Puzzled by Infection Preventionists in Water Management?

© Special Pathogens Laboratory
Laura Morris, MT (ASCP), CIC
Education Coordinator
PUZZLED BY
THE ROLE OF
INFECTION
PREVENTIONISTS IN
WATER MANAGEMENT

Thank you!

What Is an Infection Preventionist?
• Healthcare professionals dedicated to
preventing healthcare-associated
infections
• The infection preventionist’s highest
priority is keeping patients, visitors,
volunteers, employees and
healthcare providers safe form
healthcare-associated infections
(HAIs)

Infection Preventionist Wear Many Hats
Construction
HLD/Sterilization
C.difficile
CAUTI

IP Responsibilities
• Surveillance, analyzing and reporting HAIs
• Infection Prevention rounding/EOC Rounds
• Education patients, staff and visitors
• Liaisons with health departments
• Outbreak investigations
• Emergency preparedness
• Regulatory preparedness
• Members/lead IP committees
• Construction /renovation
• New product evaluation
• Subject matter expert

CDC Focuses on Effective
Water Management

ASHRAE 188/CDC Toolkit

CMS Memo

Coordinate Team

Water Management Team
GENERAL
• Building
manager/administrator
• Maintenance /engineering
employees
• Safety Officers
• Contractors/consultants
• Environmental health
specialist
• State and local health
officials
ADDITIONAL FOR
HEALTHCARE
• Someone who
understands accreditation
standards and licensing
requirements
• Someone with expertise
in infection prevention
• A clinician with expertise
in infectious diseases
• Risk and quality
management staff

Study
We analyzed data from 83 healthcare
facilities we have consulted with since
June 2017 (CMS issued)
• Questions-
 What was the team composition?
 Was infection prevention present on team?
 Were facilities proactive (before a case) or reactive in WSMP
development?
 Were facilities acute care or long-term care?
 What were the water system components?

https://commons.wikimedia.org/wiki/File:Map_of_USA_with_sta

Results
Team Composition Data:
 Team size range - 1-18
members
 Average size – 4.6
members
 95% of teams had facilities
/engineers on team
 72% of teams had a water
treater on team
 54% of teams had
administration on team
 53% of teams had IP on
team
95%
72%
54% 53%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Percentage of Teams with Department
Represented

Results
Proactive vs. Reactive WSMP Development
• Proactive WSMP development - 86% (71/83)
• Reactive WSMP development – 14% (12/83)
 IP on reactive team - 58% (7/12)
 IP NOT on reactive team – 42% (5/12)

Testing Is Revealing
Hospitals performing
Legionella environmental
testing were more likely to
prevent cases of
hospital-acquired
Legionnaires’ disease
Squier CL, Stout JE, Krystofiak S, McMahon J,
Wagener MM, Dixon B. Yu VL. Am. J. Infect.
Control 2005; 33(6): 360-367.

TESTING PLAYS AN
IMPORTANT ROLE IN
LEGIONELLA PREVENTION

Legionella Colony Morphology
Colonies of Legionella pneumophila have a
typical ground-glass, opalescent morphology

Environmental Cultures
• IP may be responsible for
 Collecting cultures
 Interpreting results
 Reporting to Water Safety Management
Team
 Making sure schedule is being followed

Clinical Cultures
• Providers should be educated to
maintain a high index of suspicion for
diagnosis of healthcare-associated
Legionellosis
• Should perform cultures for
Legionella of appropriate respiratory
specimen and urinary antigen test

Diagnosis: Order Culture and
Urine Antigen!
https://www.cdc.gov/legionella/clinicians.html

Surveillance HA-Legionellosis
• Does lab notify IP immediately of positive
Legionella clinical test?
• In house testing vs. outside lab?
• Communication with lab
• Electronic surveillance system set up to
alert IP

Definitions Healthcare-associated
• Incubation period for Legionnaires’
disease is typically 2-10 days, but can be
longer
• Presumptive case: A case with ≥ 10
days continuous stay at HC facility in 14
days before onset of symptoms
• Possible Case: admitted for a portion of
the 14 days prior to onset in one more HC
facilities but does not meet presumptive
case definition

Problem
• The average length of stay for pneumonia
in the U.S. is 5.4 days.*
• Very few cases will fulfill the definition for
“Presumptive” healthcare-acquired
Legionnaires’ disease.
*According to the Healthcare Cost and Utilization Project Nationwide
Inpatient Sample from the Agency for Healthcare Research and Quality

Health Department Liaison
• Reporting – within 24 hours
• Water history reporting
• Treatment

Types of Waterborne Pathogens
• (Opportunistic) Pathogens
 Legionella, Pseudomonas, Mycobacteria,
etc.
 DW treatment (filtration/disinfection)
• May not remove or inactivate 100%
 Can amplify after treatment in distribution
• Nutrients, lack of disinfectant, other organisms
 Total Coliform or HPC cannot be used as
an indicator or presence/absence

CMS Examples of
Waterborne Pathogens
• Legionella
• Pseudomonas aeruginosa
• Acinetobacter
• Burkholderia
• Stenotrophomonas
• Nontuberculous mycobacteria (NTM)
• Fungi

Legionella vs. Other
Opportunistic Pathogens
LEGIONELLA
• Source
 Building Water Systems
OTHER PATHOGENS
• Source
 Building Water Systems
 Surfaces
 Soil
 Air
 Dust
 Cleaning Solutions
 Sink Drains
 Flowers, Fruits and
Vegetables
 Other infected patients
 Etc.

LEGIONELLA
• Primary Infection Site
 Lungs / Pneumonia
OTHER PATHOGENS
• Infection Sites
 Lungs / Pneumonia
 Urinary Tract
 Soft Tissue / Eyes
 Burns
 Wounds
 Blood
 Etc.

LEGIONELLA
• Transmission
 Aspiration
 Inhalation / Aerosols
 Direct instillation into
the patient
OTHER PATHOGENS
• Transmission
 Aspiration
 Inhalation / Aerosols
 Direct Contact
• Hand-to-Hand
• Medical Equipment
• Medical Solutions
 Environmental Contact

• Other differences
 Growth factors
• temperature, nutrients, etc
 Survival outside of water
 Susceptibility to disinfectants

• Conclusion
 Water Safety and Management Plan
(ASHRAE 188) specific for control of
Legionella and prevention of
Legionnaires' disease
 Other pathogens should be considered,
but require other infection control
procedures to control growth and
prevent disease

LEGIONELLA
• Infection Prevention
 Identifying the risk
through proactive
monitoring for Legionella
 Development and
implementation of water
management programs
in building water
systems.
OTHER PATHOGENS
• Infection Prevention
 Hand hygiene,
 Cleaning and disinfecting
environmental surfaces and
reusable medical equipment
 Use single-use devices
when feasible
 Using sterile water and
solutions when indicated
 Minimizing the use of
invasive medical devices
 Antibiotic stewardship

Surveillance Other
Waterborne Pathogens
• Closely track any common waterborne
pathogens
• Look for trends
 Pseudomonas
 Acinetobacter
 Burkholderia
 Stenotrophomonas
 Nontuberculous Mycobacteria
 Fungus

List Listing Data
• List all patients with the following information:
 Name
 Medical record
 Date of birth
 Date of admission
 Admission diagnosis
 Underlying immunocompromising diseases
 Date of positive test
 Type of laboratory test ( urine Ag, culture)
 Date onset of symptoms
 Date of all visits to facility with in last 2 weeks ( in and
outpatient)
 Location of all inpatient stays ( room number)

Construction
• IP important member of team
• Involved from design phase
• Commission post-construction
 Flushing
 Culturing

Design Considerations
• Sinks
 Number and location
 Hand washing sinks
 Drains offset
 Electronic faucets
• Toilet location
• Supplies not by water source/splash
guard

Disturbing Findings

Infection Control Hospital Epid 2012
University Study 2012

Decorative Water Features
Not recommended for healthcare facilities
 Aerosolization
 Submerged lighting
 Submerged pumps
Guidelines for Environmental Infection Control in Health-Care Facilities
(2003) ,CDC and HICPAC
• Avoid placing decorative fountains and fish tanks in patient-care areas
• FGI Guidelines 2018
 Unsealed (open) water features are no longer permitted inside a
hospital or in a licensed outpatient health care occupancy area

Decorative Fountains
Water Wall Sponge-like foam material
1.2 million CFU Legionella
Infection Control and Hospital Epidemiology, 33, No. 2 (February 2012),185-191

Ice/Water Dispensers
• Cause for concern
 Cold water feed
 Increased internal
water temperatures
• Location
 Service to at-risk
individuals
• Manufacturer
guidelines
 Performance not
biofilm

External Events
• Vibrations and change in water
pressure can dislodge biofilm and
free Legionella into the water entering
your building
 Construction
 Water main breaks
• Change in Municipal water quality

New Products Committee
Will it -
 contain water?
 require water?
 attach to water line?
Think waterborne pathogen prevention!

Transmission by CPAP?

Recalls

Stay Informed
• CDC
• APIC
• CMS/The Joint Commission
• Local and State Health Departments

Reopening Building Water Systems
Resources for Water Safety and Management Teams:
• “Building Water System.” Centers for Disease Control
and Prevention, Centers for Disease Control and
Prevention, 3 Apr. 2020, www.cdc.gov/coronavirus/2019-
ncov/php/building-water-system.html.
• “Building Water Quality and Coronavirus: Flushing
Guidance for Periods of Low or No
Use.” Esprinstitute.org, Environmental Science, Policy &
Research Institute, 2020, esprinstitute.org/wp-
content/uploads/2020/04/FINAL_Coronavirus-Building-
Flushing-Guidance-20200403-rev-1.pdf.

Reopening Building Water Systems
Resources for Water Safety and Management Teams:
• DeMarco, Peter. “Rehabilitating Stagnant Building Water Systems
– A Timely Reminder from the IAPMO Group.” IAMPO.org,
www.iapmo.org/media/23575/flushing-stagnant-plumbing-
systems.pdf.
• “Shutoffs and Return to Service Guidance.” American Water Works
Association, www.awwa.org/Resources-Tools/Resource-
Topics/Coronavirus#10681543-shutoffs-and-return-to-service-
guidance.
• “Water Transmission and COVID-19: Questions and Answers.”
Centers for Disease Control and Prevention, Centers for Disease
Control and Prevention, 3 Apr. 2020,
www.cdc.gov/coronavirus/2019-ncov/php/water.html.

THANK YOU! STAY SAFE!
WWW.SPECIALPATHOGENSLAB.COM
INFO@SPECIALPATHOGENSLAB.COM

WEDNESDAY WEBINARS
MAY 20, Puzzled by Water Quality Measurements and
Legionella Risk?
JUNE 3, Puzzled by Point Of Use Water Filters?

Puzzled by Infection Preventionists in Water Management?

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Puzzled by Infection Preventionists in Water Management?

Similar to Puzzled by Infection Preventionists in Water Management? (20)

Recently uploaded

Recently uploaded (20)

Puzzled by Infection Preventionists in Water Management?