Control of Legionella and Pseudomonas Policy

Transcription

1 Control of Legionella and Pseudomonas Policy Classification: Policy/Procedures Lead Author: Paul Chadwick Additional author(s): Dave Handley (Authorising Engineer Water), Sid Swindells Authors Division: Clinical Support Services & Tertiary Medicine, Estates Department Unique ID: TWCIC01(17) Issue number: 1 Expiry Date: December 2018 Contents Section Page Who should read this document 2 Key messages 2 Policy 3 1 Policy Statement 3 2 Roles & Responsibilities Accountability Management Responsibilities 6 3 Procedures General Risk Assessment - Legionella Risk Assessment Pseudomonas aeruginosa Operational Monitoring Microbiological Testing Maintenance Disinfection 21 4 Records 22 5 Training 23 6 Start Up and Shut Down Procedures Mains Water Systems Cold Water Systems Hot Water Systems 25 7 Emergency Procedures 26 8 Standards - Statutory Regulations and Guidance 29 9 Explanation of Terms and Definitions 31 Document control information (Published as separate document) Page 1 of 33 32

2 Policy Implementation Plan 33 Monitoring and Review 33 Endorsement 34 Screening Equality Analysis Outcome 35 Page 2 of 33

3 Who should read this document? Estates managers Infection control staff Facilities managers Senior nursing staff Key Messages The Responsible Person (Water) will ensure that an up to date Legionella Risk Assessment is in place for all Trust sites Risk Assessment of Augmented Care Units for Pseudomonas aeruginosa shall be undertaken by the Infection Control Team Arrangements shall be put in place for the domestic staff to carry out daily flushing of underused outlets that cannot be removed under the supervision of the Department/Unit/Ward manager. The completed signed off log sheets for the underused outlets flushed by Domestics shall be reviewed and held by the Hotel Services Manager. A suitable contractor shall be appointed to undertake a comprehensive programme of temperature testing, tank inspections, showerhead cleaning and testing and servicing of Thermostatic Mixing Valves. A Written Scheme for the testing and the associated records shall be kept on an electronic record system. Water samples shall be taken at agreed locations and tested for the presence of Legionella bacteria. A programme of testing for the presence of Pseudomonas aeruginosa shall be maintained for Augmented Care Units. Page 3 of 33

4 Policy 1. Policy Statement 1.1 The Trust attaches the greatest importance to the health and safety of patients, visitors and staff. Good quality water, free from hazard including microbiological contamination and safe working temperatures in relation to water installations, is essential to good health. This is particularly relevant to hospitals which contain patients that are at particular risk as a result of their condition, medication or treatment. To ensure that an appropriate environment compatible with the provision of services to patients is maintained, all Trust staff are required, as far as is reasonably practicable, to achieve compliance with the guidance scheduled in Appendix A and the specific requirements of this document. 1.2 Relevant statutory legislation and guidance requires both management and staff to be aware of their collective health and safety duties and responsibilities. This places a duty on management to ensure the competence of staff to carry out their duties with respect to health and safety by ensuring that they are adequately trained and that policies and procedures are in place for their guidance. 1.3 The safe control of water is a continuing responsibility. The effectiveness of precautionary measures should be continually monitored and a programme implemented to ensure awareness of risks devised. 1.4 The policy and procedures contained in this document are based on the guidance in Health Technical Memorandum (HTM 04-01) Safe water healthcare premises, the Health and Safety Commission Approved Code of Practice & Guidance L8 The Control of Legionella Bacteria in Water Systems (HSC ACOP L8) and the associated guidance in HSG 274 Part 2 The control of legionella bacteria in hot and cold water systems and HSG 274 Part 3 The control of legionella bacteria in other risk systems. 1.5 This Policy should be used in conjunction with the Water Safety Plan and Written Schemes of Control for specific areas. 1.6 In the event of a suspected or confirmed case of Legionella infection suspected to be attributable to a hospital source, the action set out in the Joint plan for the investigation and control of Legionella infection, prepared by the Health Protection Agency North West, shall be implemented. Page 4 of 33

5 2 Roles & Responsibilities 2.1 Accountability The Chief Executive is the duty holder and has overall responsibility for all aspects of the quality of water supplies within his/her organisation and has the responsibility for ensuring the designated staff are appointed The procedures adopted should be such as to demonstrate that any person on whom the statutory duty falls has fully appreciated the actual and potential risks of microbial contamination and safe working temperatures in relation to water installations. This will be implemented through compliance with statutory regulations and best practice guidance. Whilst the requirements of these procedures and the source documents may be delegated to staff or contracted, accountability cannot be delegated A Responsible Person (Water) possessing adequate professional knowledge and with appropriate training, possessing a thorough knowledge of the control of microbial contamination and safe working temperatures in relation to water installations should be nominated in writing by the Chief Executive (and have accepted the responsibility in writing) to devise and manage the necessary procedures to maintain the quality of water supplies. The Responsible Person shall be the Head of Estates. This person s role in association with the Infection Control Team and maintenance staff involves:- a) Ensuring that there is an appropriate risk assessment and management plan for all water systems which may pose a reasonably foreseeable risk. Advising on the potential areas of risk and identifying where systems do not comply with the procedures and guidance. b) Liaising with the water undertakers and environmental health departments to advise on the necessary continuing procedures and ensuring the delivery of acceptable water supplies. c) Monitoring the implementation and efficacy of these procedures and identifying and approving any necessary changes. d) Ensuring the adequate operating and maintenance instructions exist and are carried out and maintaining adequate records. e) Ensuring that Quality Assurance procedures are in place. The Responsible Person (water) shall appoint a Deputy to whom delegated responsibilities may be given. The Deputy should act for the Responsible Person on all occasions when the Responsible Person is not available. The Responsible Person will be supported by the Infection Control Team in the production of the policy and management procedures and their implementation An Authorising Engineer (Water) possessing a thorough knowledge of the control of microbial contamination and safe working temperatures in relation to water installations should be appointed in Page 5 of 33

6 writing by the Responsible Person. The Authorising Engineer (Water) {AE(W)} will act as an independent professional adviser to the healthcare organisation. The AE(W) should be appointed by the organisation with a brief to provide services in accordance with HTM 04. The AE(W) should be a Chartered Engineer, Microbiologist or other suitably professionally qualified person. This person s role, in association with the Responsible Person, Infection Control Team and other members of the Water Safety Group involves:- a) Conducting regular routine audits of the Trust s compliance with the ACoP L8 and HTM-04 with reports submitted to the Water Safety Group Chair advising of the prevailing status and setting out recommendations to ensure that the Trust meets the requirements of the ACoP and HTM. b) Attending the quarterly Water Safety Group Meetings and providing such technical advice/expertise as shall be required. c) Ensure that updates or amendments to the ACoP, HTM-04 or other relevant documents are communicated to the Trust. d) Provide such technical advice and/or support as shall be required by the Trust both with site attendance and ad-hoc remote verbal advice The Water Safety Group (WSG) is the body that monitors the Trust s compliance with its statutory obligations with respect to managing the risks associated with water systems. The Group has an agreed set of Terms of Reference that clearly set out its specific purpose. The group membership is drawn from representatives of departments that have a specific role in ensuring that the risk posed by water systems is properly managed within the Trust and provides a forum where different professional bodies can coordinate their work to minimise the risks. The WSG meets quarterly and produces a written record of each meeting. The Water Safety Group is the body that monitors the trusts compliance with its The Infection Control Team is involved in the development and revision of the policy and management procedures for the control of water systems. Similarly, this team has a key role in formulating the plans for its implementation. The Infection Control Team and Estates Management team shall liaise closely together to manage the risk. Representatives of the Infection Control Team shall be members of the Water Safety Group and Infection Control Committee Any policies should be acceptable to the Infection Control Committee and the Water Safety Group and any changes to accepted policies must be agreed by those groups A Competent Person/Maintenance Technician is someone who has sufficient knowledge and the experience necessary to carry out maintenance and routine testing of water storage and distribution systems. Page 6 of 33

7 2.1.9 The following structure shows the lines of responsibility for the maintenance of water quality free from contamination. Page 7 of 33

8 Management Structure Chief Executive Responsible Person (Water) Operational Estates Manager Authorising Engineer (Water) Infection Control Team Deputy Responsible Person (Water) PFI BBW Responsible Person (Water) All Staff Contractors PFI Staff 2.2 Management Responsibilities Management Responsibilities are detailed in full in the Water Safety Plan and that document should be referenced for this information. Page 8 of 33

9 3. Procedures 3.1 General The procedures set out in this Policy document, the Water Safety Plan and Written Schemes have been implemented by the Trust to achieve the standards required to meet statutory requirements with particular emphasis on microbiological contamination and safe working temperatures in relation to water installations The following areas are identified in the hospital have been identified following risk assessment as having (at risk) immuno-compromised patients:- Critical Care and high dependency wards (Pods A, B, C, D & E). Ward H8 (IFU) Haematology Unit Ward H1 (MHDU) and Renal HDU Wards H2 & H3 Renal Unit M3 Ward Where problems are identified on any system supplying areas with immuno compromised patients, these shall be reported immediately to the Responsible Person (Water) and the Infection Control Team which will initiate appropriate action. 3.2 Risk Assessment - Legionella The Responsible Person will ensure that an up to date L8 Risk Assessment is in place for all Trust sites A suitable consultant will be selected to undertake the water risk assessments. The risk assessments will be undertaken to the standards detailed in BS8580: 2010 Water Quality Risk Assessments for Legionella Control Code of Practice The consultant shall be registered to the Legionella Control Association Code of Conduct and preference shall be given to companies who are also UKAS accredited to ISO for the completion of Legionella risk assessment The risk assessment shall take into consideration; Contamination;- Likelihood that Legionella Bacteria will proliferate, Amplification;- Design & Install, Rate of Change, Quality of Water Source, Water Temperature, Control Measures / Management Transmission;- Droplet Formation, Duration of Exposure, Frequency of Exposure. Susceptibility;- Exposed Population Page 9 of 33

10 3.2.5 The Responsible Person will ensure that its risk assessments are periodically reviewed and updated as necessary The consultant undertaking the risk assessment should indicate the recommended period for review. Generally, the Risk Assessments should be reviewed no later than every two years for all clinical areas of the hospital and no later than four years for all nonclinical areas e.g. residential accommodation, administrative buildings etc The risk assessment must be reviewed immediately when a significant change to a site, block or specific water system has taken place. A significant change could be considered as; changes to the water system or its use; changes to the use of the building in which the water system is installed; the availability of new information about risks or control measures; the results of checks indicating that control measures are no longer effective; a case of Legionnaires disease/legionellosis is associated with or is suspected to be associated with the system Upon receipt of a Risk Assessment, the Responsible Person will ensure that the Infection Control Team is presented with a copy for their review and engagement appertaining to any clinical and / or infection control aspects of the report On receipt of the risk assessment report it will be tabled at the next meeting of the Water Safety Group or, as necessary, a special extraordinary meeting arranged to avoid delay in review The Water Safety Group will review the report and consider the report risk assessment and overall recommendations. The minutes of the meeting shall formally record the discussion, rationale and agreement of how the report recommendations will be integrated into the Trust system for assessing each risk issue and for escalation and action The Water Safety Group will monitor implementation of the report recommendations and risk control action plans. Page 10 of 33

11 3.3 Risk Assessment Pseudomonas aeruginosa Risk Assessment of Augmented Care Units for Pseudomonas aeruginosa shall be undertaken by a representative of the Infection Control Team and will include the following areas: Critical Care and high dependency wards (Pods A, B, C, D & E). Ward H8 (IFU) Haematology Unit Ward H1 (MHDU) and Renal HDU Wards H2 & H3 Renal Unit M3 Ward The Risk Assessment will be undertaken annually as an integral part of the Infection Control audit, but shall be specifically detailed as a separate item Risk Assessment of Augmented Care Units for Pseudomonas aeruginosa will, as a minimum, include a review of the following: Clinical practice where water my come into contact with patients Cleaning of patient equipment Disposal of blood, body fluids and patients wash water The maintenance and cleaning of wash-hands basins and associated taps and other water outlets Engineering assessment of water systems including the correct design Under-used outlets/flushing regime The sampling, monitoring and testing programme Education and training Upon completion of a Risk Assessment, the Infection Control Team will ensure that the Responsible Person is presented with a copy for their review and engagement appertaining to any engineering/maintenance control aspects of the report On receipt of the risk assessment report it will be tabled at the next meeting of the Water Safety Group or, as necessary, a special extraordinary meeting arranged to avoid delay in review The Water Safety Group will review the report and consider the report risk assessment and overall recommendations. The minutes of the meeting shall formally record the discussion, rationale and agreement of how the report recommendations will be integrated into the Trust system for assessing each risk issue and for escalation and action The Water Safety Group will monitor implementation of the report recommendations and risk control action plans. Page 11 of 33

12 3.3 Operational Details of all deficiencies and defects identified and remedial action taken shall be reported to the Operational Estates Manager and entered in the system log All domestic water plant, equipment and systems will be designed and maintained to achieve the delivery of at the point of use of safe good quality water free, as far as is practicable, of unacceptable levels of chemical, organic and bacterial contamination. To achieve this, installations shall be designed, installed and maintained as far as is reasonably practicable to achieve compliance with the guidance detailed in the ACoP and HTM Regular contact will be maintained with the local water undertaker to keep up to date with changes that may affect water quality or other operational changes affecting the premises Water systems and all associated components will be checked regularly for signs of leakage. Where water conservation measures are to be considered however, a risk assessment will be undertaken to ensure there is no detrimental impact that may cause stagnation or low water usage in the existing water or drainage systems In public areas, hot water temperatures are moderated to prevent the risk of scalding by use of Thermostatic Mixing Valves (TMVs). TMVs are not used in staff-only areas where conventional taps are used instead. Suitable Caution Hot Water signs will be posted at outlets where domestic hot water is not moderated. These shall contain a visual indication that a risk exists in accordance with signage requirements The installation of individual separate hot and cold taps on wash hand basins is not permitted on new installations in public areas. There is a risk that separate cold water taps do not get used on basins where a TMV fed hot water tap is provided Particular attention will be given to ensuring that pipework containing blended water is kept to a minimum. Generally, the downstream supply from the mixing device should not exceed 2 metres When pressurisation systems with 2 or more pumps are employed, the sequence controller should be set so that each pump operates every 4 hours. The lead pump should be changed weekly and the change logged No domestic water system is to be isolated or its operation modified without notifying and discussing with senior staff the actual or potential changes to the supply and their impact on the operation of the department(s) or unit(s) affected. Infection Control shall be notified of any loss of service expected to exceed 1 hour prior to any service Page 12 of 33

13 interruption to facilitate a Risk Assessment and action taken to mitigate any perceived risk Disused and underused taps and other outlets are identified by the Responsible Person (Water) in collaboration with the Infection Control Team and users and removed, together with associated pipework, if not essential to the operation of the department/unit. The proposed removal of taps or outlets in clinical areas shall be referred to Infection Control Team for conformation that hygiene will not be compromised Arrangements shall be put in place for the domestic staff to carry out daily flushing of underused outlets that cannot be removed under the supervision of the Department/Unit/Ward manager During the temporary closure of wards or departments all outlets will be flushed by estates staff twice a week; where this cannot be achieved the system must be fully disinfected prior the unit being brought back into use. A signed record of the action taken shall be maintained and forwarded to the Responsible Person (Water) for audit at monthly intervals and on completion of a system s disinfection. The Infection Control Team shall be notified of the actions taken/results and informed of any matters that may compromise the water quality. All records shall be held for a minimum period of 5 years During any renovation of a unit/ward/department, the Contractor shall flush each outlet within the work site twice weekly. On completion of any modifications to the system it shall be disinfected in the presence of an Estates Department representative and a certificate issued before being brought back into use. A signed record of the action taken shall be maintained and forwarded to the Responsible Person (Water) at monthly intervals and on completion. All records shall be held for a minimum period of 5 years Hot water systems should only have a single inline circulating pump with a non-return valve to prevent back flow. Systems with a standby pump shall have the lead pump changed regularly (every 3 hours), where these are not considered essential for operational reasons, they should be modified as soon as practical to remove the pump and associated pipework to avoid the risk of tepid water being held in the system. The standby pump should be cleaned, disinfected and capped to prevent the entry of any substance and stored complete with any necessary gaskets adjacent to the operating pump to facilitate a quick replacement. The replacement pump shall be disinfected prior to installation Calorifiers that are taken out of service for more than a few days should be drained and should not be refilled until ready to return to service. The drain valve should be left open throughout the period that the calorifier is out of use Whenever a calorifier is taken out of service, it should be drained, refilled, drained and refilled again and the entire contents brought up to Page 13 of 33

14 70 o C and held for a minimum of 1 hour prior to being returned to its normal operating temperature of 60 o C and being brought back on line. If the Calorifier s temperature falls below 45 o C for any reason for longer than 30 minutes then the entire contents should brought up to 70 o C and held for a minimum of 1 hour prior to being returned to its normal operating temperature of 60 o C. The calorifier must remain isolated until the procedure is complete and service valves opened slowly to avoid disturbing any sediment Whenever a substantial part of the hot water system is taken out of use for longer than a week the system shall be held at its normal operating temperature of 60 o C for an hour with the circulating pumps in operation before being brought back into use Care must be taken to protect maintenance personnel when draining or opening calorifiers or systems known, or suspected, to be infected by Legionella or Pseudomonas aeruginosa. 3.4 Monitoring A competent person/maintenance technician will monitor the systems at regular intervals. The frequency is dependent upon; the specific items of plant, equipment, location and associated risk and is specified in the relevant Written Scheme The following table extract is from Table 1 in HTM 04:01 Part B: Operational Management Checklist for hot and cold water systems (adapted from 274 Part 2 indicates the items which shall be monitored and the results logged to ensure that the water temperature control regime for the control of Legionella is being maintained and the installed components (tanks, calorifiers etc) are in a satisfactory condition Paragraph 7.53 of HTM 04:01 Part B notes the following: In Table 1 the suggested frequencies of inspecting and monitoring the hot and cold water systems will depend on their complexity and the susceptibility of those likely to use the water, and are for guidance only. The risk assessment should define the frequency of inspection and monitoring depending on the type of use and user and particularly where there are adjustments made by the assessor to take account of local needs. The water quality and evidence base will influence the risk assessor s decision. Page 14 of 33

15 Service Action to take Frequency (see paragraph 7.53) Calorifiers Inspect calorifier internally by removing the inspection hatch or using a boroscope and clean by draining the vessel. The frequency of inspection and cleaning Annually, or as indicated by the rate of fouling should be subject to the findings and increased or decreased based on conditions recorded Hot Water Services POU water heaters Where there is no inspection hatch, purge any debris in the base of the calorifier to a suitable drain Collect the initial flush from the base of hot water heaters to inspect clarity, quantity of debris, and temperature Check calorifier flow temperatures (thermostat settings should modulate as close to 60 C as practicable without going below 60 C) Check calorifier return temperatures (not below 50 C, in healthcare premises not below 55 C) For non-circulating systems: take temperatures at sentinel points (nearest outlet, furthest outlet and long branches to outlets) to confirm they are at a minimum of 50 C within one minute (55 C in healthcare premises) For circulating systems: take temperatures at return legs of principal loops (sentinel points) to confirm they are at a minimum of 50 C (55 C in healthcare premises). Temperature measurements may be taken on the surface of metallic pipework For circulating systems: take temperatures at return legs of subordinate loops, temperature measurements can be taken on the surface of pipes, but where this is not practicable, the temperature of water from the last outlet on each loop may be measured and this should be greater than 50 C within one minute of running (55 C in healthcare premises). If the temperature rise is slow, it should be confirmed that the outlet is on a long leg and not that the flow and return has failed in that local area All HWS systems: take temperatures at a representative selection of other points (intermediate outlets of single pipe systems and tertiary loops in circulating systems) to confirm they are at a minimum of 50 C (55 C in healthcare premises) to create a temperature profile of the whole system over a defined time period Check water temperatures to confirm the heater operates at 55 C, or check the installation has a high turnover Annually, but may be increased as indicated by the risk assessment or result of inspection findings Monthly Monthly Monthly Quarterly (ideally on a rolling monthly rota) Representative selection of other sentinel outlets considered on a rotational basis to ensure the whole system is reaching satisfactory temperatures for legionella control Monthly six monthly, or as indicated by the risk assessment Page 15 of 33

16 (no greater than 15 litres) Combinati on water heaters Cold water storage cisterns Cold water services Showers and spray taps Inspect the integral cold water header tanks as part of the cold water storage tank inspection regime, clean and disinfect as necessary. If evidence shows that the unit regularly overflows hot water into the integral cold water header tank, instigate a temperature monitoring regime to determine the frequency and take precautionary measures as determined by the findings of this monitoring regime Check water temperatures at an outlet to confirm the heater operates at C Inspect cold water storage tanks and carry out remedial work where necessary Check the tank water temperature remote from the ball valve and the incoming mains temperature. Record the maximum temperatures of the stored and supply water recorded by fixed maximum/minimum thermometers where fitted Check temperatures at sentinel taps (typically those nearest to and furthest from the cold tank, but may also include other key locations on long branches to zones or floor levels). These outlets should be below 20 C within two minutes of running the cold tap. To identify any local heat gain, which might not be apparent after one minute, observe the thermometer reading during flushing Take temperatures at a representative selection of other points to confirm they are below 20 C to create a temperature profile of the whole system over a defined time period. Peak temperatures or any temperatures that are slow to fall should be an indicator of a localised problem Check thermal insulation to ensure it is intact and consider weatherproofing where components are exposed to the outdoor environment Dismantle, clean and descale removable parts, heads, inserts and hoses where fitted Annually Monthly Annually Annually (summer) or as indicated by the temperature profiling Monthly Representative selection of other sentinel outlets considered on a rotational basis to ensure the whole system is reaching satisfactory temperatures for legionella control Annually Quarterly or as indicated by the rate of fouling or other risk factors, eg areas with high risk patients Page 16 of 33

17 POU filters Base exchange softeners Multiple use filters Infrequent ly used outlets TMVs Inline strainers Pressuris ation and expansion Record the service start date and lifespan or end date and replace filters as recommended by the manufacturer (0.2 μm membrane POU filters should be used primarily as a temporary control measure while a permanent safe engineering solution is developed, although long-term use of such filters may be needed in some healthcare situations) Visually check the salt levels and top up salt, if required. Undertake a hardness check to confirm operation of the softener Service and disinfect Backwash and regenerate as specified by the manufacturer Consideration should be given to removing infrequently used showers, taps and any associated equipment that uses water. If removed, any redundant supply pipework should be cut back as far as possible to a common supply (eg to the recirculating pipework or the pipework supplying a more frequently used upstream fitting) but preferably by removing the feeding T Infrequently used equipment within a water system (ie not used for a period equal to or greater than seven days) should be included on the flushing regime Flush the outlets until the temperature at the outlet stabilises and is comparable to supply water and purge to drain Regularly use the outlets to minimise the risk from microbial growth in the peripheral parts of the water system, sustain and log this procedure once started. Where integral, inspect, clean, descale and disinfect any strainers or filters associated with TMVs To maintain protection against scald risk, TMVs require regular routine maintenance carried out by competent persons in accordance with the manufacturer s instructions. There is further information in paragraphs of HSG 274 Part 2. Where fitted, inspect, clean, descale and disinfect any strainers or filters associated with TMVs or other sensitive equipment. Where practical, flush through and purge to drain. Where removable, bladders or diaphragms should be changed according to the manufacturer s guidelines or According to manufacturer s guidelines Weekly, but depends on the size of the vessel and the rate of salt consumption Annually, or according to manufacturer s guidelines According to manufacturer s guidelines Twice-Weekly in Healthcare or as indicated by the risk assessment Annually or on a frequency defined by the risk assessment, taking account of any manufacturer s recommendations Annually or on a frequency defined by the risk assessment, taking account of any manufacturer s recommendations Monthly six monthly, as indicated by the Page 17 of 33

18 vessels as indicated by the risk assessment risk assessment Biocidal treatment systems Check the dosing and control system operation including alarms Measure the treatment parameters to establish the required values are being achieved at representative outlets including sentinel outlets Note: Consider 24-hour automatic monitoring for biocidal treatment on large or complex systems Weekly Weekly Validation and calibration of the automatic monitoring system should be carried out at the frequencies recommended by the manufacturer The following table indicates the items which shall be monitored and the results logged to ensure that the control regime for the control of Legionella is being maintained in systems other than hot and cold water systems. Service Action to Take Frequency Hydrotherapy Pool Measure ph value. Target , Limit Measure free chlorine. Range mg/l. Measure combined chlorine. Minimum 1.0 mg/l. Check that dosing pumps are operating Ensure water clarity is bright and clear. Ensure dosing injection system working correctly with adequate chemical treatment in the supply tank Daily (by attendant before use and at 2 hour intervals throughout the day) Daily (by attendant before use and at 2 hour intervals throughout the day) Daily (by attendant before use and at 2 hour intervals throughout the day) Daily (by attendant before use and at 2 hour intervals throughout the day) Daily (by attendant before use and at 2 hour intervals throughout the day) Weekly Microbiological check for routine parameters as per Hydrotherapy Pool Weekly Page 18 of 33

19 guidelines Ice Making Machines Renal Water Take samples for bacteriological count. Target below 10 cfu/ml. Maximum 100 cfu/ml. ( cfu/ml acceptable provided coliforms/e.coli or Pseudomonas aeruginosa are not present.). Samples to be analysed by a UKAS Accredited Laboratory. Machine to be maintained and sanitised by Manufacturer Renal water quality to be maintained and monitored to ensure compliance with ISO 13959, ISO and Renal Association Guidelines. Heat disinfection, along with chlorine, hardness and conductivity monitoring. Microbiology and endotoxin testing Chemical disinfection Chemical analysis Monthly 6-Monthly Weekly Monthly Quarterly 6 - monthly The results of all the examinations and checks must be fully recorded in a log, the location of which is to be agreed with the Operational Estates Manager; entries in the log shall carry the date, name and signature or electronic ID of the person carrying out the work. Any failures to meet the required standard shall be reported verbally and in writing the Operational Estates Manager In addition to the routine checks set out in the Written Schemes, a number of control parameters are continuously monitored by the Building Management System (BMS). a) Incoming cold water mains temperature at the water meter. b) Inlet, outlet and storage water temperature of cisterns and cold water feed tanks to calorifiers/plate exchangers. c) The operation of pressurisation and circulating pumps and water treatment systems for fault conditions Excursions below the minimum flow temperature from calorifiers/plate exchangers of 60 o C and return temperature of 50 o C should not exceed Page 19 of 33

20 20 minutes with a maximum of 2 excursions in a 24 hour period. The BMS is used to monitor and log excursions beyond these parameters. 3.5 Microbiological Testing Monitoring for Legionella - The Trust has instituted a programme of routine sampling to detect the presence of Legionella in hot and cold water systems across the retained estate. The sampling protocol will be enhanced where Legionella is detected, hospital acquired Legionella infection is identified or suspected, or where the Infection Control Team recommends such additional testing Any user reports of musty or tainted water will be investigated with water samples for analysis being taken from the tap(s) if deemed necessary, if positive sample are identified then re-samples will be taken plus an additional representative tap on the same system. In the event that a high Total Viable Count is found, samples shall be taken for tests to determine if Legionella bacteria are present before the system is disinfected. This will provide an audit trail in the event that an outbreak of Legionnaires disease is identified Tests for the presence of Legionella bacteria and other microorganisms which can be hazardous to health shall be carried out if the control regime is not being consistently met, (specified levels not being maintained). Samples shall be taken from: Cold Water The water storage tank and the furthest outlet from the tank on major circuits of a system. Specific Departments/Wards/Units with At Risk patients. Hot Water The plate exchanger/calorifier drain, the first outlet on the flow and the last outlet on the return of major circuits of a system. Specific Departments/Wards/Units with At Risk patients. Each assisted (Arjo) bath. The analysis shall be undertaken by a UKAS accredited laboratory which takes part in the Health Protection Agency Water Microbiology External Quality Assessment Scheme for the Isolation of Legionella from Water, with certification directly from that laboratory provided with all results If positive results are obtained from a sample, the maintenance regime set out in Section 3.6 shall be enhanced to incorporate a complete cleaning, flushing and disinfection routine for the infected system as recommended in the Health & Safety Commission Approved Code of Practice & Guidance (H&SC ACoP L8) and British Standard BS8558:2011 Clause Flushing & Disinfection (see Appendix A). Any work associated with the chemical disinfection of a system is to be Page 20 of 33

21 carried out by trained specialists and monitored by Estates Staff. When considering a contractor to carry out the work, preference shall be given to companies/individuals, who are members of the Legionella Control Association When a positive result has been obtained from a sample, repeat testing will be undertaken and the location will remain on the testing schedule until such time as three consecutive negative results have been obtained Where repeat or persistent positive results are obtained and the outlet(s) cannot be removed from service for practical reasons, pointof-use (POU) filters will be installed on all relevant outlets. POU filtration should be considered and agreed by the WSG only as an interim safeguard where control measures have been ineffective or where additional protection is required for vulnerable patients. Continuous long-term use of POU filters is not recommended, except where there is no effective alternative. Where POU filters are installed as a temporary measure, they should be changed in accordance with the manufacturers recommendations, typically at least once a month. Once removed for whatever reason, a replacement filter should be fitted. When changing filters, it is recommended that sampling of water quality takes place at outlets identified as sentinel points before refitting a replacement filter. It is essential to ensure that where filters are to be used they are constructed of the appropriate materials (see paragraph 3.1 in HTM Part A) Monitoring for Pseudomonas aeruginosa - The multidisciplinary Water Safety Group will advise on the requirement for microbiological monitoring for Pseudomonas aeruginosa in water samples from clinical areas in the hospital. This is routinely required at six monthly intervals; unless there are positive samples or monitoring of patient isolates for Pseudomonas aeruginosa indicates there is suspicion of a pseudomonas aeruginosa contamination Sampling shall be undertaken in accordance with the HTM This requires that sampling be undertaken during a period of, preferably, no use (at least 2 hours or preferably longer) or if that is not possible, a time of low use. Sampling should therefore be taken during the early hours of the morning, when usage of outlets will be at a minimum. Testing should be undertaken in a UKAS accredited laboratory When a positive result has been obtained from a sample, repeat testing will be undertaken and the location will remain on the testing schedule until such time as three consecutive negative results have been obtained Where repeat or persistent positive results are obtained and the outlet(s) cannot be removed from service for practical reasons, pointof-use (POU) filters will be installed on all relevant outlets. POU filtration should be considered and agreed by the WSG only as an interim safeguard where control measures have been ineffective or where additional protection is required for vulnerable patients. Page 21 of 33

22 Continuous long-term use of POU filters is not recommended, except where there is no effective alternative. Where POU filters are installed as a temporary measure, they should be changed in accordance with the manufacturers recommendations, typically at least once a month. Once removed for whatever reason, a replacement filter should be fitted. When changing filters, sampling of water quality will takes place at outlets identified as sentinel points before refitting a replacement filter. It is essential to ensure that where filters are to be used they are constructed of the appropriate materials (see paragraph 3.1 in HTM Part A). 3.6 Maintenance Routine maintenance will be carried out at intervals determined for specific plant, equipment and components to ensure that systems are operating correctly and the cleanliness of the systems is maintained Safe maintenance practices have been established to prevent injury, contamination or infection Details of all deficiencies and defects identified and remedial action taken shall be reported to the Operational Estates Manager and entered in the system log Following the monitoring regimes set out in the Written Schemes the hot and cold water installations shall have the maintenance procedures undertaken and remedial action carried out when deficiencies or defects are identified. All maintenance and remedial work undertaken shall be logged No modifications will be made to a system its plant, equipment or components without the authorisation of the Responsible Person (Water) Systems will be adjusted to maintain design parameters (water temperatures etc.), cleaned and disinfected to the standard set out in the Written Schemes and the Trust s Policy Document Inspection Cleaning and Disinfection of Domestic Water Tanks to eradicate/prevent the growth of the Legionella and Pseudomonas aeruginosa bacteria. All actions will be logged. The systems and procedures of external contractors will be reviewed prior to the commencement of work and the efficacy of the work assessed Storage calorifiers without inspection/access ports should be scheduled for replacement or the fitting of inspection/access ports, particularly if part of a system supplying areas with immuno-compromised patients Hot water systems should only have a single inline circulating pump with a non-return valve to prevent back flow. Systems with a standby pump shall have the lead pump changed regularly (every 3 hours), where these are not considered essential for operational reasons, they should be modified as soon as practical to remove the pump and Page 22 of 33

23 associated pipework to avoid the risk of tepid water being held in the system. The standby pump should be cleaned, disinfected and capped to prevent the entry of any substance and stored complete with any necessary gaskets adjacent to the operating pump to facilitate a quick replacement. The replacement pump shall be disinfected prior to installation Calorifiers that are taken out of service for more than a few days should be drained and should not be refilled until ready to return to service. The drain valve should be left open throughout the period that the calorifier is out of use Whenever a calorifier is taken out of service, it should be drained, refilled, drained and refilled again and the entire contents brought up to 70 o C and held for a minimum of 1 hour prior to being returned to its normal operating temperature of 60 o C and being brought back on line. If the Calorifier s temperature falls below 45 o C for any reason for longer than 30 minutes then the entire contents should brought up to 70 o C and held for a minimum of 1 hour prior to being returned to its normal operating temperature of 60 o C. The calorifier must remain isolated until the procedure is complete and service valves opened slowly to avoid disturbing any sediment Whenever a substantial part of the hot water system is taken out of use for longer than a week the system shall be held at its normal operating temperature of 60 o C for an hour with the circulating pumps in operation before being brought back into use Care must be taken to protect maintenance personnel when draining or opening calorifiers or systems known, or suspected, to be infected by Legionella or Pseudomonas aeruginosa. Page 23 of 33

24 3.7 Disinfection Disinfection should be undertaken under the following circumstances: New systems prior to handover. If not brought into regular use within 7 days every outlet should be flushed until the temperature stabilises; Existing hot water systems where any part of the calorifier or circulation system has fallen below 45 o C. Hot and cold water systems after modification. This includes new pipework, plus any of the original pipework which may have become contaminated by extraneous material or biofilm damage. In many cases this will mean disinfection of the whole system. If a cold water supply exceeds 25 o C. If systems are below 25 o C (preferably below 20 o C) at all times from meter to outlet routine disinfection is unlikely to be required. Microbiological monitoring tests show that a system is infected with organisms hazardous to health Tanks will require regular draining, cleaning and disinfection. The frequency will be dependent upon the condition found and recorded during routine monitoring Calorifiers should always be thoroughly cleaned and disinfected following being opened for statutory inspection or annually Cleaning, flushing and disinfection routine for the infected system shall be as detailed in the Standard Operating Procedure Inspection, Cleaning & Disinfection of Domestic Water Tanks and generally in accordance with the Health & Safety Commission Approved Code of Practice (ACoP L8), associated Guidance (HSG 274 Part 2 and BS8558:2011 (see Appendix A). Any work associated with the chemical disinfection of a system is to be carried out by trained specialists and monitored by Estates Staff. When considering a contractor to carry out the work, preference shall be given to companies or other entities, who are members of the Legionella Control Association. Page 24 of 33

25 4. Records 4.1 The name and position of the Duty Holder, the persons appointed as Responsible Person and Deputy Responsible Person, along with details of those who conducted the risk assessment shall be recorded in the Written Schemes. 4.2 The names and positions of the persons responsible for carrying out tasks identified in these procedures and written schemes for specific systems and their lines of communication. 4.3 Full Record Drawings Maintenance and Health & Safety Manuals must be available prior to acceptance of a new installation. These should show the design and operational intent. 4.4 As Fitted drawings of all hot and cold water services are to be produced and maintained up-to-date for all installations. These must indicate the layout of all calorifiers, plate exchangers, pumps, cisterns and the pipe work arrangement, with direction of flow indicated, deadlegs and blind ends identified. 4.5 Schematic drawings of all hot and cold water services are to be produced and maintained up-to-date for all installations. Schematic drawings are simple but accurate illustration of the configuration of the water system, including parts that are out of use. They are not formal technical drawings and are intended to be easy to read without specialized training or experience. The schematic drawings will be the basis on which the risk assessments are developed. 4.6 Details of the status of systems, operational procedures and records of the results of the monitoring and maintenance carried out and action taken to correct any deficiencies identified must be logged and held to identify trends. 4.7 The completed signed off log sheets for the underused outlets flushed by Domestics shall be reviewed and held by the Hotel Services Manager. 4.8 Reports of the cleaning and disinfection procedures carried out with certificates. 4.9 All records of monitoring, maintenance, system enhancement, flushing, disinfection Legionella tests etc. shall carry the name, date and signature of the operative carrying out the task and supervising manager. All records shall be kept for a minimum period of 5 years Details of the training given to hospital personnel and the training and experience of any contract/contactors staff employed New installations and equipment which uses water will not be accepted by the Trust unless the system complies with all relevant legislation, meeting current guidance and standards for the supply of good quality Page 25 of 33

26 water free from hazardous substances including microbiological contamination, has been fully commissioned and the following documentation provided. i) 'As Fitted' drawings, including schematic diagrams. ii) Plant Manuals, including a statement of design intent manufactures equipment information and operating instructions. iii) Commissioning Manuals listing design data, commissioning results and a certificate of disinfection Each item of plant and equipment will have an asset number, which will be affixed to the plant. All system documentation will be filed against this number A log book will be maintained for each system to record plant operation. These should indicate settings, monitoring, maintenance, defects and remedial action. The records will be kept for a minimum of 5 years. 5. Training 5.1 All personnel charged with the operation, inspection, service, maintenance, repair or testing of water supply systems shall be competent to carry out the duties assigned to them. It is the responsibility of the Responsible Person (Water) in consultation with the line manager (whether in-house or contractor) to assess the competence of staff and arrange or recommend training necessary to achieve the level of expertise and familiarisation with the systems necessary to discharge their duties. Particular emphasise will be placed on the specific risks associated with Legionella and Pseudomonas aeruginosa bacteria and measures to eliminate them or reduce concentrations in installations that have been colonised. Refresher training should be given at intervals not exceeding every three years and records of all training maintained All personnel, including Nursing Staff and Domestics, involved in the control of Legionella should be aware of the measures to minimise the risk of the bacteria, within the Trust s water systems. 5.3 Nurse Managers will be given regular briefings by the Infection Control Team to emphasise the importance of ensuring that any underused outlets are identified and reported to Infection Control which will assess need and where appropriate arrange for the outlet to be removed. Where removal is not possible Nurse Managers are to be made aware of the importance of regular flushing by the domestic staff and nurse cooperation in ensuring that this is emphasised. 5.4 Control of Legionella is a specific item covered during the induction of Domestic Staff joining the Trust. This will include the importance of identifying and flushing underused taps as a control measure. The importance of this will be emphasised during annual training. Page 26 of 33