Hydrotherapy tub article review

Environmental Health Review Spring 2002


Hydrotherapy Tub Usage
Infection Risks - Cleaning and Disinfecting
by
Scott Budgell, B.Sc., CPHI(C) and Bernice Thompson, R.N., B.N., E.T.




Recently the David Thompson Health bathing devices have the potential to act
Region, located approximately as reservoirs and sources for the spread
equidistant between Calgary and of nosocomial pseudomonas infection.
Edmonton in the Province of Alberta, Pseudomonas aeruginosa, a gram-
struggled with the complex issue of negative bacterium, is the fourth leading
hydrotherapy tub usage, including the cause of nosocomial infections.
Hydrotherapy tubs have the cleaning and disinfecting processes that Pseudomonas is able to thrive in moist
potential to act as reservoirs for would optimize infection control efforts environments, grow with minimal
the spread of nosocomial associated with safe tub usage. nutritional requirements, tolerate a
infection. Of primary concern is variety of temperatures, and is innately
Unacceptable Levels resistant to antibiotics (APIC, 1996),
Pseudomonas aeruginosa, the
as well as being somewhat impervious
fourth leading cause of In 1998, a cluster of Pseudomonas to certain chemical disinfectants.
nosocomial infections. In order to aeruginosa infections in residents and
ensure resident security, staff in a 100-bed long-term care (LTC) Bacterial Biofilm
facility in central Alberta led to an
guidelines have been
investigation into the exact cause. Pseudomonades are able to thrive within
recommended that address the Hydrotherapy tubs within the facility and around hydrotherapy tubs due to
cleaning and disinfecting needs of were sampled and found to have the protection they have from the
the hydrotherapy tub. unacceptable levels of Pseudomonas chemical disinfectants. Alginate slime
aeruginosa, heterotrophic plate counts forms the matrix (or the substance
and both fecal and total conforms. This within which) the pseudomonas biofilm
led to a hydrotherapy tub-cleaning anchors its cells. This biofilm, within
project that, to this day, remains on which the pseudomonas bacteria are
going and viable. shielded, is capable of retarding access
of disinfectants to the bacterial cells
This project saw the introduction of a within. This biofilm is able to produce
About the authors: number of policy recommendations and degradative enzymes capable of
procedures necessary to ensure that neutralizing certain chemical
Scott Budgell, B Sc, CPHI(C), is bathing water quality is maintained in disinfectants. Genetic exchange
Communicable Disease Control Specialist, hydrotherapy tubs used in regional long- between biofilm bacteria cells can also
Public Health Inspector/Executive Officer, term care facilities. Issues related to reduce the effectiveness of disinfectants
Health Protection and Prevention, David the recommended cleaning and and may increase resistance to the
Thompson Health Region, Red Deer disinfecting processes, the chemicals disinfectants. For example, according
Community Health Centre, Red Deer, required, the effectiveness of the to McDonnel, et al. (1999), "the
Alberta, Canada. cleaning process, the cost as well as the adaptation of Pseudomonas aeruginosa
risk factors of infection, will be dealt to quaternary ammonium compounds is
Bernice Thompson, R N, B N, E T, C I with in this paper. well known."
C., is Infection Control Practitioner, David
Thompson Health Region Laboratory, Red Nosocomial infections Known reservoirs for Pseudomonas
Deer Regional Hospital Centre, Red Deer, aeruginosa in LTC/health care
Alberta, Canada. Of primary consideration is that these facilities, besides hydrotherapy tubs/

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Environmental Health Review Spring 2002
whirlpool baths also include sinks and Unregulated Tub Usage be restricted to patients with intact skin.
mops, respiratory equipment, cleaning He also said that elderly and debilitated
solutions, medicines, disinfectants, and A Communicable Disease Report from patients could still be at risk even with
food mixers. All these devices or items 1995 discusses pseudomonas isolated intact skin.
tend toward a moist environment. in wounds of 4 of 24 nursing home
Hydrotherapy tubs, as we shall see, can residents who had used a whirlpool bath For example, Pseudomonas aeruginosa
present with their own unique problems. from which Pseudomonas aeruginosa has also been implicated in urinary tract
The pseudomonades are able to attach was also isolated. The recommendation infections in healthy individuals using
to the piping and other internal following the incident was that the use whirlpool hydrotherapy baths. Salmen,
plumbing structures of the hydrotherapy of the whirlpool bath should be et al. (1983) reported on three such
tub in a slimy matrix that extends restricted to continent residents with cases where two adolescent females and
considerable protection to the bacteria intact skin and that the bath should be a 25 year old man suffered from urinary
from chemical eradication. Thus, if the cleaned with a degreasing agent and tract infections traced to contaminated
disinfection process employed is disinfected with hypochlorite (chlorine whirlpool baths. The authors point out
incomplete or not done in a scrupulous bleach) between use by the individual that infections such as dermatitis and
manner, biofilm fragments remain and residents. Their conclusion was: "The UTI's are probably under reported,
will reattach. Once established, prevalence of known infection with either because the cause is not identified
pseudomonades can be checked, but Pseudomonas aeruginosa was low in or a skin rash may be self-limiting. The
probably never obliterated (Mak, the residents of the nursing home, but authors further theorize that water jets
Zazulak, Hanna, 1995). the unguarded and unregulated use of in hydrotherapy tubs or whirlpool baths
whirlpool baths may present an may propel water-laden bacteria into the
Opportunistic Pathogens infection hazard to residents using the urethra, or colonization may occur
bath and to hospitals that admit predisposing the person to a urinary
Pseudomonades are opportunistic; they residents from such nursing homes" tract infection.
are relatively resistant to antibiotics and, (Hollyoak, et al., 1995).
although they rarely cause disease in Chapped Hands/Open Pores
healthy individuals, are capable of In the United States, between 1989 and
placing at risk susceptible populations 1996, a number of waterborne disease In an anecdotal reference from another
such as people on antibiotics, people outbreaks were investigated. Study study, it was reported that a nursing
with open sores, those with indwelling results of these outbreaks consistently home staff member developed a
catheters, and those who are showed that the most frequently cellulitis in her thumb. Extensive
immunocompromised. reported hot tub or whirlpool associated treatment with antibiotics was required
illness was pseudomonas dermatitis. before the inflammation subsided. It
Respiratory infections, urinary tract (Herwaidt, et al., 1991; Kramer, et al., was concluded in a Workers'
infection's (UTI), wound infections, as 1996; Moore, et al., 1993) Compensation Board report that,
well as endocarditis, bacteremias, although the exact etiology of the
central nervous system infections, ear In a study from Germany (Bethe and bacteria was not clear, it would be
and eye infections, bone and joint Krusche, 1995), a high count of reasonable to suspect a pseudomonas
infections and gastrointestinal infections pseudomonas was found in a bacterial infection. Its conclusion was
can be caused by pseudomonades hydrotherapy tub. Use of the tub was that the infection started at the site of
(Todar, 1997). prohibited because of the risk of the preexisting hairline cut (related to
infections. High pseudomonas count chapped hands), and that the most likely
Discharge from an infection caused by was identified as being due to the design source of the bacteria would be the
a pseudomonas usually has a greenish of the pumps and different procedures nursing home setting.
or blue hue and a sweet, grape like for cleaning and disinfection.
odour. It often presents as a slimy, Even with the absence of open sores,
mucous appearance to urine and In a letter to the British medical journal, pseudomonades can gain entry through
respiratory secretions. Human The Lancet, the author suggests that the skin. Dilated skin pores,
colonization is frequently at moist sites microbiologic advice be sought before moisturizing and softening of the skin
like the ear, axilla, and perineum. such a bath is purchased. The writer can facilitate their entry (Mak, et
(Fallon, 1995) states that tub use should al.,1995). Further, there is the


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Environmental Health Review Spring 2002
possibility of increased risk with the surfaces. However, for disinfecting from the bottom of the tub/foot well.
propulsion of warm water through hydrotherapy tubs used by residents Scrub chair, footpads and any other
agitator jets. whose skin is not intact, the components.
recommendations are for cleaning
Even a low level of pseudomonas in a followed by an intermediate level 5. Circulate the disinfectant cleanser for
hydrotherapy tub presents a risk to a disinfectant. the prescribed time (according to
susceptible population. Host factors, manufacturer's instructions). This
it appears, rather than the number of Factors that affect the level of is necessary in order to ensure ad-
Pseudomonas aeruginosa organisms disinfection to be employed (low, equate contact time between the dis-
isolated, may be a factor in determining intermediate or high) include the infectant and all internal surfaces.
clinical outcome (Mak, et al., 1995). presence of organic material (i.e., feces,
urine, wound drainage), water 6. Open the drain, direct water from the
Cleaning and Disinfecting temperature, the concentration of active shower spray into all inlets until the
ingredients of the disinfectant, contact water discharging from the outlets is
The challenge for any facility, just as it time, the hardness of the water, and clear. Rinse the tub, chair, footpads,
continues to be for the facilities in the interfering residues that remain etc. with clean water. At this point,
David Thompson Health Region in after cleaning (Health Canada, the tub is ready for use.
Alberta, is to develop consistent and Communicable Disease Report, 1998).
effective cleaning and disinfecting 7. At the end of each day, after clean-
processes that are safe, practical, fast In order to accurately determine the ing and disinfecting, drain the tub but
and easy for staff to use. quantity of disinfectant required, the do not rinse it. Allow the disinfect-
volume of water needed to cover the ing solution to remain in the lines
Guidelines drafted for hydrotherapy tub intake valve must first be determined. overnight.
cleaning and disinfecting usually Following the manufacturer's direction
recommend 10-15 minutes tub on use, the appropriate amount of 8. The following morning, sanitize be-
disinfection, with a quaternary chemical is added to the tub to a final fore the first use.
ammonium compound (QAC), or concentration as noted in the tables.
another appropriate disinfectant, before Methods confirming the strength of the Important considerations
bathing residents, between baths and disinfectant should be provided by the
after baths are completed. The lines supplier. · If infections are occurring or increas-
must also be purged at this time (at the ing, the tub should be closely moni-
conclusion of the last bath of the day) Cleaning/disinfecting procedures tored in cooperation with an infec-
in order to prevent build-up of biofilm, tion control practitioner or public
and to thoroughly clean the tub's 1. Drain all water from the tub and rinse health inspector.
plumbing (Policy Statement, Regional the inside surface of the tub with
Public Health, Department of Health clean water from the shower hose. · Always wash hair and shave resi-
Protection and Prevention, David dents at the end of the bath. Water
Thompson Health Region, 1999). 2. Close the drain and fill the tub with should not be circulated either dur-
cool water until the intake valve is ing or after these procedures.
Cleaning is always essential prior to covered.
disinfection. An item that has not been · If resident is incontinent of feces,
properly cleaned, cannot be properly 3. In the tub basin, prepare at least an shut jets off, drain tub and rinse thor-
disinfected. Therefore, it is necessary intermediate level disinfectant solu- oughly.
to clean, rinse and disinfect all tion according to Health Canada's
components of the hydrotherapy tub Infection Control Guidelines: Hand · Always rinse tub thoroughly prior to
including tub basin or foot well, the Washing, Cleaning, Disinfection and use.
internal plumbing systems, lift chair and Sterilization in Health Care and/or
any other components that may be Long Term Care Facilities (Health · Hang brush to dry - away from the
employed with the tub. Canada, 1998). tub area.

Usually, low level disinfection is 4. Scrub the interior of the tub using · Ensure that the shower hose is stored
adequate to kill pseudomonas on the prepared disinfectant solution outside the tub during tub use.

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Environmental Health Review Spring 2002
· Do not use bath oils. Use only skin as soon as possible for analysis. · Avoid inhalation of chemicals.
care products approved by tub manu-
facturer. This sampling protocol is necessary to · Chlorinated disinfectants (bleach)
ensure that water quality is maintained may corrode metal components of the
· Check tub condition regularly for so that not more than two consecutive hydrotherapy tub and odour prob-
presence of chips or cracks in the tub water samples and not more than 15% lems may arise with usage.
surface. of the series of samples taken over a six
month period shall: Choosing a Disinfectant
· Residents (and staff) who exhibit
open sores or skin infections should · contain more than 200 bacteria per Not all-chemical disinfectants are equal.
not engage in bathing activities in milliliter, Some are more appropriate than others
recirculating hydrotherapy tubs un- · show the presence of coliform organ- in such areas as efficacy in sanitization,
less the infection site is covered with isms or, staff preparation and ability to comply
waterproof dressing. · show the presence of pseudomon- with process involved (ease of use), risk
ades. of corrosion, potential to inflict harm
· The presence of low levels of Pseu- to user, and cost.
domonas aeruginosa in tub water Safety Considerations
samples may not be a concern if cor- Quaternary ammonia compounds,
responding infection rates are low. Most tub cleaning guidelines allude to appropriate for low level disinfecting,
staff safety and the risks involved in for antisepsis and cleaning, have been
· When a standard and consistent handling chemicals. Choosing a found to be expensive to use in effective
method of tub cleaning has been es- disinfectant that will be relatively safe dilutions have been associated with
tablished, it should be clearly posted and acceptable is not easy. The Health respiratory irritation, and have a narrow
for all staff. Canada Communicable Disease Report microbial spectrum. In addition, the
(1998) refers to chemical disinfectants ability of Pseudomonas aeruginosa to
Sampling as a double-edged sword: "Although adapt to QAC's and develop a
their use is necessary in many routine resistance is well known.
All provinces have regulations that health care settings, the ability of these
require regular water sampling of all products to kill infectious agents also Chlorine bleach, although it has a broad
aquatic facilities such as whirlpools, makes them potentially harmful to spectrum of antimicrobial activity, is
hydrotherapy tubs and special purpose humans and the environment." less expensive and fast acting; but it is
pools. These regulations usually also corrosive and is a respiratory, skin
involve taking at least one sample of Safety Procedures and eye irritant.
water at specified intervals.
· Wear personal protective gear when A number of facilities in the David
In Alberta, at least one sample of water working with concentrated chemi- Thompson Health Region, after weeks
shall be taken at intervals of not more cals. of trialing various products and making
than seven days, and shall be submitted comparisons with other chemical
to the Provincial Laboratory of Public · Read and understand the Material disinfectants, opted for the use of an
Health for examination. (Facilities can Safety Data Sheet (MSDS) on all accelerated hydrogen peroxide
obtain information from their regional chemicals being used. If unfamiliar compound. This product has been
public health offices on the specific with MSDS, seek an explanation or found to have advantages over other
regulations as they apply to respective training from an infection control chemical cleaners and disinfectants in
provinces). practitioner or Occupational Health a number of areas including disinfection
and Safety representative. capabilities, efficiency in cleaning and
These samples are to be collected first cost effectiveness. As well, this
thing in the morning after the tub has · All disinfectants and chemicals are hydrogen peroxide technology is said
been cleaned, disinfected, refilled, is to be stored in appropriately labelled to be superior to many other
operating, and shall be taken from a containers. Incompatible chemicals environmental surface disinfectants
point near an outlet (jets). These should not be mixed or stored to- which may require three times as long
samples must be refrigerated (<4oC), gether. to achieve the same results (Sattar, et
packed with freezer packs and shipped al., 1998). These authors also found

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Environmental Health Review Spring 2002
hydrogen peroxide safer for staff, and infection control practitioners, as well aeruginosa and whirlpool baths (letter), The
environmentally friendly. as the tub and chemical disinfectant Lancet; 346; (8978):841.
manufacturers.
Gerba, C., Rose, J., Haas, C. (June 1996).
Cost Factors Sensitive populations: Who is at greater risk?
Hydrotherapy tub cleaning and International Journal of Food Microbiology;
A number of costs are associated with disinfecting is an on-going process. It 30(1-2); p. 1 13.
the identification of Pseudomonas is encouraging to note that through
aeruginosa and other pathogens in consistent cleaning methods with a safe, Herwaldt, B., Craun, G., Stokes, S., Juranek,
D. (December 1991). Waterbome disease
hydrotherapy tubs and in the strategies effective product, a better quality of tub outbreaks, 1989-1990. Morbidity and
necessary to effectively disinfect. These water can result. With commitnient and Mortality Weekly Report; CDC Surveillance
costs relate to staff time (15 minutes support, caregivers are able to provide Summaries; 40(3); p. 1-21.
before, between and after bathing each a safe and comfortable bathing
resident), the price of the chemical environment for residents. Hollyoak. J.A., Boyd, P., Freeman, P. (June
1995). Whirlpool baths in nursing homes: use,
cleaner/disinfectant, the testing and
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Environmental Health Review Spring 2002
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