On Infection Prevention & Control

Experiences, case studies and news about infection prevention and control.

Reducing the Risk of Legionnaires Disease and Other Waterborne Pathogens


By Sylvia Garcia-Houchins, MSN, RN, CIC, director of infection prevention and control
Years ago, I had an experience with Legionella that I’ll probably never forget. Working as a “moonlighter” research coordinator on a clinical trial to treat patients with IV azithromycin, I encountered a patient who had been admitted just a few hours before, but was quickly succumbing to pneumonia and had just been transferred to the ICU. 
He struggled to talk, but was able to give consent for the study. I arranged for a Legionella urine antigen test and culture. The urine antigen test is a rapid screening tool that detects Legionella pneumophila serogroup 1, the most common cause of Legionnaires disease. Isolation of Legionella by culture can detect other species and serogroups that cause disease and can help link possible sources with cases of disease.
I made sure that the specimens were in the lab and headed home, quite sure that his test would be negative. 
Less than an hour later I was called because his test was positive. When I arrived back in the ICU, his doctor was talking about putting him on a ventilator because his respiratory and mental status were deteriorating quickly. The test and the study antibiotic probably saved his life, or at least a stint on the ventilator. His doctor had not suspected Legionnaires disease and had started him on an antibiotic that would not have been effective. He was significantly better after just one dose, and the person that I met the next morning was alert, talkative, and breathing easily. 
But outcomes aren’t always this positive. 
Escalating Legionnaires Crisis
Legionnaires disease keeps popping up in the news lately, and the source is often determined to be a hospital or nursing home’s water system.
According to the Centers for Disease Control and Prevention’s (CDC) Legionella Toolkit, Legionnaire’s disease has increased nearly four-fold since 2000. It’s a problem that’s costing insurers $144 million yearly, according to an article by University of Minnesota’s Center for Infectious Disease Research and Policy. Many cases of Legionnaires disease are acquired in a healthcare facility. It’s estimated by the CDC that 9 out 10 of the infections acquired in a health care setting could have been prevented with better water management.
Increased Regulatory Focus
With the increase in reported cases of Legionnaires disease and outbreaks of other waterborne organisms, regulatory bodies have responded. 
The Centers for Medicare & Medicaid (CMS) released a memo last June, requiring Medicare-certified hospitals, critical access hospitals and long-term care facilities develop, implement, and monitor the effectiveness of  water management programs to protect patients, visitors, and staff from exposure to waterborne pathogens, including Legionella pneumophila. 
The Joint Commission did not need to develop new standards to survey to this requirement because existing standards already required an accredited organization to plan, implement and evaluate programs to protect the health and safety of patients. Relevant standards include:
  • EC.01.01.01: The hospital has a written plan for managing its utility systems
  • EC.02.01.01: The organization manages safety and security risks.
  • EC.02.05.01: The organization manages risks associated with its utility systems
  • EC.02.05.05: The organization inspects, tests, and maintains utility systems.
  • IC.01.03.01: The organization identifies risks for acquiring and transmitting infections
  • IC.01.05.01: The organization has an infection prevention and control plan
  • IC.02.01.01: The organization implements its infection prevention and control plan
  • IC.03.01.01: The organization evaluates the effectiveness of its infection prevention and control plan
Demonstrating Compliance
During surveys, The Joint Commission  look for evidence of compliance with the following key elements:
  • Facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system or equipment that contain or use water
  • Water management program that considers American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Standard 188 and the CDC toolkit Developing a water management Program to Reduce Legionella Growth & Spread in Buildings: A Practical Guide to Implementing Industry Standards 
  • Testing protocols and acceptable ranges for control measures, with results of testing and corrective actions taken, or to be taken, when control limits are not maintained
In addition, surveyors may ask about situations that could put a facility’s water system at risk and what the facility has done or would do to mitigate the risk, including:
  • system start-ups and shutdowns 
  • areas of the facility that are closed or have low census
  • changes to municipal water treatment
  • water main breaks
  • construction or renovation
  • fluctuations in source water temperature
Building a Water Management Plan
Creating and implementing a water management program can seem daunting! ASHRAE and the CDC have created excellent resources.  Both address these key elements.

1 .Establish a water management team. There’s flexibility as far as the team members but important backgrounds to consider on the team include:

  • facilities management
  • microbiology
  • infection prevention
  • risk management 
  • occupational health.
2. Describe the building’s current water system. Create a diagram that highlights:
  • points of entry
  • water distribution
  • storage 
  • use
 Most facilities already have building drawings that include their plumbing systems, so that’s a great place to start.
3. Identify where Legionella and other pathogens can grow. Joint Commission surveyors expect facilities to identify at-risk systems and equipment with respect to their:
  • components
  • installation
  • configuration
  • use
  • condition

The vulnerability of persons served by the systems must be considered as well.

4. Determine control measures and how to monitor. Control measures must be developed for each risk point. Facilities must determine what they are going to check to ensure that their control measures are effective. Examples include, but are not limited to, monitoring compliance with:
  • routine maintenance
  • water temperature
  •  pH
  • chlorine levels
  • cultures
Although routine culture testing for Legionella and other pathogens isn’t required by CMS, it is required in the state of New York. 
5. Establish interventions when clinical limits are not met. The expectation is that facilities plan what they will do if a healthcare-associated case of Legionella is identified or suspected, or if control measures are not being met.
6. Make sure the program is functioning as designed and is effective. Validate that all control measures have been implemented as designed, and have established procedures to confirm the water management program is effectively controlling water related hazards.
7. Document and communicate. Your program should be documented. It’s good to let those at risk know that you have a plan in place and welcome suggestions to make it even better. Be proud of the great work you are doing to keep everyone safe!  If something does happen, cases of one of more laboratory-confirmed or two or more suspected Legionella must be reported to the health department. In addition, some states also require that any suspected or confirmed cluster of infections be reported.
Stopping these deadly infections won’t be easy, but it’s certainly possible. You must be systematic and diligent at looking for sources and implementing control measures. I ran an infection control program that went 20 years without a hospital-acquired case. We can all get to zero if we follow ASHRAE and CDC’s guidance.
Sylvia Garcia-Houchins is the Director, Infection Prevention and Control in the Division of Healthcare Improvement. Garcia-Houchins has over 30 years of experience in infection control in both hospital and long term care settings, as well as eight years of clinical microbiology experience. Most recently, she served as the Director, Infection Control at University of Chicago Medicine and was also an intermittent consultant for Joint Commission Resources for 10 years. Ms. Garcia-Houchins has provided infection prevention and control consultation, assessment and education in a variety of health care settings including hospitals, health clinics, ambulatory surgery, and dialysis centers both domestically and internationally.