Tuesday
January 13, 2004
Although numerous hospital sources cause nosocomial outbreaks, perhaps the most overlooked, important and controllable source of nosocomial pathogens is hospital water, according to the paper "The Hospital Water Supply as a Source of Nosocomial Infections--A Plea for Action," which appeared in the July 8, 2002, issue of the American Medical Association's Archives of Internal Medicine.
The paper states that "the annual mortality from waterborne P. (Pseudomonas) aeruginosa nosocomial pneumonia in the United States is approximately 1,400." This is equivalent to the mortality rates for Legionella in health care facilities. In addition to these pathogens, others identified as causing health care-related waterborne infections include mycobacteria, fungi, viruses and parasites.
Waterborne pathogens represent a serious and growing concern for health care facilities. "A Plea for Action" is a timely statement. Several East Coast states experienced a 200 percent to 300 percent rise in reported cases of Legionnaires' disease in 2003. Because of the growing awareness of waterborne pathogens, the focus of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to reduce health care-related infections, and a host of new guidelines and regulations on this subject, more and more health care facilities are planning to take action.
The new Centers for Disease Control and Prevention (CDC) Environmental Infection Control Guidelines aptly sums up the problem and solution with the following sentence, "Although Legionnaires' disease is a respiratory infection, infection-control measures intended to prevent health care-associated cases center on the quality of water--the principal reservoir for Legionella spp."
Design factors that impact growth of Legionella in building water systems are temperature, flow, multiple stories, complex systems and intermittent use. In each and every one of these areas the typical health care facility is at either a high or very high risk level for culturing waterborne pathogens.
The latest American Institute of Architects (AIA) Guidelines for Design and Construction of Hospital and Health Care Facilities revisions reduced the risk of pathogen growth based on water temperature by allowing up to 120 degrees Fahrenheit, but dramatically increased the risk based on water flow rate.
Previously, there were two patients in a room and one sink, resulting in a ratio of 0.5 sinks per patient. In new facilities based on AIA guidelines there is now typically one patient and two sinks in a room, resulting in a ratio of two sinks per patient and a resultant fourfold increase of sinks in relation to patients.
Because the plumbing guidelines for pipe sizing in a health care facility are based on the number of sinks and these guidelines have not been changed, the situation regarding flow rates has worsened. In addition to increased risk of waterborne pathogens, these oversized pipes significantly increase the cost of new construction. Many states will accept requests for variances based on design concerns and allow pipe sizing based on design flow rather than distal sites.
What should a health care facility do to minimize health care-related infections from waterborne pathogens?
The first and most important action steps for controlling waterborne pathogens in a health care facility are an environmental risk assessment of the building water systems followed by implementation of a waterborne pathogen risk management plan as required by JCAHO Environment of Care® and recommended in many other guidelines, including those of the Occupational Safety and Health Administration and several of the states.
Surveys by the author's firm have indicated that, to date, only 5 percent of health care facilities have developed and implemented a waterborne pathogen risk management plan for their building water systems.
Previously, the CDC guidelines focused almost entirely on clinical methods to control Legionnaires' disease in health care facilities. With these new CDC guidelines, there is now 100 percent agreement in all U.S. regulations and guidelines that environmental (engineering) measures are needed to control waterborne pathogens in health care potable water systems.
Performing the proper engineering procedures, including the risk assessment and risk management plan, is critical. In addition to these steps, treating health care potable water systems with a disinfectant is becoming more and more common.
To the author's knowledge, Wisconsin is the first and only state so far to include regulations for waterborne pathogen control for health care facilities in its plumbing guidelines. Implemented in May 2003, these guidelines require one of the following for new hot water systems in existing buildings or new construction:
This is a very positive approach to addressing a problem that has a dramatic impact on health care-related illnesses and costs due to waterborne pathogens. The full guidelines can be accessed at www.legis.state.wi.us/rsb/code/comm/comm082.pdf.
What regulations impact health care facilities that treat their potable water? In accordance with U.S. Environmental Protection Agency (EPA) regulations, any system that regularly serves at least 25 individuals and provides treatment or storage of water to be used for human consumption is considered a public water system (PWS) and must comply with the Safe Drinking Water Act (SDWA), which can be accessed at www.epa.gov/safewater/sdwa/sdwa.html.
Additionally, effective Jan. 1, 2004, any PWS treated with a disinfectant that serves at least 25 people on a regular basis will be required to meet the EPA Stage 1 Disinfection Byproducts Rule (Stage 1 DBP), posted at www.epa.gov/safewater/mdbp/dbp1.html.
Any health care facility adding a disinfectant to a hot water system or a cold water system that serves at least 25 people is considered a PWS and must comply with the SDWA and Stage 1 DPR. This EPA regulation can have a dramatic impact on the cost of controlling waterborne pathogens for health facilities.
Maryland is the only state to address the Stage 1 DBP implementation, to the author's knowledge. It has taken a very positive step to minimize the cost of these regulations.
Following is a summary of the steps a hospital must take to ensure it is in compliance with the EPA regulations:
Step 1. The disinfectant must be an EPA-registered product for use in potable water treatment.
All disinfectants, whether used in potable water or for lawn care grub control, have always required, by law, EPA registration. "Any substance or mixture of substances intended to prevent, destroy, repel or mitigate a pest is considered to be a pesticide," Dennis Edwards, regulatory management branch chief of the EPA's Antimicrobials Division, tells the author. "Anyone selling or distributing a pesticide product must register the product. Disinfection is a pesticide claim. Therefore, the manufacturer must register the product unless the product meets the definition of a device found in 40 CFR 152.500."
In the case of chlorine dioxide, for instance, the chlorite precursor must be EPA registered as a disinfectant for potable water. With an electrochemical chlorine dioxide generator, chlorite is the only precursor used to generate chlorine dioxide.
For copper/silver or silver systems, Edwards says, "If the copper and silver are added separately to the machine, then they would be treated as precursors and each would require registration. Additionally, Edwards states, "Claims determine whether a product requires registration. If a water filter is described as filtering out microorganisms, then the product appears to meet the device definition. If the filter can demonstrate through efficacy data that it meets a disinfectant standard, then it can be labeled accordingly. If a filter contains a chemical, such as silver, and claims are made beyond the silver being in the filter to protect the filter or media, then the filter requires registration" as a pesticide.
Step 2. Use a state-approved monitoring and testing plan.
States are responsible for enforcing the EPA PWS regulations. Maryland has taken a positive step to minimize the cost of these regulations for health care facilities. Maryland is in the process of finalizing its plans for implementation of the EPA disinfection byproducts rule as it relates to water systems with treatment for Legionella.
According to Nancy Reilman, division chief of the Maryland Department of the Environment--Water Supply Program, Maryland's proposed plan currently impacts buildings treating their potable water with any disinfectant that is regulated (such as chlorine or chlorine dioxide), and that serve at least 25 people on a regular basis. They will be considered a public water supply and will be required to implement the EPA disinfection byproducts guidelines.
The state has adopted the regulations that specify requirements for facilities to implement this regulation. At this point, the only submittal they have received is for a chlorine dioxide system to control Legionella. Other treatment systems will be reviewed and a monitoring plan determined upon submittal to the state.
Disinfectants not regulated at this time, such as silver or copper, would have to be reviewed separately by the state and would require EPA registration. If the facility purchases water from a regulated public water system, then adds a disinfectant, it is classified as a consecutive water system.
The proposed Maryland plans for chlorine dioxide systems are as follows:
This is a short synopsis of proposed plans by the state of Maryland. Final plans on chlorine dioxide systems are expected by the time this article is printed. Plans for other systems will be developed as they are submitted for approval. Maryland has also stated that it will accept the EPA-proposed new test method using lissamine green for chlorite determination. This test method is very simple and inexpensive.
The "Report of Maryland Working Group to Study Legionella in Water Systems in Healthcare Institutions," can be accessed at www.dhmh.state.md.us/html/legionella.htm.
The above plan has taken the new EPA regulations and developed an implementation solution that will have a low-cost impact on health care facilities.
Hopefully, other states will take an equally positive position.
Tim Keane is president of Environmental Infection Control Consultants (EICC), Chalfont, Pa., and an expert on Legionnaires' disease in health facilities. The opinions expressed in this article are his own. A list of links referenced in the article, and links to state authorities, is at www.eicconsultants.com/links/links_water.htm. EICC has two-day seminars on "Sensible Strategies for Environmental Infection Control in Healthcare Facilities." For information, log on to www.eicconsultants.com/seminars.