Infection Control Today

MAR 2019

ICT delivers to infection preventionists & their colleagues in the operating room, sterile processing/central sterile, environmental services & materials management, timely & relevant news, trends & information impacting the profession & the industry

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16 ICT March 2019 Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs, and decorative fountains. According to CMS, legionella infections increased 286 percent in the United States (U.S.) during 2000 to 2014, with approximately 5,000 cases reported to the Centers for Disease Control and Prevention (CDC) in 2014. Approxi- mately 9 percent of reported legionellosis cases are fatal. In a recent review of LD outbreaks occurring from 2000 to 2014 in the U.S., 19 percent were associated with long-term care facilities and 15 percent with hospitals. Outbreaks generally are linked to environ- mental reservoirs in large or complex water systems, including those found in healthcare facilities such as hospitals and long-term care facilities. Transmission from these water systems to humans requires aerosol generation, as can occur from showerheads, cooling towers, hot tubs, and decorative fountains. Legionella is less commonly spread by aspiration of drinking water or ice, and only one case of possible person-to-person transmission has been reported. Legionella bacteria can grow in parts of building water systems that are continually wet, and certain devices can spread contam- inated water droplets via aerosolization. Examples of these system components and devices include hot and cold water storage tanks; water heaters; water-hammer arrestors; pipes, valves and fttings; expansion tanks; water flters; electronic and manual faucets; aerators; faucet fow restrictors; showerheads and hoses; centrally-installed misters, atomizers, air washers and humidifiers; non-steam aerosol-generating humidifers; eyewash stations; ice machines; hot tubs/ saunas; decorative fountains; cooling towers; and medical devices such as CPAP machines, hydrotherapy equipment, bronchoscopes and heater-cooler units. Keane says many healthcare institutions are lacking in awareness about the reservoirs and transmission routes of waterborne pathogens, giving them a grade of C-minus or D in this area. "There is confusion in some facilities on who's on frst base," Keane says. "There are three parts to this issue. Part one is the clinical aspect, which falls under the purview of infection control. This includes disinfection protocols for clinical equipment as well as patient surveillance. Part two is the building water system aspect, which falls under the purview of engineering. Part three is overall plan management which typically falls under infection control as well. In cases where infection control tries to manage the engineering aspect, that results in problems. Also, there are a lot of conficting recommen- dations out there, which is a challenge for engineers relating to who to believe. One of the most problematic is VHA Directive 1061; many think that because the VA is the largest hospital system in the world, it must know the best way, the most cost-effective way to address this issue. Nothing could be further from the truth." Department of Veterans Affairs VHA Directive 1061, called the Prevention of Healthcare-Associated Legionella Disease and Scald Injury From Potable Water Distribution Systems, establishes policy for the prevention and control of healthcare -associated Legionella disease in VHA-owned buildings in which patients, residents, or visitors stay overnight. This directive outlines controls such as maintenance of appropriate water temperatures in building water distribution systems and maintenance of biocide at a recommended level for legionella control. Per industry standards, the main Legionella control measures include physical controls, temperature management, disinfectant levels, visual inspections, and environmental testing for pathogens. As we have seen, healthcare institutions must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other oppor tunistic pathogens in water. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of the ASHRAE standard, providing environmental, clinical and epidemiologic considerations for healthcare facilities. Pertinent CMS regulations include, but are not limited to: • 42 CFR §482.42 for hospitals: "The hospital must provide a sanitar y environment to avoid sources and transmission of infections and commu- nicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases." • 42 CFR §483.80 for skilled nursing facilities and nursing facilities: "The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections." • 42 CFR §485.635(a)(3)(vi) for critical access hospitals (CAHs): CAH policies must include: "A system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel." Expec- tations for Healthcare Facilities CMS expects Medicare and Medicare/ Medicaid certifed healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Facilities must have water management plans and documentation that, at a minimum, ensure each facilit y conduc t s a facility risk assessment to identify where Legionella and other oppor- tunistic waterborne pathogens (such as Pseudomonas, Acinetobac ter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria and fungi) could grow and spread in the facility water system; develops and implements a water management program that considers the ASHRAE indus tr y s t andard and the CDC toolkit; specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained; maintains compliance with other applicable federal, state and local requirements. Let's review the key reser voirs and infection prevention strategies against waterborne pathogens. Potable water, tap water and hospital water systems can be significant reservoirs • Hot water temperature at the outlet at the highest temperature allowable, preferably >51°C. • Water disruptions: post signs and do not drink tap water. • Maintain standards for potable water (<1 coliform bacterium/100 mL). • Rinse semi-critical equipment with sterile water, fltered water, or tap water followed by alcohol rinse. • Some experts have recommended periodic monitoring of water samples for growth of Legionella. • Potential methods of eradication include fltration, ultraviolet, ozonization, heat inactivation (>60°C), hyperchlorination, and copper-silver ionization (>0.4 ppm and >0.04 ppm, respectively)

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