• Safe use of water
• Minimise patient contact with tap water
• Use of sterile water
• Milk
• Use of ice

Safe use of water

It is important that the potential HAI risks from water systems are understood by those delivering care, specifically the potential transmission routes for water system-associated organisms, which can include:

• direct contact with water, for example oral care, washing and bathing, hydrotherapy
• indirect contact with contaminated equipment, medical products, staff and other patients
• aerosolisation from aerosols generated from the process of water splashing and spraying, and aerosols released from contaminated water-based equipment for example cardiopulmonary bypass machines and heater-cooler units used during cardiac surgery
• aspiration from inhalation of contaminated water into the airways, usually by patients that are intubated, via nasogastric tubes (where the contaminated water has been used to prepare the food), those requiring oral fluid replacement and those requiring orally administered medications

Minimise patient contact with tap water

Staff should consider the location and proximity of high-risk patients to tap water, drains and any associated splashing or spraying.

Alternatives to tap water, such as cleansing wipes, hand rub and water free shampoos should be considered while taking into account patient needs, patient choice and infection risk.

Use of sterile water 

• For severely immunocompromised patients, for example allogeneic stem cell transplant patients, sterile water should be considered for drinking, oral care and washing.
• Sterile water should be considered to replace tap water for washing babies within neonatal settings specifically for babies that:
  • are under 28 weeks gestation
  • have non-intact skin
  • have invasive devices 
  • are in humidified incubators

Milk

Powdered infant formulas should be prepared using freshly boiled water according to manufacturer’s instructions.

Frozen breast milk should be defrosted in one of the following ways:

• using a water-free warming device
• in a designated fridge
• at room temperature 

Any water free warming devices should be single patient use, and stored in an appropriate, clean and patient identifiable container, with a fitted lid.

Once defrosted, any unused milk should be discarded in accordance with local waste policy and never disposed of via a clinical wash hand basin (CWHB).

Use of ice

Installation of ice machines should be by approval of the Water Safety Group (WSG) and in accordance with manufacturer instructions and SHTM 04-01 Part A . A WSG approved cleaning, maintenance and audit schedule should also be in place.

Ice for consumption

• Ice for consumption by high-risk patients should not be made using ice-making machines.
• Where ice is required for consumption in these patient groups, it should be made by putting drinking water into single-use ice-making bags and frozen in a conventional freezer.
• Alternatively, iced water may be provided by freezing single bottles of commercially available spring water and allowing patients to drink that ice water as it melts.

Ice for treatment

• Where ice is required for treatment purposes by high-risk patients, it should not be made using an ice machine. It should be made using water obtained through a microbiological point of use (POU) filter, sterile water, or cooled boiled water in single-use ice-making bags and frozen in a conventional freezer. 
• Conventional freezers used in healthcare should be maintained and cleaned in line with manufacturer’s instructions with an agreed cleaning, maintenance and audit schedule in place.