What to Do When Legionella is Found in Hospitals & Healthcare Settings?

In this article the healthcare specialists at Legionella Control International look at what to do when legionella is discovered in a hospital or healthcare setting.

It looks at the role of Public Health England, Health Protection Teams and the hospital Water Safety Group.

It considers the key responsibilities of the Water Safety Group and Health Protection Teams, when the Health Protection Team needs to be notified of any legionella positive tests, and what should be done to bring the situation back under control.

Responding to the discovery of legionella in hospitals and healthcare premises

Public Health England (PHE) takes on the role of protecting and improving the health of those in England via several means.

One part of their remit is to provide Health Protection Teams, otherwise known as HPTs. A survey was conducted that determined the response and reaction to situations where Legionella bacteria have been discovered in hospitals and healthcare premises.

This applied to all scenarios, regardless of whether the levels of bacteria were minor or pronounced.

It was discovered that the response varied between health protection teams.

Therefore, Public Health England produced guidance via a 21-page report that could be read and referred to by those working in HPTs. This covers various relevant areas of interest and concern including:

• Routine water management.
• The composition of the Water Safety Group.
• Information regarding the Water Safety Plan.
• Further information and checklists.

The PHE guidance makes it clear which situations would require a local Health Protection Team to be contacted by the relevant hospital or healthcare premises.

It also provides information and support on the required steps to be taken by that team.

The role of routine water management in keeping hospitals and healthcare premises free from legionella

Whenever an outbreak of Legionnaires’ disease occurs, it is often found that steps were not taken to prevent this.

Proper management and control of all the water systems – whether it be hot, cold, or both – is required to minimise the chances an outbreak could occur.

Appropriate water safety controls and good management processes must be in place to ensure Legionella bacteria does not get the chance to grow and spread throughout the water systems.

Having a well-balanced Water Safety Group is essential

Every hospital and healthcare facility should have its own Water Safety Group (WSG).

This group is comprised of several specialists each with a role to play in maintaining the safety of the water supply.

The members of the WSG, including a named responsible person and a deputy in case that person is away or ill, should meet often enough to review current issues, strategies and performance.

The group should also assess the results of any recent test results, including water samples, determining whether further action needs to be taken to maintain safe water systems.

• Learn more about the Water Safety Group

Should the Water Safety Group include someone from the Health Protection Team?

It is often prudent for these water safety groups to nominate a local member of the HPT staff to be involved.

While it is not necessary for that person to attend every meeting, it may help – and will certainly improve lines of communication between the local Water Safety Group and Public Health England.

This team member can gain an inside view of how the Water Safety Group is performing, learning which measures are being used to keep the premises safe from infection.

They can also provide advice and support wherever required to clarify the role of the group and its performance.

• Find your local Health Protection Team

Covering the paperwork

Another important role the Water Safety Group is responsible for is ensuring suitable water safety risk assessments are carried out which take account of the specific risks present in their hospital or healthcare facility.

For example, the health of certain patients or residents may put them at greater risk of infection if Legionella bacteria or Pseudomonas are present in greater numbers.

The water safety risk assessment should be reviewed as needed, as part of the ongoing tasks the Water Safety Group is responsible for.

• Learn more about legionella risk assessments

Other documentation that forms a necessary part of the role of the WSG is also highlighted in PHE’s report. This includes:

• A scheme identifying how the water safety group will control all identifiable risks.
• Current schematics of all the water systems in use.
• Appropriate schedules for outlet flushing, descaling, disinfecting and sampling of the water systems; these should include which sites are targeted and how often.
• Plans for controlling water temperatures.
• Records of all tests, sampling, and monitoring undertaken by or on behalf of the hospital, and their results.
• A schedule covering maintenance, chemical dosing, inspections, cleaning, and disinfection – where, when, and how each task is undertaken.
• Details of who to contact if something should occur out of hours.

When and how should the Health Protection Teams respond to a rise in legionella counts?

One of the main tasks of the report from Public Health England is to gain consistency between Health Protection Teams in different areas.

It makes it clear how the team should respond given a scenario where a hospital or healthcare facility reports elevated levels of Legionella bacteria following testing.

To achieve this outcome, the Health Protection Team must gather information to determine how serious the situation is.

This will include assessing the potential risk to health from Legionnaires’ disease.

The appropriate infection control team can then decide on the most sensible steps to take to minimise risk and gain control of the situation as quickly as possible.

Should the Health Protection Team always be told of a rise in legionella bacteria?

No, it is not always necessary to tell the Health Protection Team of a rise in detected Legionella bacteria.

If levels are still low (according to the PHE document, they should be below 100 colony-forming units per litre or cfu/l), the Water Safety Group may take remedial actions to bring down the levels once more.

• Learn more about legionella testing

When should the Health Protection Team be informed?

Scenarios where the HPT should be informed of a rise in the detection of Legionella bacteria include the following:

• Situations where legionella counts have risen beyond 100 cfu/l.
• Legionella bacteria is identified as multiplying even when standard control measures are still in place.
• Situations where areas providing augmented care are affected, i.e. intensive care units, high dependency units, critical care units.
• Scenarios that include potential nosocomial cases, i.e. cases of Legionellosis that have been identified as potentially coming from that hospital or healthcare facility.

The role of the HPT when legionella levels in healthcare settings have risen

The Health Protection Team will review, provide support, and assess various elements when they are brought in. These include:

• Reviewing the water safety risk assessment and associated procedures adopted by the Water Safety Group.
• Advise on additional monitoring, sampling, and testing.
• Advise on suitable remedial controls required to bring legionella counts back to an acceptable level.
• Provide advice on laboratory testing and support.
• Identify possible cases associated with the raised counts, researching the previous two-year period and identifying all those on site during that time.
• Advise on the identification of a point at which the water system can be confirmed to be back under safe control.

The role of the Health Protection Team should not extend to engineering elements of the water systems, nor should it cover future ideas for managing that system.

Using the step-by-step algorithm to identify the correct response to any situation

Public Health England has included an in-depth algorithm in its report.

This is designed to provide a sensible flow chart, allowing Health Protection Teams to identify the correct actions they should take given raised levels of Legionella bacteria in a water system.

By following the process on paper, it becomes far easier to see what the response should be and what the next steps are.

The first appendix in the report then provides more advice and support when viewing the algorithm.

Since all Health Protection Teams will have access to this algorithm, it becomes easier for the correct response to be given consistently, in all areas and all situations.

This also means any potential outbreak of Legionnaires’ disease will be handled in the proper manner and resolved as quickly as possible, while limiting the possible health implications for those in the hospital or healthcare premises.

Legionella emergency response checklist to ensure nothing is missed

Finally, the second appendix of the report provides a very useful checklist that provides assurance that the situation is being handled responsibly and in the correct way. This checklist covers the following:

• Positive sampling.
• Environmental systems.
• Water safety risk assessment, paperwork, and maintenance.
• Diagnostics.
• Further investigation.
• Control measures.
• Communications.

Guidance on what to do when legionella is discovered in a hospital or healthcare setting

Overall, the report provides practical guidance on what to do when Legionella bacteria are discovered in a hospital or healthcare setting.

It does not simply identify when a Health Protection Team should get involved. It also identifies how they should become involved and what measures are required to bring a situation under control.

As Health Protection Teams across England adopt the guidance given in the report, it means consistency will be improved with every area providing the same response.

Healthcare water safety specialists

Our Authorising Engineers (Water) and team of healthcare water safety specialists support those responsible for the control of waterborne pathogens including Legionella bacteria in the workplace, helping them to protect their people and meet their health and safety obligations in this specialist area.

We are experienced in the role of Authorising Engineer (Water) and deliver professional water safety risk assessments for legionella, pseudomonas and other waterborne pathogens, water testing, independent compliance auditing, City & Guilds training and other environmental risk management services that help keep staff and others safe.

If you have questions about any of the issues raised above or you would like to speak with one of our healthcare specialists please call us today on 0330 223 36 87 or contact us here.