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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18 ICT March 2019 www.infectioncontroltoday.com • Remediation expertise: For example, how frequently does the company provide remediation services and can they describe situations where they remediated Legionella from a building water system in a facility of your size/ type? Can the company discuss the benefts and challenges associated with multiple approaches to remediation? • Water management expertise: For example, how much experience does the company have creating water management programs compliant with industry standards for a facility of your size/type? What level of support does the company provide with creation and implementation of water management programs? What is the spectrum of services they offer once the water management program is established? • Knowledge of codes, standards, and regulations: For example, does the company have previous experience working in your state and/or juris- diction? How familiar is the company with state and local building codes in your jurisdiction, water treatment regulations, healthcare accreditation and survey requirements, and public health reporting requirements? Local building code offcials or your health department may be good resources for knowledge about existing codes, standards, and regulations. • Potential conflicts of interest: For example, does the company have interest in promoting specifc services or products? Let's review the basics of risk management relating to waterborne transmission. Spagnolo, et al. (2016) remind us that the CDC provides guidelines for water quality in healthcare facilities. The CDC recommendations include strategies to minimize the growth and persistence of Gram-negative waterborne bacteria, such as the recommendation that cold water in healthcare facilities should be stored and distributed at temperatures below 20°C and that hot water should be stored above 60°C and circulated with a minimum return temperature of 51°C. In 2011, the WHO issued guidelines on the quality of water for human consumption, including hospital water supplies. These guidelines recommend the adoption of a Water Safety Plan (WSP) for water-risk management which provides for implementing active surveillance of infections; preventing contamination during storage and distribution; monitoring the quality of water sampled at the most signifcant points of the water system in the healthcare facility and adopt procedures for sanitation (to eliminate or reduce contamination); and for the maintenance of plumbing systems. Freije (20 05) provides useful touch points relating to the development of a risk reduction strategy which takes into consideration three factors that are required for waterborne illness to occur: contaminated water, transmission of pathogens to a person, and a susceptible host: • What is the incidence and severity of associated illness? • Is water the predominant source? • Are problems with this pathogen rooted primarily in the water supply (e.g., city water), or in plumbing systems within buildings? • Are accurate environmental detection methods available at a reasonable cost? If not, you will be unable to determine potential risk or measure the effectiveness of your environmental preventive efforts. • Are effective preventive and remedial measures available? If not, you should focus on protecting patients from exposure. • What is the hospital's potential liability if this pathogen is implicated in nosocomial disease? Although patient care should be the foremost concern, legal and fnancial implications must also be considered. Freije (2005) recommends the following action steps, based on published guidelines and studies: 1. Form a team, appoint a leader, and establish communication. The team should include members from facilities management, infection control, risk management, administration, and the medical staff. Write a management plan for waterborne pathogens and meet periodically to ensure that the plan is being implemented, to review results, and to consider revisions. 2. Identify high-risk building areas based on water exposure and patient susceptibility. 3. Establish patient sur veillance for Legionnaires' and other waterborne disease, per CDC guidelines. Provide the laboratory tests required to diagnose Legionnaires' disease and encourage clinician suspicion for it. 4 . Co nduc t an env iro nm ent al risk assessment. Have an outside expert evaluate the cooling towers, potable water systems, and other aerosolizing devices for conditions that promote growth of waterborne pathogens. 5. Implement reasonable environmental preventive measures. D esigning, constructing, operating, and maintaining potable water systems, cooling towers, and other aerosolizing devices to minimize pathogens can reduce the risk of waterborne illness. In addition to implementing remedial measures, write policies for regular maintenance and operation of systems. 6. Consider routine environmental sampling to indicate the success of preventive measures. An important issue, practically and legally, is deciding which patients are "high risk." Where should you draw the line? In making this recommen- dation, the CDC cited patients who have had transplants as an example, but in various CDC documents, it has suggested that cancer patients, patients on antirejection medication or steroids, surgical patients, dialysis patients, and patients with chronic underlying illnesses are also at high risk of acquiring Legionnaires' disease, and smokers and persons more than 65 years old are at moderately high risk. As Freije (2005) notes, "In my opinion, based on experience in conducting Legionella risk assessments of hospitals and as an expert in litigation related to Legion- naires' disease, Legionella environmental sampling is a wise investment if carried out properly and for the right reasons; it can play an important part in reducing risk of disease for the patient and in reducing legal risk for the hospital. For other pathogens, routine sampling may not make sense on the basis of available detection methods, cost, and other factors. For some pathogens, however, water sampling should be considered if associated nosocomial illness occurs." 7. Wr i te a d i s e a s e re s p o ns e p la n. Outline steps for epidemiologic as well as environmental aspects of an investigation, and for emergenc y disinfection of cooling towers and potable water systems. Include it in your management plan. 8. Implement appropriate remedial measures. Preventive maintenance, including high hot water temperatures, is not a guarantee against waterborne pathogens, so installing a continuous disinfection system or point-of-use flters is sometimes necessary. Disinfection technology is available to control Legionella and most other bacteria at a reasonable cost.

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