Beware the bio slime: Legionella problems can lurk even in new pipes
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September 1, 2019
By A.J. Plunkett (email@example.com)
Include your water management team in planning and execution of construction and renovation projects to ensure checks are done for Legionella and other waterborne infections before patients and staff move in.
Put those checks, which should include flushing of water lines and testing for Legionella and other bacteria, on your pre-occupancy punch list.
Doing so could not only save lives but save your hospital from expensive water remediation later—and protect your accreditation as well.
Hospital faces investigation
Just because your facility is new (or newly remodeled) and has passed building inspections doesn’t mean problems don’t already lurk within your water system.
Barely a month after opening in late April, the Mount Carmel Grove City hospital outside Columbus, Ohio, began battling an outbreak of Legionnaires’ disease (LD) and now faces at least five lawsuits, including one from the family of a woman who died. At least 16 patients were identified in the outbreak.
In a public statement, Mount Carmel Grove City President Sean McKibben said that water samples taken during an investigation shortly after the outbreak of LD among patients “showed significant Legionella bacteria were in our hot water system at that time. We believe the bacteria are linked to inadequate disinfection prior to Mount Carmel Grove City’s opening.”
The hospital faces continued investigations by state public health inspectors, as well as The Joint Commission and CMS. Last year, the federal agency began requiring hospitals to be able to show inspectors a water management plan and specifically cited concerns with Legionella (IJC 7/23/18).
Water management problems or the lack of a management plan are often cited under CMS Conditions of Participation for Physical Environment, Infection Control, and Quality Assessment and Performance Improvement.
Problem is always there
Legionella bacteria exists in every public water system but can grow lethal if kept unchecked, especially if water sits in so-called “dead legs” of piping, such as out-of-service bathrooms, infrequently used sinks, or fixtures in unused building areas. When aerosolized by a shower or other spray, any then-airborne bacteria are easily inhaled, leading to LD or other pneumonia-like infections.
“The problem of Legionella proliferation in both in existing buildings and a new building have the same general risk factors—but those risk factors are actually compounded in a new building or renovation,” says Bryan Connors, MS, CIH, HEM, the managing principal consultant for Environmental Health & Engineering Inc. in Newton, Massachusetts. Connors is a certified industrial hygienist with expertise in Legionella control.
Residual disinfectants in public water systems generally keep Legionella in check, but once that water enters a hospital’s water system, the effect of that residual disinfectant begins to decline as it is distributed throughout the facility, he explains.
A new or renovated hospital building, by its nature, already has stagnant water somewhere. The water may be turned on in a particular part of the facility weeks or months before patients are seen there. If there are no protocols for proper flushing of the lines, the water generally sits unused, notes Connors.
The same is true for existing lines if patient units are shut down for remodeling or to concentrate treatment areas for maximum efficiency.
When a patient unit is in regular use, flushing of the water lines is more frequent. But even a single patient room with a bathroom that has been unused for any period of time could begin to host Legionella growth, which could then infect the rest of the system—as well as any patients who are already immunocompromised.
That means even a controlled environment needs to ensure the flushing of lines, plus a water management program that includes regular testing for parameters such as residual disinfectant, temperature, and pH at point-of-use sources such as sinks and showers; these interventions “cannot be forgotten about,” warns Connors.
Proactive management is invariably easier than treatment after the bacteria is discovered. And it is much easier, and cheaper, than caring for patients or staff infected by airborne particles.
Watch for dead legs
Municipal water systems rely on disinfectants, often chlorine or other chemicals, to control bacteria like Legionella. That residual disinfectant is present when the water comes into your hospital, whether the building is existing or new. From there, the disinfectant—unless there is on-site treatment, which is rare—can only decrease, notes Connors. The water is often stored in areas such as the hospital’s cooling towers and hot water heaters, but is eventually distributed throughout the hospital to sinks, showers, kitchens, piped eyewash stations, laboratories, and other areas.
As the water is distributed, the disinfectant can naturally lose its effectiveness. That problem is compounded if the water isn’t being used.
“You’ve heard the words dead legs or low-use locations—that’s true of both a new hospital and a renovated or existing hospital,” says Connors. “But the risk there is actually compounded at a new or renovated hospital in that, by its nature, at the end of renovation or construction there is a real risk of stagnant water.”
The water is often turned on in the building weeks or months before patients move in, he notes. During that time, it’s stagnant. It may get some usage, but without a coordinated and planned “flushing program,” that usage is very likely to be low, he says.
The problem is biofilm, “which is just a way of saying slime—bio slime,” says Connors.
“You look down your sink drain and you see that film within the piping system,” he explains. Often you see slime in waste piping, but the same type of “thing can occur in incoming water, and that’s where these bacteria love to proliferate. Once the Legionella bacteria get within, and protected by, this biofilm, it’s difficult for the disinfectant to reach it and kill the bacteria.”
Controlling the growth of Legionella is more easily managed in buildings where you can run water or flush the systems regularly. Legionella growth can also be controlled by keeping water above or below certain temperatures. However, the CDC’s toolkit for managing water systems to reduce the risk of Legionella notes the bacteria can still grow outside that range; the toolkit also warns that some local and state anti-scalding regulations may restrict how hot the water can be kept.
Beware the slime
Even with monitoring of disinfectant and water temperatures, problems can still occur if there are dead legs of piping, such as a patient room that has been converted to storage or a care unit where patients rarely shower. If biofilm collects, “you can be potentially too late,” says Connors.
“You have to remember that Legionella grows in these biofilms. Once the biofilms are in your piping system, it’s very difficult to get rid of. We have to be very thoughtful about ensuring we don’t allow a problem to occur.”
And you have to be even more thoughtful with new or renovated areas. Those water systems need to be flushed and tested before hospital staff or patients take occupancy. “That needs to be built into a commissioning checklist and the commissioning process,” says Connors. Managing residual disinfectant can be difficult, especially in a complex building like a hospital, he reiterates. Therefore, “you have to take it very, very seriously.”
Here are some tips from Connors for managing Legionella growth in your facility:
Ensure flushing of the system is done regularly. “Flushing is the primary preventive measure here,” Connors says. “Now depending on the system, that could be more and more complex. The domestic water system is pretty easy to flush, but there are various utility systems as well, so you need to think about those water systems’ area so that you can be sure there’s not stagnant water.”
Test close in and far out. Test for Legionella to ensure the residual disinfectant is maintaining adequate strength throughout your facility, especially when opening a new wing or reactivating a unit. “Typically before you open, you’ll get some kind of final water quality testing,” says Connors. Usually the water is tested at the point it comes into the facility, but the farther away from where the water comes into the hospital, the greater the risk of the residual disinfectant losing its effectiveness. So “at the distal or furthest outlets you’ll want to be measuring for residual disinfectant,” as well as temperature and pH, and any other parameters set out in your facility’s water management plan.
Remember your ice machines. Testing often focuses on sinks, showers, and faucets as well as cooling towers. But don’t forget your ice machines and any plumbed eyewash stations where water can become aerosolized. Discuss with your infection prevention team about whether other areas, such as dialysis centers or bone marrow transplant patient care, also need regular comprehensive monitoring.
Protect your staff. Anyone testing cooling towers, showers, or other areas for Legionella should wear the respirators recommended by the CDC and as set out by OSHA requirements.
Engage housekeeping for help. As part of the policies and procedures for cleaning rooms, have the environmental services crew flush showers if a patient has not used the shower, or in rooms that have not had patients for a set period of time.
Legionella can still grow
What if you’re flushing your system, checking for residual disinfectant, and find that it’s low in certain areas of the building? Or, worse, patients begin to be diagnosed with LD?
“Say during construction you were flushing once a week, and you were measuring residual disinfectant and it wasn’t sufficient but you didn’t yet have Legionella,” says Connors. You would want to flush more often, maybe once a day at these faucets, he says. But keep monitoring the water. Flushing may solve any problem if there isn’t yet any significant biofilm.
If a problem develops, look for stagnant water.
“Let’s take a much more serious problem. You determine you don’t have enough residual disinfectant but you are also getting high levels of Legionella bacteria as well. What that very likely means is you do have that biofilm, or slime,” in your water lines, says Connors.
In that case, you cannot rely just upon a flushing program; you likely have to treat. That means introducing higher levels of disinfectants or bringing water temperatures to a high level to chemically or thermally shock the bacteria and kill the biofilm, he says.
There are protocols by OSHA and the CDC that outline both chemical and thermal options. Which ones you use depends on the severity of problem and the type of piping.
“There are lots of pros and cons to these various methods, so you want to be cautious about how you apply them. You’d want to work with a professional to determine which method is appropriate,” warns Connors.
Some chemicals can damage or cause pitting in some types of piping. That can compound your future water management issues by making those areas more likely to collect biofilm in the future.
Work with an industrial hygienist, engineer, and other facility professionals—“someone who’s familiar with the pros and cons”—before starting treatment.
Team response required
In all cases, the first thing you do when you determine you might have a Legionella problem is to activate your water management and infection prevention teams.
“Remember, by definition, your water management team is a multidisciplinary team,” says Connors. That team should include facility engineers and infection control and prevention experts, including any medical director of infection control.
Then determine “if it truly is from your hospital. Remember Legionnaires’ disease also occurs in the community,” notes Connors.
LD usually has an onset of symptoms within two to 10 days. Your infection prevention and water management team should have protocols in place to both watch for infection and how to react once identified to determine the likelihood it happened within your facility or elsewhere.
“In any case, you’re doing follow-up and some kind of remedial action, but the extent will be determined by that team,” says Connors.
The response is often multi-tiered. “You might want to move patients out of the area. If you have one or more cases and from the same area where you found Legionella, you most certainly would be shutting down rooms and floors,” in addition to starting treatment of your water system.
Don’t be afraid of hiring professionals to help you set up a water management system or to deal with an out-of-control Legionella problem. It’s not only smart but may be a required step to show you are serious about dealing with the issue.
Once Mount Carmel Grove City and the Ohio Department of Health realized they were dealing with an outbreak, the hospital brought in an expert and touted that effort later as it made a public statement about steps it was taking to mitigate the problem. (For more on Mount Carmel’s plan of correction, see p. xyxyx.)
Look for experience, unbiased advice
When looking for a consultant to evaluate and manage your water system, beware of companies that also try to sell you other services, such as periodic testing or disinfectant supplies and treatment, advises Connors.
While hiring a consultant, look for three things, he says: experience, competence and credentials, and unbiased advice.
“For example, I talked about a chemical shock treatment. There are a lot of good companies out there that do really good with chemical shock treatments or with thermal shock treatments, and they can be very effective. There’s pros and cons. But I wouldn’t rely on that company to tell me if I have a problem. I’d rely on a third party to tell me I have a problem, and then hire that [other] company to treat.”
He continues, “In terms of experience, ask them what other hospitals they’ve worked on for this particular issue. In terms of competence and credentials, you would look for nationally recognized certifications—certified industrial hygienist, professional engineer, experience within healthcare systems.”
Interview the consultants, ask how they’ve addressed this issue before, and ask them to document their competence and certifications, says Connors, whose company often serves in that consultant capacity.
Most importantly of all, in a worst-case scenario where you are facing local, state, or federal investigations, be truthful.
“When dealing with regulators, be open, honest, and transparent. Hospitals have very complex water systems, and mistakes are made sometimes,” says Connors. “What you need to do is figure out what happened, and in order to do that, often you need to take a hard look in and share information that’s requested with regulators. And from there you can move forward.”
“When and if you are inspected by CDC or CMS—and we have had clients that have been—then you just want to be transparent with what’s available,” he notes.
And make sure to listen. Those regulators usually bring in their own experts, who can help you “course correct for the future.”
“The risks here are real,” notes Connors. Hospitals “are required to have an effective plan. There’s liability concerns, as you’ve seen in the news; there have been fatalities of late—there are lots of reasons to ensure you have an effective water management plan.”
Proactiveness is by far the best approach. “I have been through several of these responses, and though maintaining an effective plan requires some effort, the amount of effort involved in dealing with patient infection is 100 or 1,000 times what would be required to just maintain the plan to begin with.”
Use these resources to review your water management plans
Flushing your water system is a must before opening or reopening a hospital facility. But plan ahead.
Pardee Hospital in North Carolina used the CDC’s toolkit on implementing industry standards in developing a water management program to reduce Legionella in buildings, says Ivan W. Gowe, MS, BS, MLS(ASCP) CM, CIC, infection preventionist at Pardee.
Those industry standards include the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Guideline 12, Minimizing the Risk of Legionellosis Associated With Building Water Systems, and ANSI/ASHRAE Standard 188-2018, Legionellosis: Risk Management for Building Water Systems.
The CDC toolkit “has a soft recommendation for daily flushing and monitoring (temperature and residual chlorine) during construction,” notes Gowe. However, “there is no stated volume of flush, which can be problematic. Depending on the size of the construction effort or the unit that is closed due to construction, flushing every water outlet can be a huge task.”
The Association for Professionals in Infection Control & Epidemiology (APIC) has an internet reference database, APIC Text Online, which earlier this summer published updates on Legionella information.
“APIC Text Online recommends proactive water cultures at least annually to as frequently as every 90 days in the first program year, reducing frequency as long as there are no patient cases,” says Gowe. “Utility of water cultures as a prevention strategy is not entirely agreed upon by experts, but culturing after a hospital-onset case is a must. Cultures must be collected from every location that housed the patient. Specimen volumes must be at least 250 ml.”
Include testing along with flushing, he recommends.
“The primary step after construction is testing water outlets before opening or reopening a facility, especially since flushing alone is not evidence-based,” he says, referring to information on APIC Text Online.
Case study: Steps hospital takes after Legionella outbreak
In June, Sean McKibben, president of Mount Carmel Grove City hospital in Columbus, Ohio, issued a statement detailing the steps the facility took after 16 patients were diagnosed with Legionnaires’ disease, including at least one patient who died.
After notifying local health officials, an investigation pointed to Legionella that proliferated in the system during the construction of a new facility on campus. Tests showed significant levels of Legionella in the hot water system, “We believe the bacteria are linked to inadequate disinfection prior to Mount Carmel Grove City's opening,” said McKibben.
Here are the steps McKibben said the hospital took during and after its investigation:
- Working with Franklin County Public Health and following CDC guidance, they determined three positive cases for Legionella, the earliest being diagnosed May 15 and reported to the health department on May 16.
- A common source could not be identified during this time due to the individual circumstances of
- each case, including exposure to other healthcare facilities during the incubation period.
- Water samples were taken May 23 through June 1, and heightened surveillance for other
- potential cases identified a fourth case. At that point, a full investigation of an outbreak began on
- May 31.
- Mount Carmel quickly implemented water restrictions on May 31 for the safety of their patients as they
- prepared to hyperchlorinate (disinfect) the entire water system by June 2.
- They installed temporary water filters known to provide an extremely effective barrier to Legionella
- transmission by June 6. (Once continuous extensive testing is complete, the temporary filters were to be removed.)
- Installed a permanent supplemental disinfection system—with 24/7 monitoring and controls—
- which continuously adds chloramine to the water supply on June 11.
- Updated protocol that every patient room (occupied and unoccupied) will be flushed daily.
Future actions will include disinfecting and cleaning the cooling tower, along with upgrading the hospital’s disinfection controller.
Read the full statement at https://www.mountcarmelhealth.com/assets/documents/mchs-media-statement-june-13-updated.pdf.