for a hospital setting is to give the maximum level of protection to all users.” And this is where IoT sensors come in.

Data capture

 Potts explains: “The challenge that hospitals face, in particular, is that they generally don’t know which taps aren’t used frequently through normal daily activating and, therefore, where bacteria can grow. “Unfortunately, new taps do not address this challenge, so what some hospitals do to control the risk, and comply with safety standards, is to flush each tap manually twice a week for an extended period of time and record this activity for compliance purposes. “Some hospitals will have over 2,000 tap and shower outlets, so this is by no means a straightforward undertaking and takes a huge amount of resource. So, when developing a water system, or considering an upgrade, it is worth considering that IoT sensors can be fitted to these systems to more effectively monitor usage – and this can automate tracking and help ensure teams focus on running the taps that have been used the least, first.” Pitcher advises: “Engagement with the end user is crucial when specifying outlets. “A really-useful consideration is whether the proposed outlet design allows the fitting of point-of-use filters and ensuring a scald risk assessment has been completed.” Potts adds: “Some taps have evolved to address certain legionella issues, but they can’t address the problem of water stagnating within the pipes itself.

Reducing the burden

 “However, this is where IoT sensor technology can be used to reduce the burden on staff and control the risks. “An automated monitoring solution using the latest IoT temperature sensors can be fitted and will automatically and digitally record which taps are used through daily activity. “Reports can then be easily generated, highlighting a significantly-smaller number of outlets that must be flushed manually; thereby reducing the burden on staff and enabling them to be deployed to other areas. “This approach also reduces the amount of paperwork required for compliance purposes as this is generated automatically; and helps to save water and energy, contributing to a more- environmentally-friendly process.” As well as an increase in the specification of IoT devices, manufacturers are also reporting greater use of Thermostatic Mixing Valves (TMVs) and Thermal Mixer Taps (TMTs) within health and care settings. Pete Tyson, commercial director at the Water Hygiene Centre, told hdm: “ TMTs negate the need for a TMV further upstream of the outlet, which potentially allows for better thermostatic control and avoids lengths of pipework that could sit at the favourable proliferation range for legionella.

 Digital advancements

 “Automatic flushing devices have also been introduced to help reduce the human factor scenario of regular flushing regimes. “And the ability of thermal disinfection through and within an outlet has greatly improved and has allowed thermal pasteurisation of both hot and cold supply streams, which means that a local thermal control measure could be utilised at the point of use. “Overall tap designs have become less complex, with fewer components, and the quality of the finish has been improved to help reduce areas and surfaces on which biofilm can establish.” Skinner adds: “Over the past 10 years, engineering advancements have led to new ways in which taps can actively resist the formation of bacteria. “Sensor products were historically favoured for their non-touch operation, but there was nervousness over the use of the solenoid valves as these components managed water flow, but were typically complex parts built from materials more prone to bacterial growth. “Digital advancements and smart engineering have enabled manufacturers like us to achieve non- touch functionality in taps without using solenoid valves. “TMV technology has also evolved. Locating them within the tap, rather than an external component connected by pipework, can simplify the water’s journey before it reaches the user. “This all means less water-to-surface contact and, ultimately, less opportunity for bacteria such as legionella to form.” Rada recently helped Dudley NHS Foundation Trust to improve water safety with the installation of its digital range of non-touch taps, Intelligent Care. The taps automatically record performance and usage data and feature a smart duty flushing functionality so they will only flush when needed.

Exciting times

 With the COVID-19 pandemic still impacting hospitals, and infection prevention and control high on the agenda, interest in these modern solutions is expected to continue to increase. Brindley said: “We’ll be seeing some exciting advancements over the next few years. “Smart technology and the Internet of Things (IoT) are set to be the next evolution in tap design. These will enable connectivity between different systems, allowing users to track key usage information such as hydration and energy efficiency. “Additionally, this will also have a positive impact on the maintenance side due to features such as remote access, diagnostics, and predictive servicing.” Pitcher adds: “I would hope that the design, the internals, and the options available to us from a component perspective continue to improve and develop, with legionella and other waterborne pathogens taken into consideration. “The fewer parts of a tap, the more difficult it is for bacteria to colonise an outlet; the fewer parts within an outlet, the easier it is to keep clean; and the fewer crevices the outlet has from a smoothness of the internal metallurgy or from general areas of potential stagnation between working parts, the better. “Serviceability is also an area that would greatly reduce the risk as the easier it is to clean the working parts, both internally and externally, the easier it is to reduce bacteria contamination. “Living in a digital age more technology will be associated with the outlet, for example temperatures being captured and details of operation and run time electronically recorded for review and analysis.”

The direction of travel

In conclusion, Skinner said: “The Government’s new A Digital Health and Social Care Plan speaks for itself – frontline care delivery and estates can truly harness digital technology. “We’re only just starting to see what digital can offer water management, and the new levels of precision and control that can unlock even greater operational efficiencies. “Multiple outlets can be connected into a building management system (BMS) so that functionality, including flow times, temperatures, and infection control regimes, can be automated and monitored from a central dashboard. “This ensures high levels of accuracy, reducing the risk of human error while increasing operational efficiencies. “This also offers intelligence on product usage, which can inform data- driven adjustments to the system. “Using actionable intelligence to make best-practice-led adjustments can help estates to ensure water management is always optimised. “For us, that’s the direction of travel – continuous improvement and driving innovations in water delivery technology that support greener, safer healthcare.”

www.radacontrols.com

 www.waterhygienecentre.com

www.anttelecom.co.uk

www.zipwater.co.uk