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INFECTION CONTROL


document and must be reviewed on a regular basis to ensure it continues to be relevant and effective in Legionella management and control. This is a significant change to guidance and puts it in line with other ACoPs. There are specific reasons stipulating when a risk assessment must be reviewed, with ‘changes to key personnel’ now added to the list. The new HSG 274 Part 2, on the other


hand, does offer specific advice on water systems in healthcare facilities, including a new section dedicated to special considerations for hospitals and care homes based on information provided in HTM 04- 01. Responsible persons for healthcare need to be aware of these to ensure compliance with Legionella control regulations. One of the key requirements borrowed


from HTM 04-01 is outlined in Info Box 2.10 regarding the implementation of Water Safety Groups. These are multi-disciplinary committees convened to consider all water safety issues, from assessing risks to microbiological control. Normally led by the Director of Infection Prevention and Control, the groups often include representatives from estates management, microbiology, nursing, hotel services, domestic services, capital planning and external consultants. Water Safety Plans are also required for


healthcare environments under the new HSG 274 Part 2, working alongside existing written schemes for Legionella management and control. In writing these, healthcare facilities managers are referred to advice in Water Systems Health Technical Memorandum 04-01: Addendum, Pseudomonas aeruginosa.


Water system design The updated L8 and HSG 274 highlights the importance of careful water system design in minimising Legionella risk, regardless of the purpose of the building. In particular, it highlights the importance of water usage and good water turnover. For healthcare premises, though, it is now recommended that water systems should be designed to offer a 12-hour turnover of cold water tank systems a change from the 24 hours recommended in HTM 04-01. It is advised, where possible, that low-risk


systems and self-flushing technologies, such as automated sensor outlets, be used to maximise the effectiveness of control measures and minimise the potential for bacterial growth. Higher risk systems, and those with sustainability measures to reduce water usage and improve energy efficiency,


‘The revisions to L8 and technical guidance documents HSG 274 Parts 1-3 provide more practical and dedicated advice for healthcare facilities managers on the management and control of Legionella.’


IFHE DIGEST 2015


need to be carefully considered before installation to maintain adequate Legionella control. As always, domestic water systems should


be designed to minimise the potential for bacterial growth, ensuring good water turnover and good temperature control. Calorifiers still need to have a flow temperature of at least 60˚C, but hot water return and outlet temperatures must be 55˚C, bringing this guidance in line with HTM 04- 01. It also advises on the type and use of thermostatic mixing valves to help building managers alleviate the risk of scalding that these control temperatures entail, particularly for vulnerable patients.


‘The new HSG 274 Part 2 recommends the flushing of infrequently used water outlets at least twice a week in healthcare and care homes, with daily flushing for all outlets augmented care units.’


In paragraph 2.35 of HSG 274 Part 2,


healthcare estates and facilities managers are now advised against the use of ethylene propylene diene monomer (EPDM) lined flexible hoses in their water systems, as these have been shown to be at increased risk of microbial colonisation. Guidance is given based on the Department of Health Estates and Facilities Alert DH (2010) 03, issued in 2010. There are also new recommendations for healthcare estates and facilities managers regarding the use and monitoring of point-of- use and multiple-use filters, water softeners and thermostatic mixing valves (TMVs). Additional information is provided on


expansion vessel design and installation for both healthcare and non-healthcare systems, as recent research has suggested they may accumulate biofilm, a potential breeding ground for Legionella and other bacteria. Ideally, regardless of the building, flow-through systems are recommended, but if their use is not possible, isolation valves and drains need to be fitted to facilitate effective flushing.


Control measures For hospitals and larger healthcare buildings with more complex water systems, Table 2.1 of HSG 274 includes requirements for additional sentinel point monitoring, including sub-ordinate loops and return leg temperature checks on hot water systems as well as temperatures checks on long runs of hot and cold water systems. There are many other changes to monitoring programmes in table 2.1, when compared to the previous L8 document, which many healthcare facilities will already have in place. However, having guidance on point of use filters, expansion vessels, the use of TMVs, to name but three new areas, will be useful in emphasising the requirements for control measures and monitoring that may already have been adopted within healthcare environments. In addition, in line with current guidelines in HTM 04-01, the new HSG 274 Part 2 recommends the flushing of infrequently used water outlets at least twice a week in healthcare and care homes, with daily flushing for all outlets augmented care units. While many hospitals have already


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