Healthcare-associated infections (HCAIs) are one of the most common adverse events affecting hospitalised patients [Haque, 2018], particularly those on intensive care units (ICU). These patients are often critically ill and immuno-compromised, which increases their susceptibility to HCAIs, [Haque, 2018]. Up to 37% of patients on ICU acquire an HCAI [Haque, 2018], and are likely to have a worse clinical outcome in terms of morbidity, mortality, and length of stay, than patients without, [Nuvials, 2015].
In paediatrics, the pattern of HCAIs is different, with more serious infections such as bloodstream infections being commonly seen (45%), followed by respiratory tract infections (22%), [Zingg, 2017]. Many of these hospital-related infections are also multi-drug resistant, making their treatment more complicated, [Zingg, 2017].
HCAIs are caused by a range of microorganisms; with around 15 causing up to 87% of HCAIs; including S. aureus, E. coli, Staphylococci, Klebsiella and Pseudomonas aeruginosa, [Haque, 2018]. Approximately 20% of HCAI causing pathogens include multidrug-resistant (MDR) types, making treatment particularly challenging, [Haque, 2018].
To reduce the risk of HCAI, effective infection prevention strategies are essential, particularly in ICUs. Research in Birmingham demonstrates that when effective infection control policies are implemented in ICU, there is a positive effect on the reduction of HCAIs throughout the hospital, [Bradley, 2017].
Water used in hospitals often harbour pathogenic organisms that can threaten patient safety, [Perkins, 2019]. There is evidence of a clear link between hospital-acquired waterborne infections and water systems. Up to 30% of washing facilities may be contaminated with waterborne bacteria, including sinks, taps and splash zones, [ Garvey, 2019; Hebdon, 2022; Weinburg 2022].
It has been reported that up to 20% of patients in critical care will get a waterborne infection, [Perkins, 2019], which carries an increased financial cost of around £27,000 per infection, [Stone, 2009].
The value of water-free approaches in reducing infection rates is becoming increasingly recognised; helping both to prevent patient infections and limit the dispersal of antimicrobial resistance, [Inkster, 2024].
This strategy includes the removal of hand washing basins from patient cubicles and using wipes or wash mitts for hygienic patient care. The Department of Health (DOH) (2016) acknowledged that water is a risk to patients in augmented care setting such as critical care and has provided guidance regarding water management (flushing, POU filters and drinking water).
Following a review of published data and a visit to Radboud university medical center in The Netherlands – where water-free ICUs have been pioneered – the Adult Critical Care Unit, Kings Mill hospital, Nottinghamshire began the switch to waterless care a year ago. It was noted that the Radboud Medical Centre ICUs achieved a 50% reduction of all gram negative bacilli by removing all tap sourced water from patient care, including staff hand washing, [Hopman, 2017].
Equipment required for patient hygiene using water
CASE STUDY 1
Tina Wright, Department Leader, Adult Critical Care Unit, Kings Mill hospital
The 15 bed adult CCU manages level 2 and 3 critical care patients; with an average length of stay around 5-7 days. The CCU switched to water-free patient washing one year ago, as part of a two year study to assess the impact on reducing hospital acquired waterborne bacteraemia’s. The move was supported by evidence showing a 76% reduction in waterborne infections by using a wipes-based system, instead of soap and water for patient hygiene [Baker, 2021]. This water-free strategy aims to reduce the number of hospital-acquired waterborne infections by 50%.
Traditional soap and water has been replaced with a wipes-based system for all patient hygiene needs. All patients are washed for five days with octenidine containing wash mitts in line with the Trust’s MRSA de-colonisation protocol, then a non-antimicrobial wash mitt is used. A new study has shown a 17% risk reduction in primary bacteraemia by using octenidine-containing wipes compared to placebo, [Schaumburg, 2024].
Equipment required for water-free patient hygiene
Prior to the study, the unit identified 4 hospital acquired waterborne infections in two years, based on blood culture samples. Since changing to water-free washing, no waterborne bacteraemia’s have been recorded. The wash mitts provide time and cost savings, as well as being preferred by staff and patients.
Data show the mitts save 9 minutes 47 seconds per patient every day compared to washing with a bowl and water. Cost savings have been achieved as laundry costs are reduced, fewer replacement point of use water filters are required and preventing a single HCAI potentially saves £27,000.
Patients ‘like the feel of the mitts’ which are warmed prior to use. The mitts have also enabled some patients to self-care as they are easier to use than a bowl and water, meaning there is a positive impact on rehabilitation.
CASE STUDY 2
A Pearson, Charge Nurse, Paediatric ICU, Bristol Royal Hospital for Children
The Paediatric Intensive Care Unit at the Bristol Royal Hospital for Children cares for over 700 children each year. With 18 beds on the unit, it is one of the larger intensive care units for children in the UK, providing up to Level 3 advanced critical care.
Latest data show 63% of patients are emergency admissions. The remainder are elective patients, many of whom require surgery for congenital cardiac anomalies. Research suggests there is a high prevalence of HCAI in paediatric intensive care units (15·5%) [Zingg, 2017]. Children who develop an HCAI spend on average an additional 7 days on PICU, compared to those without an infection, [Sodhi, 2016].
Caring for such vulnerable patients means the highest standards of infection prevention are paramount. S. aureus remains a major cause of healthcare-associated infections, [Mason, 2024] and up to 30% of people are carriers, [Jeans, 2018]. Prior to admission, patients are screened for staphylococcus. Children who are positive undergo a 5 day protocol with an octenidine containing wash and a nasal ointment prior to admission. Whilst on the unit they receive their remaining treatment using octenidine containing wash mitts. Patients admitted as emergencies or who are transferred from other hospitals are swabbed routinely on admission, any positive cases are then treated with wash mitts and nasal ointment, for 5 days before a pause in treatment. Re-swabbing then takes place and further treatment is administered if required.
The aim is to reduce the likelihood of an MRSA or MSSA infection and cross contamination resulting in HCAI. The wash mitts have been in use for three months and staff prefer their ease of use compared to washing with octenisan wash and water. There is no need to rinse which helps minimise the exposure of infants, helping to maintain their body temperature. They also reduce environmental waste as there are no plastic soap bottles to dispose of; also packaging and microplastic waste are reduced.
Two to three mitts are usually sufficient for one patient and the mitts are warmed before use.
References
Baker, A.W., Stout, J.E., Anderson, D.J., Sexton, D.J., Smith, B., Moehring, R.W., Huslage, K., Hostler, C.J. and Lewis, S.S., 2021. Tap Water Avoidance Decreases Rates of Hospital-onset Pulmonary Nontuberculous Mycobacteria. Clinical Infectious Diseases; Clin Infect Dis, 73 (3), 524-527.
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