A pragmatic approach to Legionella control
Airmec MD Andrew Steel argues that there are no magic wands when it comes to Legionella control – but just throwing money at the problem is not the answer.
This article was first published in Health Estate, October 2014
Airmec MD Andrew Steel argues that there are no magic wands when it comes to Legionella control – but just throwing money at the problem is not the answer.
This article was first published in Health Estate, October 2014
Avoiding Legionella outbreaks is a constant concern for any building or facilities manager and there is certainly no shortage of advice to be had; especially since the guidance and regulations were updated earlier this year. The challenge is to find your way through the maze and devise a regime that is both effective and affordable for your premises.
Of course, budget is not the main issue here, and the potential consequences of an outbreak are incalculable. So signing up for the latest big and probably expensive idea may be attractive, but will
rarely provide a panacea. It is best to take time to ponder how you can most effectively balance the law and code of practice guidance with your real-world budget. The guidance is written by experts with the cumulative benefit of large amounts of experience. Take time to absorb it, act appropriately, and make sure your staff training is up to date, especially if you are seeking the significant savings that can come from tasking your own staff with routine monitoring and flushing.
The current frenzy of news about Legionella control has surrounded the latest publication by the Health and Safety Executive of the 4th edition of what is known as “ACOP L8”, the Approved Code of Practice and Guidance on Regulations for the Control of Bacteria in Water Systems. To be clear, an ACOP is not actually a law, but it does enjoy special legal status. In a nutshell, the latest, fourth edition of the ACOP contains revisions intended to simplify and clarify the text, although in practice the main change has been the removal of the technical guidance, which is now published separately as HSG274. However, when reading the fine print of HSG 274, Parts 1 to 3, you may find that some of the intended clarity could be lost on you.
For healthcare estates, there is an additional requirement to adhere to the relevant Health Technical Memorandum (HTM). HTM 04-01 or to give it its full title “Health Technical Memorandum 04-01: The control of Legionella, hygiene, “safe” hot water, cold water and drinking water systems”. HTM 04-01 builds on L8 but provides additional requirements. Originally published by the Department of Health in 2006, it is subject to addendums. For instance, March 2013 saw new guidance on control of Pseudomonas aeruginosa in augmented care units (2014 for Wales).
However, the way to avoid risk and to achieve the certainty and clarity the final guidance aims to provide, is probably not to throw money and expensive technology at what might not be the real a problem after all. It may be far better to take a holistic view of the systems in your premises, review your schematics and risk assessments; and then tailor appropriate preventive measures to what you can afford and have the resources to apply properly. There’s no point in fitting devices if you are unaware of their limitations. Look, for instance, at the trend towards UV sterilization of taps and shower heads, which are, however, only part of a potential solution unless combined with a robust water management plan. Can you afford to manage that risk as well as to service the capital cost and maintenance of the units? If so, all well and good, if not, perhaps a more pragmatic approach is called for? There may be less capital intensive alternatives which will be just as effective
There is, at the end of the day no magic wand: risk management always starts with a comprehensive risk assessment, which should be treated as a live working document and not something that can be filed away for two or more years. It might be thought that every responsible organisation already has such a live risk assessment…but surprisingly few do: there is a lot of work out there which is either outdated or just plain inaccurate. Yet the cost of dealing with a positive lab analysis or even an outbreak rises dramatically, as does the cost of operational disruption, if there is not a good risk assessment to work from.
Of course, budget is not the main issue here, and the potential consequences of an outbreak are incalculable. So signing up for the latest big and probably expensive idea may be attractive, but will
rarely provide a panacea. It is best to take time to ponder how you can most effectively balance the law and code of practice guidance with your real-world budget. The guidance is written by experts with the cumulative benefit of large amounts of experience. Take time to absorb it, act appropriately, and make sure your staff training is up to date, especially if you are seeking the significant savings that can come from tasking your own staff with routine monitoring and flushing.
The current frenzy of news about Legionella control has surrounded the latest publication by the Health and Safety Executive of the 4th edition of what is known as “ACOP L8”, the Approved Code of Practice and Guidance on Regulations for the Control of Bacteria in Water Systems. To be clear, an ACOP is not actually a law, but it does enjoy special legal status. In a nutshell, the latest, fourth edition of the ACOP contains revisions intended to simplify and clarify the text, although in practice the main change has been the removal of the technical guidance, which is now published separately as HSG274. However, when reading the fine print of HSG 274, Parts 1 to 3, you may find that some of the intended clarity could be lost on you.
For healthcare estates, there is an additional requirement to adhere to the relevant Health Technical Memorandum (HTM). HTM 04-01 or to give it its full title “Health Technical Memorandum 04-01: The control of Legionella, hygiene, “safe” hot water, cold water and drinking water systems”. HTM 04-01 builds on L8 but provides additional requirements. Originally published by the Department of Health in 2006, it is subject to addendums. For instance, March 2013 saw new guidance on control of Pseudomonas aeruginosa in augmented care units (2014 for Wales).
However, the way to avoid risk and to achieve the certainty and clarity the final guidance aims to provide, is probably not to throw money and expensive technology at what might not be the real a problem after all. It may be far better to take a holistic view of the systems in your premises, review your schematics and risk assessments; and then tailor appropriate preventive measures to what you can afford and have the resources to apply properly. There’s no point in fitting devices if you are unaware of their limitations. Look, for instance, at the trend towards UV sterilization of taps and shower heads, which are, however, only part of a potential solution unless combined with a robust water management plan. Can you afford to manage that risk as well as to service the capital cost and maintenance of the units? If so, all well and good, if not, perhaps a more pragmatic approach is called for? There may be less capital intensive alternatives which will be just as effective
There is, at the end of the day no magic wand: risk management always starts with a comprehensive risk assessment, which should be treated as a live working document and not something that can be filed away for two or more years. It might be thought that every responsible organisation already has such a live risk assessment…but surprisingly few do: there is a lot of work out there which is either outdated or just plain inaccurate. Yet the cost of dealing with a positive lab analysis or even an outbreak rises dramatically, as does the cost of operational disruption, if there is not a good risk assessment to work from.
Best practice in risk assessment
The requirement for detailed schematics , and other, requirements for risk assessment is laid out quite clearly in ACOP L8 : if designated responsible people within an organisation do not comply with its requirements the courts may hold them personally responsible for the consequences.
A key requirement of HTM04-01 is that risk assessments should be carried out by competent persons, and British Standard BS 8580:2010 Water quality – Risk assessments for Legionella control – Code of practice clearly lays out the best practice for risk assessments. The British Standard takes the form of guidance and recommendations rather than being a definitive specification and, being first published in 2010, is not referred to in the current edition of HTM 04-01. However, prudent health estates managers would certainly wish to consider the recommendations contained within this document. Experienced water hygiene specialists will be familiar with these recommendations, and undertake risk assessments that conform to the best practices is suggests.
A risk assessment identifies any reasonably foreseeable risks to health, and so reveals the necessary precautionary measures that need to be taken to prevent, or adequately control, the risk. Of course, prevention is always going to be better – and more cost effective – than cure. It also enables the person on whom the statutory duty falls to show that all the steps needed to prevent or control foreseeable risk have been considered, but should of course be seen as a living, working document, not a compliance exercise.
It should be a given – but all too often in our experience is not the case – that risk assessments should be undertaken before an effective maintenance regime can be put in place. This is especially important with so many trusts now preferring to manage routine work internally.
Employing your own staff to undertake routine tasks like flushing is a logical approach that offers significant cost savings, but these will quickly be wiped out if the regime fails to address the risks and there is an outbreak. The answer lies in working with specialists to develop the risk assessment and a comprehensive asset register and schematic, and then align your monitoring, inspection and flushing schedules with the actual and current risks.
(HTM) 04-01 and HSE ACOP L8 – how do they work together?
HTM 04-01 is actually more stringent than ACOP L8 in a number of areas, so be sure your advisers are fully conversant with its extra requirements
One example of HTM04 – 01 exceeding the requirements of ACOP L8 is the treatment of water outlets that are not in regular use. ACOP L8 states that such outlets should be flushed weekly. HTM 04-01 suggests that such outlets should be flushed more frequently, and should form part of the daily cleaning process. In practice it can be very difficult for managers to determine those outlets that are regularly used and those that are not (unless an area has been closed down). The only reliable way of doing this is to have a comprehensive asset register identifying location of all outlets.
Another key area where the requirements differ between HTM 04-01 and ACOP L8 is the Temperature Control Regimen. HTM 04 – 01 asks for higher temperatures and details the tests to be carried out on hot and cold water outlets, and the standard frequency is monthly for all sentinel taps, typically the first and last taps on a hot water recirculating system or the nearest and furthest taps from the tank on a cold water system.
Biological monitoring is not generally considered necessary unless there are taste or odour issues, however HTM04-01 does make it clear that the infection control team will need to consider the level of risk and decide if such monitoring should take place.
It is also very clear that there must be a nominated Responsible Person in the organisation, appointed in writing, in possession of adequate professional knowledge and training to devise and manage the necessary procedures and with sufficient authority to ensure that all procedures in place are carried out in a timely and effective manner. Although the definition of a responsible person in HTM 04-01 is similar to that defined in ACOP L8, the HTM again goes further. Paragraph 6.5 of the HTM document suggests that a responsible person should ideally be a chartered engineer, microbiologist or other professionally qualified person.
A health estates manager who puts in place and operates systems as defined in HTM 04-01 can also be confident that they are meeting the requirement of ACOP L8. If they, or their advisers, are fully conversant with both documents, they will also be able to establish and manage a regime which meets current requirements to optimise budgets. Best practice and smart budgeting need not be mutually exclusive.
The requirement for detailed schematics , and other, requirements for risk assessment is laid out quite clearly in ACOP L8 : if designated responsible people within an organisation do not comply with its requirements the courts may hold them personally responsible for the consequences.
A key requirement of HTM04-01 is that risk assessments should be carried out by competent persons, and British Standard BS 8580:2010 Water quality – Risk assessments for Legionella control – Code of practice clearly lays out the best practice for risk assessments. The British Standard takes the form of guidance and recommendations rather than being a definitive specification and, being first published in 2010, is not referred to in the current edition of HTM 04-01. However, prudent health estates managers would certainly wish to consider the recommendations contained within this document. Experienced water hygiene specialists will be familiar with these recommendations, and undertake risk assessments that conform to the best practices is suggests.
A risk assessment identifies any reasonably foreseeable risks to health, and so reveals the necessary precautionary measures that need to be taken to prevent, or adequately control, the risk. Of course, prevention is always going to be better – and more cost effective – than cure. It also enables the person on whom the statutory duty falls to show that all the steps needed to prevent or control foreseeable risk have been considered, but should of course be seen as a living, working document, not a compliance exercise.
It should be a given – but all too often in our experience is not the case – that risk assessments should be undertaken before an effective maintenance regime can be put in place. This is especially important with so many trusts now preferring to manage routine work internally.
Employing your own staff to undertake routine tasks like flushing is a logical approach that offers significant cost savings, but these will quickly be wiped out if the regime fails to address the risks and there is an outbreak. The answer lies in working with specialists to develop the risk assessment and a comprehensive asset register and schematic, and then align your monitoring, inspection and flushing schedules with the actual and current risks.
(HTM) 04-01 and HSE ACOP L8 – how do they work together?
HTM 04-01 is actually more stringent than ACOP L8 in a number of areas, so be sure your advisers are fully conversant with its extra requirements
One example of HTM04 – 01 exceeding the requirements of ACOP L8 is the treatment of water outlets that are not in regular use. ACOP L8 states that such outlets should be flushed weekly. HTM 04-01 suggests that such outlets should be flushed more frequently, and should form part of the daily cleaning process. In practice it can be very difficult for managers to determine those outlets that are regularly used and those that are not (unless an area has been closed down). The only reliable way of doing this is to have a comprehensive asset register identifying location of all outlets.
Another key area where the requirements differ between HTM 04-01 and ACOP L8 is the Temperature Control Regimen. HTM 04 – 01 asks for higher temperatures and details the tests to be carried out on hot and cold water outlets, and the standard frequency is monthly for all sentinel taps, typically the first and last taps on a hot water recirculating system or the nearest and furthest taps from the tank on a cold water system.
Biological monitoring is not generally considered necessary unless there are taste or odour issues, however HTM04-01 does make it clear that the infection control team will need to consider the level of risk and decide if such monitoring should take place.
It is also very clear that there must be a nominated Responsible Person in the organisation, appointed in writing, in possession of adequate professional knowledge and training to devise and manage the necessary procedures and with sufficient authority to ensure that all procedures in place are carried out in a timely and effective manner. Although the definition of a responsible person in HTM 04-01 is similar to that defined in ACOP L8, the HTM again goes further. Paragraph 6.5 of the HTM document suggests that a responsible person should ideally be a chartered engineer, microbiologist or other professionally qualified person.
A health estates manager who puts in place and operates systems as defined in HTM 04-01 can also be confident that they are meeting the requirement of ACOP L8. If they, or their advisers, are fully conversant with both documents, they will also be able to establish and manage a regime which meets current requirements to optimise budgets. Best practice and smart budgeting need not be mutually exclusive.