Legionella Control for Dental Practices

The risk of contracting Legionnaires’ disease from medical and dental practices

The requirement to have a Legionella Risk Assessment may have come as a surprise to many dental practices when HTM 01-05 included it. The same applies to medical centres who also have to satisfy the Care Quality Commission (CQC) that under outcome 10 their buildings comply with all legal requirements. The law under the Control of Substances Hazardous to Health Regulations 2002 as amended (and earlier versions) (CoSHH) and the Health and Safety at Work Act 1974 (HaSaWA) have been around for many years. Even so many people including those in the medical profession and dental industry have a perception that it is ‘a new law’ which makes me smile. Having worked in legionella control since 1999 this regularly happens. The Approved Code of Practice is over 10 years old and it is known as ACoP L8 and is referred to in Chapter 19.2 of HTM01-05. HTM 04-01 also refers to it.

Many dental practices are relatively small buildings as they are based in residential type properties. The water systems on the domestic usage are typically fairly simple, small and pose a low risk. The main area of risk is from the dental unit water lines. Dentists know about biofilm formation, bacteria build up and the need for sterilisation etc. Even so we do find some where control measures are absent and risk factors are present. Some staff lack knowledge and understanding which raises further concerns.

Medical practices, GP surgeries and health centres vary in size and some are almost like small hospitals. The range of water systems is greater so they tend to be more complex. This increases the need to have a first class survey and legionella risk assessment.

It should be pointed out that Legionnaires’ disease is a rare form of pneumonia and that the attack rate is very low. This means that the majority of the population would not contract the disease even if exposed to viable bacteria in fine water droplets. So the chances of catching it are very small. It is also a disease that can be tested, diagnosed and treated successfully although most cases go undiagnosed and unreported.

Complacency should not creep in because the main issue is one of compliance, adequate management and control of the risk. The investigating and regulatory authorities will frown upon practices that are unable to demonstrate they are complying with the laws. The risk of bad press, high level of stress, patient dissatisfaction, fines and damage to business is considerable.

The death in Rome, Italy in June 2012 of a lady who attended the dentist proves that fatalities can occur as a result of not managing the risk. Imagine the consequences of that happening in your practice. Also in 2012 there have been several high profile outbreaks. January saw 3 Britons die in Benidorm from a hotel, 3 in Edinburgh in May from a cooling tower, 2 in a Stoke retail outlet from a hot tub, 3 in a Chicago hotel from a water feature, 13 in Quebec from a cooling tower and 1 in New Zealand in November from compost. There are many more that go unreported.

Doctors themselves rarely see cases of Legionnaires’ disease and benefit from specialist advice. At one health centre in West Yorkshire we found the hot water cylinder set at 37°C by the principal doctor to save money (fuel). This is fine except it is perfect for legionella bacteria to multiply to dangerous levels and he inadvertently was putting staff and patients at risk.

When choosing a firm use the following as guide because some people who are not from legionella control have set themselves up and targeted dental and medical practices. The industry is not regulated and qualifications are not required to offer this service.

Questions to ask

1. How long has the (your) firm been doing legionella control? Prove it.

2. How long have you (or the risk assessor) been working in legionella control? Prove it.

3. Which firms did you work for before? (You can contact them to verify) Ask for a CV. Go on line at Linkedin or Twitter or elsewhere on the internet to do background checks.

4. Who signed you off as reaching Competent Person status? Again contact that person to clarify and ask them to put it in writing making them accountable as well. (This should catch out the bad apples).

5. When did you reach Competent Person status? Prove it. Again this will help gauge their experience. Be wary of anyone with limited experience i.e. under 5 years.

6. Ask for copies of their Employers Liability, Public Liability and Professional Indemnity insurances. (If they even have them).

7. Is the company limited (when), a partnership (who) or a sole trader? Then decide whether you prefer dealing with a one man band, a small firm or a larger firm. There are of course advantages and disadvantages for all.

8. Ask for testimonials and make sure they are genuine. Speak to the person, focus on the work done rather than the “he was nice and we got our report quickly” as many slick sales people use charm to hide inexperience or worse still incompetence.

9. Do they provide training? Attend a course as this is a great way to assess them. If they aren’t up to it then walk away. If they are good enough then you can be confident in your choice. If they do a 10 minute temperature testing session with you and class that as training then send them away fast, that is nowhere near adequate. It is worrying as untrained people who think they are trained pose an even higher risk than not being. Make sure you staff are competently trained by an experienced person.

10. Ask for a copy of their personal training record for legionella control. What you should see is a thorough, detailed, in depth, professional training matrix. To reach Competent status requires understanding in many areas so see what they send. You can easily compare companies and individuals.

Slick telesales and cheap jobs with a friendly approach does NOT equal Competence, neither does ‘we’ve done it since November 2010 for lots of others.” This just means they tricked and lied to the first few dental practices and carried out.

A story with a parable.

Once upon a time in Leeds in September 2010 an older man D claimed to join company A to become a legionella risk assessor. He wasn’t any good and failed to reach Competent status. He worked part time for 2 months and his few reports were inadequate and had to be correctly re-written. He then faded away.

It was all a con. He had schemed with his son C purely to glean enough information from A to set up company B. What made it worse was C employed telesales staff to phone dental practices claiming to be from well respected company A. They got the sale; D went to site then wrote the legionella risk assessment as company B and asked for payment to company B. Under the Fraud Act this is misrepresentation claiming to be something they are not.

This continued until A found out went to the Police, sent a letter to cease this outrageous behavior and C denied it to A which was nonsense. Company B stopped claiming to be company A but carried on this time representing themselves. C who is a salesman also started acting as a legionella risk assessor. The evidence seen by A shows company B staff are Not competent. They are NOT giving correct advice and their work does NOT meet ACoPL8 standards.

The moral is only use Competent firms with experienced staff. Otherwise your time and money is wasted. HTM0105 refer to 19.19 Contract Maintenance When selecting subcontractors, particularly in relation to the control of Legionella, their competence should be established beforehand (for example, companies/individuals who are members of the Legionella Control Association).

Also 19.2 All premises are required to have a written scheme and a Legionella risk assessment for controlling any identified risks in accordance with the Health and Safety Commission’s (2000) Approved Code of Practice L8: The risk assessment should be carried …by experienced and competent people.

11. Are they members of the Legionella Control Association? See on line http://www.legionellacontrol.org.uk and you can ‘phone to check.

12. Ask for examples of their work such as a legionella risk assessment and log book. Read them and see how well you understand them. If they are hard to follow that probably doesn’t bode well. How good is the schematic drawing? Some larger companies sell on volume and cut costs by efficient processing, the downside is that they are known to miss key water systems and basically do a superficial job. Whilst this might be acceptable to councils or others with a large portfolio of buildings who just want lowest cost compliance it is not wise for clients with 1 to 5 sites. LRA differ from companies and there is huge variation. When buying decide what level of compliance, quality, detail, cost, service, professionalism, expertise, advice etc that you want.

If you follow even half this process it will give you a very good understanding of who you are dealing with and hopefully weed out those who shouldn’t really be doing this work. A lot of them are only interested in making money. Look for those who genuinely want to help you with infection control and risk management.

Beware slick sales and low prices, if it is presented to you as an apple but is in fact an orange then that’s like a firm doing asbestos and fire safety making out they can do legionella after 3 months part time training that they failed and left. Would you really trust them when they then set up on their own?

The medical profession and dental industry should continue to take responsibility for water systems on their practices. Even though the chances of catching legionellosis are statistically low there is still a risk from legionella to patients and staff. It is a preventable disease and relatively low cost to manage. Adequate risk assessments, effective control measures, good quality training and annual auditing can control and minimise the risks to staff and patients. This leaves you to concentrate on delivering your services to your patients.

(This article was first published in the online website Dentinal Tubules article 23 Feb 2012 and has been updated.)