How should asbestos 
be managed in hospitals?

The remit for the health and safety manager in a large university health board not only covers various clinical safety risks but also involves the more traditional health and safety hazards facing most large organisations. This includes the management of asbestos containing materials that still exist in many of our healthcare premises. This article aims to provide a brief description of what asbestos is, its associated health risks and how we managed a very large asbestos environmental clean in one of our hospital sites following an HSE investigation.

What is asbestos?
Asbestos is a family of naturally occurring minerals, found in serpentinite and other metamorphic rock. Because of its strength and resistance to heat, asbestos was used for insulation, heat resistant clothing, roofing and fire proofing. It was also used as an additive to ease the manufacture and application of ceiling and wall finishes, tape joint compounds, floor tiles and mastics.
    
There are up to six million tonnes of asbestos in schools, hospitals, ships, offices and factories – and the homes we live in. Asbestos was used extensively as a building material in the UK between the 1950s and the mid-1980s, and so any type of building built before 2000 could still contain asbestos. You can find asbestos in many places, for example: as a sprayed insulating coating on steelwork and concrete; as lagging on pipes and boilers; as insulation board in walls, on doors and ceilings; as asbestos cement for roof and wall coverings, pipes and tanks; and in other products, e.g. floor tiles, sealants, textured decorative coatings (such as artex), rope seals, millboards, paper products, fire doors, cloth (e.g. fire blankets).

Health Risks
Asbestos is the greatest single cause of work‑related deaths in the UK. While asbestos in good condition is not harmful as such, it becomes highly dangerous once the material is damaged and a person breathes in the asbestos fibres. Inhaling the fibres can cause deadly diseases currently resulting in more than 5,000 deaths a year in the UK – 13 people for every day of the year.

The three main diseases caused by asbestos are lung cancer, asbestosis (scarring of the lung), and mesothelioma (cancer of the lining of the lung). However, symptoms of these diseases often do not show up clinically for 15-50 years after first exposure to asbestos fibres. Most people with asbestos-related diseases were exposed to elevated concentrations whilst working with the product.
    
Blue and brown asbestos have not been imported into the UK for nearly 20 years and their use was banned in 1985. With the introduction of The Asbestos (Prohibitions) (Amendment) Regulations in 1999, white asbestos was finally banned except for a small number of specialised uses.
    
Asbestos in healthcare is not a new issue. For as long as asbestos has been identified as a problem, money has been spent on removing it or managing its risk in hospitals and other healthcare premises.

Hospital buildings
A lot of healthcare premises are quite old and although new hospitals are being built, there are a large number of hospitals and healthcare buildings built using asbestos containing materials. These were often found in large boiler houses, lagging on steam pipes located in under floor voids/subways, asbestos insulating board protecting pipework in clinical environments all of which are realities of its use from not too long ago.
    
From the patient’s viewpoint, however, these asbestos installations were not really likely to affect their health as the asbestos containing material tended to be in locations where only a limited number of staff or contractors worked and therefore did not impinge upon the patients or the majority of healthcare staff. This sadly was not the case for some hospital maintenance workers who worked in often cramped and difficult conditions within service ducts and service risers. Many have undeniably been exposed to asbestos fibres and some even died as a result. It is also possible that more will suffer as a result of their past exposure in the future.

Duty to manage
Since 2004 the law has required that asbestos in healthcare premises, together with all non-domestic properties, should be managed. This management is intended to ensure those that occupy the buildings are not exposed to asbestos and those that work upon the fabric of the building are informed about the asbestos that is present, so that they can avoid it.
    
The law requires that there be a duty holder. In many acute general hospitals this is normally the delegated responsibility of the estates department.

The Duty Holder
The first thing that is needed is an up to date asbestos survey in order to determine what asbestos is present in the premises, its condition and importantly its risk. This survey will then be used to produce an Asbestos Register, which provides information to not only hospital staff but also visiting contractors who may require access to areas of the hospital premises.
    
The ‘duty holder’ should also prepare a management plan that shows how the organisation will manage asbestos within its premises. There is no need for a huge document – a straightforward statement of what is to be done and who will do it, highlighting problem areas if any exist.

During 2009 three individual NHS Trusts merged to form Hywel Dda Health Board, and as part of this process an internal review was undertaken to determine the level of compliance with the Asbestos at Work Regulations. This review discovered a number of concerns and the organisation informed the Health and Safety Executive of our findings. This resulted in a formal investigation relating to the historical management of asbestos at Bronglais General Hospital, Aberystwyth by the HSE during 2010/11.
   
The HSE’s investigation report made several recommendations including: the appointment of an estates compliance manager with specific responsibility for the management of asbestos; an electronic asbestos risk register, updated on a constant basis, that shows where asbestos containing materials (ACM) are present, its condition and control measures required; asbestos awareness training to be provided to all estates staff including the estates management teams; and respiratory face fit testing for all Estates staff requiring it.
    
Finally, there was a recommendation for the health board to undertake a cleaning regime to ensure so far as is reasonably practicable that Asbestos Containing Materials (ACMs) are removed from under floor service voids and vertical service risers at Bronglais General Hospital.
    
The specification for the project related to asbestos removal and decontamination works of the between floor voids and vertical service risers. It was planned that the works would be undertaken over an 18 month period.

Challenges
One of the main problems facing both the Contractors and the Health Board was the project having to be carried out with the minimum disruption to clinical services. The only access into the floor voids were via floor hatches located in the main corridors located in ward areas. Therefore, the access required to undertake asbestos removal/cleaning works would have considerable impact on the day to day running of the hospital. In order to avoid this, the selected contractor had to create suitable access/egress points into the voids by breaching the exterior walls at a number of specified locations along the rear elevation of the hospital. These cut-out access points were often only 500mm in height therefore creating difficult conditions for the asbestos removal contractors working in confined spaces and working at considerable height.
    
As the site was to remain a live working environment, the amounts of services that could be isolated were minimal. Services that remained live were hot water for heating systems, live steam and electrical installations. Therefore hot work and heat stress were identified as being likely issues for the contractor’s staff. Hywel Dda Health Board had to co-operate with the principle contractor in reducing the risk that these hazards presented, by isolating hot services as far as practicable. The contractor had to have procedures in place for the regular assessment of the risk of heat stress and monitoring of employees and contingencies were put in place to supply suitable engineering and procedural controls e.g. additional cooling and ventilation, ‘cool’ rest areas, limiting working time in high risk areas etc.

A successful project
Undertaking the majority of the removal work externally avoided the temporary closure of clinical services for the duration of the contract. Vertical riser access did however impact slightly on the clinical environment with the only practical entry into these areas was via access doors on each landing, airlocks had to be assembled on each landing, and sufficient space was left on the stairwells and landings to allow these stairs to be used for emergency evacuation of the building. Also, suitable access was made through the windows on these stairs to allow removal operatives’ equipment and waste to transit in and out of the building via the scaffolding without entering the live areas of the hospital.
    
Scaffolding was erected on the rear elevation of the hospital and had suitable protection to maintain enclosure integrity during poor weather. Prior to any breaches into the fabric of the building a thorough examination of the floor void was undertaken. The walls were breached under controlled conditions in specified locations. Enclosures were built for the breaching work to be undertaken in, with the aim of preventing air from flowing into the void to reduce the risk of disturbing any asbestos containing material in the void.
    
Once the breaching works were finished and the enclosures complete, air locks and bag locks were located on the scaffolding, with negative pressure units in place. In order to test the integrity of the areas each void was smoke tested, which in itself was a risk in a fully occupied hospital.
    
The project was extremely successful with very few incidents reported throughout the scheme, and these generally involved reassuring hospital staff of the actual work undertaken. The work has resulted in clean voids and risers that now provide a far safer environment for both our hospital maintenance staff and contractors who are required to access these areas.

Tim Harrison is the Health and Safety Manager for Hywel Dda Health Board and a member of the iosh Healthcare Group

Further information
www.iosh.co.uk