Every hospital in the country knows the legionella rules. ACOP L8, HSG274 Part 2, HTM 04-01, the BS 8580 risk assessments. Nobody’s confused about what needs to be done. The hard part is actually doing all of it across a few thousand outlets with an estates team that’s already stretched thin, and then being able to prove you did it. The costs are significant, and the risk if you get it wrong is high.

Why legionella control is complex

The issue in hospital estates is the sheer number and variety of outlets that need to be considered. Taps, showers, sluices, TMVs, spray taps, bedpan washers, dialysis feeds, ice machines. Even a small hospital will be well into the thousands.

Some of those are in wards running at full capacity all year and so they’re fine, because water moves through them constantly. It’s the others that are less regularly used that can present problems. A side room that’s been empty for six weeks. A decant ward that closed after a reconfiguration and never quite reopened. A shower in a plant space that nobody’s used since the contractor left. Those are the outlets where the risk of legionella is high – where there’s warm water, no movement and time – exactly the conditions in which legionella develops.

The complexity of hospital estates increases the challenge. Long pipe runs. Oversized historic systems designed for a different bed count. Dead legs left behind after refurbishment, half of them not on any drawing. It’s not bad management, it’s just what happens to a complex set of builds that are continuously being adapted.

Add to this the fact that hospitals are, by their very nature, full of vulnerable people who are prone to infection and the challenge is clear.

Why legionella control is expensive

The monitoring schedule required for legionella control is significant. Sentinel outlet temperatures monthly, cold below 20°C within two minutes and hot at 60°C in healthcare. Calorifier flow and return monthly. Showerheads and spray taps stripped, cleaned and descaled quarterly. TMV strainers done annually, tanks inspected annually. Anything unused for a week gets flushed through until it runs to supply temperature.

The individual tasks are not difficult. What’s tricky is managing these processes at scale, and the cost of doing it is high.

The primary issue is labour. A person with a thermometer has to spend time physically travelling around the estate visiting every outlet, repeating that every month across every site. In a multi-site trust it’s a permanent budget line that produces nothing except numbers written on a sheet.

A less obvious issue to consider is that the monthly readings produced by a manual process are only a snapshot of what was happening in a particular outlet on a particular day. They don’t reveal anything that might be happening on the other 29 days of the month. If a circulating pump packs in two days after it was last monitored, the estates team will only find out weeks later when it’s next monitored, or from a case of legionella arising.

There’s also the issue of variability which is inherent to any human-based monitoring process. A temperature reading depends on how long the tap ran first. Thirty seconds and sixty seconds give you different answers. Two competent people following the same procedure can produce a pass and a fail on the same outlet, which means your evidence base is only as consistent as everyone’s habits.

Legionella prevention in the fire service

It doesn’t have to be this way. Manual processes can be replaced with much more reliable (and cheaper) automated processes that address all the issues raised above.

The UK fire service faces very similar issues, with a great many outlets spread across many small sites, but now uses automated solutions to improve reliability and cut costs.

Monthly legionella inspections were costing the fire service around £40,000 a year, mostly in travel time to go and take readings in person. Aguardio hygiene sensors went onto the electric showers and the hot and cold taps, with a couple of Bluetooth gateways feeding a central hub. Readings are now taken automatically after 60 seconds of flow, every single time, so the human variable disappears entirely. The hub shows green or red by sensor. That £40,000 went back into the budget.

Automating the temperature monitoring

The first move for most hospitals is to stop paying people to be thermometers.

Aguardio hygiene sensors clip onto the existing pipework. There’s no cutting or new electrical supply needed so nothing that means taking a ward out of service. Each sensor takes about a minute each to fit and will run for up to five years on the battery.

The sensors report not only on pipe temperature but also on usage frequency – additional data that manual monitoring cannot supply. Manual monitoring cannot answer the question “is anyone actually using this outlet?”

Stagnation risk isn’t a fixed property of a building, it moves around with occupancy, and most flushing lists were written when the risk assessment was done and haven’t been revisited since. Sensors tell your water safety group which outlets are quiet now, not which ones were quiet two years ago.

Alerts fire when a parameter is breached, so you hear about the pump that stops working as soon as it happens rather than the next time it’s manually inspected. The system provides automated reports which can immediately be download instead of needing to be manually typed up. And when the authorising engineer or a CQC inspector asks how you know an outlet is under control, the answer is a continuous record rather than a book of monthly readings.

Automating the flushing and disinfection too

Monitoring tells you what’s happening but it can’t make any changes to those processes for you. At some point you need more than just visibility of the outlet – you need to be able to control it.

The usual objection at this stage is that control means installing a central water management system, and retrofitting one into a working hospital is a serious undertaking.

However, it doesn’t have to start there. The CONTI+ lino AS tap does the two things that matter most at the outlet itself.

The first is flushing. The tap runs its own hygiene flush, either at times you set or automatically after 12, 24 or 48 hours of inactivity. That deals with the weekly flushing requirement for infrequently used outlets at the outlet itself.

The second is scald protection without a TMV. The lino AS uses dynamic water balancing, so if the cold supply is interrupted the hot water shuts off automatically. That removes the thermostatic mixing valve from the outlet, and with it the annual job of inspecting, cleaning and disinfecting the TMV strainer.

Everything the tap does is readable over Bluetooth. A CONTI+ BLE converter connects it to the CONTI+ Service App on a phone or tablet, so an engineer can set flush duration, run-on time, sanitary rinse intervals, sensor sensitivity and a maximum run time cut-off, then read back battery status, operating hours, usage frequency, water consumption and a count of every hygiene flush the tap has carried out. Reports download straight from the app.

Combine that with Aguardio sensors and the ground is covered. The tap handles the flushing, the sensors handle the temperature record, and the app collects the evidence for both. This combination is currently being installed at ExCeL London, where the constraint is the same one hospitals face: a live, busy building where a full water management installation would be difficult to justify and harder to deliver.

Where a full system does make sense, and it often does in new build or major refurbishment, the CONTI+ CNX water management system is the step up. CNX 2.0 centrally manages up to 64 fittings and devices per controller, and controllers can be linked together to cover a larger estate, connected by standard cable within a maximum run of 350 metres. You programme hygienic flushing and thermal disinfection across the whole network from a browser on a tablet or a laptop, and the system documents the parameters behind each one, including temperatures, actions and results. It will link into a building management system as well.

Most legionella spend in hospitals goes on proving control after the event. Automating it moves the spend onto delivering control instead, and the proof comes out the other end for free.

Protecting the last half metre

You can have perfect distribution temperatures and still have a problem at the outlet, because that’s where biofilm forms, where the aerosol is generated and what the patient actually touches.

The miscea aqualibur system is built specifically for that last half metre. It’s internationally patented technology designed to stop stagnation, recontamination and biofilm forming at the point of use. Its inline circle system runs scheduled internal purges and disinfection without discharging anything from the outlet, which is the difference between a control measure you can run in a side room and one you can’t. The hygienic drain is designed to EN 1717 with overflow sensors that block access if they detect water, so a blocked waste can’t turn into a backflow route.

During thermal disinfection the fittings restrict use or hold the water to a safe temperature themselves. During chemical disinfection they lock out completely. Compare that with a manual disinfection where the control measure is a sign on a door.

Building legionella control into a broader water management strategy

There’s a tension sitting in the middle of every hospital water safety plan. The main control measure for stagnation is pouring clean treated water down a drain. And, whilst legionella control takes priority, every trust in the country is simultaneously under pressure to cut water use, cut the energy that heats it and cut carbon.

Manual flushing regimes are conservative by design, because the person doing them can’t see any data and so they run everything for longer than it probably needs. Automated flushing driven by real usage data doesn’t have to work that way. If the sensors show an outlet was used four times yesterday, it doesn’t need the full cycle tonight. You save the water, the energy and the money, and your safety case gets stronger rather than weaker, because now it’s built on evidence instead of assumption.

This is the point where legionella control stops being a standalone compliance job and becomes part of a water strategy. The technology that makes the hygiene regime easier is the same technology that brings consumption down.

Take a holistic view of water management

Most hospitals buy water safety in pieces. Risk assessment from one supplier, monitoring contract from another, taps from whoever the M&E contractor uses, remedials from whoever’s free. Everybody does their own bit well but nobody owns the whole picture, which is exactly how a trust can end up with an immaculate paper trail but still have an uncontrolled outlet in a ward that was decanted six months ago.

Ecoprod is the first company in the UK to offer a fully integrated end to end water design and management service. For a healthcare estate that means the strategy, the audit, a risk based flushing regime, the sensors, the control platform, the taps and showers themselves, leak detection across the site and the maintenance behind all of it. Designed, delivered and maintained by one partner who’s accountable for the lot.

It also means the legionella conversation and the water reduction conversation are the same conversation, as they should be. Water you never use doesn’t need pumping, treating, heating or sending back down the drain. Water you never leave standing doesn’t grow legionella.

If your current answer to “how do you know that outlet is safe” is a monthly reading and a flushing list, there’s a better version of this and it costs less to run than what you’ve got. Get in touch to find out more about how we can help you.