1. Nalco Water Safety: The Broader Picture Scott Projahn – Senior Water Safety Consultant

3. Managing The Risk of Water Safety
Water entering a building is not sterile
Design and use creates biofilms
Pathogens may be present in biofilms
Water can be a source and vector of infection
Infection risk can be reduced

4. Cms requirement S&C 17-30
Requires healthcare facilities to develop policies/procedures to inhibit microbial growth in water systems
A facility must……
Conduct a facility risk assessment
Implement a water management program per ASHRAE 188 & CDC Toolkit
Define and specify testing protocols/ranges for control measures & document specific actions

5. Cms requirement S&C 17-30
Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities:
Conduct a risk assessment – identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system.
Implement a water management program – includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.
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.
The Joint Commission, DNV, ACHA will check for compliance and will cite non-conformances; risk of citation for non-compliance.

6. Water is Not Sterile Is my building at risk?
Public Water System
Building Water System
10 Bacteria/mL X 3,785 mL/Gal
10 Bacteria/mL X 3,785 mL/Gal = 37,850 Bacteria/Gal
37,850 Bacteria/Gal X 100,000 Gal/Day Used =
3,785,000,000 Bacteria
37,850 Bacteria/Gal X 100,000 Gal/Day Used
<500 Heterotrophic Aerobic Bacteria per mL (MCLG)
10 Bacteria/mL
Could 3.8 Billion bacteria be entering the building every day?
37,850 Bacteria/Gal
Is my building at risk?
Let’s dig a litter deeper into this.
Water is treated to a treatment technique to provide drinkable water. It must meet EPA requirements for organic and inorganic contaminants. Drinking water must also meet the Coliform rule (<1 CFU/100mL, MCL) as an indicator water is safe to drink and is not contaminated with fecal matter or microorganisms that can cause dysentery.
Water also is treated to a maximum contaminant level goal for HAB (<500 CFU/mL); this is a goal and is not enforceable. Hence it does not necessarily need to be met.
Let’s do a little math! How many bacteria could be entering our building every day?
Chlorine or Chloramine
Up to 4 mg/L (MCL)
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7. Risk in Building Water Systems
US-CDC
Keep it Cold
To Outlets
≥124°F
To Outlets
<77°F
Keep it Hot
Keep it Moving
Limit Water Age
Maintain Water Temperature
Maintain Oxidant Residual
Remove Dead-legs
Keep it Clean
Return
≥124°F
<77°F
Stored at ≥140°F
Design and use may create biofilms
Pathogens may be present in biofilm
Water entering a building is not sterile
Infection risk can be reduced
Water can be source & vector of infection

8. Elements of a Water Management Program
Program Team
Development & Implementation 1 2 3 4 5 6 7
Describe Water Systems & Flow Diagrams
Analysis of Building Water Systems
Control Measures
Monitoring & Corrective Actions
Confirmation
Documentation

9. WATER SAFETY PLANS Start With a Water Safety Plan
Expert Risk Management
Start With a Water Safety Plan
Define your team
Develop simple process flow diagrams and assess risk
Design a strategy and implement
Confirm performance and continue the process
So far today, we’ve discussed now Legionella and these other bacteria get into your facility through your city water main and how your facility’s engineered water systems provide the perfect conditions to enable Legionella and these other bacteria to proliferate in biofilms and dead legs. Additionally, we’ve discussed the public health risk that water borne pathogens pose to people that utilize your facilities. From there, we discussed the Public Image and Legal risks that you and your facility could be exposed to if you’re the source of an outbreak. As a result of these discussions you may be asking yourselves a very important questions. That is what can we do to reduce our risk level associated with Legionella and other waterborne pathogens. The good news is that there are several things you can do to reduce your risk level. These actions will help to put you and your facility in the best defensible position should you have the unfortunate experience of being the source of an outbreak. The first action that we recommend that our clients take is to complete a comprehensive Water Safety Plan for your facility. It seems quite intuitive that you first need to understand the where water enters your facility and how it’s used to best determine how you can reduce your over all risk. A comprehensive water safety plan will start first with your team. A comprehensive team should include representatives, engineering, operations, E,H&S, IP, PR, Senior Level management. The more compressive this team the better. follow water from when it enters your building at the main to each and every point of use (i.e. domestic cold and hot services, cooling towers, ice machines, showers, critical patient care areas such burn units, oncology ,etc.). It will categorize each end user with a risk level. Understanding where your water is going and how it will be used will allow you to design and implement strategy to reduce risk. Next you need to implement a process which confirms that these actions are working as designed and will continue in to the future.
Water Safety is a
Continuous Process

10. Elements of a Water Management Plan per ASHRAE Standard 188
DO YOU HAVE A PLAN? 1
Program Team
Development & Implementation 5
Monitoring & Corrective Actions 2
Describe Water Systems & Flow Diagrams 6
Confirmation 3
Analysis of Building Water Systems 7
Documentation
The biggest takeaway from Standard 188 is that all buildings shall implement a Water Management Program, and the Program must contain these 7 key elements. First, form a cross-functional program team to oversee the program. Next, take a water system inventory, describe all of the water systems, and create simple process flow diagrams showing how the water is used throughout the building. Then, analyze the various hazards of each process step of the water systems. Identify what control measures will be implemented, what monitoring is to be performed, and what the corrective actions will be if the targets are not met. The Program also needs to incorporate methods of confirmation that the plan is being carried out and that it is effective and what it is intended to do, which is reduce risk. We also call that verification and validation of the Program. Finally, it all needs to be tied together with solid documentation every step of the way. Because if it’s not documented, it’s like it never happened. 4
Control Measures

11. Oxidant and Temperature Mapping
DISINFECTANT RESIDUAL
TEMPERATURE
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12. How Residual is Impacted
1 ppm
0.4 ppm
1 ppm
0.06 ppm
City Water In Residual Out Additional Issues Holding Time In Distribution System, Temperature, Recirc. BioLoad

13. Growth Risk Potential HOT WATER LOW MODERATE HIGH Temperature ≥124°F
123 to 118°F
<118°F
Free-Chlorine
>0.3
0.1 to 0.3 mg/L
<0.1 mg/L
Total-Chlorine
>0.5
0.3 to 0.5 mg/L
<0.3 mg/L
COLD WATER
LOW
MODERATE
HIGH
Temperature
≤68°F
69 to 77°F
>77°F
Free-Chlorine
>0.5
0.2 to 0.5 mg/L
<0.2 mg/L
Total-Chlorine
>1.0
0.5 to 1.0 mg/L
<0.5 mg/L

18. Utility & Domestic Services Temperature vs. Proliferation Risk
212
Steam Humidification
Disinfection Range °F
Hot Water Boilers
176
Slowly Die °F
131°F ; die within 5-6 hrs
140°F ; die within 32 min.
151°F ; die within 2 min.
140
Temperature, °F
Hot Water Storage
Hot Water Services
104
Spas & Bathing Showers
Growth Range °F
°F optimum
Cooling Towers
Temp Details
Cold Water Services 68
HVAC Condensate
Cold Water Tanks
Spray Humidifiers
Do Not Grow Well 68-77°F
Below 68°F Dormant
Mains Cold Water 32
Proliferation Risk

19. COOLING TOWER Clean & Disinfect
Follow OSHA Best Practice
Wear proper PPE
Use A Contractor Who Is Proficient in Water Management
Cleaning & Disinfection of cooling towers is crucial to the safety of patients, staff and visitors
18,000 test per year

20. Clean & Disinfect: Cooling Towers
OFF-LINE (Seasonal)
Dose to achieve 10 ppm free halogen and maintain 5 ppm free for 6 hrs
Alternatively, dose to achieve 25 ppm free halogen and maintain for 1 hr
Apply biodispersant (optional)
Recommended for seasonal (at startup or shutdown) off-line clean and disinfect, in response to heavy persistent microbial activity, or per plan contingency.
ON-LINE (Remedial)
Maintain 5 ppm free halogen for 6 hrs
Recommended for periodic on-line disinfection to respond to heavy biofouling, process leaks, or other issues that may contribute to excessive microbial activity.
OFF-LINE (Emergency)
Dose to achieve ppm free halogen and maintain 10 ppm free for 24 hrs
Apply biodispersant
Recommended for emergency disinfection to respond to an outbreak situation or heavy persistent microbial activity.
ON-LINE (Shock Dose)
Dose to achieve 5 ppm free halogen
Recommended for periodic on-line disinfection to respond to persistent biofouling, process leaks, or other issues that may contribute to excessive microbial activity. May also be used weekly to monthly as a pre-emptive control strategy during warmer summer months when microbial activity is highest.

21. PATHOGEN ANALYTICAL AND PRIMARY ENGINEERING CONTROLS
Legionella Culture Testing
Follow the ISO11731 culture procedure
Use a certified CDC-ELITE proficient lab
Use A Lab Who Can Help You With Interpretation
Testing plans are essential for
program confirmation
18,000 test per year
Cooling Water from
1976 American Legion Legionellosis Outbreak at Philadelphia Hotel

22. Legionella colonies on selective agar
Legionella Culturing
Does the lab use culture testing which is the “gold standard” (ISO Method)
Quality
Standardization
Consistency
Does the lab follow ISO without modifications?
Is the lab CDC ELITE proficient?
Testing requires days for completion
Bacteria colonies are confirmed via serotyping
Risk assessment should be considered a prerequisite to Legionella testing.
Where a risk assessment has been performed and a risk management plan is implemented by the owner, routine environmental analyses including Legionella testing in conjunction with total viable bacteria testing, water temperatures, biocide residual monitoring, and other monitoring procedures are critical for measuring the effectiveness of control measures.
Testing should be performed at a frequency that allows trending results as system dynamics and control measures change.
Annual “spot checks” are rarely adequate. The risk assessment and management plans provide information required to interpret positive and negative Legionella test results.
Analytical data is best used as a monitoring tool to confirm that control measures have been effectively applied, to document diligence in risk management, and to identify contaminated areas in a water system.
Legionella colonies on selective agar

23. Legionella Action Levels (Best Practice) Potable Water
CFU/mL
Recommended Action 1
Non-Detect
Acceptable control. No remedial action required 2
10 or less
Immediately implement corrective action by flushing affected outlets or systems; or take other precautions. 3
More than 10 and up to 100
Immediately review treatment program and risk assessment to develop remedial risk management plan.
Immediately implement corrective action by flushing affected outlets or systems; cleaning; biocide treatment; or take other precautions 4
More than 100
Take prompt action to prevent employee exposure. Immediately review treatment program and risk assessment to develop remedial risk management plan. Amend risk assessment accordingly and consider additional monitoring.
Immediately implement corrective action by cleaning & disinfecting; superheating; shock dose chlorination; or take other precautions.

24. Legionella Action Levels (Best Practice) Cooling Water
CFU/mL
Recommended Action 1
Non-Detect
Acceptable control. No remedial action required. 2
100 or less
Shock dose system with biocide. 3
More than 100 and up to 1,000
Immediately review treatment program and risk assessment to develop remedial risk management plan.
On-line disinfection with biocide plus dispersant. 4
More than 1,000
Take prompt action to prevent employee exposure. Immediately review treatment program and risk assessment to develop remedial risk management plan. Amend risk assessment accordingly and consider additional monitoring.
Off-line cleaning & disinfection with biocide plus dispersant.

25. DISINFECTION Domestic Water – Short Term and Long Term
Chlorine Dioxide
Chloramine
Chlorine
Copper-Silver Ions
Super Heat & Flush
Ozone
UV light
Domestic Water – Short Term and Long Term
DISINFECTION

26. Contingencies to Regain Control in Building Water Systems
SHORT TERM
REMEDIATION STRATEGIES
Hot & Cold Hyperchlorination
Super Heat & Flush
Important to note about these remediation strategies:
They are short-term
They are short-lived (months to weeks)
These have logistical challenges relative to both system issues and patient awareness

27. SECONDARY DISINFECTION
A Continuous Treatment Strategy
Hot & Cold Potable Water Treatment
NSF-61 certified equipment
NSF-60 certified chemistry
Water Treated per US-EPA Regulations
Water must be treated per the SDWA*
Requirements are set by the state and may vary
System Assurance Center
Web enabled system monitoring 24/7/365
Continuous monitoring of disinfectant residuals
Notification of system alarms
Safe Drinking Water Act (SDWA), Title XIV of the Public Health Service Act (42 U.S.C. §§300f, et seq.).

28. Long-Term Continuous Control Strategies:
Continuous system disinfection
What about these?
Chlorine Dioxide
Chlorine
Chloramine
Copper-Silver Ions
Ozone
UV light
OZONE – NOT PRACTICAL
Cannot maintain residual due to volatility.
UV-Light – NOT PRACTICAL
Point-disinfection only.
No Residual.

29. POINT-OF-USE WATER FILTERS
A Point Control Strategy
A Filtration Barrier for Waterborne Pathogens
Delivers sterilizing grade filtered water down to .2 micron
For High Risk Healthcare Patients
Burn, BMT, Organ Transplantation, Hematology/Oncology, Intensive Care
For Immediate Response
Confirmed outbreak
Suspected incident
Keeps the water moving
Point-of-Use Water Filters as a Control Barrier
Validated 0.1 micron filter media
Deliver sterilizing grade filtered water
62-, 31- and 14-Day Life

30. Compliance Determination
Potable Water
Systems
Cooling Towers
& Evaporative
Condensers
Whirlpools or Spas
Ornamental
Fountains & Other
Water Features
Aerosol Generating
Misters, Atomizers, Air
Washers & Humidifiers
AT-RISK WATER SYSTEMS
Compliance Determination
I mentioned earlier that water is being used in a lot of different ways.
So which water systems in our facilities are we concerned with? Well, it could be any of them, but especially ones that operate within the ideal temperature growth range (77-122), or water systems that produce sprays or aerosols. In the next discussion, we will focus on potable water systems and cooling towers since that’s where a majority of cases arise from. But keep in mind, there are other “At risk” systems with specific control strategies that may be used – like spas, pools, decorative water fountains, and misters.
With all systems in general, the rule of thumb is to keep hot water hot, cold water cold (and therefore out of the ideal growth range), keep the system clean, and keep the water moving.
Start with a Water Safety Plan!
FOCUS ON CONTROL MEASURES

31. WATER SAFETY EXPERTISE
Our Legionella lab is a charter member of CDC-ELITE proficiency program
Research
Microbiologists,
Scientists & Engineers
Global Experts in
Water Safety
25+ years
Starting in
1999
80,000
tests/year globally
We have boots on the ground everywhere.
10,000+ Water Safety Plans & Programs Implemented Globally
Healthcare, Hospitality, Education, Commercial, F&B, Manufacturing, Industrial
Disinfection of 1 billion+
gallons
(This is Nalco Water’s resume around Water Safety)
(You can read key elements that you want to share with the customer)
of potable & non-potable water annually
Local service delivered
by sales & service associates worldwide.
EXPERTISE AND SOLUTIONS THAT MAKE THE WORLD CLEANER, SAFER AND HEALTHIER