1. Water Risk Management in the Health Service
Tom Martin BSc
Environmental Innovations Ltd

2. Introduction
- Water risk management does not just concern itself with Legionnaires disease
- As a widely understood risk, this presentation seeks to highlight some of the more quietly talked about risks which can be just as costly and damaging
- A healthcare facility should be treated with the same regard as a conventional industrial or commercial facility when considering the nature of water on site
- Generally speaking, many healthcare facilities, especially campus style hospitals have old inherited sites with ongoing or difficult to deal with water management plans
- Based on the above point, this puts healthcare FM at a disadvantage to private industry
Water risk doesn’t contain itself to the obvious legionnaires disease, and other water borne virus's which so many exhibitors specialize in.
Although this is important, and a massive sector of the water risk management industry, it will not be the focus of this presentation based on the fact that it is probably the most widely understood risk factor regarding water flows on site. With this in mind, I hope to explore with you some of the other water risks being ignored, disregarded and uncosted.
As exhibitors we have taken the approach, which I am sure most of you will agree with, that the idea healthcare based facilities bears the same water and flow risks as many other facilities, whether this be industrial or commercial sites across the UK. Generally healthcare sites, especially campus style hospitals will have more complicated sites with inherited historic and longstanding issues. This is where healthcare facilities are somewhat at a disadvantage to many modern industrial and commercial facilities. Unfortunately, the water risk issue is compounded by the sensitivity of a health based facility. I am going to keep at the forefront of your mind a food manufacturer when we go through the following slides, imagining the corporate risk or implications to such a manufacturer. Realistically speaking, this should be no different with the health industry.

3. Legionella - Regulation outlining Legionella ACOP L8
- Legionella is dormant below 20oC and wont survive above 45oC.
- Water tanks should be at 60oC or higher, and distribution at the coolest part should be at 50oC or higher.
- Human audits should take place monthly and recorded accurately.
- Insulation is flagged up at numerous times. Bear in mind a five story building with a tank at the highest point, where would you start to find the point at which the water is cooling for example?
- Many facilities are increasing their water temperature at great cost, however the outcome is generally that of scalding
So, the topic I told you all I wasn’t going to talk about. I’m not going to focus on this, but realistically we do need to talk about it.
As you will know, the key regulation regarding Legionella is the L8 part of the APPROVED CODE OF PRACTICE. What I want to discuss here is the management of risk, with a view to resolving the issue. Temperature monitoring of tanks, mixer valves and thermostats can show where systems should be more regularly flushed, or are not meeting temperature requirements. Bearing in mind, that stored water should be at 60degreesC, with the coolest part of entire system at 50degreees, monitoring at various points across the flow network can highlight issues prior to manual sampling and testing. Furthermore, they can reduce costs by mitigating the need for manual testing on either a daily or monthly basis.
Technology on the market offers wireless and automated readings which can output realtime reports, ensuring the L8 is adhered to.
Many facilities are simply increasing their water temperature to either overcome cool areas of their system where perhaps insulation isn’t sufficient. Although solving one part of the problem, costs of heating the water to higher and unnecessary temperatures can far outweigh the costs of technology to correct the issue.
Temperature increases on the whole then causes another risk factor as many facilities will be outputting water at temperatures which could scald.

4. Scalding
- Although widely addressed in America, the UK does have HSE regulation on this
- Care homes, pre-schools, wards where patients who have reduced mental capacity, are vulnerable to hot water and therefore scalding.
- American study shows 5 out 6 surveyed facilities had water which could scald out their ‘faucets’.
- Real-time Temperature monitoring can reduce costs in the form of waste
- Hot surfaces - HSE suggest that surfaces should not exceed 43degree when a 'system' is at its maximum. This must mean that a radiator should be limited via the thermostat.
Although focused on less in the UK, our experience in America has shown that reviews on the temperature of water from taps or 'faucets' if we want to get American have shown that scalding has become an issue through mismonitoring of water outputs.
Care homes, pre-schools, wards where patients who have reduced mental capacity, (and people who cannot react appropriately or quickly enough to prevent injury) all have vulnerable service users which may not be able to control a mixer tap.
We were directed to an academic study in America took temperatures from consumption points across a range of different health facilities to see where tap temperature was equal or above the scald point at which a 2nd and 3rd degree burn would occur. Ironically tests at charities supporting burns victim showed the highest water temperatures, which would cause third and second degree burns should somebody use the hot water taps in their washroom facilities.
Automated monitoring and reporting of temperatures can address where mixer valves should be, but are not currently limiting the max temperature. Lastly, many mixer valves and taps can suffer from limescale issues where they stick, and therefore could allow hot water to pass through consistently.
Protecting vulnerable service users should be paramount to operators of the facility and as such, they could and should monitor beyond infrequent tests which may or may not be carried out.
Related to this is temperature of surfaces, which should not exceed 43oC. In essence this relates to radiators, however many older hospitals and faculties will have heating which exceeds this limit. Although thermostats should be limited to a maximum output of no more than 43oC, if this cannot be achieved due to costs of replacements, real-time monitoring of surface temperature can indicate issue with surfaces that are too high in temperature and may cause scalding.
Somewhat unrelated to the slide of scalding, but monitoring the temperature of radiators can initiate costs savings in the sense that patterns will show when they are being kept on too long, being switched on too early and being used inappropriately compared with ambient temperatures. Correcting these issues can save cold hard cash.

5. Graph from Study, showing American Burn Association (ABA), and Burn Foundation of Delaware Valley (DV) having temperatures within the second and third degree burn curve

6. Leakage, and mismanagement of water
- Leakage can lead to waste in terms of costs and down time
- Leakage can cause outages in terms of repair times for major bursts
- All of the above can cause ward closures, breaches in facility standards, and to the extreme, undiscovered leaks can cause building defects and structural problems.
- Water costs, although relatively low in the UK, can add to a massive sum when considering the size of some health facilities.
- Referring back to the scalding slide, changing the way health facilities use their radiators can go towards a cost cutting exercise
Many of us have driven down a road where a pipe has burst, and we see it go unrepaired for stupid lengths of time.
Measuring water use can mitigate the lack of detection of a water leak, or water mismanagement. By introducing pulse counters on flowmeters, patterns should show periods where water use is less than it is at peak, mainly at night. Given a building is closed down at night, we may even see zero usage throughout some hours. If we find that usage barely changes over a given period, we can start to look at practices on site, usage rates and whether certain practices can be stopped at night, thus saving costs.
Further costs are attributed to leakage and water mismanagement in the style of correction time. If a ward must be closed to repair a pipe underground, the factored cost of this is large. Further, you may not know how challenging it could be to repair pipes in hard to reach locations – down time and therefore repair has a cost, and is rarely cost efficient.
I just want to refer back to the last page when considering water mismanagement, in the sense that by monitoring things such as radiators, waste can be picked up on almost immediately. Changing practices without compromising the service can be a good way of finding cost savings, simply by speculating in monitoring technology.

7. Blocked Sewers and Sewer Surcharging
-Hospitals seem to be dogged with this issue more than most due to the nature of the media being disposed of
- Wirelessly monitoring provides a real-time retro-fit solution which can plug straight into the building management system
- As particularly sensitive areas can be affected, early warnings provide a proactive response rather than costly reactive responding
Unfortunately, large campus style hospitals cannot hide from pipe and drainage defects.
From our market research, to many people we spoke to yesterday, we have found that blocked sewers seem to a problem dogging most healthcare facilities. From gloves, to sanitary products, nappies to macerated paper and medical waste, the foul drainage network seems to be awash with nasties which have a habit of showing themselves in some of the most inconvenient of places.
Recently we addressed a blocked sewer issue whereby the pinch point outlet of a particular hospital building was an old style 6” bore pipe. Any waste entering the system seemed to block just after this manhole, meaning the resulting cocktail of sewage was backing up into part of the maternity care facilities – where they made newborn baby formula. An early warning system alarming at the detection of a blockage, and hence a backing up of water has not ensured they can move back into their facility having been barred from it for over 3 months.
Pressure points on the drainage system can be addressed wirelessly, without the need for intrusive cabling and ducting required with most systems. They transmit to gateway receivers which themselves have volt free contacts for plugging straight into the BMS or SCADA system.
The same process can be used for sewer surcharging where the adjoining water company may be either putting pressure on your particular area of the network, or where their systems cannot cope with a hospitals discharge and is therefore backing up the system on site.
Being in control of these ensure you are proactive rather than reactive in a particularly sensitive area.

8. Major Spills and Oil Interceptors
Hospitals, much like other industrial sites will be have deliveries of, and storing bulk quantities of liquids, chemicals and hydrocarbons. As with these other site, the risk of spills and firewater is ever-present. The environmental Agency haven’t recently pulled the plug on very reasonable guidance to industry to protect themselves against the vast fines which can be forced upon a polluter based on both EU and UK regulation. The guidance once upon a time provided the procedures and steps to take to ensure spills were mitigated and the risks minimized.
Storage areas and delivery points are the weakest when it comes to their risk of a spill, and therefore Hospitals as well as other stes should act responsibly towards their risks. Bund should be properly lined, with bund sump pumps with sensors to cut them out if a spill occurs. This however is given that a bund exist at all. I have been to all too many Hospitals where old oil tanks have merely a brick surround. Even if a bund is present it is generally old, deteriorated and breached with pipes and services.
Spills of bulk liquids into the surface water drainage system can cause severe problems with the receiving water receptors, i.e. rivers, lakes and ponds. This water risk is one which is generally overlooked by hospitals, as it is deemed for industry, however hospitals I have been to often store vaster quantities than manufacturers.
Automated or remotely operated penstocks are the only way to isolate the surface water drainage network sufficiently to proactively deal with a spill.
In line with this, many large campus style hospitals have oil interceptors which are largely ignored, or assumed to be performing. Worse than this, some hospitals sign up for milk round serving of the tanks which is equivalent to throwing money down the drain. Interceptors should be managed properly, ensuring they are fit for purpose, followed by a structured servicing plan based on automated auditing and alarm systems. My customers tend to fin the addition of an interceptor alarm cuts operating costs by up to 50% and see a ROI within 12 months. The quantity of car parks and vehicles moving about a site, along with silt and heavy metal depsits make this a real risk which should be managed.
Incorrectly stored IBC’s on Hospital site, over surface water outlet
Sensitive receptor which had a spill pollution a 5KM stretch, and killing all local fish species
Remote and Automated Penstock valve for drain isolation
Wireless interceptor alarm, retro-fitted for cost savings. Reduced services by 60%

9. Summary Thank you - Legionella - Scalding
- Leakage and Mismanagement of Water
Blocked Sewers and Sewer Surcharging
- Major Spills and Oil Interceptors
So in summary, I’m hoping to have addressed some know water risk management factors, and perhaps introduced some new ones which aren’t as well covered.
It doesn’t matter what factor the risk is, whether it be service user, with the consequence of illness, burns or scald, or the environmental recptor; if water risk management is focussed upon in any of these areas the benefits ultimately are costs savings. Throw in a couple of regulations from the government and realistically speaking, all of the list on the screen should be talking points, or areas to address when meetings are happening up and down the country in facility management practices.
Thank you