Water treatment in hospitals called into question after pseudomonas outbreak

Water industry experts are urging hospital trusts across the UK to step up the monitoring and treatment of water systems following the Pseudomonas outbreak which killed three babies in Northern Ireland.

The country’s Health Minister, Edwin Poots, this week announced a ‘full and rigorous’ investigation into the outbreak at the Royal Jubilee Maternity Unit, which is believed to have stemmed from faulty taps on the neonatal intensive care ward.

The probe will be chaired by Professor Patricia Ann Troop, former chief executive of the Health Protection Agency (HPA), and will be facilitated by the Regulation and Quality Improvement Authority (RQIA). It will investigate the reasons for the outbreak, the actions taken, and any lessons that can be learned.

I will leave no stone unturned in my quest to reduce the risk of Pseudomonas infection in neonatal units.

These areas for improvement are expected to include the development of updated guidance on water treatment and monitoring practices in healthcare settings.

Speaking this week Poots said: “Given the gravity of what has happened, my priority is to ensure that the review is thorough and rigorous, but also makes recommendations on any immediate actions that we need to take. I want an interim report by the end of March, so that urgent actions can be taken.

“We know that Pseudomonas is a very difficult organism to eradicate completely and permanently and we know that it is not the only potential threat to those vulnerable babies in neonatal units. Therefore, I have directed that the RQIA develops, with expert public health input from the Public Health Agency (PHA), a range of specialised audit tools.

There is no single simple quick fix solution and while we need to move swiftly and decisively, we must be sure we do the right things based on the best scientific evidence available.

“These will provide independent assurance to the public, and to myself, of the standards of infection prevention control within neonatal units and other augmented care settings. This audit tool will provide self assessment standards for trusts. RQIA will provide the necessary independent assurance that these are being fully followed and implemented.

“Let me reassure the public that my first priority is to ensure the safety of all babies in our neonatal units. Safeguards are in place to protect babies and, as a precautionary step, any potential risks as a result of contamination of taps and water outlets are being addressed.”

As a result of the outbreak in Northern Ireland, every tap on every clinical handwash basin in every neonatal unit is being changed and water samples from those outlets tested. In the meantime only sterile water will come into contact with babies and staff have been told to thoroughly wash and dry their hands and use a special handrub before touching any patients.

Poots said: “I will leave no stone unturned in my quest to reduce the risk of Pseudomonas infection in neonatal units. There is no single simple quick fix solution and while we need to move swiftly and decisively, we must be sure we do the right things based on the best scientific evidence available.”

The incident at Belfast has given everybody in the healthcare industry a stark reminder of the importance of considering every aspect of microbiological control, including Pseudomonas , within water systems

This need for increased vigilance, particularly in high-dependency settings such as intensive care units, is supported by industry.

Offering advice to hospital trusts across the country, Jill Cooper, group microbiologist at B&V Water Treatment, told BBH : “Pseudomonas species can cause problems within water systems as they will produce biofilm on surfaces. Biofilm is a layer of slime such as that you would find on a pebble in a stream. Obviously a biofilm layer on a pebble is not a problem, but when this is present on the pipework of a water system it protects and harbours harmful bacteria such as Pseudomonas and legionella and is difficult to remove.”

She added: “Preventing the growth of Pseudomonas species, and legionella bacteria, within water systems requires similar and relatively straightforward procedures.

”The first line of defence against Pseudomonas colonisation and proliferation within the system should be considered as everything covered by the legionella risk assessment remedial actions and monitoring regimen. If all remedial actions have been completed and all ongoing monitoring, such as flushing and temperature controls, are maintained and the problem persists, it may be necessary to implement a chemical dosing regimen to the water system onsite.”

Standard treatments include continuous dosing of the water system with chlorine dioxide, the installation of silver-copper ionisation equipment, and, to a limited extent, the use of UV and ozone. Point-of-use filters can also be used to reduce risk, but do not, in any way, address any underlying microbiological problems.

The first line of defence against Pseudomonas colonisation and proliferation within the system should be considered as everything covered by the legionella risk assessment remedial actions and monitoring regimen

Cooper said: “All healthcare premises should have a risk assessment and regular review every two years as part of their legionella control programme. This should be carried out by a reputable water treatment company, which will have risk assessors with specific training and experience in conducting risk assessments.

”A good water treatment provider will be able to advise on all aspects of microbiological control within water systems in healthcare premises. The incident at Belfast has given everybody in the healthcare industry a stark reminder of the importance of considering every aspect of microbiological control, including Pseudomonas , within water systems.”

If all remedial actions have been completed and all ongoing monitoring, such as flushing and temperature controls, are maintained and the problem persists, it may be necessary to implement a chemical dosing regimen to the water system onsite

This week the PHA said that since the bug was first discovered at the Royal Jubilee Maternity Hospital, seven confirmed cases of infection have been recorded there. Colonisations had also been found at a number of other neonatal units in the region including Antrim Area Hospital, Altnagelvin Hospital and Craigavon Hospital. Pseudomonas has also been discovered in water outlets in the neonatal intensive care unit at Ulster Hospital.