Hospitals Hydrotherapy This document may be reproduced and distributed freely, provided that the Dutch Workingparty Infection Prevention is cited as the author each time. Please make sure that you have the most recent version of this document. To do so, go to www.wip.nl. Once a new version of a guideline appears on the website, the Dutch Workingparty Infection Prevention is no longer responsible for the content of the versions it replaces. Dutch Workingparty Infection Prevention Published: Febuary 2000 Changed: December 2003 Revision: February 2005
Table of contents 1 Therapy baths........................... 3 2 Points of interest.......................... 7 2.1 Linido mattresses and chairs.................... 7 Appendix A References........................ 8 2 Hydrotherapy
1 Therapy baths After each use of the water bath, the walls of the bath or the tank must be cleaned and then disinfected with a chlorine solution. If the water bath is to be used by successive patients, a disinfectant must be added to the water as is also required by law (Besluit Hygiëne en Veiligheid Zwemgelegenheden (Decree on Hygiene and Safety in Swimming Facilities) 1994) [1]) for swimming water in public places. With this it is important that the water in therapy baths receives a heavier load of contaminants, and that patients may have reduced immunity to infections. Therefore proper disinfection is essential; the best way of accomplishing this is by adding chlorine. Only if the bath is only be used once and if it is not filled by means of a pump, is it not necessary to add a disinfectant to the water. Automatic chlorination of the bath water is preferred. If the water bath is only being used once, and a pump is used to fill it and circulate the water, it is also necessary to add a disinfectant to the water, because water, which can contain large quantities of microorganisms, always remains in the pump. The water must meet the following standards: Hydrotherapy 3
Table 1: Standards for swimming water in circulation pools [2, 3] taken from the standards chart for swimming water, published by the province of Noord Brabant Parameters a Unit Standard To be carried out by manager of laboratory 1. Germs growing at 37 C number per ml less than 100 m 2. Coliform bacteria number per 100 ml not demonstrable m 3. Clarity metres to the bottom d m 4. Potassium permanganate consumption mg/l 70% of the potassium permanganate consumption of the make-up water + 6 m 5. Acidity ph 6.8-7.7 ph d m 6. Urea mg/l less than 2 m 7. Free available chlorine 8. Free available chlorine if cyanic acid is used (in this case the standard below 7 does not apply) mg/l 0.3 at ph below 7.5 0.5 at ph above 7.5 d m mg/l more than 2.0 d m 9. Bound chlorine mg/l less than 1.0 d m 10. Cyanic acid (if this is used in any form) To be measured in supply water: 11. Ozone (if this is used as oxidant) mg/l less than 100 m mg/l not demonstrable d m a. to be measured in each pool, at the site where the value of the parameter/parameters is the least favourable d: to be measured every day - at least at opening and around closing time m: monthly examination carried out by a laboratory The concentration of cyanic acids may not be higher than 100 g/m3. Continuously adding chlorisocyanurates creates a risk of accumulation of cyanic acid. The quantities of free and bound chlorine, acidity and clarity of the water must be checked daily. The microbiological examination must be carried out by an independent laboratory at least once a month. 4 Hydrotherapy
When using (mobile) whirlpools, people must remember that water can remain in the pump system after use and cleaning. Large quantities of bacteria (including Legionella) can develop in this water and be released when the whirlpool is used again. Disinfecting the machine with chlorine before using it is a good preventive measure. More detailed measures are being developed for the prevention of Legionella. Cleaning and disinfection takes place in accordance with the schedule below, using agents that are suitable for application in swimming pools. Hydrotherapy 5
Table 2: Cleaning and disinfection schedule taken from the standards chart for swimming water, published by the province of Noord Brabant Cleaning Cleaning Disinfection Disinfection *Small number of visitors *Large number of visitors *Small number of visitors *Large number of visitors Floors of toilets 1 x a day 1 x per 2 hour 1 x a day 1 x per 2 h Walls of toilets 1 x a day 2 x a day - - Floors of dressing rooms Walls of dressing rooms Floors of cloakrooms Walls of cloakrooms 1 x a day 2 x a day 1 x a day 2 x a day 1 x a week 1 x a day - - 1 x a week 1 x a day 1 x a week 1 x a day 1 x a week 1 x a day - - Floors of showers 1 x a day 2 x a day 1 x a day 2 x a day Walls of showers 1 x a week 1 x a day - - Walls of swimming room Decks in swimming room 1 x a week 1 x a day - - 1 x a day 2 x a day 1 x a day 1 x a day Drainage channels in floors - - drains with stink trap weekly disinfect with sodium hypochlorite Heated benches 1 x a day 2 x a day 1 x a day 2 x a day Overflow rims To be carried out at a reduced water level Frequency depends on the amount of dirt deposits - - Pool bottom, pool walls, moveable floor 1-2 times a year when pool is empty. Bottom and moveable floor 2 x a week using swimming pool vacuum cleaner * Small or large number of visitors is not established in standardisation, is left to the discretion of the management of the swimming pool 6 Hydrotherapy
The frequencies listed apply under normal circumstances. The disinfection programme can be intensified if the infection risks are substantially higher. Floors that are used intensively (group dressing rooms, changing cubicles, etc.) can be cleaned between times by rinsing thoroughly with water. 2 Points of interest Disinfection must always be preceded by cleaning. In the event of strong contamination, combined cleaning and disinfection often does not provide satisfactory results. Always use agents approved for this purpose for disinfection. Avoid cleaning and disinfection solutions from coming into contact with the swimming water. Disinfection of surfaces with chlorous swimming water or diluted sodium hypochlorite only has a short-lived effect. These methods provide no lasting effect. Above the water surface it is best to clean the edges of the pool with a soda solution (125 ml. soda per 10 l. water). This keeps contamination of the swimming water to a minimum. In the logistic use of therapy baths, there must be a clear structural division between the clean area (walked on with bare feet) and the dirty area (walked on with shoes). There are no standards for the results of microbiological examination of the surroundings for floors in hydrotherapy rooms [4]. Floors around baths that are walked on with bare feet must be provided with a smooth finish that is suitable for cleaning and disinfection. Furthermore, these floors must slope sufficiently so that no puddles can form [3, 5]. 2.1 Linido mattresses and chairs Linido mattresses and chairs (frames wrapped in plastic thread to be used in therapy baths) should be used as little as possible as they are difficult to dry. Smooth materials are preferred. If Linido mattresses and chairs are nevertheless used, every week they must be cleaned, sprayed clean using a shower and then dried. Hydrotherapy 7
Appendix A References 1. Staatsblad, Besluit tot uitvoering van de Wet Hygiëne en Veiligheid Zwemgelegenheid. Staatsblad, 1994. 6 oktober. 2. VROM, Duik er eens in, technische info. VROM, 1985. 3. GGD Midden Brabant, Protocol hygiënebegeleiding zwemgelegenheden. 1987. 6. 4. Snoeren, R., Hygiëne in de hydrotherapie. Ziekenhuishygiëne en infectiepreventie. 5: p. 127-133. 5. Gezondheidsraad, Hygiëne in zwemgelegenheden, advies uitgebracht door een commissie van de Gezondheidsraad aan de ministers van VROM en WVC. 1989. 8 Hydrotherapy