Nalco ALASHE 2017 presentation 5-5-2017 · Microsoft PowerPoint - Nalco ALASHE 2017 presentation...

6/29/2017

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© 2015 Ecolab USA Inc. All rights reserved.

OTHER WATERBORNE PATHOGENS

© 2017 Ecolab USA Inc. All rights reserved. © 2015 Ecolab USA Inc. All rights reserved.

Water as a Source and Vector of Infection (1)

38

Anaissie et al, 2002Anaissie et al, 2003Cervia et al, 2010Exner et al, 2005Holmes et al, 2009Walker et al, 2013Crumby personal communication


Multiple reports of infections linked to water Legionella pneumophila Pseudomonas aeruginosa Stenotrophomonas maltophila Acinetobacter baumannii Mycobacterium chelonae Aspergillus and Fusarium spp.

Literature citations of WHAIs Bone marrow transplant units Oncology wards Surgical ICUs Subacute care units Neonatal units Burn units

© 2015 Ecolab USA Inc. All rights reserved.39 © 2017 Ecolab USA Inc. All rights reserved.

74% of taps without temperature selection were contaminated with P. aeruginosa (2001)

In 15 of 45 patients, the genotypes of P. aeruginosainfections matched isolates from faucets in patient rooms

132 patient cases of P. aeruginosa were investigated In 42% of these cases, the DNA fingerprint of P. aeruginosa infections

from patients was identical to the DNA fingerprint of P. aeruginosafound in the inner part of faucets in an ICU

38 patient cases of P. aeruginosa were investigated 39% of water samples from electronic faucets in areas including hematology units and ICUs

nyielded P. aeruginosa.

Myers et al, 2014


© 2015 Ecolab USA Inc. All rights reserved.40

A 2009 study showed that NTMs are enriched > 100-fold above background water samples in showerhead biofilms

In 2010, a hospital-acquired outbreak of LD sickened 8 people. The source was identified as a decorative fountain in the hospital public area

A 2014 study showed that NTM was found in 106/183 (58%) of endpoint water samples over a three year surveillance period. Authors cited concern with risks of infection

A 2015 study showed the source of a postoperative breast infection by Mycobacterium fortuitum to be the hospital water supply

A pseudo-outbreak of Elizabethkingia meningoseptica infection in 30 patients over a 22 month period was epidemiologically linked to the hospital water system

Crago et al, 2014Feazel et al, 2009Haupt et al, 2102Jaubert et al, 2015Moore et al, 2016



IMPLEMENTING A WATER SAFETY PLAN: A KEY STRATEGY TO REDUCE INFECTION RISKS FROM POTABLE AND UTILITY WATER

Ian Eisner – Water Safety Consulting Manager

© 2015 Ecolab USA Inc. All rights reserved.© 2017 Ecolab USA Inc. All rights reserved.

Managing The Risk of Water Safety

6/4/2015ASHRAE 188 Standard Establishes Risk Management Requirements for Building Water Systems

6/1/2016CDC June Vital Signs Publication Requests Building Owners Follow

ASHRAE 188 Standard.

A “Site Specific Legionella Water Management Program”

Follow ASHRAE Standard 188 7-Step Model

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TJC and DNV-GL are Auditing for WMP’s!

1/22/2017

TJC Audit indicating Water Management

Plan Non-Compliance


Legionellosis Risk By Age Group 2000-2009

Age group (years) Number of cases

% of cases Incidence rate per 100,000 population

<9 79 0 0.02

10‐19 125 1 0.03

20‐29 516 2 0.13

30‐39 1473 7 0.36

40‐49 3622 16 0.81

50‐59 5401 24 1.44

60‐69 4658 21 1.94

70‐79 3672 16 2.29

>80 2864 13 2.66

6-fold

17-fold

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6032a3.htm



Elements of a Water Management Plan to Reduce Riskper ASHRAE Standard 188

Program Team Development &Implementation

1

2

3

4

5

6

7

Describe Water Systems& Flow Diagrams

Analysis of BuildingWater Systems

Control Measures

Monitoring &Corrective Actions

Confirmation

Documentation

DO YOU HAVE A PLAN?


System Assets & Risk Analysis

Reference Guides (Best Practices)

Program Manual


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Organize a Team

Describe Your Systems

Define Control Measures & Monitor Them

Intervene When Control Limits are Not Met

Review & Confirm Program

Document, Communicate & Adjust

Analyze System Hazards

ASHRAE 7-Steps Description

1. Organize a Program Team Identifying persons (the “Team”) responsible for Program development, implementation and compliance.

2. Describe Water Systems & Flow Diagrams

Describing the potable and non-potable water systems during walk-thru. This will include simple process flow diagrams (not engineered drawings).

3. Analysis of Building Water Systems (“Risk Assessment”)

Completing an assessment during the on-site walkthrough to evaluate where hazardous conditions may occur in the water systems and determine where control measures can be applied.

4. Define Control Measures & Monitor Them

Determining locations where control measures must be applied, monitored, and maintained in order to stay within established control limits.

5. Intervene When Control Limits are Not Met

Providing guidance to Customer to establish control limits and to define corrective actions necessary to correct the condition when test results occur outside of the control limits.

6. Review & Confirmation Program

Program confirmation step… (1) to verify the program is being implemented as designed (are the control measures and monitoring/maintenance tasks being followed and is action being taken and documented), and (2) to validate the program is working to control the hazardous conditions based on scientific principles and monitoring evidence.

7. Document, Communicate & Adjust

The Program specifies documentation and communication procedures.

Completed On-site

Defined in Program Manual



PROGRAM VERIFICATION AND VALIDATION

Verify Program, Document Results & Activities in Logs Semi-Annual Team Review to Communicate & Adjust

Water Safety is aContinuous Process

Routine MonitoringPotable Water

SystemsCooling Water

SystemsOther At-Risk

Systems

Inspection & Maintenance

Water Temperatures

Oxidant Residual

Legionella Testing

Water Quality

Bacterial Dip slide


Water Management Plan

PROPOSED PLAN TO BE FINALIZED

BY MANAGEMENT TEAM


Planning To Successfully Reduce Risk:WMP Review Meetings

52

Four (4) Program Reviews per year are RecommendedMonth 1 2 3 4 5 6 7 8 9 10 11 12

Year 1 Building the Program (Assess → Develop → Implement → Review) Review Annual

Year 2 Review Review Review Annual

Year 3 Review Review Review Annual **

.

Review = System Review ^^ | Annual = Program Review ^^


Elements of a Water Management Plan per ASHRAE Standard 188:The Risk Assessment

Program Team Development &Implementation

1

2

3

4

5

6

7

Describe Water Systems& Flow Diagrams

Analysis of BuildingWater Systems

Control Measures

Monitoring &Corrective Actions

Confirmation

Documentation


Managing Risks of Legionella

Riskof

ContractingLegionnaires’ Disease

SusceptiblePopulation

PathogenProliferation Transmission

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Managing Permissive Growth Conditions

<77°F

Return≥124°F

To Outlets≥124°F

Stored at ≥140°F

To Outlets<77°F

Keep it ColdKeep it HotKeep it MovingKeep it Clean Limit Water Age Maintain Water Temperature Maintain Oxidant Residual Remove Dead-legs

US-CDC

Domestic Water Treatment Strategy


Waterborne microbes enter into the healthcare environment via:

Sources of Waterborne Pathogen Exposure

Direct contact

with water streams

Aerosols from

showers and faucets

Improperly reprocessed

medical devices


Direct contact with ice

Utility Water?<100 cfu/ml

Sterile Water?Critical

Water?<10 cfu/ml



DISINFECTANT RESIDUAL

TEMPERATURE

Oxidant and Temperature Mapping


Growth Risk Potential


How Residual is Impacted

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Disinfection Range158 - 176°F

Slowly Die122-158°F • 131°F ; die within 5-6 hrs• 140°F ; die within 32 min.• 151°F ; die within 2 min.

Growth Range77 - 122°F 95 - 115°F optimum

Do Not Grow Well68-77°F Below 68°F Dormant

Proliferation Risk

Utility & Domestic ServicesTemperature vs. Proliferation Risk

Tem

pe

ratu

re, °

F

Cold Water Tanks

Mains Cold Water

212

176

68

104

140

32

Cold Water Services

Hot Water Services

Spas & Bathing Showers

Hot Water Storage

Steam Humidification

Hot Water Boilers

Cooling Towers

Spray Humidifiers

HVAC Condensate


General Issues that Contribute to Risk

Building 4 Penthouse 5402: Dead Legs

Sinks and Showers blocked off in Bio Medical Engineering Offices where 11 former patient rooms have been converted to offices.

Building 5 Room G869 Employee Shower. Note: Rarely Used


Cooling Water Treatment Strategy

FROM

Performance-Based

Focused on

System Efficiency

Scale & Corrosion Control

Biofouling Control

TO INCLUDE

Health-Based

Focused on

Legionella Risk Management

Legionella Control & Monitoring

Cleaning & Disinfection

Confirmation of Risk Management

Fouling

Water Treatment Model

TheMicrobial

World

<100 CFU/mL (OSHA) Legionella

<10,000 CFU/mL Aerobic Bacteria


General Issues that Contribute to Risk

Main Street Cooling Towers Bldg. 4 Penthouse Towers 58 Bldg. Cooling Towers


Managing Risks of Legionella

Riskof

ContractingLegionnaires’ Disease

SusceptiblePopulation

PathogenProliferation Transmission

DW System Low Flow

DW System Dead legs

DW System/CW New Construction

DW System Lengthy Outages

DW System Temperatures

DW System Sequencing (Booster Pumps/Cross Connects)

DW Critical Equipment (HC Heater/Cooler)

DW Line Disturbances

DW Softeners/Heat Exchangers

DW/CW Pathogen Testing (Dip Slides)

CW Basin Accumulation/Fill Cleanliness

CW High Solids/Organics

CW System Higher Life Forms (DMA)

CW System Biofilms

CW System Deposits

CW Biocide(s) used (pH and dual)

CT C&D

Cooling Towers

CT Fill Cleanliness (DP)

Water Features (Spray, Pond, Cascade)

Sanitary Showers

Safety Showers

Aeration Ponds

Whirlpools/Jacuzzi’s

Hot Tubs

Faucets

Toilets

Irrigation Systems

Icemakers

Firewater Systems

Droplet Size

Distance

Age

Gender

Immunocompromised

• Critical Care

• Sick

• Other Complications (Asthma/HIV)

Smokers

DW = Domestic Water, CW = Cooling Water

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Contingencies to Regain Control in Building Water Systems

Hot & ColdHyperchlorination

Super Heat & Flush

Short Term Remediation Strategies


Long-Term Continuous Control Strategies

Chlorine Dioxide

Chlorine Chloramine Copper-Silver Ions

Ozone UV light

What about these?What about these?

OZONE – NOT PRACTICAL

Cannot maintain residual due to volatility.

UV-Light – NOT PRACTICAL

Point-disinfection only.No Residual.

Contingencies to Maintain Control in Building Water Systems


What’s the Optimal Solution?

Control, Monitoring,& Assurance Reporting

GenerationTechnique

PermittingRequirements


• A Filtration Barrier for Waterborne Pathogens− Delivers sterilizing grade filtered water down to .2 micron

• For High Risk Healthcare Patients− Burn, BMT, Organ Transplantation, Hematology/Oncology, Intensive Care

• For Immediate Response − Confirmed outbreak− Suspected incident− Keeps the water moving

70

Point Of Use Water FiltersA Point Control Strategy


Reducing Risk of WHAIsA Comprehensive approach is vital to Reduce Risk

Legionella AnalyticalSelect a CDC ELITE

certified lab

POU disposable filters Wound care and shower unit


Tower Cleaning & Disinfection

Risk AssessmentHazard analysis and full

service remediation

Secondary DisinfectionPotable water disinfection systems

with non-acid footprint toattain safest approach


Key Takeaways

Water entering a hospital is not sterile

Design and use creates

biofilms

Pathogens may be

present in biofilms

Water can be a source and vector of infection

Infection risk can be

reduced

Water can be a source and vector of infection

Evidence showing infection risk, illness, and death on the rise

Legionella, Pseudomonas, NTMs and others can colonize water systems and subsequently cause WHAI’s

Strategies to reduce risk include Awareness, Water Management Plan, Secondary Disinfection, and POU Filters

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Prevention or Emergency Response“Only you can prevent WHAI’s!”

73

Two Choices, Two Costs One Preferred Option!

Helmet $279

Mask $380

Axe $75

Gloves $150

Jacket $1,800

Boots $450

Cylinder $6,500

Hat$25

Jeans$16

Shovel$30


Thank You


QUESTIONS?

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