The technical bulletin was developed to enhance the current HTM 04-01 (2016) guidance in response to an outbreak of M. abscessus, an NTM associated with a newly constructed lung transplant unit. Following that outbreak, a coroner published a prevention of future deaths report in 2022, which highlighted concerns around the risk to augmented care patients and healthcare water systems and recommended a review and update of the current guidance.
The bulletin aims to ensure that the design, construction, and operation of new specialised wards/units, or significant refurbishments of existing clinical spaces intended for patients at high risk of healthcare-associated infections (HCAI), do not cause harm from exposure to water sprays or aerosols derived from water, wastewater systems, and associated equipment.
NTM are opportunistic pathogens that present a significant risk in healthcare environments due to their ability to cause infections in vulnerable immunocompromised populations and their antibiotic resistance. In addition, they are resistant to standard water treatment measures used to control Legionella and Pseudomonas, enabling them to thrive in water systems, on surfaces, and in medical equipment and devices.
This makes them a persistent source of HAIs, posing a significant threat, especially to those with weakened immune systems, such as cancer patients, organ transplant recipients, and cystic fibrosis patients. These patients are more susceptible to pulmonary, skin, and soft tissue infections and disseminated diseases caused by NTM from water sources.
NTM are categorised by NHS England as emerging human pathogens of concern as the number of cases is increasing. Pulmonary NTM infections have been rising, with estimates indicating that the prevalence is around 2.9 cases per 100,000 population.
The following patient groups are designated as high-risk. A precautionary approach is necessary to protect these patients from infection by NTM and other waterborne pathogens.
Although the new guidance focuses on new construction and major refurbishment projects, its scope also applies to existing buildings where the infrastructure allows patients at high risk of water and wastewater infections to be protected. Therefore, the guidance applies throughout all capital and significant refurbishment project stages from inception to handover, regular operation, and planned and reactive maintenance.
Patients at risk from NTM are equally at risk from infection by other opportunistic waterborne pathogens. Adopting the guidance is anticipated to help prevent infections from other waterborne hazards by taking a patient safety first approach.
Boards are required to ensure that effective governance is in place to deliver a building that is safe for its intended population, starting at the point of project inception. A project duty holder should be appointed for each project, with clear targets set and the expected outcome that the building poses no risk of harm to patients in regard to waterborne hazards. A Project Water Safety Group (PWSG) should be formally appointed and empowered to ensure the project delivers a safe building for patients.
The PWSG should develop a project-specific water safety plan (PWSP), identifying all sources of exposure to water and wastewater that could pose a risk. Each stage of the process, from concept to handover and beyond, should be risk-assessed by considering the susceptibility of patient groups. The design of water systems must minimise the risk of microbiological contamination. This includes ensuring that no materials, components, or fittings used in the water system present a risk of microbial contamination, i.e., avoiding wet testing and ensuring each item is unused, individually packed, and certified.
All involved in the project must receive appropriate training to understand the factors that can cause harm from water, wastewater systems, and associated equipment and how to prevent them. Ensuring relevant experience and competence, rather than relying solely on job titles, is the key to success. Detailed consideration and expertise are needed to ensure all system hazards and associated risks have been identified and mitigated in the water system’s design, construction, installation, and operation. Crucial installation related to water systems should only be carried out by those specifically trained to work on healthcare water systems and follow processes approved by the PWSG. This ensures that all individuals understand the risks to patient safety from their actions.
Procurement practices must consider the need to ensure that water safety is a critical element of the new build process and does not introduce risks to patient safety throughout the lifecycle of the building. To prevent contamination of water, wastewater systems, and associated equipment before handover, site welfare facilities must be provided for all contractors. The tender specification must clearly define the water system acceptance criteria, which should be agreed upon by the PWSG. The tender specification should include the sampling and monitoring plans, and the data required to determine that all systems are safe.
The filling and commissioning plan must follow the PWSP and reflect that all systems should only be filled and operated with disinfected water through the point of entry filtration system.
Commissioning must occur at the latest possible time before handover after all other building elements have been commissioned. This plan needs a high level of focus and effort to prevent contamination of the water and wastewater systems as set out at project inception and agreed upon by the PWSG. For acceptance at handover, all commissioning records should be made available, and these records should form part of the BIM as a fitted model handed to the operations team.
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