long-term care infection prevention
long-term care infection prevention
By Buffy Lloyd-Krejci , DrPH , MS , CIC , LTC-CIP
Legionnaires ’ Disease , Water Management , and Long-Term Care Facilities : Starting the Conversation
Legionnaires ’ disease — a severe form of lung inflammation that can be fatal — is on the rise . Caused by Legionella bacteria , the disease can cause headaches , muscle aches , fever , chest pain , gastrointestinal symptoms , confusion , and more . It can also lead to life-threatening complications , including respiratory failure , septic shock , and acute kidney failure . 1 Unfortunately , these complications are particularly prevalent among long-term care facility residents , who are usually older and often have multiple comorbidities .
Despite the fact that some infection prevention and control experts are beginning to focus on preventing Legionnaires ’ disease , it continues to be significantly underreported and underdiagnosed . In fact , experts estimate the disease affects anywhere from 1.28 to 2.7 times the number of people than is currently reported . 2 One of the main reasons for this is that Legionnaires ’ disease is frequently misdiagnosed as pneumonia . However , the two are different in several key ways , including how they are transmitted and how they can be prevented .
Legionnaires ’ disease isn ’ t communicable in the same way most forms of pneumonia are — it doesn ’ t spread through coughing or sneezing , for example . Instead , it ’ s transmitted through water and mist ( such as from shower spray ), which means that without the right water management program , the risk of Legionnaires ’ increases . And in long-term care facilities , where the mortality rate from Legionnaires ’ disease is close to 40 percent , that ’ s a risk staff and residents just can ’ t afford .
The first step to reducing and preventing Legionnaires ’ outbreaks in long-term care facilities is to raise awareness about this dangerous disease . However , it will take more than just becoming aware of the problem to solve anything . It will also take a coordinated effort from various staff members .
In 2018 , Centers for Medicare and Medicaid Services ( CMS ) introduced guidance about reducing Legionella risk in healthcare facilities . 3 Essentially , these regulations require facilities to put water management policies in place to reduce the growth and spread of Legionella ( and other opportunistic pathogens ) in building water systems .
To assist facilities in adhering to these regulations , the Centers for Disease Control and Prevention ( CDC ) developed a toolkit to help building owners and managers develop and implement a water management program . 4 This toolkit describes the elements of a good water management program , offers advice about how to identify which buildings are at increased risk , and outlines how to develop a good water management program in your facility .
As the CDC ’ s toolkit points out , there are certain factors to consider when it comes to maintaining a low Legionella bacteria count . These include temperature , chlorine concentration , pH , flow rates , and flow times . Just as importantly , you should also reflect on how your facility is set up . Does it have fish tanks ? Cosmetic water features ? What about water coolers ? Spas ? Bathtubs with spray jets ? All of these things can harbor Legionella bacteria , particularly if they aren ’ t cleaned properly or often enough .
Given federal regulations , not to mention how prevalent Legionnaires ’ disease is , it ’ s important to make sure your facility
has a water management policy . If it doesn ’ t , you need to create one . If it does , pull the policy out , dust it off , and review it — even if , up to this point , CMS surveyors haven ’ t focused on your water management program . Taking the time to review and evaluate your policy is even more important to do if your facility , like so many others , has experienced staff turnover since your water management policy was first written . As you review ( or write ) your policy , make sure it includes the elements outlined in the CDC toolkit . You also need to verify that it adheres to the ASHRAE 188 , which outlines the minimum risk management requirements for buildings . 5
Along with making sure your policy is in line with CDC and ASHRAE guidance , you should also make sure it allows for the infection preventionist ( IP )’ s involvement in water management . Remember , mitigating Legionella requires a concerted effort by multiple staff members . Even though water management in long-term care facilities typically falls under the jurisdiction of the maintenance director , to reduce outbreaks , it ’ s important to involve the IP as well . The IP should regularly review the laundry area , the kitchen , and the showers . This is a crucial point : Far too often , we regrettably see that IPs are told to stay in their lane — to mind their own business . But as an integral part of infection prevention and control , water management is as much their business as hand hygiene or enhanced barrier precautions .
If the water management program has historically fallen to the maintenance director to oversee , the IP should meet with that person to learn about their protocols . What gets checked and how often ? To be effective , water management must be an ongoing process ; by educating themselves about it , the IP can become an active and valuable member of the water management team .
I know there are many regulations that long-term care facilities must follow . There ’ s no question that adding Legionella and water management to that list may be daunting . However , outbreaks are on the rise , which means vulnerable populations — especially nursing home residents — are at greater risk than ever before . To protect them and keep them safe , happy , and healthy , it ’ s crucial to start taking steps today to ensure your facility ’ s water management program is up to standard .
Buffy Lloyd-Krejci , DrPH , CIC , LTC-CIP , is a leading authority on infection prevention in the long-term care industry . Her firm , IPCWell , delivers in-person gap analysis , training , and support to nursing homes across the country .
References :
1 . Legionnaires ’ disease ( https :// www . mayoclinic . org / diseases-conditions / legionnaires-disease / symptoms-causes / syc-20351747 )
2 . Legionella ( Legionnaires ’ Disease and Pontiac Fever ) Fast Facts ( https :// www . cdc . gov / legionella / fastfacts . html )
3 . Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires Disease ( LD ) ( https :// www . cms . gov / medicare / provider-enrollment-and-certification / surveycertificationgeninfo / policy-and-memos-to-states-and-regions-items / survey-and-cert-letter-17-30- )
4 . Toolkit : Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings ( http :// www . cdc . gov / legionella / WMPtoolkit )
5 . Guidance for Water System Risk Management ( https :// www . ashrae . org / technical-resources / standards-and-guidelines / guidance-for-water-system-riskmanagement ) june 2024 • www . healthcarehygienemagazine . com •
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