IPC PGN 27… · 2020. 4. 2. · IPC-PGN-27.1 - Legionella Management and Control – V04 Issue 2 – April 2020 Part of CNTW(C)23 – Infection Prevention Control Policy 2 1.3.2

Cumbria Northumberland, Tyne and Wear NHS Foundation Trust – IPC-PGN-27.1 - Water Safety–Management-Control Legionella-water-borne bacteria –V04 Issue 2 –April 2020 Part of CNTW(C)23 – Infection Prevention Control Policy

Infection Prevention and Control Practice Guidance Note

Water Safety – Management and control of Legionella and water borne bacteria – V04

Date Issued Issue 2 – April 2020

Planned Review

March 2023 IPC–PGN 27.1 – Part of CNTW(C)23

Infection, Prevention and Control

Author / Designations Kay Gwynn, Infection, Prevention and Control Modern Matron

Matthew Lessells, Head of Estates, NTW Solutions Ltd

Responsible Officer /

Designation Anne Moore - Director of Infection Prevention and Control

Revision History V04 - updated to reflect change in authors and job role/responsibility for responsible persons

V04- Iss 2 updated to reflect correct authors and inclusion of 5 year retention period for records

Section Contents Page No

1 Introduction 1

2 Scope 2

3 Policy Statement 2

4 Responsibilities 2

5 Operational Framework 5

6 Statutory Obligations 6

7 Course of Action if an Outbreak is Suspected 7

8 Estates Procedures Overview 8

9 Risk assessment 9

10 Record keeping and monitoring 9

11 Water Sampling 10

12 Training 11

13 External audits 11

14 References 11

KEY POINTS Practice Guidance Notes form part of the Trust’s Infection Prevention and Control policy, and it is expected

that staff will follow the guidance contained within them unless there is a compelling reason to deviate from it. Such reasons should be documented whenever the circumstance occurs and notified to the IPC team so that modifications to future editions can be made if necessary

There are typically 300 cases of Legionnaires Disease reported in England and Wales each year with a fatality rate of 10%, around 5% of cases are healthcare acquired

Legionella is naturally occurring and is widely found in water systems

Legionella can be controlled by ensuring water systems maintained and operated correctly The Trust will operate a Water Safety Group comprising a multi-disciplinary team to oversee and manage

risks associated with water borne bacteria within CNTW

Cumbria Northumberland, Tyne and Wear NHS Foundation Trust – IPC-PGN-27.1 - Legionella Management and Control – V04 Issue 2 – April 2020 Part of CNTW(C)23 – Infection Prevention Control Policy

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1 INTRODUCTION

1.1 Background 1.1.1 Water systems in healthcare premises can harbour potentially life threatening

bacteria. Management of water systems to reduce the risk of microbial growth including opportunistic pathogens such as Legionella and P. aeruginosa is vital to patient safety. It requires surveillance and maintenance of control measures including temperature control, usage, cleaning and disinfection measures as identified within the risk assessment and Legionella control scheme for both hot- and cold-water systems.

1.1.2 The Legionella bacteria survive and grow particularly well in man-made environments, especially if water is in a temperature range of 27-47oC and growth can be facilitated by the presence of certain other micro-organisms. In hospitals, Legionella are regularly found in hot & cold water systems. Other water borne bacteria survive in water and the control measures also aim to minimise their multiplication.

1.1.3 Whilst this PGN will focus on the management and control of Legionella within

the Trust, the Water Safety Group will also consider the risks of infection from other organisms.

1.2 Risk of Infection

1.2.1 Legionnaires Disease is an uncommon infection with between 300 reported cases each year in England and Wales. (Public Health England 2014).

1.2.2 Whilst previously healthy people may develop Legionnaires Disease, there are a number of factors which increase susceptibility:

Increasing age, particularly above 50 years (children are rarely infected)

Sex: males are three times more likely to be infected than females

Existing respiratory disease

Smoking, particularly heavy cigarette smoking, because of the

probability of impaired lung function

Patients on renal dialysis, or on immuno-suppressant drugs which inhibit the body's natural defences against infection

1.3 Reducing the Risk 1.3.1 The risk of infection depends upon the ability of these organisms to multiply to

significant levels, to be then dispersed into the air as an aerosol and to be inhaled in sufficient numbers by susceptible individuals.


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1.3.2 The risk can be reduced by identifying through risk assessment the risk areas, operating the water and ventilation systems in accordance with NHS standards, this includes ensuring water systems are regularly used.

2 SCOPE

2.1 This Practice Guidance Note (PGN) together with any associated procedures and guidance notes, shall be observed by all employees of Cumbria Northumberland, Tyne and Wear NHS Foundation Trust (the Trust/CNTW) and is applicable to all occupied Trust premises. The PGN is to be administered and implemented by the Water Safety Group.

3 STATEMENT

3.1 The Trust is committed to effective management of water safety and control in

order to reduce the risks to patients, staff, visitors and members of the public. 3.2 The Trust will maintain an operational and managerial structure that accords

with Legislative Standards, Approved Codes of Practice, Health Technical Memorandum 04-01, national and local guidance and current best practice.

3.3 The Trust will operate a Water Safety Group which will be a sub-group of the

Infection and Prevention Control Committee, the WSG will be Chaired by the DIPC with the Head of Estates as the Deputy Chair. The Group will comprise of a multi-disciplinary team from: NTW Solutions Limited (NTWS), Estates, Facilities, IPC, PFI representatives and an external specialist in the field of Legionella. The Trust will ensure that the Water Safety Group is supported by the resources required to meet the objectives of this PGN.

3.4 The Infection, Prevention and Control Team (IPC Team) will support the

Estates Department in issuing relevant PGN to support this PGN and will offer support in the clinical aspects associated with water system hygiene and Legionnaires disease.

4 RESPONSIBILITIES

4.1 Chief Executive 4.1.1 The Chief Executive shall be responsible for ensuring that all Health and

Safety Regulations and Approved Guidance Documents are complied with. In practice the responsibility for ensuring that regulations and guidance relating to Legionella are complied with, will be delegated to the Head of Estates (NTWS) who will have responsibility for monitoring records, policy documentation, compliance with all Statutory Instruments and Approved Codes of Practice relating to Water Safety and Legionella management.


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4.2 Director of Infection and Prevention Control

4.2.1 The DIPC will be appointed in writing by the Chief Executive and shall

ensure the Trust has a robust approach to Water Safety and Legionella Management and Control. They will Chair the Infection and Prevention Control Committee (IPCC) and the Water Safety Group which is an identified sub-group of IPCC. The DIPC has direct access to the Chief Executive and in the event of any serious concerns raised in respect of Water Safety will advise the Chief Executive.

4.3 Head of Estates

4.3.1 The Head of Estates will be appointed in writing by the Chief Executive

and has been identified as the “Responsible Person” for Legionella Management within the Trust and has been appointed into this role by the Chief Executive. The Head of Estates will ensure all Estates Procedures in respect of Water Safety are adhered to and will provide regular reports back to the Water Safety Group and the IPCC and in the event of serious concerns will raise them directly with the DIPC or in his absence the Chief Executive.

4.4 Facilities Manager 4.4.1 The Facilities Manager as responsibility for ensuring associated Facilities

Procedures and this PGN is adhered to in all localities, and that any deviation is rectified and brought to the attention of the Head of Estates.

4.5 Operational Estates Managers

4.5.1 The North, Central and South sectors and Support Services, Operational

Estates Managers have responsibility for ensuring associated Estates Procedures and this PGN is adhered to in their localities and that any deviation is rectified and brought to the attention of the Head of Estates.

4.6 Duty Responsible Officer (Estates)

4.6.1 The Duty Responsible Officer, under the direction of the Operational Estates Manager, is responsible for:

a) Ensuring up to date knowledge of current best practice b) Maintaining all records associated with Legionella management,

c) Arranging and supervising regular inspection protocols.

d) Ensuring staff are trained to comply with this procedure.

e) Advising other Estates Officers and Staff of their responsibilities with

regards to the safe operation of the systems and procedures


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4.6.2 The Deputy Responsible Officers for the various localities will be appointed in writing by the Head of Estates and Facilities.

4.7 Infection Prevention and Control Team

4.7.1 The Infection Control Team will be consulted on the content of the Estates

Procedures and Legionella water system status reports will be provided to the Infection Control Team for review and comment.

4.7.2 In the event of a suspected or confirmed case or outbreak of Legionnaires’

Disease, the Director of Infection and Prevention Control, will chair the Trust outbreak team, co-ordinating the investigation, providing the link between Estates, the Board of Directors, any third parties such as the HSE, or medical colleagues treating those with the suspected illness.

4.7.3 Advise on the management of operational issues contained within the Estates Procedures for the Control and Management of Legionellosis.

4.7.4 The Infection Prevention Control Committee will meet on a quarterly basis and will also be the Trusts Group for Legionella Management and Control. This meeting will provide the main forum for monitoring the Trust’s Control and Management of Legionellosis. The Committee will meet under the Chairmanship of the Director of Infection and Prevention Control.

4.7.5 The IPC Nurses will be appointed in writing by the DIPC.

4.8 Capital Projects Manager 4.8.1 The Capital Projects Manager will be appointed in writing by the Chief

Executive and will be responsible for ensuring all Capital works which incorporate a modification, addition or comprise new works which involve risk systems associated with Legionella are designed, installed, tested, commissioned and handed over to the Operational Estates Teams in accordance with this PGN, the documents listed in Section 6 and any other relevant document or standard.

4.8.2 The Capital Projects Manager will be responsible for ensuring the staff within

the Capital Projects Team, are suitably trained to ensure they are competent in the delivery of schemes which involve risk systems associated with Legionella.

4.9 Trust Staff

4.9.1 It is the responsibility of all Trust employees to comply with this and associated PGN’s and applicable associated operational procedures. In particular:

a) Report any underused or redundant water outlet to Estates who will have it removed


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b) During periods of low activity, ensure outlets not used on a daily basis are flushed for 2 minutes, twice per week and that this activity is recorded and kept for 5 years

c) Ensure all water outlets in clinical areas are flushed for 2 minutes

twice per week and that this activity is recorded and kept for 5 years. If flushing is carried by domestic staff the ward manager is still overall responsible to ensure this is completed in all areas. Also report it electronically via the intranet link to give central assurance the twice weekly flushing is happening.

d) Non-inpatient areas need flushed for 2 minutes once per week and

this recorded and kept for 5 years.

e) Report to Estates any discolouration of water

f) Report to Estates any unusual variance in water temperature

5 OPERATIONAL FRAMEWORK

5.1 This document forms part of a framework, which comprises the following elements: Trust Infection and Prevention Control Policy and this PGN -

Outlines the overall responsibilities of the organisation, details responsibilities of individuals, define outline operational duties and record keeping requirements.

Estates Operational Procedures Details the operational criteria that must be achieved for all systems identified in the Risk Assessment as being susceptible to colonising Legionella. Details the specific maintenance criteria that must be achieved to minimise the risk as identified in the HTM’s and any Risk Assessment

Risk Assessment A risk assessment carried out to identify and assess the risk of Legionellosis from work activities and water sources within the Hospital and identification of any remedial or precautionary measures that need to be undertaken. The risk assessments may be carried out internally or externally or a combination of both. The frequency of risk assessments will be 2 years, additionally risk assessments may need to be carried out following major changes to water systems, layout, installation of new equipment etc.

Operational Log Books These will detail any maintenance work, plant modifications, tests, monitoring etc., undertaken on any part of the water systems, ventilation systems or other risk areas, as defined in the Risk Assessment.


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6 STATUTORY OBLIGATIONS 6.1 Duties under the HSW Act (1974) extend to risks from Legionella arising from

work activities. In addition, harmful micro-organisms (biological agents) are subject to the Control of Substances Hazardous to Health Regulations 1999 (COSHH), meaning that the requirements to carry out a risk assessment, and to prevent, or adequately control exposure etc. apply to risks created by the Legionella bacteria. An assessment needs to take into account all persons likely to be exposed, including employees and members of the public, especially those who may be particularly susceptible to infection. The Management of Health and Safety at Work Regulations 1999 (MHSWR) are also important with respect to management arrangements.

6.2 HSE L8 (Fourth edition) Published 2013 The Control of Legionella Bacteria in

Water Systems is the Approved Code of Practice and Guidance for the control of Legionella bacteria in water systems sets out the statutory requirement for dealing with risk. This applies to all premises with a water system/s.

6.3 HSG274 Part 2: The control of legionella bacteria in hot and cold water

systems this guidance is for those in control of premises and those with health and safety responsibilities, to help them comply with their legal duties. It gives practical guidance on how to assess and control the risks due to legionella bacteria specifically for hot and cold water systems.

6.4 HSG274 Part 3: The control of legionella bacteria in other risk systems this guidance gives those in control of premises and those with health and safety responsibilities, to help them comply with their legal duties. It gives practical guidance on how to assess and control the risks due to legionella bacteria specifically for systems other than hot and cold water systems.

6.5 The ACoP places responsibility on employers to:

Identify and assess risks from Legionella

Manage the risks, including the appointment of a person, or persons, to take managerial responsibility and to provide supervision and training of personnel

Avoid the use of systems that give rise to a reasonably foreseeable risk of legionella or, where this is not reasonably practicable, prepare a written scheme for minimising the risk from exposure

Implement, manage and monitor the scheme of precautions; and

Keep appropriate records

The ACoP also sets out the responsibilities of manufacturers, importers, suppliers and installers of products and services


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6.6 In addition to the above documents the NHS has Health Technical Memorandum 04 – 01 “The control of Legionella, hygiene, “safe” hot water, cold water and drinking water systems” which will be complied with.

6.7 “Responding to the detection of legionella in healthcare premises 2015”. This

describes the guidance for IPC and Estates teams if legionella is discovered in the water and when Health protection teams should be contacted.

7 COURSE OF ACTION IF AN OUTBREAK IS SUSPECTED

7.1 In the event of a suspected case or outbreak of Legionnaires Disease, then

refer to IPC-PGN-06 - Major Infection Prevention and Control Incidents.

7.2 Legionnaires disease is a notifiable infection to the Proper Officer under the Health Protection Regulations (2010). The contact details for the Health Protection Unit, North East and the local office for the HSE are as follows:

North East HPT, Floor 2 Citygate, Gallowgate, Newcastle upon Tyne, NE1 4WH Tel: 0300 303 8596 (option 1)

Health and Safety Executive Benton Park View, Newcastle upon Tyne, Tyne and Wear NE98 1YX

Tel: 0191 202 6200

7.3 Investigation

7.3.1 If only one case is diagnosed, a number of courses of action may follow. For those occurring in a hospital, it will be thoroughly investigated, because of the potential risk to other patients. For those with a suspected occupational source, the enforcing authorities are more than likely to be involved. In other cases it is possible that no action will be taken as it may be extremely difficult to identify the source.

7.3.2 The Responsible Person and the Infection Prevention Control Team will be notified and they will commence an investigation. It is essential that systems are not drained or disinfected before samples have been taken.

7.3.3 The Responsible Person will guide the Infection Control Team to the various water systems within the building and in particular to the points from which samples can be easily taken.

7.3.4 The investigation shall concentrate on all potential sources of legionellae including:-

Domestic hot and cold water systems

Showers or spray washing equipment

Drainage systems and traps

Therapy Pools

Humidifiers in ventilation systems

Fountains and sprinklers


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7.3.5 The Responsible Person will make available details of all records and

maintenance procedures together with details of any associated equipment. Also details of any modifications to water or drainage systems.

7.3.6 The team is responsible for identifying the cause of infection and will advise

cleaning, disinfection any modifications and long term measures which need to be taken.

7.3.7 The following is an aide-memoir of information that will be required should an

outbreak occur:-

a) Identification of patient area b) Description of premises and services

c) Existing procedures for the prevention and monitoring of Legionellae

d) Breakdown analysis

e) Risk assessment

f) Engineers investigation log book

g) Compliance with HTM 04-01.

h) Compliance with H.S.E. guidance

i) All patient records

j) List of people involved in the investigation

k) Engineers drawing of services

l) Minutes of all relevant meetings

m) Engineers action plan

8 ESTATES PROCEDURES OVERVIEW

8.1 Operation and Maintenance 8.1.1 To avoid proliferation maintenance procedures have been introduced which will

avoid, as far as is reasonably possible, conditions arising in the water systems which are known to increase the risk. These are: -

Avoidance of water temperatures between 20 degrees C and 47 degrees C. To achieve this temperature checks are carried out at critical points in the hot and cold water systems, storage cisterns and calorifiers

Avoidance of water stagnation as this may encourage the growth of bio-film (slimes that form on surfaces in contact with water) which can harbour legionellae and provide local conditions that encourage its growth


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Avoid the use of materials in water systems that can harbour or provide nutrient for bacteria and other organisms. Only pipe fittings, jointing materials and components which are compliant with the Water Supply (Water Fittings) Regulations 1999 shall be used on water systems and the 2010 water supply (water quality) regulations.

Keep systems clean in order to avoid the build-up of sediments, etc., which may harbour bacteria or provide a nutrient source for them.

8.1.2 A full schedule of maintenance regimes is detailed in the Estates Operational

Procedures for Legionella and water systems management.

9 Risk Assessments 9.2.1 In addition to the measures taken to avoid conditions, which permit legionellae

to proliferate, risk assessments will be carried out at all Trust occupied premises and an action plan prepared in priority order. This assessment will need to be reviewed regularly and specifically when there is reason to suspect it is no longer valid. An indication of when to review the assessment and what consider should be recorded and this may result from, e.g.

a change to the water system or its use

a change to the use of the building where the system is installed

new information available about risks or control measures

the results of checks indicating that control measures are not effective

changes to key personnel

a case of legionnaires’ disease/legionellosis associated with the system

10 Record Keeping and Monitoring 10.1 To ensure that precautions continue to be carried out and that adequate

information is available for checking what is done in practice, records of all maintenance work remedial work and changes to the systems will be kept, by Estates.

10.2 Paper copies of flushing regimes must be kept by all departments for 5 years.

This is essential due to the level of detail contained in the paper copies. 10.3 The Ward/Departmental manager is responsible for validating the flushing

regimes and ensuring the electronic reporting is completed. This is reported by the Performance Team to the Group Quality and Performance meetings and reviewed by the Associate Directors. Themes and none recording will be followed up by the Associate Directors.


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11 WATER SAMPLING

11.1 For monitoring purposes the following water tests will be carried out.

Location /

System

Type of

Test

Action

Limit Frequency Action Comments

Potable cold water storage tanks

TVC. 22oC TVC 37oC E. Coli Coliforms

≥300 ≥50 0 0

6 monthly If tests are above limit then advise IPC and take appropriate action and retest.

DHWS Calorifiers with a storage above 50l

Legionella Pre and post flush

> 0cfu/l ≥100cfu/ml

Annual If tests are between 0-100 cfu/ml then contact IPC take appropriate action and re-test If above the 100cfu action limit then contact IPC and take appropriate action and retest

Note the retest should be repeated 2 weeks after any remedial work

Hot and Cold water outlets. Sample up to 10% to include representative unblended and TMV outlets. Actual amount tested on each area to be determined based on risk assessment

Legionella Pre and post flush

> 0cfu/l ≥100cfu/ml

Residential sites - Six monthly on a rolling program Small site with non-residential patient use – Six monthly Small sites with staff only - Annual

If tests are between 0-100 cfu/ml then take appropriate action and re-test. If above the 100cfu action limit then contact IPC and take appropriate action and retest.

Note the retest should be repeated 2 weeks after any remedial work

11.2 The percentage of hot and cold water sample outlets to be sampled will be reviewed by the locality water safety team at the monthly meetings and decisions brought to the quarterly safety group for review.

11.3 At any time where results give cause for concern the frequency and type of test will need to be adjusted to take into account the circumstances.

11.4 At any time where maintenance activities are giving cause for concern then a review of testing frequencies will be carried out.

11.5 Any positive legionella results should be reported via the Web Based Incident reporting system by the Deputy Responsible person for that sector.


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12 Training

12.1 Effective management of Legionella requires knowledge of a specialised area. The Trust will ensure that key personnel across a range of disciplines who are involved in the management of Legionella, will receive formal training, these staff include:

Estates Responsible and Deputy Responsible persons

Estates Capital Projects team

IPC Nurses

Director of Infection and Prevention Control

Facilities Manager

Facilities staff

12.2 Estates Department will ensure regular and appropriate training is provided to estates maintenance staff in order for them to understand their role and carry out their duties effectively.

12.3 The Facilities Department will ensure regular and appropriate training is provided to FM staff, particularly Domestics and their Supervisors, in order for them to understand their role and carry out their duties effectively.

12.4 All staff will undertake Infection Prevention and Control training every 3 years

13 External Audits

12.1 The Trust will appoint an external organisation with recognised expertise in

Legionella management and control to audit and report on all aspects of the Trusts compliance with L8, HTM 04-01 and recognised good practice. The audits will comprise periodic site visits which shall examine records of maintenance, operational compliance, training records, operational procedures etc.

14 References

Health and Safety Commission (2000) Approved Code of Practice Legionnaire’s Disease: the control of Legionella bacteria in water system (L8) Health and Safety Executive 2000

Health Technical Memorandum 04-01: The control of Legionella, hygiene, ‘safe’ hot water, cold water and drinking water systems, Department of Health (2006).

Water supply Regulations 2010

Legionnaires’ disease in England and Wales 2012 Public Health England July 2014


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“Responding to the detection of legionella in healthcare premises” Guidance for PHE health protection teams – August 2015

Relevant PGN’s, E-LOP12 – Water Safety Management and Standards Manual

HSG274 Part 2 The control of legionella bacteria in hot and cold water systems,2014