Although this blog is based on a Healthcare webinar where the author was a panellist answering questions, this is part 2 of the blog, answering the question on little used outlets, is helpful read for all industry sectors!!
During 2021, the Healthcare Infection Society [HIS] hosted a webinar, the session being part of their ‘IPC challenges and solutions – audience lead webinar series’. The format for the webinar was a Q&A session with no presentation, but with a four-person panel of experts answering questions submitted electronically by the audience in advance of the event. I was asked to be one of the four-panel experts, each of the experts was then provided with two questions they had to answer during the session.
These questions were really very interesting to answer, and it made sense to share them!
The question posed…
“What are the formal definitions for ‘little use’ of an outlet? And how many of our individual patient rooms in a hospital are likely to represent these?”
To begin with, where does this term ‘little use’ come from, is it included in the current guidance….?
Approved Code of Practice L8 [ACoP L8]:
- There is no use of the term ‘little used’, although does have two references to ‘…parts of system used intermittently’.
HSG274 Part 2:
- ‘Little use’ is detailed on three occasions, twice within ‘supplementary controls’ and once within appendix 2.1.
- An alternative term is also referenced, ‘Infrequently used’. This term is used several times throughout HSG274 part 2 (once within ‘supplementary controls’).
HTM04 Part B:
- References: “6.42 - HSG274 Part 2 recommends that generally, for ‘infrequently used outlets’, flushing is carried out once a week but that in healthcare facilities the Legionella risk assessment, as agreed by the Water Safety Group, may indicate a higher frequency, and water draw-off should form part of the daily cleaning process.”
- References: “6.44 During the temporary closure of wards or departments, a flushing regime should be instigated to maintain system hygiene” – no terms such as ‘little use’ or ‘infrequently used’ detailed.
- References: “Table 1 Checklist for hot and cold-water systems (adapted from HSG274 Part 2) ‘’Infrequently used equipment’ within a water system (i.e. not used for a period equal to or greater than seven days) should be included on the flushing regime.”
- References: “Appendix D Augmented Care: Pseudomonas aeruginosa detected at outlet: ‘D22 If a water outlet has been taken out of service because of contamination with Pseudomonas aeruginosa, continue daily flushing while the outlet is out of normal use to prevent water stagnation and exacerbation of the contamination.”
HTM04-01 Part C:
- References: “1 …..Infrequently used water outlets and low water throughput. Such outlets form a greater risk of contamination by Pseudomonas aeruginosa than those that are used more frequently.”
- References: “1 / J: All taps that are used infrequently on augmented care units should be flushed regularly (at least daily in the morning for one minute).”
SHTM04 Part B:
- Uses the term ‘infrequently used facilities’.
- Several uses of ‘sporadically used outlets’. Including the statement in Note 4: ‘if used less than once week, showers should be removed’.
Having considered the most current guidance available it is clear to see that there are a variety of terms being used to describe outlets that are not being routinely used. It is worth exploring further looking towards published standards and even past guidance to make sure we’ve not missed anything….
BS 8680 2020 Water Quality - Water Safety Plans - Code of Practice:
- No reference to little-used outlets, infrequently used outlets, or flushing.
- Although does use the term “outlets no longer being used.”
- References: “C6 - All outlets and pipework no longer required are removed and cut back to the circulating pipework with no dead legs of any size, to reduce the potential for stagnation.”
BS PD 855468-2015 Guide to flushing and disinfection of services supplying water for domestic use within buildings:
- Hygiene flushing to avoid stagnation.
- Regular hygiene flushing in those builds temp out of use.
- References: “12 Hygiene Flushing - The system should be flushed weekly (twice weekly in healthcare premises) to maintain a flow of water. The design of the flushing programme should be in accordance with the HSE’s Approved Code of Practice L8 , and HSG274 Part 2.”
[Pre runner to L8 and HSG274]
- References ‘intermittently used taps.
HTM2027: Hot water & cold-water supply storage and mains services [published 1995]
- No reference.
HTM2040: Operational Management [published 1993]
[Pre runner to HTM04:01]
- References ‘showers regular daily use’.
HTM2040: Management Policy [published 1993]
[Pre runner to HTM04:01]
- References: ‘Appendix – Management Checklist – 3e) identification of LITTLE USED OUTLETS and associated pipework’
Having reviewed current guidance, past guidance, and published standards, the use of the term ‘little use’ has been found:
- HSG274 Part 2: used on three occasions, with many references to infrequently used.
- HT2040 Mgt Policy: used on one occasion.
To answer the question, what is the formal definition of a ‘little use’ outlet (infrequently used outlet), when referring to the various references above, my opinion being a ‘little use’ outlet (infrequently used outlet) in the healthcare setting is an outlet that is not being used at least daily. ‘Daily’ use of outlets is essential to minimise the period of no flow and stagnation and is regular use of the outlet which minimises the risk of microbial growth in the water system.
To help qualify this response…
HSG274 part 2 details the flushing of infrequent used outlets as “Weekly or as indicated by your risk assessment - For high-risk populations, e.g., healthcare and care homes, more frequent flushing may be required as indicated by the risk assessment.”
Then, HTM04-01 states… “in healthcare facilities the risk assessment, as agreed by the Water Safety Group, may indicate a higher frequency, and water draw-off should form part of the daily cleaning process.”
And HTM04-01 Part C details “infrequently used outlets to be flushed daily in augmented care areas.”
This higher frequency of flushing linked with daily cleaning practice indicates the need to keep water turning over daily!
To answer the second part of the question: And how many of our individual patient rooms in a hospital are likely to represent these?
Not all hospitals are the same! There are big, small, old and new hospitals. The key here is the clinical risk assessment to identify patient susceptibility cohorts, then determine who is in the patient rooms and the use of those services i.e., bed-bound patient in an ensuite facility, if the patient is not able to get out of the bed, then they are not going to use services i.e., shower, toilet, and basin. So, these services need flushing and considering my answer to the previous element of this question, that’s daily use.
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Editor’s Note: The information provided in this blog is correct at date of original publication – January 2022.
© Water Hygiene Centre 2022