Risk Management Plan For LEGIONELLA CONTROL
Risk management plan forLEGIONELLACONTROLin the operation and maintenance of thewater systems ofFacility nameFacility nameFacility addressResponsible personRevision historyRevision1CommentDateRisk management plan for Legionella control for (FACILITY NAME)Initials
Contents1Risk management team. 12Risk analysis . 23442.1System description . 22.2Hazard identification and risk assessment . 6Risk management . 103.1Control procedures . 103.2Monitoring. 11Responding to detections or cases . 154.1Key incident response people and their responsibilities . 154.2Response procedures . 15Review of plan . 17Appendix . 18Key contacts . 18Key documents . 18Advisory noteThis template has been provided to assist in the development of a risk management plan forLegionella control based on the information and processes described in the enHealthGuidelines for Legionella control in the operation and maintenance of drinking waterdistribution systems in health and aged care facilities.Advisory information has been included in certain sections to assist with the interpretationand completion of relevant plan details. It is expected that this content will be either deletedor replaced with content specific to your facility in your final document.In the event of complicated plumbing infrastructure, positive Legionella test results that arenot easily controlled via the implementation of measures within the plan, an outbreak ofLegionnaires’ disease, or lack of confidence in in-house ability to prepare the plan, externalexpert assistance should be sought.iRisk management plan for Legionella control for (FACILITY NAME)
1 Risk management teamSummary of actions: Nominate Legionella risk management team members.Record why team members have been selected to participate in Legionella risk management.Clearly articulate the responsibilities of each member of the risk management team.Table 1 Risk management team membersName1OrganisationPositionLegionella riskmanagementresponsibilitiesRisk management plan for Legionella control for (FACILITY NAME)Skills/knowledge/experience(reasons for being in team)Contact details
2 Risk analysisSummary of actions: Gather information on the water supply system.Gather information on the water uses and users within the facility.Describe the system (including treatment).Discuss the quality of incoming water.Identify hazards associated the facility’s water supply system.Identify existing control measures.Perform risk assessment.2.1 System descriptionInsert a flow diagram/schematic drawing/plan of your facility’s system. An example is shownbelow.BackflowpreventionIncoming Water from XXXCouncilRainwater tanksBackflowpreventionCHLORINATIONIce machineFire fightingColdWaterStorageCold WaterStorageLaundry & KitchenShowers & wash basins inWards 1 -5, maternity (andbirthing pools), ICU andfoyer. Water dispenser –foyer, dental suiteShowers & wash basins inWards 1 -3 and maternityward (including birthingpools)Air coolingWaterHeaterWaterHeaterTMVsTMVsShowers & wash basins inWard 4 and dental suiteWaterHeaterTMVsShowers & wash basins inWard 5 and ICUFigure 1 Schematic of Facility name water delivery system2Risk management plan for Legionella control for (FACILITY NAME)irrigation
2.1.1 Uses of waterList uses of water within the facility, for example: drinking (includes feed into ice machines and water dispensers)clinical uses (e.g. dialysis, hydrotherapy, dental chairs)swimming and spa poolsbathingtoilet flushinglaundryfirefighting and fire suppression (including sprinklers)air conditioningfood preparation (including ice making)irrigation of groundsbirthing poolsdecorative fountains.2.1.2 Users of waterProvide details of water users in the facility, for example: facility population/number of bedsclinical functions (e.g. maternity, intensive care etc)specialist functions (e.g. dental)approximate percentage and location (if possible) of high and low clinical risk patients.2.1.3 Incoming waterProvide details of incoming water, both potable and non-potable. If there are varioussources, identify the linked uses (see 2.1.1). For example: What is the source of the incoming water (e.g. bore, surface, rainwater)?What treatment processes does the incoming water undergo before entry into facility?Where are the entry points for the incoming to the facility?How reliable is the incoming water?Is the water treated within your facility?Is there an emergency supply and what is its source and quality?2.1.4 Quality of incoming waterDescribe the typical water quality characteristics of the incoming water. Parameters toconsider are disinfection residual in the water entering the facility, temperature, pH,turbidity, water chemistry, metals and bacteriological quality.2.1.5 System detailsProvide overview of water system, for example: 3Incoming water is supplied to a water heater of xxx litres capacity, set at xx degrees C.Water within the system is treated using xxx (e.g. copper silver ionisation)Risk management plan for Legionella control for (FACILITY NAME)
4Heated water is supplied to outlets in two ICU rooms and 5 general wards. Outletsconsist of showers, baths, wash basins and sinks.Each outlet has a TMV with the maximum distance between heater and TMV of xxxmetres.Guidelines for Legionella control
Table 2 Inventory of system components (edit, add or delete rows asrequired)SystemcomponentCharacteristicHot water heatersNumber, location, capacityType of heatingDetailse.g. solar, gas, instantMax. temperatureAge of heatersCapacityCold water storagesNumber, location, capacityCapacityWater treatmentPipeworkMateriale.g. concrete, steel, plasticWater age (i.e. time sincedisinfection)If knownType, locatione.g. chlorine disinfectionDose rate (if chemical treatment)e.g. 1 mg/LTarget residual at most distal pointin water system (if chemicaltreatment)e.g. 0.5 mg/LAgeMaterialType and extent of insulationNumber of dead legs and locationsAreas of low flow% of pipework that is accessibleOutletsTMVs and temperingvalvesNumber, type and location of hotwater outletse.g. 5 sinks in kitchenNumber, type and location of coldwater outletse.g. 8 taps in landscaped gardenNumber, type and location ofwarm water outletse.g. 35 showers in maternity unitType, number, age and locationInclude date of last serviceDistance from outletsAccessibilityMaximum temperature at outletOther componentsthat use waterHydrotherapy baths, birthing poolsHumidifiersWater dispensing machine5Risk management plan for Legionella control for (FACILITY NAME)
SystemcomponentCharacteristicDetailsIce machinesCooling towersRainwater tanksFire protection systemRPZ – backflowpreventionNumber and location2.2 Hazard identification and risk assessment2.2.1 Hazard identificationIdentify the hazards and potential hazardous events that could affect the water qualitywithin the described water supply system, promoting Legionella colonisation and growth,along with their corresponding control measures. The table below lists some examples ofpotential hazardous events commonly associated with a facility’s water system.Table 3 Examples of potential hazardous eventsSystemcomponentEventIncoming waterIncoming water contaminationLoss of supplyFailure of backflow prevention deviceSolar preheatsystemsWater stored at below 60 CHot water storageHeater failure or under capacityBooster failureBuild-up of sludge in tankThermal stratificationStorage temperature too low (below 60 C)Cold water storageWater stagnationContamination of storage tankBuild-up of sludge in tankWater temperature 20 CPipework/plumbingDead legs and capped pipesCross connections between potable and non-potable pipesDeterioration of insulation (lagging) around pipesTMV malfunction or inadequate maintenanceLong distances between TMVs or tempering valves and outlets6Guidelines for Legionella control
SystemcomponentEventCorrosion due to deterioration of materialsPipe leaks due to ageHeating of cold water in pipes ( 20 C)Low flow in recirculating loopsLack of accessibility for repairs and maintenanceOutletsPoorly maintained outletsUnused outletsFlow restrictorsAeratorsOutlets that hold water after use (e.g. shower heads or hoses)Treatment systemsDosing failureInsufficient dosingRunning out of disinfectant2.2.2 Risk assessmentThis section includes qualitative measures of likelihood and consequence to allow you tocalculate the level of risk for different potential adverse outcomes in your facility.Remember that some controls will be insufficient in themselves to get the level of risk downto low, so keep adding controls until the risk is acceptable.Table 4a Qualitative measures of likelihoodLevelDescriptorExample descriptionAAlmost certainIs expected to occur in most circumstancesBLikelyWill probably occur in most circumstancesCPossibleMight occur or should occur at some timeDUnlikelyCould occur at some timeERareMay occur only in exceptional circumstances7Risk management plan for Legionella control for (FACILITY NAME)
Table 4b Qualitative measures of consequence or impact on facilityLevelDescriptorExample description1InsignificantInsignificant impact, little disruption to normal operation, low increase innormal operating costs (e.g. temporary low chlorine residual that can beresolved via increased flushing)2MinorMinor impact for part of facility, some manageable disruption to normaloperation, some increase in operating costs (e.g. several rooms or one wingwith total bacterial count 500 CFU/mL, requiring more frequent flushing tomaintain chlorine residuals)3ModerateMinor impact for most of facility, significant but manageable modification tonormal operation, increase in operating costs, increased monitoring (e.g.extensive bacterial growth with some Legionella, requiring extensive flushingand additional controls)4MajorMajor impact for part of facility, systems significantly compromised,abnormal (if any) operation, high level of monitoring required(e.g. temporary closure of part of facility requiring extensive disinfection)5CatastrophicMajor impact for whole of facility, complete failure of systems (e.g. extensiveLegionella colonisation, with possible cases of Legionnaires’ disease)Table 4c Qualitative risk analysis matrix – level of erate4Major5CatastrophicA (almostcertain)ModerateHighVery highVery highVery highB (likely)ModerateHighHighVery highVery highC (possible)LowModerateHighVery highVery highD (unlikely)LowLowModerateHighVery highE (rare)LowLowModerateHighHigh8Guidelines for Legionella control
Table 5 Hazard identification and risk assessment table, includingexamples (edit and add rows as required)SystemcomponentHazard and hazardouseventRiskscorePossible control measuresIncomingwaterSupply of water with lowchlorine residualMediumInstall onsite chlorination to achieve0.5 mg/L at all high risk outletsIncomingwaterSupply of microbiologicallycontaminated waterMediumAgreement with water supplier to notifyfacility manager of any bacteriologicalcontamination; increase chlorine dosechlorinator; flush out contaminated waterHot watersystemWater temperature too low(to inhibit growth ofLegionella and otheropportunistic pathogens)MediumMeasure temperature daily and adjust iftoo lowWarm watersystemDistance from TMV to outlet 6 m leading to Legionelladetections in high risklocationHighMove TMV closer to outlet or install pointof use filter on outletPipeworkLow flow in several areas(allows adherence andproliferation of Legionellaand other opportunisticpathogens)HighWeekly flushing of water in areas of lowuse9Risk management plan for Legionella control for (FACILITY NAME)
3 Risk managementSummary of actions: Identify and implement control measures for management of risks.Establish an operational monitoring program.Develop written procedures for required actions.Determine and implement corrective actions for exceedance of critical operationallimits.Establish a verification monitoring program.Determine and implement responses to exceedances of limits in the verificationmonitoring program.3.1 Control proceduresAll control measures and monitoring activities, whether they are regular maintenance,operational practices or corrective actions, require written procedures detailing how toundertake the required tasks. Complete the table below with control measures identified inthe hazard identification and risk assessment table and operational procedure.Table 6 Risk management plan procedures (edit, add or delete rowsas required)System componentControl measureProceduree.g. pipeworkRegular (weekly) flushing oflow use arease.g. MTS xxxx Flushing of pipesin Ward 2e.g. treatmentChanging dose rate ofdisinfectante.g. OPS xxxx Adjustment ofchlorine dosee.g. outlet — TMVRegular maintenance of TMVe.g. MTS xxxx Cleaning of TMVand thermal disinfection of allpipework and outletsdownstream of TMV - yearlye.g. outletsCollecting warm watersamples for Legionella testinge.g. SP xxxx Sample collectionfor Legionella – Warm waterANDe.g. SP xxx – sample storageand transportation to CityLaboratory10Guidelines for Legionella control
3.2 Monitoring3.2.1 Operational monitoringMany control measures that manage risk in the water supply are in fact corrective actions to measured parameters at particular frequencies and locationswhen such parameters exceed a critical limit.Populate the table below with all the operational (i.e. ‘real time’) monitoring undertaken in the facility.11Risk management plan for Legionella control for (FACILITY NAME)
Table 7 Operational monitoring, showing examples (edit, add or delete rows as required)SystemcomponentRiskIncoming waterLow disinfectantresidualChlorine residualOnline or weeklyPoint of entryinto facilityHot WaterLowtemperatureTemperatureWeeklyWarm waterWatertemperaturethat rGuidelines for Legionella controlFrequencyLocationCritical limitRecordCorrective action(where is themeasurementrecorded)(all corrective actionslisted here should have aprocedure listed inTable 6)Less than0.5 mg/LChlorineresidual recordsheet CR 1.001Increase chlorine dosewithin facilityHot waterOutlet inkitchen (sinktap at far rightcorner)Temperatureless than 65 CWeeklytemperaturekitchen recordsheetTP 4.333Increase temperature ofwater heaterOutlet furthestfrom waterheater (washbasin tap inroom xx)Temperaturegreater than20 C and lessthan 50 CDailytemperature –ward 2 recordsheetCheck heatertemperature and adjustif required, checkpipework for loss ofheat, check operation ofTMVTP 1.333
3.2.2 Verification monitoring and responsesVerification monitoring involves the taking of samples for analysis of a particular parameter. The results of the samples confirm that control measures areeffective and water quality risk is being managed.All verification monitoring results that are outside quality standards or critical limits, and confirmed cases of Legionellosis, require responses.Populate the table below with all the verification monitoring undertaken in the facility.13Risk management plan for Legionella control for (FACILITY NAME)
Table 8 Verification monitoring, showing examples (edit, add or delete rows as required)ParameterFrequencyLocationLimitReported toOperational response to exceedance ofcritical limit (all responses should have aClinical response toexceedance of limitprocedure as per Table 6)(all responses shouldhave a procedure listedas per Table 6)Heterotrophicplate countMonthlyDistal warmwater taps —wash basinsin rooms xxxGreater than500 CFU/mLBuilding,engineering andmaintenanceservices (BEMS)supervisor1. Check operational measurements(temperature, pH, turbidity, disinfectantresiduals and dose), maintenance schedules(including flushing regimes) and structuralintegrity2. Flush water through until sufficientdisinfectant residual is achieved at samplingpoint3. Resample after responses are completedNoneLegionella spp.QuarterlyDistal warmwater taps –wash basinsin room withlow riskpatientsGreater than10 CFU/100 mLBEMS managerand CEO1. Check operational measurements,maintenance schedules and structural integrity ofsystem2. Clean and sanitise TMV and outlet fittingRemove patient/s fromaffected roomDistal warmwater taps —wash basinsin room withhigh riskpatientsGreater than10 CFU/mLLegionella spp.14QuarterlyGuidelines for Legionella control3. If resample positive, move to next rowBEMS managerand CEO1. Check operational measurements,maintenance schedules and structural integrityof system2. Clean and sanitise TMV and outlet fitting3. Clean pipework4. Superchlorinate systemRemove patient/s fromaffected room
4 Responding to detections or casesSummary of actions: Identify measures for responding to Legionella detections and cases in various scenarios.Identify key people and their responsibilities and authorities when responding todetections or cases.Develop written procedures for required actions.4.1 Key incident response people and theirresponsibilitiesIn an incident situation, the risk management team will meet to assess the availableinformation and direct the appropriate responses. The following people will be required todirect those responses and ensure they are undertaken in accordance with documentedprocedures.Table 9 Incident response key personnel and their responsibilities(edit, add or delete rows as required)ResponseResponsible personContact informatione.g. water sampling / systeminvestigatione.g. coordinating systemdecontaminatione.g. high risk patientidentificatione.g. implementation of highrisk patient protectionprocedurese.g. media liaison4.2 Response proceduresResponse activities, whether they are investigations, remedial action or stakeholder liaisons,require written procedures detailing how to undertake the required tasks. Complete thetable below that matches responses identified in the incident response measureidentification process.Some of these responses will be sequential and will require information obtained followingthe implementation of other proceeding procedures. It may also be useful to prepare flowcharts showing the sequence of actions required in various incident scenarios.15Risk management plan for Legionella control for (FACILITY NAME)
Table 10 Incident response procedures (edit, add or delete rows asrequired)IncidentResponsesProcedure namee.g. isolated Legionella speciesdetectionWater sampling or systemevaluatione.g. INV xxxx Undertaking aLegionella colonisationinvestigatione.g. isolated Legionella speciesdetectionLocalised partial systemdecontaminatione.g. INC xxxx Assess andundertake appropriate localpartial systemdecontaminatione.g. single confirmedLegionnaires’ disease caselinked to facilityCase activity investigatione.g. INC xxxx Assess potentialcase exposures duringincubation periode.g. single confirmedLegionnaires’ disease caselinked to facilityHigh risk patient identificatione.g. INV xxxx Undertaking ahigh risk patient identificatione.g. single confirmedLegionnaires’ disease caselinked to facilityImplementation of high riskpatient protection procedurese.g. INC xxxx Protectingidentified high risk patients16Guidelines for Legionella control
4 Review of planSummary of actions: Prepare a schedule for review of the plan.List reasons for updating of plan.A full review of the plan will be conducted on a XXXX basis.The plan will be reviewed more frequently as a result of: 17List reasons: (e.g. change in infrastructure, detection of Legionella, new staff or roles,changes in legislation or standards etc)Risk management plan for Legionella control for (FACILITY NAME)
AppendixKey contactsList key contacts for the plan including risk management team members, laboratory testing,equipment suppliers or service agents, local public health units etc.Key documentsList key documents for reference, such as national guidelines, state/territory legislation,procedures etc.18Guidelines for Legionella control
1 Risk management plan for Legionella control for (FACILITY NAME) 1 Risk management team Summary of actions: Nominate Legionella risk management team members. Record why team members have been selected to participate in Legionella risk management. Clearly articulate the res
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