Protecting patients from Legionnaires' disease

Patients are particularly vulnerable to Legionnaires’ disease. Establishing a water quality management plan therefore isn’t just best practice — it can save lives.

Legionnaires’ disease is a disease of increasing importance worldwide. The Center for Disease Control (CDC) in the USA estimated in 2016 that the incidence of Legionnaires’ disease has increased by 400% over the last 15 years. In Australia, there have been several high-profile outbreaks both in hospitals and in the community. Recent issues have been found in several hospitals all over Australia, with the most well-known recent outbreak taking place in the Wesley Hospital in Brisbane. The most common species discovered in outbreak situations in health care is Legionella pneumophila, although there are many other species of Legionella that cause illness in humans.

Legionnaires’ is a respiratory disease that can affect anyone but predominantly affects the elderly and those with other conditions such as diabetes, with more men being infected than women. It can cause significant morbidity and mortality, and has a high level of admission to intensive care.

Applying best practice

The Wesley Hospital outbreak resulted in the production of guidelines for the control of Legionella and other microorganisms in Queensland and, ultimately, in the 2015 publication of the enHealth Guidelines for Legionella Control in the operation and maintenance of water distribution in health and aged-care facilities.

The enHealth guidelines apply to all water systems in aged-care facilities and health facilities in Australia, with the exception of cooling tower systems. In Queensland, producing a plan for the control of Legionella in a facility is compulsory under the Public Health (Water Risk Management) Amendment Act 2016. Queensland also has compulsory reporting of the results of Legionella testing in a health facility on a publicly available website. At present, most states have indicated that the guidelines will become compulsory in the future. As they stand, the guidelines are best practice within Australia, and it would be wise for any facility to produce a plan for the safety of their residents and patients.

While the guidelines refer mainly to Legionella, it is the view of many professionals that while producing a Legionella management plan, it is vital to assess and manage the risk of other waterborne pathogens such as Pseudomonas aeruginosa, Xanthamonas maltophila, Acinetobacter species and organisms such as non-tuberculosis Mycobacterium species. Pseudomonas aeruginosa is a common cause of hospital-acquired pneumonia in Europe and can be difficult to treat due to antibiotic resistance.

Creating a management plan

Step 1: Establish a project team and seek stakeholder input

The first step of creating the plan is to establish a Legionella risk management system, the first step of which is assembling a risk management team to produce the document. A team may include engineering staff, external consultants, infection control practitioners, clinical staff and executive level members. It should be ensured that the people producing the plan have the relevant expertise to do so, and extra training or the consultation of external experts may be required to produce an effective plan. The team should then produce suitable and effective written procedures for Legionella risk management within the facility.

Also, when the plan is being created, it is critical to seek input from all staff, not just those directly involved in the risk management team. Effective awareness training for all staff, along with an easy system for reporting any risks noted within the building, will improve the plan.

Step 2: Analyse the water systems

A full analysis of the water systems within the facility should be undertaken — a task which will require both trades and clinical staff to be effective. At this stage, the vulnerability of the patients to acquiring waterborne disease should also be assessed — for example, areas such as oncology will have higher risk patients than a mental health outpatient clinic, and a greater degree of control will be required in these areas. A list of uses and users of water should also be prepared — this list will be extensive, and should include input from as many sources as possible to capture as many uses as possible. This will include everything from showers and dental chairs to humidifiers and steam mops.

Check shower heads as part of the review. Image credit: Sarah Bailey.

Step 3: Identify hazards and risks and implement controls

Identifying the hazards and risks is the next stage, followed by implementing controls and monitoring — managing the risks. The hazards and risks from the water system will be many and varied, and some will require urgent action — this may be an engineering intervention or a change in clinical practice. All risks should be ranked, with the highest risk actions remediated first. Examples of this include ensuring that the hot water is circulating at the correct temperatures throughout the hospital water system, that shower heads are not affected by limescale, that water in the cold water tanks is circulating properly and that chlorine residuals in the tap outlets are at the proper concentrations.

Step 4: Establish a monitoring program

A suitable operational and verification monitoring program should then be set up for the facility. Operational monitoring is the tests that can be carried out day to day — often with instant results to determine if the controls implemented are working. Common operational monitoring includes testing for chlorine residuals in the water supply, temperatures from the taps and from the water heaters, the pH of the water and the turbidity of the water. Verification monitoring tests are those for Legionella species and, often, for heterotrophic colony counts (sometimes also referred to as total viable counts or total plate counts). As these verification tests take many days to get results, they should not be relied upon as the primary form of monitoring. Operational monitoring can provide on-the-spot information as to how a system is performing, and if the conditions for Legionella proliferation are prevalent in the system. This can allow a fast response to deteriorating conditions and reduce the chances of patients becoming exposed to Legionella species and other waterborne pathogens.

Step 5: Review the plan regularly

Finally, the document, once produced, is a living document. It should be reviewed at regular intervals and additionally it should be reviewed if a case is detected, if the results of testing indicate the plan is not working effectively or if there are any changes to the water distribution system.

An effective program, put together by staff who have adequate training and resources, will increase patient safety within the facility.

*Sarah Bailey is a Senior Consultant at QED Environmental Services, primarily working in the health and aged-care sectors in water and air quality, and infection control. Prior to her appointment at QED, she worked for many years as a microbiologist in the Australia and the UK, including for the Health Protection Agency, where she was involved in infection control and Legionella control. Visit www.qed.com.au.

Top image credit: ©stock.adobe.com/au/vchalup