‘Hand and bucket’ shower cleaning regimes pose risk of infection

Showers are an ideal environment for the development of biofilms which makes them a key risk for managing HCAIs. WET specialises in water hygiene and Legionella prevention services, here it discusses shower management strategies for hospitals and healthcare environments

Shower hoses known to be cleaned by a ‘hand & bucket’ procedure have been found to contain significantly high levels of bacteria. Most notably, a count of 2.4m cfu P. aeruginosa in just 1ml of water was observed by W.E.T during a recent research project investigating the link between showers and Healthcare Associated Infections (HCAIs).

Why is this being researched?

According to the National Institute for Health and Care Excellence (NICE) up to 300,000 patients a year acquire a Healthcare Associated Infection (HCAI) as a result of care within the NHS. To help combat this, NHS Improvement have tasked Infection Prevention and Control teams with the objective of reducing the number of healthcare associated Gram-negative bloodstream infections by 50%, by March 2021. More specifically, Public Health England, the body responsible for monitoring the number of infections that occur in healthcare settings, extended the surveillance of Gram- negative organisms to include Pseudomonas aeruginosa, which was recently mandated in September 2017.

It is widely accepted that showers are a source of contamination and a distributor of pathogenic bacteria such as Legionella pneumophila and Pseudomonas aeruginosa. This is because showers are an ideal environment for the development of biofilms as they operate within temperatures prime for bacteriological proliferation, contain crevices which harbour bacteria and are manufactured from materials that are nutrient rich. Combined with the shower atomising water, it is logical to determine showers as a key risk for managing HCAIs.

What is the current problem?

A shower hose will often contain more bacteria than the rest of the building’s plumbing system. A research team led by Frederik Hammes has been investigating this topic for the past four years. In their latest global study, they analysed biofilms in 78 shower hoses from 11 countries, and in 21 of them, they detected legionella.

H&S guidance documents such as HTM 04-01 and HSG 274 provide clear advice with regards to regular cleaning and disinfection of showers. As a result, maintenance teams and water hygiene companies have quite rightly included this as a PPM task in their water hygiene control schemes, adopting a hand and bucket cleaning and descale.

During W.E.T’s research, one study took 16 shower hoses from healthcare settings known to be cleaned using a hand and bucket methodology and tested them for TVCs and Pseudomonas. 94% of these hoses were found to be contaminated with Pseudomonas, with an average count of nearly 200,000 cfu / 100 ml sample.

This result may seem high against routine sampling at the shower outlet, which is due to the methodology of sampling. Instead of simply relying on planktonic counts at the outlet, W.E.T dissected the hoses into 10mm lengths and vortexed the material in a sterile solution, which released biofilm and bacteria off the internal surfaces. This demonstrated the high levels of contamination adhered to the internal hose surfaces, which provide perfect breeding grounds for opportunistic pathogens such as Legionella, presenting a real risk to shower users.

Why are hand and bucket procedures seemingly not working?

W.E.T offers several possible limitations with the hand and bucket process:

  • Too much focus on the shower head instead on the shower hose
  • Air pockets during disinfection, preventing full surface contact of the disinfectant
  • Pitted surfaces of materials hampering disinfection by shielding biofilms
  • Biofilm and organic matter not effectively removed from the shower hose length
  • Contact time of disinfectant not sufficient
  • Disinfectant chemical not suitable to penetrate thick biofilms
  • Bias towards descaling rather than disinfection
  • Lack of quality control processes and therefore inconsistent procedures
  • Hasty procedures, relying only upon a single chemical disinfection

In addition, having safe methods of working in accordance with COSHH regulations is a significant challenge for healthcare providers.

W.E.T’s research has shown that following hand and bucket cleaning, organic matter is left behind in the hoses, which goes on to become a food source through a process of necrophagy for pioneering bacteria coming in from the mains supply. Therefore, hand and bucket cleaning processes could actually be exacerbating the problem of microbiological proliferation in shower hoses.

What alternative solutions are available?

In 2010, it was widely broadcasted through an estates alert by the Department of Health, that flexible water supply hoses may have an enhanced risk of harbouring harmful microorganisms. Evidence pointed towards problems with the materials used to manufacture the products such as EPDM (Ethylene Propylene Diene Monomer rubber). In many cases, healthcare providers resorted to replacing under sink flexi hoses with fixed plumbing. To date, flexi hoses installed on showers have not come under the same scrutiny. This may be because they can’t be ‘designed out’ and were believed to be subjected to an effective and regular cleaning regime.

One of the ways the market has responded to this problem, is the use of disposable antimicrobial shower heads and hoses, but this is an over-engineered, expensive and wasteful solution. During W.E.T’s research, it was also observed that in some cases, the actually hose being supplied under these contracts was not actually impregnated with the silver ions, again as a result of the market focussing too much of their attention of the shower head instead.

An alternative solution being adopted by NHS Trusts and FMs alike is an innovative service offered by W.E.T, developed and launched following a successful pilot in 2017. The Hygiene 20™ Shower Management system overcomes the challenges of the existing procedures and has been evidenced to achieve superior performance of cleaning having undertaken trials with microbiologist Professor Hilton.

W.E.T’s new production facility can manage the cleaning of 10,000s showers; more economically and effectively than any known process available today, proven to kill 99.9% of bacteria. The Hygiene 20™ Shower Management solution is an innovative 6-stage process available for NHS Estates to outsource the cleaning of their showers via a ‘collection, clean and return’ process. The showers are collected from sites, inspected, bar coded for audit purposes and sent through the 6 stage Shower Management process from decontamination to final pasteurisation and returned to site.

What’s next?

W.E.T is continuing its research, highlighting the need for an alternative, sustainable solution to prevent the risk of infection and recontamination of shower heads and hoses in healthcare settings. They believe that a combination of a suitable and improved product design with antimicrobial properties, combined with an effective shower cleaning system such as Hygiene 20™ Shower Management, is sure to be the most-effective and compliant solution, alongside effective water hygiene control schemes.<./p>

For further information or to discuss your shower management strategy in further detail visit: http://www.wet-services.com/services/shower_management.php