Where there's moisture there could be mold. That is the most basic fact that hospitals dealing with the otherwise-complicated issue of mold growth must understand before they can begin to tackle this dangerous, potentially deadly foe.
From leaky pipes to moisture trapped in wall cavities--or any number of other scenarios--moisture is the first condition that must be present for a mold spore to grow. Add the right temperature and a carbon-based material for a spore to feed on, and it will begin to multiply--quickly.
"It supposedly takes a mold spore just four hours to germinate once it gets wet. After that it sends its roots out to look for carbon sources and the spores will begin developing," says Andrew Streifel, hospital environmental specialist with the University of Minnesota and a recognized expert on the subject. "Water, food and the right temperature . . . these are really the three ingredients necessary for mold growth."
Aspergillus, a species of mold capable of growing at body temperature, is often fatal for those who come down with invasive aspergillosis--the actual disease. In fact, the Centers for Disease Control and Prevention (CDC) estimates that health care-associated infections affect two million patients a year, with more than 90,000 people dying per year as a result. Of that number, about 1,000 deaths each year are related to aspergillosis, experts say.
But hospitals shouldn't get so scared they start randomly ripping out walls looking for hidden fungi. Although mold is everywhere and there is no such thing as a mold-free facility, the spores are only dangerous when they come in contact with a person susceptible to infection, like a highly immunosuppressed patient.
How do hospitals prevent that from happening? By becoming adept at responding to water damage, and finding, removing and preventing mold as well as assessing the risk for its potential growth.
More hospitals--many spurred by a litany of mold-related lawsuits--are learning to do just that.
So many variables
Hospitals have made progress in fighting fungus, but it hasn't been an overnight process, simply because mold is such a slippery issue. Every scenario is different and so many variables are involved--everything from the amount of mold to the type of surface it's growing on, to its proximity to highly immunosuppressed patients--that hospitals often aren't sure where to turn for definitive answers.
Hospitals are advised to follow environmental guidelines from organizations like CDC and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) but, so far, no agency has created regulations governing mold. That's because standards for judging what is an acceptable, tolerable or normal quantity of mold have not been established.
"We're getting closer to creating a standard of prevention and control, but I don't think we'll be able to come up with a standard for thresholds," says Judene Bartley, M.S., M.P.H., CIC, vice president of Epidemiology Consulting Services, based in Beverly Hills, Mich. "When it comes to mold, litigation is as close as you get to a regulation."
The best approach a hospital can take is to make sure the staff knows what to look for and what to do if they find something.
"Hospitals always have to deal with this issue themselves first," Streifel says. "If a water pipe breaks and there is a flood, a hospital has to know in advance how they will handle that."
Since mold is a multipronged issue, more hospitals are forming teams or committees made up of various departments to oversee mold issues. The facility manager usually heads up the team, which may also consist of infection control, engineers, health and safety, risk managers and other staff.
Since many hospitals have safety and infection control committees, Bartley says some facilities are creating subcommittees to handle indoor air quality issues, including mold. Or, a facility might incorporate indoor air quality issues (like mold) into its Environment of Care inspections, or use the team already assembled to handle Infection Control Risk Assessments (ICRA), which are recommended before construction projects are launched. The facility might also include a mold remediation specialist, depending on the problem.
"Not every hospital does this, but facilities should consider how they handle mold and other indoor air quality issues, which may include mold remediation," says Bartley. "The way they structure this is up to the facility."
The bottom line? No matter how they do it, every facility should have a plan in place, she says.
Looking for signs
Locating mold can be a tricky proposition because it often isn't visible. Fungi may be well-hidden in places like the back of drywall, wallpaper or paneling, the top of ceiling tiles, the undersides of carpet, or in even more elusive locations such as inside ductwork and in roofing materials.
But unless it's disrupted, mold doesn't pose an immediate danger, experts say. "As long as it's in the dormant stage, it's not presenting a problem," says Dale Woodin, CHFM, deputy executive director, advocacy, for the American Society for Healthcare Engineering (ASHE). "But if you rip into it and it becomes airborne, now you have issues with exposure to patients."
So rather than tearing off wallpaper in a scramble to find a colony of spores, hospitals are better off looking for signs that mold is growing. "We don't think there's a need to do a mold inspection for the sake of doing one," says Ronald V. Gobbell, FAIA, president and founding partner of Gobbell Hays Partners, a Nashville, Tenn.-based architectural, engineering and environmental consulting firm. "We think there needs to be some causation to generate an inspection."
The two main ways to recognize mold are sight and smell.
Hospital staff doing regular inspections should watch for any sign of water exposure such as water stains or discoloration on surfaces such as the ceiling, walls, floors or carpeting. Mold can also grow on materials such as glass, tile and stainless steel if there is some organic source for it to feed on such as oil, film and dirt.
If you can't see it, experts recommend doing the "sniff test" to direct you to the spores. "Different mold species smell differently," says Streifel. "But generally, it's that musty smell you want to be aware of. That could lead you to the source."
There is also equipment that can lead to the source of moisture. A moisture meter, which Streifel says can be purchased for about $300, helps identify wet materials behind wall finishes or coverings such as paints, drywall or wallpaper. It also gauges the level of moisture relative to dry areas. "It will tell you whether the area is dry enough so that it will no longer support fungal growth," he says.
Thermal imaging, which uses an infrared thermometer, is another tool for finding hidden water leaks behind walls or other areas exposed to water intrusion. "An infrared thermometer is used to detect cooler surfaces after water leaks, and the wet test meter is used once we have found them," says Streifel.
Hospital staff can be trained to use the moisture meter, which takes direct contact readings, but thermal imaging should only be utilized by a trained professional, he says.
Even if you can't see or smell mold growth, an investigation would still be warranted if there is a reason to suspect a mold problem, such as tracking an infection to mold and/or someone filing a lawsuit against the hospital over such an incident. This could involve examining building cavities and the HVAC systems to find the source of the moisture--a process that can be potentially complicated and costly.
"It may be as simple as a broken water pipe that has since been repaired or as complicated as the failure of the exterior walls to retard water vapor once the HVAC systems put the building under negative pressure," says Gobbell.
To sample or not to sample?
The discovery of such a mold-related illness is one of only two instances when CDC recommends doing environmental sampling to determine the type of mold growing in a facility. In its "Guidelines for Environmental Infection Control in Healthcare Facilities," CDC says: "When indicated, conduct microbiologic sampling as part of an epidemiologic investigation or during assessment of hazardous environmental conditions to detect contamination or verify abatement of a hazard."
Otherwise, CDC advises against "random, undirected microbiologic sampling of air, water and environmental surfaces," in health care facilities, mainly because there is no threshold for an acceptable amount of mold and all fungi is a potential health risk to susceptible patients. And, although there are plenty of environmental firms out there who insist that sampling is necessary, others do not.
"I spend more time talking clients out of testing than I do trying to convince them that they should," says Wayne Hansen, P.E., CEM, REA, director of engineering for Mintie Corp., a Los Angeles-based national indoor environmental solutions provider. "In most cases, it is more beneficial and cost-effective to assume that there is a mold issue and conduct an investigation accordingly."
Apart from the CDC recommendation, Streifel says sampling before a facility is reoccupied after remediation is a good idea to provide a measure of assurance and documentation. "Otherwise, the main priority should be making sure the building systems--the ventilation, pressurization and filtration--are all working as intended," he says.
Gobbell says he does not encourage sampling, but that if testing is done, you should have plans for the results. "Never take a sample unless you know what you are going to do with the answer," he says. "That's lesson number one."
Inexact science
The high number of variables (such as the amount, location, surface it is growing on) involved in mold removal means it won't ever be an exact science. But experts agree that, generally, you can wipe off a small amount of visible mold but should use controls, such as barriers and respiratory protection, for larger mold remediation projects to guard against the potential danger involved with mold removal--especially during construction and renovation projects.
"If we are going to disturb mold, we better have a game plan," says Woodin. "Do we need to seal the area off, or create hard barriers? These are the things hospitals need to consider."
"The cleanup procedures should incorporate environmental control measures to keep the mold spores contained," says Gobbell. "And the level of effort for this containment should be directly related to the amount of material affected by the mold growth."
The facility manager should establish standards for the cleanup procedure, starting with published recommendations and adapting them for their own facility.
The H2O factor
The time element in your cleanup procedure is all-important because mold grows so quickly. "That first 48 hours is critical," says Gobbell. "If you can get something dried out in that time period, the odds are that you won't have much of a problem."
Most experts recommend having a water intrusion management plan in place so the staff knows how to handle moisture problems as soon as they occur, and who to call if they need help.
Streifel recommends adopting the water damage checklist outlined on the University of Minnesota's Web site (see the first item in the sidebar on page 17). An abbreviated version of some items covered on the list includes:
- Ceiling tile. Remove and dispose of all wet ceiling tiles within 24 to 48 hours of water damage. The only exception would be if the ceiling tile has become wet due to a small steam leak and the shape of the tile has not been altered. In this situation the ceiling tile can be air-dried and reused.
- Drywall/lathe plaster. Remove
and replace all water-damaged drywall and insulation within 24
hours. If the drywall is not removed within 24 hours or if previous
water damage has caused microbial growth, extensive controls
will be necessary for the removal process.
These controls include set up of critical barriers, negative air, appropriate respiratory protection for the workers, gloves and disposable coveralls. - Carpet. Any carpet that has been contaminated over a large area with sewage backup should be discarded under controlled conditions and the entire area disinfected with bleach and water.
- Furniture. Upholstered furniture that has become wet due to floods, roof leaks, sewage backup and groundwater infiltration should be disposed. Upholstered furniture damaged by steam leaks or direct contact with drinking water should be dried within 24 hours and monitored for fungal growth and odors.
Construction connection
With the record number of hospitals doing construction or renovation and the number of infection-related deaths related to construction and maintenance practices in hospitals (about 5,000 each year, according to the CDC), hospitals are becoming more focused on infection control during construction.
Fortunately, a number of agencies have published newly revised or updated guidelines on this issue and all strongly recommend that hospitals do an Infection Control Risk Assessment before launching a construction, renovation or demolition project. Bartley says it's important for the ICRA to include many departments--as well as contractors--since mold can originate from so many different sources.
"For example, a technology company might come in and start punching a ceiling tile and not pay attention to the fact that one of them is stained," says Bartley. "The contractor should be in on the planning, and it should be done at the earliest possible moment."
Since contractors work in many different parts of the building and are dealing with a wide variety of materials and equipment, all contractors should be aware of the hospital's infection control protocols, says Hansen. He says Mintie oversees his client's contractors who can often number in the triple digits depending on the project. "There could be 100 cable jockeys in there at a time," he says. "There has to be a program to monitor the contractors. The worst nightmare a facility manager could have is having that many contractors to oversee."
Hospitals planning new construction or renovation should also make sure contractors understand the potential infection risks of leaving the building exposed to water during the building process. "Contractors are notorious for installing interior finishes before putting the roof on," says Peter Cappel, vice president of Gobbell Hays Partners. "But if there is a rainstorm and the drywall gets wet, you're looking at a big mold project before you ever occupy the building."
Hospitals should also consider using building materials in their construction projects that can prevent mold problems from starting. For example, Georgia Pacific produces an interior wall panel, Dens Armor Plus, that is "highly mold-resistant," according to Pat Marcouiller, manager of corporate accounts. He says the product has a pure gypsum core and that paper has been replaced with fiberglass mats. "And if there's no paper, there's no mold," Marcouiller says. "It's a paperless, inorganic product that can't serve as a source of food for mold."
Clean bill of health
Experts are still debating the value of post-remediation assessment for most building types because there are any number of variables that can confuse the sample data. However, hospitals need to demonstrate--on paper--that they don't pose an infection risk, so microbial mold sampling is suggested as one method that provides such evidence following remediation, according to Streifel.
He suggests that the criteria for "what is clean" should be agreed upon by both parties prior to the sampling. This is often a case of getting what you pay for. "There is a difference between cheap labor and skilled labor," Streifel says. "If you're paying top dollar, the guarantee should be there."
For prevention, the main lesson hospitals need to absorb is: If you control moisture you control mold. Keeping a building as dry as possible should be a top priority. And putting measures in place--such as an indoor air quality team, mold cleanup procedures, and an overall mold strategy--will help.
No hospital will totally eliminate mold--that is a naïve notion. But they are making real progress in finding, removing, and preventing mold from becoming a dangerous, costly problem. "Management is the key," says Streifel. "Hospitals need to remember that."
Beth Burmahl is a Chicago-based freelance writer and a former HFM staff editor.
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