NYC Executive Patient Safety Forum Presentation - Ron Garnett...

PRESENTED BY:

Ron Garnett

NYC Patient Safety Forum

Hospital Water Is Perhaps the Most Overlooked, Important, and Controllable

Source of Hospital Acquired Infection.-American Medical Association

Like Blood Vessels, Pipes Can Develop Plaque, Which Can Harbor Bacteria

CDC - Legionnaires’ Disease IncreaseMore than 40,500 cases reported over the past 15 years

Num

ber

of R

epor

ted

Cas

es

% In

crea

se in

U.S

.

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

5,500

5,000

4,500

4,000

3,500

3,000

2,500

2,000

1,500

1,000

Reference: CDC Weekly MMWR 2000-2015

400

350

300

250

200

150

100

50

0

1,110 reported cases in 2000

5,299 reported cases in 2015 – a 370% increase

Proprietary and confidential ©2016

• NY State Law mandates water sampling and management plans to reduce legionella infections and ensure proper maintenance of water systems

• Includes both and water

Effective December 1, 2016


NYSDOH Legionella Regulations

Presentation will introduce the following:


¨ NYSDOH-Compliant Environmental Assessment

¨ Recommended Actions for Legionella within a Healthcare Facility

¨ Copper-Silver Short-term Disinfection

¨ Copper-Sliver Ionization Long-term Control

¨ Bacteria, Not Just A Cooling Tower Issue

¨ Waterborne Hospital Acquired Infection Driving Up Healthcare Spending

¨ Legionella Risk, Facility Liability & Regulation

¨ Community vs. Hospital Acquired Disease

¨ Hospital Acquired Infections Caused by Waterborne Bacteria

¨ At-Risk Populations and Groups

¨ Facility Surveillance for Legionella

¨ Investigation and Control of Legionella

¨ Interpretation of Legionella (Culture) Test Results

Potable water sources accounted for 67% of health care associated legionella outbreaks (in hospitals and long-term care facilities) Morbidity and Mortality Weekly Report (MMWR)

It's not just about cooling towers!

Community vs. Hospital Acquired Infection


Community Hospital Acquired Infection

Surveillance definitions apply to Legionnaires’ disease given an incubation period of 2 to 10 days

The patient/resident was in the community for the entire incubation period and presented with onset of illness within 48 hours of admission.

Possible healthcare facility-associated The patient/resident was not in the facility during the entire incubation period.

Definite healthcare facility-associated The patient/resident was in the facility for the entire incubation period.

HAIs Caused by Waterborne Bacteria

HAIsBiofilm

Corrosion Stagnation

Aging Pipes

Heat and flush and hyperchlorination can dislodge bacteria into water supply

HAIs Caused by Waterborne Bacteria


HAI Characteristics

In non-circulating loops or

stored water systems.

Strong association with water

biofilms

Growth in hot water

environments

Correlation between

infection and construction

activity

Aerosols, ingestion, &

contact

New NYSDOH regulations require facilities to adopt and implement a sampling and management plan, incl. the following minimum standards:

¨ Legionella culture sampling at a minimum of 10 sites as determined by the environmental assessment.

¨ Legionella culture sampling and analysis at intervals not to exceed 90 days for the first year; and at least annually thereafter.

¨ A response plan for positive legionella culture analysis results.

Effective December 1, 2016


Facility Surveillance for Legionella

Investigation and Control of Legionella


Report to the NYSDOH and local health department

The NYSDOH will open an

investigation and provide consultation

Recommendations for control will

vary

The percentage of positive sampling sites will determine the response to legionella sampling results


¨ GREATER THAN 30%- acute treatment is recommended

¨ EQUAL TO 30% - treatment may be needfor this borderline condition

¨ LESS THAN 30% - monitor the facility on a quarterly basis

Legionella Sampling Guidelines

New NYSDOH regulations require facilities to perform a compliant environmental assessment at least annually (or whenever when major construction is conducted at the facility).

A separate environmental assessment is needed for each facility and for each hot water system within a building. Its purpose is to discover any vulnerabilities that would allow for amplification of legionella and to guide its environmental sampling.

By December 1, 2016


NYSDOH Environmental Assessment

NYSDOH Compliant Assessments Include

Facility Characteristics

• Types of care• Age of buildings• Floor space and

capacity

Construction Issues

• Internal plumbing repairs or construction

• External construction• Water main breaks

or repairs• Colored water issues• Potential cross-

connections

Source of Water Supply and Treatment

• Hot and coldwater temperature profiles

• Free chlorine residuals

• Presence and location of thermostatic mixing valves

• Presence and service of water softener systems

• Supplemental (long-term) water treatments for microbial contamination

• Other water quality parameters (pH, TOC, etc.)


Recommended Actions for Legionella


¨ Complete eradication of legionella is the goal

¨ Without long-term control measures, re-growth will likely occur

¨ First-year sampling is to be performed at intervals not to exceed 90 days

¨ Water lines that have been dormant or unused should be disinfected before being placed back into service

¨ Electronic or hands-free faucets should be monitored

¨ Aging and at-risk hospital patients should take special precautions

Copper silver remediation

generally achieves non-detectable

legionella results within 72 hours

Legionella Remediation

Short-Term Copper-Silver Disinfection


Empirical data confirms that the application of copper-silver on a temporary basis is effective in controlling the re-growth of legionella.

30-day treatment

periodCollect cultures

May last up to 6 months

1. Water passes through the flow cell chamber2. A direct current is applied across the electrodes, creating positively charged

copper silver ions3. The ions seek out bacteria throughout the entire plumbing system, providing

on-going disinfection

STEP 1 STEP 2 STEP 3


Copper Silver Ionization: How It Works

Copper Silver Ionization: How It Works

4. The positively charged copper and silver ions are attracted to the negatively charged bacteria

5. Copper weakens the bacteria cell wall

6. Silver causes cell lysis (death)

Note: contact time is crucial to bacterial death

++++

++ + +

_

__

_



Copper Silver Ionization System

Flow CellController

Ultrasonic Flow Meter

REMS

Long-Term Control Method Considerations


Inbound water quality

Configuration of hot and cold water

loops

Construction activity

Any vulnerabilities

Secure your water

Long-Term Copper Silver Benefits

99.99% kill rate of

pseudomonasEffective on hot water

systemNon-

chemical/no harmful by-

products

Prevent cross contamination

Non-oxidizing ions

Systemic solution

Biofilm reduction and

control

Real time monitoring

No negative effect on

plumbing or equipment

Ongoing prevention

Who is Using Copper Silver Ionization?


Chlorine Disinfection in Hot Water

Legionella, Not Just A Cooling Tower Issue


Amplified in hot water systems

Temperature for growth ranges from 77 to 115° F (25 to 46° C)

Chlorine treatment yields an average of 70% or more loss in disinfection capability

Copper-silver ionization maintains effectivenessregardless of time (water age) and temperature

Multi Barrier Approach to Water Security

§ Specialized mix of technology and service

§ Protect your facility from point of entry to point of use

§ Analytical approach to water management

Legionella, Mycobacterium, and Pseudomonas Likely Resulted in

80,000 Cases Per Year, with Costs Exceeding $2 Billion.

-Friedman School of Nutrition Science and Policy at Tufts University and Tufts University School of Medicine

Legionella Risks, Liability and Regulation


The recent rise in reported Legionellosis cases has led to an increase in personal injury lawsuits seeking damages for wrongful death, medical costs, lost wages, and pain and suffering. Why should this matter to healthcare facility owners and operators?

¨ Compliance with the new ASHRAE standard and NYDOH requirements will likely be viewed by courts as the standard of care in personal injury lawsuits.

¨ Adopting these standards and complying with applicable law is the best defense.

¨ Conversely, failure to follow such standards and legal requirements could increase exposure to potentially significant liability.

Thank You!

NYC Executive Patient Safety Forum Presentation - Ron Garnett...

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