By James Peterson / Special to Healthcare Facilities Today

Mount Carmel Grove City Hospital in Ohio opened its doors earlier this year. The $361 million, 210-bed facility includes a state-of-the-art newborn care unit, as well as comprehensive cancer care and bariatric services. But just two months after opening, the hospital found itself dealing with a crisis - an outbreak of Legionnaires’ disease which affected 16 people and led to one death.

Legionnaires' disease is a condition caused by inhaling airborne droplets infected by Legionella bacteria. A recent report in Opflow by the American Water Works Association revealed that nearly half of all building water systems can harbor Legionella. And while an aging infrastructure often is to blame, pipes are not the only reason waterborne pathogens are on the rise. Especially when considering the outbreak Mount Carmel Grove City, it’s clear that even with the most up-to-date equipment and facilities, the question around Legionella control isn’t a hypothetical. It is an existing, constant risk and should be top-of-mind for all hospital leaders. Legionella could affect water systems, moving through water heaters and coolers, hot water tanks, beverage equipment, washing machines and even central heating and air conditioning systems. Proper disinfection at the point of entry (POE) and point of use (POU) is critical.  

Legionella growth in water systems

While most water utilities add chlorine to water to control bacteria growth through pipes and building infrastructure, it is not a fail-proof method. Dead ends, leaks and aging systems create opportunity for bacteria to grow even after water moves from the treatment plant to the building. A POE disinfection method can prevent these microorganisms from entering the building through the utility water supply, but plumbing systems throughout the building are still left vulnerable after this point of treatment. Additionally, once the water reaches many appliances, it typically will pass through a carbon filtration device which will remove residual chlorine and create an environment increasingly susceptible to rapid bacterial growth. 

Water sitting static in appliances or taps will warm to ambient temperature, supporting the formation of biofilm, where Legionella will grow. This stagnation can occur frequently in care facilities -- for instance, water sitting idle in a rarely used faucet or water cooler. Water finally being dispensed from this point is at an increased risk for harboring contamination. However, in many cases, water that becomes airborne through steam can cause Legionella to rapidly spread throughout an entire building, contaminating new locations. This means any appliance that can store or transfer water is a potential risk for bacteria growth. In the case of Mount Carmel Grove City, the Legionnaires’ outbreak was traced back to poor water disinfection methods within the hospital’s hot water plumbing system. 

Unique considerations for care facilities

While all facilities, including schools, municipal buildings and offices, should include a water disinfection protocol, healthcare facilities are unique and must take into account the variety of risk points for Legionella and other bacteria, as well as how it can spread and put patients, caregivers and administrators at risk.

Guidelines from the Center for Disease Control (CDC) and American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE) include comprehensive recommendations for building owners and manufacturers to leverage in order to prioritize facility risk points and include special considerations for care facilities. Beyond the typical areas at risk in most buildings, such as sinks, ice machines, and water heaters, care facilities must think about areas where patients may be exposed to water droplets during certain procedures or therapies, as well as units where patients are most prone to infection. For a hospital such as Mount Carmel City Grove, there are a significant number of areas that are susceptible, and once the bacteria is present in any part of the system, the entire system must undergo remediation and continued monitoring to assure spreading can be prevented. 

Healthcare leaders and facilities managers should dedicate time and resources to mapping out their facilities’ water systems and identifying what areas are prone to external risks, as well as where Legionella is most likely to grow and spread. In addition to including facilities team members as part of this effort, it is advised that a professional with special experience in infection prevention and response is also included and well-versed in the procedures being determined for Legionella prevention. Once this is mapped out, the process for determining preventative measures and installing proper disinfection methods will be far more clear.   

Taking preventative measures to protect against Legionella

Having control measures and procedures in place is the first step in mitigating Legionella risk. While there are few regulations around Legionella, the aforementioned CDC and ASHRAE guidelines provide a sound starting point.  

Some healthcare facility managers may consider a localized disinfection facility for the entire building. This would use chemical dosing to increase the concentration of disinfectants in water and for a hospital that needs to assure safe water throughout the building, which may be worth the investment. However, with a strapped budget and limited resources, the operating requirements may prove to be more of a burden, even when many high-risk locations in the water system need to be addressed. 

Advanced technology can ensure safe water at the point of use

UV mercury lamp systems have traditionally been used and proven highly effective at reducing microorganisms, but significant maintenance requirements -- many must be replaced annually -- can drain resources and create inefficiencies and can affect disinfection performance. 

Deep ultraviolet (UVC) LEDs are the next generation of this technology and offer many of the same benefits of LEDs that consumers are familiar with, such as longer product lifetime, small product footprint and consistent performance. Because UVC LEDs are installed at the POU, it will ensure that water that may be contaminated from an external source will be disinfected to prevent the spread of harmful bacteria, including Legionella from plumbing or stored water. A recent independent study of the effectiveness of an on-demand UVC LED-based water disinfection reactor showed that it provided 99.998 percent reduction of legionella at the flow rate of two liters per minute.  

In addition to treating and disinfecting water in care facilities, with growing attention on the spread of hospital associated infections (HAIs), UVC LEDs can be integrated into new equipment to ensure that medical devices and equipment such as stethoscopes are properly disinfected, protecting against superbugs such as C. diff and Methicillin-resistant Staphylococcus aureus (MRSA).

Taking action to ensure your care facility is protected

The Mount Carmel City Grove Hospital Legionella outbreak is just one example of how this bacteria can quickly spread throughout care facilities, put patients at risk and impact the reputation of a provider. Whether you’re working to open or renovate a new facility, or are simply managing an existing one, understanding the nuances and risks in your existing water system is critical to reducing Legionella risk.

James Peterson is the product manager at Klaran, a Crystal IS product line.