While news about Ebola dominates headlines, there's another persistent risk for hospitals that deserves attention. Outbreaks of deadly Legionnaires' disease are still occurring with regularity in healthcare facilities. However, because these cases are typically localized (Legionnaires' isn't contagious), most people are unaware of the ongoing problem.
The Centers for Disease Control and Prevention estimates that as many as 18,000 people are hospitalized annually with the disease. Some 23% of those cases are hospital-acquired, and those have a mortality rate of 40%. Studies show that approximately 70% of hospitals have some level of the Legionella bacteria, which causes the disease, in their hot water systems.
One would think that with numbers like those, amid all the efforts to reduce the scourge of preventable infections, hospital-acquired Legionnaires' would be classified as a “never event,” and every hospital would be required to test the water supply for the bacteria and remediate the problem. Think again; there are few such requirements at the state and local levels, and none at the federal level. Only when patients fall ill is there any reaction, and even then almost nobody agrees on how and where to test, what level of bacteria is acceptable and what remediation approach to use.
This is why so many healthcare facilities managers were eagerly awaiting a final draft of a long-gestating set of Legionella-prevention building standards from the American Society for Heating, Refrigerating and Air Conditioning Engineers (known as ASHRAE 188P). While the fourth draft, currently under public review, is a positive step, it falls far short of what's needed to start reducing the number of outbreaks and has numerous unintended consequences.
My system, St. Elizabeth Healthcare, launched a proactive Legionella disease prevention plan in 1997 when it received some positive tests for the bacteria, a plan that enabled it to mitigate Legionella and other waterborne pathogens within its facilities. The steps taken can be easily implemented by most hospitals, including random sampling and testing as well as checking any areas where water might remain stagnant in dead plumbing legs. After carefully reviewing water treatment options, St. Elizabeth chose copper silver ionization. In addition to being environmentally safe, the method is long-term and cost-effective.
Unfortunately, those kinds of straightforward decisions are not addressed by ASHRAE 188P. Instead, it is far too prescriptive in some areas and too gray in others—including those that matter most. This is especially problematic, as these standards, once approved, will eventually become the basis of building codes and other regulations.
The document establishes a set of protocols for assessing risk in a building's water system, and requires that building owners test for “residual disinfectant,” but nowhere does the standard mandate or discuss any details of testing for Legionella or establish what kind of disinfectant to use. This is like a doctor testing a patient for a prescriptive drug level without knowing if there is illness in the first place.
The standard requires facility owners and managers to conduct and document a compliance determination, not only annually, but also anytime renovations, additions or modifications are made. That's a good thing when doing construction; but what about when adding an eyewash station or drinking fountain per a user request or due to a new function? The proposal needs to clearly define what level prompts a survey versus any building modifications.
ASHRAE 188P would require any modification to the water system, no matter how minor, to include assessment and extensive design work that many hospital may not be able to afford. For example, if a rural, critical-access hospital would like to convert an old office into a bathroom, a plumber will not be able to be called to obtain permits and complete the work; rather, a designer will need to be hired and an entire system overview performed, including schematic diagrams, monitoring and control diagrams of water systems and code compliance.
Similarly, the document requires evaluation and estimate of likelihood of Legionella whenever there is a water service disruption from the supplier. This will mean daily evaluations for most hospital owners/staff.
We must act to control Legionella in hospital water supplies, but ASHRAE 188P, in its current formulation, is one step forward and several steps back. There is no need for more arcane building codes. Instead, we should decide when, where and how water tests should be done and, if Legionella is detected, define the required steps to solve the problem, providing long-term and sustainable disinfection that keeps hospital drinking water safe for patients.
Matthew L. Greis is systems director of facilities at St. Elizabeth Healthcare, a six-hospital system serving northern Kentucky and the greater Cincinnati area.
