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Look for even more focus on water management to prevent Legionella infection


December 4, 2017

Improve your plans to manage the spread of pathogenic biological substances such as Legionella before the federal government cracks down even more on risks within your water systems. Consider including your off-campus sites in your risk assessment since that is becoming a greater concern among infection control specialists.

Legionella and other infectious organisms spread through water systems were key parts of a session at The Joint Commission’s (TJC) Executive Briefings in September that focused on infection control within the environment of care.

That came on the heels of a request from the CDC in August for more information on best practices for water management programs (WMP). In seeking public comment, one of the questions the CDC asked was if there were other standards or guidance for the prevention and transmission of Legionella “that you would find useful but do not exist or are not currently available to you? If so, what information should those standards or guidance contain?”

To regulate more or not?

The American Society for Healthcare Engineering (ASHE) answered with a firm no on more regulations. In public comments signed by Jonathan Flannery, MHSA, CHFM, FASHE, FACHE, the senior associate director of advocacy for ASHE, the group argued that Medicare’s Conditions of Participation on Infection Control, §482.42, is sufficient regulation to require the control of Legionella.

The group noted that CMS also put out further guidance for hospitals and surveyors on the control of the bacteria that can cause sometimes fatal pneumonia or other respiratory problems in June with the survey-and-certification letter, S&C 17-30 Hospitals/CAHs/NHs, “Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease.”

However, ASHE acknowledged that more needs to be done in light of the continuing problems with Legionella infections, despite years of effort to educate health organizations.

“By creating a collaborative effort between government, regulatory and professional associations a greater awareness of the key steps to successful WMPs would be emphasized, thus allowing all health care facilities to become more successful in their compliance to already existing regulations,” says the letter.

ASHRAE standard is good guideline

The CDC, ASHE and other public commenters note that there were already substantial tools to guide hospitals and other healthcare organizations in managing their water systems, specifically citing a consensus standard published in 2015 by ASHRAE (formerly known as the American Society of Heating Refrigerating and Air-Conditioning Engineers) that focused on the primary prevention of Legionella.
ANSI/ASHRAE Standard 188-2015 is a key reference in the CDC toolkit, “Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings: A Practical Guide To Implementing Industry Standards,” released earlier this year as part of a campaign to increase awareness about Legionella infection, particularly at hospitals.

But even the CDC acknowledges that the standard does not cover everything. In a frequently asked question (FAQ) on the CDC’s webpages on Legionella, it notes that ASHRAE 188 does not “provide guidance on target water parameters, such as temperature and disinfectant levels. It also does not describe how to perform emergency remediation or give guidance about what to do if cases of disease are associated with the facility.”

APIC: Ambulatory sites a problem

That’s a problem, particularly for ambulatory healthcare sites, notes the Association for Professionals in Infection Control and Epidemiology (APIC) in its public comments to the CDC that hinted that more regulation might be in order.

“It is not clear from current guidelines how institutions and healthcare professionals should be assessing risk for ambulatory care practices such as physician offices or specialty care centers. In addition, it would be helpful to have guidance on proper sampling methodology and when sampling is warranted. Specific guidance on sampling after a Legionella remediation event would also be helpful,” says APIC President Linda R. Greene, RN, MPS, CIC, FAPIC.

In answer to a CDC question about principal barriers to implementation of WMPs by building owners and managers, APIC again points to ambulatory sites as problematic.

“Many healthcare networks lease sites for ambulatory services and may also contract out certain services off campus and therefore do not have access to drawings or oversight for implementing WMPs for those sites. Having concrete directives on what project managers and owners are required to provide in order
to assist in the prevention of Legionella and other water-borne pathogens would be helpful in driving accountability with building owners. A clear understanding of high-risk populations is something that is not well understood by project managers and site owners.”

Look everywhere

The CMS guidance released in June was initially to apply to all healthcare organizations, but was revised to just target hospitals, critical care hospitals and nursing homes.

But the CDC’s request for information notes that ASHRAE’s standard recommends WMPs for the following buildings and devices:

  • Healthcare facilities where patients stay overnight
  • Buildings that house or treat people who have chronic and acute medical problems or weakened immune systems
  • Buildings that primarily house people older than 65 years (like a retirement home or assisted living facility)
  • Buildings that have a centralized hot water system (like a hotel or high-rise apartment complex)
  • Buildings 10 stories or more (including basement levels)
  • Devices that have been linked to transmission of Legionella:
  • Cooling towers
  • Hot tubs (or spas) that are not drained between each use
  • Decorative fountains
  • Centrally-installed misters, atomizers, air washers, or humidifiers

Water exposure risk can occur anywhere on hospital grounds, said Lisa Waldowski, TJC’s infection control specialist, who spoke at the Chicago session of Executive Briefings in September alongside TJC’s acting Director of Engineering John Maurer.

Hospitals must be vigilant in finding where the potential for infection lies, because in 2015, more than three-quarters of the cases of Legionnaire’s Disease, the respiratory illness caused by Legionella, were healthcare related, said Waldowski and Maurer.

Management begins with risk assessment in all areas of your hospital, the pair urged.


Assess Legionella risk, effectiveness of water management as feds renew focus

Assess your facility’s risk for Legionella infection across your campus, not just patient care areas and consider risk at off-campus sites as well.

The Legionella bacteria can lurk in many places and management programs must account for all of them, according to experts with The Joint Commission during an Executive Briefings session in September on infection control (IC) and the environment of care.

Lisa Waldowski, TJC’s infection control specialist, spoke at the Chicago session alongside TJC’s acting Director of Engineering John Maurer.

Legionella and other pathogenic biological agents can easily cause pneumonia and other respiratory problems, especially for patients who are already immune-compromised and vulnerable, says the Centers for Disease Control and Prevention (CDC) and others who are pressing healthcare organizations to do more to control such infections.

IC, EC partnership encouraged

The CDC recently asked the public for information on better ways to control Legionella through water management programs (WMPs). Public comment included calls for better oversight of ambulatory healthcare centers or other sites off traditional hospital campuses (see p. 1).

During their session at Executive Briefings, Maurer and Waldowski encouraged facilities and environment of care managers to partner with IC specialists to improve patient safety, including efforts to root out Legionella.

Hospitals are required under Environment of Care standard EC.02.05.01 to manage risks with utilities, and that includes water systems. They noted that concerns about Legionella and other infectious organism easily spread through the aerosolizing of water would most likely be cited under EP 14, which calls for hospitals to minimize “pathogenic biological agents” in such equipment as cooling towers and hot- and cold-water systems.

Look at “all your risks,” Waldowski and Maurer said, including air-handling units and water fountains in areas of the hospital that are not close to patients. Risks lurk “anywhere on the grounds,” they added.

Not all control methods work everywhere

Surveyors who identify problems can also cite hospitals under Infection Control standards that require hospitals to identify risks, have and implement a prevention and control plan and evaluate the effectiveness of that plan.

Hospitals have been cited for not having a plan, for human error in implementation such as failure to change a water filter and for equipment malfunctions with disinfection systems.

Potential sources of Legionella include lengthy pipe runs, piles with dead legs, showers, faucets, ice machines and water-based humidifiers, said Waldowski. Ask when the last time legs of piping were flushed, especially in older units. But even new buildings can foster infection, she noted.

Start with a risk assessment but beware that while there are many accepted Legionella treatment techniques, some are more effective than others, warned Maurer.

Look to CMS, CDC for more guidance

For instance, some facilities use copper or silver filtration systems as part of their water management, but that is not as effective in hard-water applications and has limited effectiveness if infection already exists in the water system, according to the briefing.

In another example, chlorine is sometimes used against Legionella, but it can have corrosive and hazardous vapors and excessive use can damage some piping or gaskets, Maurer noted.

The Legionella bacteria thrives in water temperatures below 140 degrees F. But counteracting that with hotter water can be a scalding issue for both patients and workers, which creates another water issue in managing the water outlets. And it does not take into account the cold-water systems, said Maurer.
“All have benefits, all have shortcomings,” he observed.

Maurer and Waldowski also noted that CMS issued guidance on water management and IC in a survey-and-certification memo to regional offices in June. TJC recommends checking the CDC’s website on Legionella and Legionnaire’s disease for more guidance on managing water systems and preventing healthcare-related infections (see Resources below). ASHE also has a monograph outlining 10 steps every facility can take to minimize risk.


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