safety action notice - Health Facilities Scotland

SAFETY ACTION NOTICE
By arrangement with NSS Health Facilities Scotland
SAN(SC)06/46
26 OCT 2006
Facilities
Page 1 of 2 Pages
AUTOMATIC ICE-MAKING MACHINES:
RISK OF INFECTION
SUMMARY
Automatic ice-making machines have the potential to become sources of contamination / infection if not
properly installed, cleaned or maintained. Advice is provided.
BACKGROUND
1. Reports have been received (not from Scotland) of a number of clinical laboratory specimens, taken
from water and ice in automatic ice-making machines, having grown the bacterium Mycobacterium
gordonae.
2. M. gordonae is a relatively benign bacterium that is widespread in the environment. It is sometimes
referred to as the ‘tap water bacterium’ as it is found so frequently in tap water. However, M. gordonae
is increasingly recognised as a cause of infection in the severely immunocompromised, e.g. HIV/AIDS
patients and transplant recipients.
3. Ice-making machines can become sources of infection in healthcare premises. They can be
contaminated with organisms from the water itself or from contact with contaminated hands or
fomites1, e.g. ice scoops or drinks cans inappropriately placed inside the storage compartment.
4. The build-up of micro-organisms will be aided by any ice-making machine being installed at the end of
a pipe run (dead leg) allowing water to stagnate, and by allowing warm air from the heat exchanger to
impinge directly onto water pipes, thereby raising the water temperature and enabling bacteria to multiply.
5. Ice-making machines have been associated in the past with a cluster of M. gordonae2. In this case,
cleaning of the ice machines resulted in a sharp decrease in the number of M. gordonae isolates.
6. SHFN 30(3) gives the following guidance on ice-making machines: “The type selected should be
capable of automatic dispensing of ice and without a storage reservoir, which requires the users to
scoop ice from a stock which may have been made too far in advance”. However, ice-making
machines with storage reservoirs may still be found in healthcare premises.
ACTION
7. This notice should be brought to the attention of all appropriate managers, staff and users.
8. All automatic ice-making machine installations should be inspected to ensure that:
a) The water supply is taken from a potable mains supply up-stream of a regularly used outlet with the
minimum of intervening pipe run, i.e. less than 3 metres. Additionally, it should be established that
the usage is sufficient to avoid deterioration in water quality by, for example, the inlet water
temperature rising above 20ºC,
Suggested Distribution
Community Care
Infection Control Staff
Supplies/Procurement
Accommodation Officers
Estates/Facilities
Renal Dialysis
Wards
Burns Units
Health & Safety
Risk Management
Care Home Services
Hospices
Social Services
SCOTTISH HEALTHCARE SUPPLIES
Gyle Square Edinburgh EH12 9EB
A Division of the National Service Scotland for NHSScotland
CONTACT EMAIL: iric@shs.csa.scot.nhs.uk
WEBSITE: http://www.nhsscotland.com/shs/hazards_safety/adverse_p.html
FAX: 0131 314 0722
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SAFETY ACTION NOTICE
By arrangement with NSS Health Facilities Scotland
SAN(SC)06/46
26 OCT 2006
Facilities
Page 2 of 2 Pages
AUTOMATIC ICE-MAKING MACHINES:
RISK OF INFECTION
b) The equipment is positioned so that the warm air exhaust does not impinge directly on taps, pipes
or hoses supplying mains water. Supply pipe work and hoses should be insulated to prevent any
heat gain.
10. Procedures should be in place in all wards / clinical areas to reduce the risk of healthcare associated
infections from automatic ice-making machines and these should be approved by the infection control
team, e.g. use of non-touch systems, hand hygiene practice etc. Regular infection control audits should
be undertaken.
11. Procedures governing the operation of automatic ice-making machines should include the following,
where appropriate:
a) The storage compartment should be cleaned out on a frequent basis in accordance with the
manufacturer’s instructions and procedures approved by the infection control team,
b) ‘Old’ ice should be discarded in order to avoid ice stagnating in the storage compartment. It is
recommended that this be done at least as often as the storage compartment is cleaned,
c) Lids of ice storage bins, if fitted, should be kept closed to avoid contamination of the contents.
12. Maintenance and cleaning of the machine should be carried out strictly in accordance with the
manufacturer’s recommendations and at regular intervals, and endorsed or amended by the infection
control team depending on location and usage.
13. Care must be taken not to contaminate ice and ice-making machines when removing ice for patient use,
e.g. user’s hands should not touch the ice or the storage compartment, nor should external items such as
ice scoops or drinks cans be placed in the storage compartment.
14. Ice for consumption by severely immunocompromised patients should not be taken from automatic icemaking machines but should be made with sterile water. Separate local policies for the production and
storage of ice will be required for such cases.
REFERENCES
1. Fomites, refers to any object or substance supposed to be capable of absorbing, retaining, and
transporting contagious or infectious organisms.
2. Nosocomial Mycobacterium gordonae pseudoinfection from contaminated ice making machines,
Panwalker AP, Fuhse E, Infection Control, February 1986.
3. Scottish Health Facilities Note SHFN 30 Infection Control in the Built Environment: Design and
Planning Property and Environment Forum Executive (now Health Facilities Scotland), revised August
2005.
SCOTTISH HEALTHCARE SUPPLIES
Gyle Square Edinburgh EH12 9EB
A Division of the National Service Scotland for NHSScotland
CONTACT EMAIL: iric@shs.csa.scot.nhs.uk
WEBSITE: http://www.nhsscotland.com/shs/hazards_safety/adverse_p.html
FAX: 0131 314 0722
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