Legionella Control in Healthcare

What are the Laws underpinning the Legionella control?

There is a hierarchy of laws guiding the Legionella control

• Acts - these are the primary legislation passed by the parliament. Not abiding by the law could be a criminal offence and punishable by fine or imprisonment. These are legally enforceable.
  
  - The Health and Safety at Work etc. Act 1974
• Regulations are secondary legislation, such as statutory instruments, regulations and orders. These are often issued as directives from Europe and converted to regulation in the UK. It can also be introduced in the UK by the power invested to the secretary of state by an act introduced by the parliament. Health and Safety at work is an example of an enabling act. These are legally enforceable.
  
  - Control of Substances Hazardous to Health Regulations 2002
  - The Management of Health and Safety at Work Regulations 1999
  
  
• Active codes of practice (ACOP) are not law - but are designed to help comply with the law. They have a special legal status and may lead to prosecution if not followed/breached. ACOPs are approved by the secretary of state. If you have not followed the ACOP, then you have to demonstrate how you have complied with the law by some other means in the court of law.
  
  - ACOP for Legionella ACOP: L8 2013
  
  
• Guidance - Most important documents are
  
  - HSG274 part 1 (control of Legionella in the evaporative cooling system),
  - HSG274 part 2 (control of Legionella in hot and cold water system),
  - HSG274 part 3 (Control of Legionella in other risk system),
  - HSG282 (Control of legionella and other infectious agents in spa-pool systems),
  - HTM 04-01 parts A and B Safe water in healthcare premises,
  - HTM01-05 Decontamination in primary care dental practices

ACOP L8:2013

The responsibility lies with the owner of the premises or the employer (this person is called the "duty holder"). They must identify and assess the risk, prepare a written scheme to control the risk, implement and manage the precaution, keep a record of the precaution and employ a competent person (called "responsible person") to help to take the measures needed. "Responsible person" should have a deputy. However, duty holder cannot pass their duty to any other person.

The Health and Safety at Work etc. Act 1974

Principle acts that cover health and safety in the healthcare premises. This enabling act allows the creation of specific requirements through regulations enacted as statutory instruments or through codes of practice. Statutory instruments are law. HASAW1974 do not mention specific bacteria but refers to them as pathogens.

It has 4 parts and 10 schedules. We are interested in part 1 - Health and Safety and Welfare in connection to work, and control of dangerous substances and certain emissions into the atmosphere.

There are 54 sections in part 1. We are interested in

Section 2 - general duties of employers to their employees. Employees must not be put at risk when carrying out their duties. System and machinery must be capable of safe use.
Section 3 - general duties of the employers and self-employed to persons other than their employees (contractors, subcontractors, members of the public and service providers). They are responsible for people affected, for example, by aerosols with pathogens generated by their work.
Section 7: General duties of employees at work. Although the act is mainly directed at employers, all have responsibility. We must do our tusk such a way that it does not affect us or other people at risk.
Section 36: Offences due to the fault of other persons. If the offence is caused by a person, that person will be found guilty but the corporate body still might be charged.
Section 37: Offences by body corporate. If a manager decides not to act, then they and the corporate body will be prosecuted.

Employers must control the risk to the public and staff. The act set out the general duties of the organisation. Exposure to the risk is a critical factor for prosecution, even if no incident has happened. The prosecution can go up to manslaughter. The result could be an unlimited fine (up to 6 - 7 figures) and up to 2 years of imprisonment.

All actions should be recorded. A defect log should be kept when it is corrected.

COSHH - Control of Substances Hazardous to health regulations 2002

It is law. It required assessment on all substances being used in the workplace that are described as hazardous at the health and safety data-sheet - biological agents and pathogen. If the assessment shows risk, action must be taken to minimise the risk t as low as it is reasonably practicable (ALARP).

Legionella is a human pathogen; hence, COSHH applies, and we need a risk assessment of the water system. The source of water entering the system must also be taken into consideration. The household's water supply is mainly the town's main supply and the biological load should be low. Legionella should not be present. Beware that the customer may use various other sources, and legionella may be present in those.

If the system may grow Legionella during operation, they are considered a foreseeable risk. The assessor also considers the degree of risk. The degree of risk is higher if more Legionella enters the system; the more often, the condition of growing Legionella is encountered, the more often the aerosol is generated, the more people inhale the aerosol, and vulnerable people are at risk.

If the system demonstrates foreseeable risk - When the risk is identified, see if the risk system can be eliminated; if not, can it be replaced by a system with lower risk? If not, system /control measures should be implemented to minimise the hazard. Assessors should look at the control already in place and, if satisfactory, recommend that the controls be maintained. If not, suggest measures to reduce the risk to ALARP.

The control system should be maintained and managed. If the controls need improvement assessor should comment on that. Management should review and check the competency of all involved.

Management systems should be accountable, and sustainable, and what frequency of tasks, parameters to maintain and fail-safe to cover for absence. There should be a deputy. They should be trained and competent (on the job and classroom). Refresher training should be given when required (every 3 years). The monitor should be assessed and recorded at a frequency recommended and whenever it felt necessary.

The Management of Health and Safety at Work Regulations 1999

This is a framework for all employers to follow to ensure they can work in an environment that is ALARP-safe and free from risk.

It suggests that duty holders should have access to competent help. That means that if they do not have a competent person in their employment, they should go to the marketplace to hire help. Employers must ensure that this help is competent. The Legionella control association ensures that all members follow a code of conduct to assure the employer.

Water supply (water fitting) regulations 1999
Water supply (water quality) Regulation 2016
Private water supply regulation 2009

It defines the requirements for design

It prevents misuse, waste, undue consumption or erroneous measurement of water and prevents contamination of drinking water. Apply to all premises supplied or to be supplied by a water undertaker. They start from the point water enters the premises. It does not apply to those premises which have no provision of supply from the public main.

2 cover the quality of water that enters the private property. This includes drinking, cooking, preparing food, and sanitation - The water supply abiding by this regulation is called wholesome water. Water supplied for the above purpose from any private source (RIVER, BOREHOLE) fall into the 3rd regulation. If the water is not wholesome, it should be treated before onward distribution.

Notification of cooling towers and evaporative condenser regulation 1992 (statutory instrument 2225)

Users of such a system must notify the local authority, which keeps a record. If it is removed, the users must notify the local authority within a month.

Health and social care act 2008

It has 4 parts - part 1 explains the Health and social care act 2008. It applies to registered healthcare and adult social care providers - dental care, acute care, primary care, ambulance service etc.

Part 2 gives 10 criteria against which CQC will judge the care providers regarding infection control.

Parts 3 & 4 help registered users interpret the criteria and develop risk assessments. Appendices guide how a proportionate approach can be taken. The water safety group and water safety plan is a part of it.

However, the code is not mandatory. Providers can demonstrate that they can are able to comply with the law by using a different method.

Health technical memoranda

HTM 00 - Building engineering in the health sector
HTM 04-01 - Safe water in the healthcare premises
HTM 07 - 04 - Water management and efficiency
HTM 01- 05 - Primary care dental practice

These provide comprehensive guidance on design, maintenance, and engineering technology used in healthcare. HTM remains applicable to new and existing sites. Providers have the responsibility that appropriate governance management is in place.

HBN provide best practice guidance on the design of new healthcare buildings and the adaptation of the existing facility.

Corporate manslaughter act 2007

If anyone is found to have caused harm by not abiding by the law, then that person is liable to prosecution and can be charged with manslaughter if it has caused death. If that person (called a controlling mind) cannot be found, then corporate manslaughter can be brought against the company. It may result in unlimited fines (10% of company turnover), remedial orders, and publicity orders (they need to publicly disclose what happened).

The law is not applied retrospectively. Also, if you are prosecuted does not mean you are guilty. However, if the law was breached controlling mind could be fined. To prosecute a company, it has to be shown that they have caused harm and their standard was well below the stipulated standard.

RIDDOR 2013

Another law is relevant to the water system. It is reportable under RIDDOR if the Legionella (or infection caused by a biological agent) infection occurred due to a water system in the workplace. It is reportable within 10 days, using a form downloaded from HSE or phone.

In the educational sector

School premises regulation 2012

Premises should be maintained to provide a healthy environment to the pupil and staff.
Prevent scald - temp of the outlet frequented by students should be below 43 degrees C., using TMT/TMV.

Education Regulation 1999 has a similar recommendation.