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How to slash the risk of waterborne illnes

Hospital Safety Insider, March 23, 2017

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The 10 steps every healthcare facility should take to combat Legionella and other pathogens, according to the American Society for Healthcare Engineering.

At low levels, the bacteria that cause Legionnaires’ disease are unlikely to make humans sick, but under certain conditions, especially in warm and stagnant water, the bacteria can multiply to deadly levels.

Healthcare facilities, especially, should take steps to spot and eliminate the conditions under which Legionella might flourish, so the American Society of Healthcare Engineering (ASHE) published a monograph this month outlining 10 key steps every facility should take to minimize the risk. While acknowledging the gravity of the threat, the document calls for a coolheaded and systematic approach.

“Without proper guidance, hospitals may take steps that are not required, steps that may be unnecessarily costly; or steps that are not helpful in reducing the threat from legionellosis and other waterborne pathogens,” six healthcare engineering experts wrote in the 44-page document, which is available for download from ASHE’s website.

Rather than require facilities to test for Legionella and disinfect accordingly, the 10 steps—which align with the requirements of ASHRAE Standard 188—place an emphasis on effective risk management:

1. Assemble a team. Arguably the most important aspect of implementing a water management program is putting together a team with clearly defined objectives and responsibilities, balanced roles with appropriate leadership, and strong communication. This team could be part, for instance, of a hospital’s utility management team or a subset of the Environment of Care committee.

2. Map the system. Develop a diagram that shows every source of water in the building, every treatment system, all control measures, all processing steps, and each and every end-use point. While it is not necessary for the entire team to be subject matter experts, they all should generally understand how water works its way through the facility, as depicted in the diagram.

3. Note potential hazards. The Centers for Disease Control and Prevention (CDC) reports that Legionella grows best in warm water and is likely to spread in water features such as hot tubs, hot water tanks and heaters, large plumbing systems, cooling towers (such as far air-conditioning in large buildings), and decorative fountains. Your water flow diagram should note the location of these and other potential hazards, including anywhere water may be aerosolized.

4. Highlight at-risk patients. Your diagram should also note areas in the building where higher-risk patients receive care. These may include burn units, transplant centers, critical or intensive care, surgery, emergency department trauma centers, NICU, and others.

5. Plan for risk reduction. Considering both the locations of potential hazards and the locations of higher-risk patient populations, identify locations in the water system where the team might wish to direct additional controls, such as disinfectant, heating, cooling, filtering, flushing, or other processes to keep the water supply within the identified limits.

6. Dole out responsibility. Attach each and every action step to a name. Make clear who is responsible for implementing any control measure assigned.

7. Monitor the strategy. Plan a sequence of observations or measurements to assess control measures both physically and chemically. After identifying a baseline, the team will be able to spot deviations that could herald a potential change in the waterborne pathogen risk.

8. Draft contingency plans. The team should make detailed plans for how to respond in the event of a suspected case of legionellosis or other sicknesses related to waterborne pathogens. These should include emergency disinfection plans and incorporate advice from government health authorities.

9. Document everything. Every step of the way, the team should put its plans and actions in writing to ensure that everyone involved in the water management process is on the same page now and in the future.

10. Periodically review the program. At least on an annual basis, the team should reevaluate the water flow diagram, see if any changes have been made that could introduce new hazards or at-risk populations. This should be in addition to the routine monitoring plan.

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