water management programs: best...
TRANSCRIPT
Water Management Programs: Best Practices ReviewofWaterSafety,
ImplementationStrategies,andBestPractices
May11,2018
Presented by
Jim Lyons and Kevin Pranaitis
Contents
What is Legionella?• History and Biology• Risk factors and System Amplification
Water Management Program • ASHRAE 188-2015
• CDC Guide to Implementation• Legionnaire’s Disease (LD) Case Statistics
Contents
Implementing Water Management Program• Process and Critical Stakeholders• Practical Considerations
Ongoing Improvement• Mechanical & Operational Considerations
• Construction and Infection Prevention/Control
What is Legionella?
• Gram negative bacterium
• Pathogenic
• 58 species (and counting)
How Legionella Amplifies in Systems
• Bacterium enters protozoa
• Multiplies inside until cell bursts
Legionella Transmission -> Legionellosis
Legionella in Water
Aspiration
InhalationSusceptible individual
Legionellosis Risk Factors
• Male • Over 50 • Immune
Compromised • HIV, Cancer,
Dialysis • Smoke, Drink,
Drugs Also: Heart, Lung conditions, Diabetes, Kidney disease
The Must Have’s
RiskPopulation
RiskSystem
Rightwater
conditions
“We have a responsibility to the public to provide safe and dependable institutions”
AHJ’s Follow Suit: CMS, IPDH, TJC, DNV…
Bottom Line?
One. More. Thing. ...You Have To Do
CDC Guide
Legionella Statistics
More Facts and Figures
• Estimated 8,000-18,000 people hospitalized with LD annually in US
• 90% undiagnosed • 80% associated with potable water
HospitalAcquired
Hotel,Industrial,Commercial
*Source–USCentersforDiseaseControl
Domestic Water Supply Risk
“What you hear about is the cooling towers, but the data show there’s also risk with water from showers… The key to preventing these outbreaks is
maintenance of building plumbing systems”
Karlyn Beer, MS PhDCenters for Disease Control and Prevention
Domestic Water Supply Risk
“IninstitutionaloutbreaksofLegionnaire’sDisease,epidemiologicinvestigationhasusuallyfocusedonnearbycoolingtowersandevaporativecondensers.Thisstudynowindicatesthatattentionshouldbepaidtothewaterdistributionsystemwithintheinstitution.”
-NewEnglandJournalofMedicine,1982
Need More Proof?
Case Distribution
4%
96%
Legionnaire'sDiseaseCases
Outbreaks
NotInvestigated
Outbreaks–2+cases,oftengettingpublicattentionSporadic–single,oftengeographicallyisolatedcases
Confirmation Bias and Patient Safety
• Is patient safety compromised by only looking at cooling towers as risk systems?
• Implementation of ASHRAE 188 in its entirety, not just the convenient parts is key to patient safety
“[Confirmationbias]isatendencytosearchfororinterpretinformationinawaythatconfirmsone’spreconceptions,leadingtostatisticalerrors”
Essential Components of a Water Management Program for Legionella
1: Form a team and choose a team leader
Team Leaders: Regional Director, Admin, etcProgram Administrator: Facility Manager
WaterManagementCommitteeincludes:
• FacilitiesManager• ChiefEngineer• Administrator(i.e.,VP,RegionalDirector,etc)• InfectiousDiseaseControlOfficer• SafetyDirector• RiskManagementOfficer• MedicalDirector• TrustedPartner
WMP Committee Responsibilities:
1. Implement program
2. Implement the control measures
3. Implement the validation methods
4. Review performance of the Program and revise as appropriate (Quarterly)
2: Develop a water system inventory and create flow diagrams
Essential Components of a Water Management Program for Legionella
Example�Flow Diagram�
3: Develop hazard analysis summaries including locations where control measures should and can be applied according to ANSI/ASHRAE 188-2015.
Essential Components of a Water Management Program for Legionella
4: Program Administrator establishes control measures with monitoring, performance limits, and corrective actions based on the ANSI/ASHRAE 188-2015 Standard.
Essential Components of a Water Management Program for Legionella
Control Measures Apply To:
• New Construction/Renovations/Expansion • Startup/shutdown of systems• Unoccupied spaces
• Inspections• Maintenance• Cleaning and disinfection• Monitoring (e.g., temperatures, disinfectant levels)• Water treatment• Response to Legionnaires’ disease
Construction
Facilities
InfectionControl
EX: Flush Hot Water Tanks or Heaters Monthly
Corrective Actions
If monitoring is out of specification• Hot Water Temperature out of range?• Cooling Tower Biocide measurement low?
• No disinfectant in city water?• Ice Machines not cleaned as required?• Unknown water dispenser PM schedule?
5: Program Administrator establishes verification procedures and validation methods based on the ANSI/ASHRAE 188-2015 standard.
Essential Components of a Water Management Program for Legionella
Verification & Validation
• Confirm program is being administered as designed (verification)
• Confirm the program effectively controls the hazardous conditions throughout the building (validation)
How Do You Validate?
Environmental testing for pathogens (Legionella) should be the KPI for your Water Management Program.
What are your goals?• Establish trends• Understand building/campus colonization• Identify immediate or critical risks• Further improve WMP
Device Samplestocollect
Incomingwatersupply onepost-flush
Hotwaterstoragetanksandtank-typewaterheaters
Pre-flushandpost-flushfromdrainofeach
Coldwaterstoragetanks OnePost-flushfromdrainofeach
Drinkingfountains pre-flushandpost-flushfromatleastone
Watercoolers/dispenserspre-flushfromoneofeachtype(bottledandpiped)
Icemachinespre-flushiceandwaterfromoneormore,atleastinhospitalsandnursinghomes
Faucetsandshowers• hotwaterpre-flushfromarepresentative
number• coldwaterpost-flushfromatleastone
Coolingtowers onefromeach
Decorativefountains Onefromeach
Whirlpoolspas Onesamplefromatleastonespa
Sampling Protocol
Legionella Growth vs. Temperature
< 68oF Limited/No Growth
80 -118oF Ideal Growth Temperature
> 124oF No Reproduction
> 140oF Kills in ~ 3 minutes
> 160oF Instantaneous Kill
Validation (Testing) Follow Up
• Analyze locations and risk• Re-Evaluate control measure procedures• Evaluate remediation, if required• Consider capital mechanical projects
(fixtures, piping, flow, temperatures, etc)
Potential Remediation Responses include: 1. Flushing2. Thermaleradication3. Disinfection4. Filtration/Barrier
Mechanical First
• Mechanical improvements that improve water safety
• Follow the data
• Target the root cause
• Consider capital mechanical projects (fixtures, piping, flow, temperatures, etc)
More HW Examples…
Operational Improvements
• Improve your PM program
• Better documentation of maintenance tasks
• Identify equipment that is lacking
Bio-Film: Critical Performance Factor
1. Incorporate into work order system
2. Adhere to facility standard documentation requirements (i.e. meeting minutes)
3. Track and log corrective actions (i.e. Self-Identified, PM, etc)
4. When in doubt…
Documentation: Your Favorite Task
Document, Document, Document!!
Design and Construction
• Must be involved • Critical to long-term
improvement • Reduces PM tasks • Energy Savings vs.
Water Safety
Infection Prevention / Control
• Must be involved • Critical to long-term
improvement • Can be your ally • Clinical work and
insights equally important
“Do you want to know if a patient has it?”
Top Takeaway’s: Water Safety
• Work as a Team • Do Something • Document What You Do • Continuously Improve • Reach Out to Your Peers
Comparison Information Sources