Healthcare Hygiene magazine October 2019

infection prevention By Sylvia Garcia, MBA, RN, CIC Legionella: Recognizing the Risk and the Resources E very day, patients are at risk because healthcare facilities are not aware of hazards related to water systems and equipment that uses water, or they have not prioritized it as an important issue. It is estimated by the Centers for Disease Control and Prevention (CDC) that 9 out of 10 infections acquired in a healthcare setting could have been prevented if the facility had initiated a better water management system. 1 Shockingly, 1 in 4 patients who develop healthcare-as- sociated Legionnaires’ disease will die, compared to 1 in 10 that will die from community-acquired pneumonia. 2 Even more surprising is the fact that at least 80 percent of the Legionella cases that occur in healthcare facilities could have been prevented by implementing an effective water management program. The most common sources of Legionella cases are show- ers, cooling towers, decorative fountains, and hot tubs but anything that can create droplets or aerosols could become a source. For example, putting tap water into a room humidifier could lead to infection. About half of Legionella outbreaks are linked to incidences associated with human error, such as a healthcare professional not following instructions for use of equipment. Although Legionella is highly publicized, it is not the only risk related to healthcare water systems. At the Association for Professionals in Infection Control and Epidemiology (APIC) 2019 Conference, researchers reported that 22 percent of consultations conducted by the Division of Healthcare Quality Promotion (DHQP) 3 were water-related. Causes of patient infections were identified as preventable, had the healthcare organization properly utilized available information and followed procedures communicating the need for the organization to implement an effective water management plan. For example, use of consumer-grade humidifiers in an operating room was linked to an outbreak of nontuberculous mycobacteria. Yet, the 2003 CDC Guidelines for Environmental Infection Control in Health Care Facilities clearly state that this this type of humidifier has been linked to Legionella outbreaks. As with other infection prevention and control challenges, organizations need to follow a standardized approach to reducing risk related to waterborne disease. ➊ Regulatory Requirements. Organizations should know their state’s regulatory requirements. Sources include health department and building code requirement documents. New York has enacted state regulations that require hospitals and residential healthcare facilities to perform environmental assessments, implement sampling and management plans to sample their potable water systems for Legionella and institute control measures in the event of a Legionella exceedance. New York also requires cooling towers to be 14 registered and monitored for Legionella. All states provide or employ healthcare-associated infection liaisons to direct healthcare workers to relevant information. It is also important to understand state reporting require- ments for Legionella and to identify known or suspected outbreaks caused by waterborne pathogens. To meet these requirements, facilities must implement a system to identify and evaluate possible cases. A laboratory finding is usually the first step in identifying a possible case. However, the infection preventionist or other knowledgeable person is also needed to apply generally accepted case definitions or create a case definition in the outbreak setting. State building codes vary, but many states have adopted a version of the Facilities Guideline Institute (FGI). Or- ganizations can gain access to relevant building codes or, depending on the year, can access the information directly via FGI’s read-only access. For example, FGI 2014 and 2018 state “provisions based on a risk-assessment plan shall be included in the heated potable water system to limit the amount of Legionella bacteria and opportunistic waterborne pathogens.” For the same reason, unsealed, indoor decorative fountains are prohibited in these versions. FGI also provides excellent references — including CDC Guidelines for Environmental Infection Control in Health Care Facilities, American National Standards/American Society of Heating, Refrigerating and Air-Conditioning Engineers Standard 188: Legionellosis: Risk Management for Building Water Systems, American Society of Heating, Refrigerating and Air-Conditioning Engineers Guideline 12: Minimizing the Risk of Legionellosis Associated with Building Water Systems and the American Society of Plumbing Engineer’s Legionella Control in Health Care. ➋ Centers for Medicare and Medicaid Requirements. In July 2018, CMS updated its requirement to reduce Legionella risk in healthcare facility water systems to prevent cases and outbreaks of Legionnaires’ disease. The updated requirement makes certain that Medicare-certified hospitals, critical-access hospitals and long-term care facil- ities develop, implement and monitor the effectiveness of water-management programs to protect patients, visitors and staff from exposure to waterborne pathogens, including Legionella pneumophila. This article (with references) continues online; visit https://www.healthcarehygienemagazine.com/infection- prevention/ Sylvia Garcia, MBA, RN, CIC, is director of infection prevention and control in the Division of Healthcare Im- provement at the Joint Commission. october 2019 • www.healthcarehygienemagazine.com

Healthcare Hygiene magazine October 2019 | Page 14