The U.S. Centers for Disease Control and Prevention’s (CDC) June 2017 online publication Vital Signs addressed the growing potential for amplification and transmission of waterborne hazards, including Legionnaires’ disease, in health care facilities. Based on the CDC analysis of data from 20 states and New York City, 76% of reported cases of Legionnaires’ disease were found to be associated with health care facilities. Additionally, 25% of these cases resulted in death due to the disease.
Legionella can enter building water systems through the water main or other external sources. It propagates under hazardous conditions such as high water age, high sediment or biofilm levels, low hot water distribution temperatures, and low disinfection residuals. Patients often are exposed to contaminated water through inhalation. Infants, the elderly, chronic smokers, and extremely ill, weak or immunocompromised patients are particularly vulnerable.
Potential contamination sources include showers, sinks, therapy tubs and pools, drinking fountains, cooling tower water systems and even decorative water features such as fountains in hospital lobbies.
Building Water Management Programs
CDC confirmed that more effective water management in health care facilities could have prevented most of the outbreaks of Legionnaires’ disease. The recommended approach is to develop a water management program to mitigate waterborne hazards. The Centers for Medical and Medicaid Services (CMS) Survey and Certification Group 17-30 memorandum, released June 2, 2017, applies to hospitals, critical care hospitals and long-term care facilities, and is intended to provide general awareness for health care organizations to develop and adhere to policies and procedures that inhibit microbial growth. In addition to Legionella bacteria, facilities must address other opportunistic pathogens such as Pseudomonas aeruginosa, nontuberculous mycobacteria, Acinetobacter baumanii and Staphylococcus aureus. CMS now requires health care facilities to conduct a risk assessment to identify where waterborne hazards could grow and spread in the facilities’ water systems.
Facility leaders must form an interdisciplinary team consisting of department heads, facilities engineers, infection prevention specialists, epidemiologists, laboratory personnel, industrial hygiene and safety staff, and others to conduct the appropriate risk assessment. Not all hospital water systems are the same, so they may have differing potential for pathogenic waterborne hazards, thus it is important for the assessment and resulting water management program to be site-specific.
Using the results of the risk assessment, the team must develop and implement a water management program to control the hazardous conditions that may allow for growth of these pathogens. CMS recommends using industry standards such as ASHRAE 188 and the CDC toolkit to develop the water management program. This program must specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.
Health care facilities may feel overburdened with these new requirements and unprepared to develop a water management program. Although water management programs are starting to be developed across the country, many facility leaders are concerned with the additional costs of water treatment and testing. News reports of suspected or confirmed cases of health care-associated Legionnaires’ disease have become more common. Even the discovery of high counts of Legionella in water systems makes the news.
Implementing a water management program is the best way to control waterborne hazards and hazardous conditions. Developing and maintaining a program may reduce the potential for litigation as a result of suspected or confirmed cases of disease. Program implementation also may minimize liability. In addition, effective water management can save on equipment maintenance and replacement costs, and reduce energy and treatment costs.
Guidelines & Standards
The need for more industry guidance on developing water management programs is evident. Recent regulations, such as the CMS requirements, are silent on the practical aspects of developing effective water management programs. NSF Intl., in partnership with organizations such as ASHRAE and CDC, is developing NSF/ANSI Standard 444: Prevention of Disease and Injury Associated with Building Water Systems to provide guidance on water management programs. The standard will establish minimum practices necessary to prevent disease and injury associated with water systems, including Legionella, high lead levels and scalding.
Consistent with the methodology of ASHRAE 188 and the CDC toolkit, the NSF/ANSI standard will go further to provide the means and methods necessary to mitigate physical, chemical and microbial hazards throughout the entire building water system. This standard will provide requirements on conducting risk assessments on new and existing buildings that have systems such as premise plumbing, cooling towers, decorative fountains, pools and spas, ice machines and humidifiers, and onsite water storage. The standard also includes special considerations for health care facilities, as their water management and testing requirements may differ.
Water management programs can benefit from independent auditing to verify that a program has been implemented as designed. This is especially important considering the CMS requirements and new regulations concerning water management. Risk assessments are recommended for facilities that currently do not have a water management program, because they can be used as the basis to develop a water safety plan that includes suggested control measures, site assessments and sampling procedures for the building. This simplifies the management approach by providing the necessary information to get started.
A standard such as NSF/ANSI 444 can provide a consistent framework for the development of a water management program that will evolve with the changing building water environment. A water management program will develop over time in order to combat the potential for hazards and hazardous conditions. Health care facilities can be at the forefront of implementing effective water management programs in order to protect the people most at risk of contracting health care-associated infections.