Water management Program to reduce the risk of legionella growth John Harding and Glenn Diede

On June 2, 2017, the centers for Medicare and Medicaid services (cms) sent a memorandum to state survey agency directors requiring Medicare certified healthcare facilities to develop and adhere to water management policies and procedures to reduce the risk of growth and spread of legionella and other opportunistic pathogens in building water systems.

In the memo, CMS suggested reviewing 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 published in 2015 by American society of heating, refrigerating, and air conditioning engineers (ashrae).

The memo also suggested utilizing the toolkit developed in 2016 by the centers for disease control and prevention (cdc) and its partners to facilitate implementation of this ashrae standard.

We reviewed the suggested literature and began formulating a plan that would meet the cms requirements and the needs of our facility. Since every facility differs, it is necessary to develop a plan that is specific to our building and infrastructure.

As recommended by the CDC toolkit, we began with reviewing the plumbing blueprint for our facility to determine critical control points to be monitored for waterborne pathogens.

We determined: there is a cold water dead leg at the end of the med/surg hallway (rooms 8 & 9) the shower hoses in each patient room were also a risk for water stagnation that promotes growth of waterborne bacteria

Other areas of concern identified were: the two air handlers on the roof humidifiers in the MRI area ice machines the drinking fountains in administration and the medical plaza

On September 18, 2017, we had watertech obtain samples for testing On September 18, 2017, we had watertech obtain samples for testing. They sampled: the air handlers MRI humidifiers med/surg ice machine room 10 shower

The test results were: Air handlers: heterotrophic plate count < 100 cfu/ml, no legionella detected MRI humidifiers: heterotrophic plate count <100 cfu/ml, no legionella detected Med/surg ice machine: heterotrophic plate count < 100 Cfu/ml, no legionella detected Room 10 shower: heterotrophic plate count 8,300 cfu/ml, no legionella detected

We suspected that the elevated hpc for room 10 was primarily due to the infrequent use of that room for housing patients resulting in water stagnation. Water stagnation encourages biofilm growth that creates an ideal environment for bacterial growth.

The test results gave us a good baseline for developing a policy for our water management program.

The water management policy outlines measures for reducing the risk for water stagnation by: requiring that the shower heads in the patient rooms be allowed to hang down after use to allow complete drainage of residual water Requiring the flushing of all the sinks and shower in any infrequently utilized patient room (> 30 days since last occupancy) prior to placing a patient in the room requiring maintenance to perform monthly flushing of the water system in rooms 8 and 9 at the end of the med/surg hallway to reduce the risk of water stagnation due to the cold water dead leg

The policy requires annual testing of: the air handlers mri humidifiers water fountains ice machines showers in patient rooms 2 and 10 the reverse osmosis water system that supplies central sterile processing

any test results that show a significant increase in HPC i. e any test results that show a significant increase in HPC i.e. > 2000 cfu/ml will require interventions and retesting. Interventions may include, but are not limited to: additional flushing disinfecting with a sodium hypochlorite solution Additional interventions may be warranted and will be determined as needed

Some additional interventions could include building water system injection of: Chlorine Monochloramine chlorine dioxide ozone

other additional interventions could include: Copper-silver ion generation using an electric current passed between electrodes in the water flow of the hot water loops use of ultra violet light technology

Any test results showing the presence of legionella will warrant follow up investigation to determine an acceptable resolution.

The water management policy addresses water service interruption: can cause biofilm to dislodge due to water pressure changes Possible colonization of downstream devices When water service is restored, flushing of the water system in the affected area or the entire delivery system is required Additional water testing may be warranted

The policy outlines interventions required if a patient develops healthcare-associated pneumonia. Interventions include: lab testing for legionnaires’ disease reporting confirmed cases to the state health department further investigation of confirmed cases

further investigation of confirmed cases would include: performing an environmental assessment for possible environmental exposure environmental sampling as indicated by the assessment Identify any other possible cases of legionnaires’ disease Work with NCMC leaders to determine how long heightened disease surveillance and environmental sampling should continue to ensure outbreak is over Work with water management team to review and revise the water management program, if indicated

On January 2, 2018, we did retest the room 10 shower after flushing it and the HPC decreased to 200 cfu/ml. Moving forward, our plan is to continue monitoring the water management program: to determine effectiveness make changes if warranted

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