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It’s been a quiet week in Lake Hazard-be-gone: Water and Legionella

Not a ton of “hair on fire” stuff in the news this week, so (yet again), a quick perusal of something from the “things to consider” queue.

It seems likely that Legionella and the management of water systems is going to continue to have the potential for becoming a real hot-button issue. I suppose any time that CMS issues any sort of declarative guidance, it moves things in a (potentially) direction of vulnerability for healthcare organizations. That said, it might be worth picking up the updated legionellosis standard from ASHRAE to keep up with the current strategies, etc. I don’t know that there’s any likelihood of eradication of Legionella in the general community (by the way—and I’m sure this is the case, but it never hurts to reiterate—those of you with responsibilities for long-term care facilities are definitely in a bracket of higher vulnerability). But there remains a fair amount of risk in the community, as evidenced by the most recent slate of outbreaks. Water is definitely the common denominator, but beyond that, this can happen anywhere at any time, so vigilance is always the end game when it comes to preventive measures.

As a final thought for the week, I wanted to share a blog item (not mine) that I found very interesting as food for thought (the concept is very powerful, though you may have a tough time convincing your boss to embrace it, as I think you’ll see): treating failure like a scientist. You can find the whole post here, but the short take is that you may have a positive or a negative result of whatever strategy you might employ—each of which should be considered data points upon which you can make further adjustments. Not everything works the way you thought it would, but rather discarding something outright if it doesn’t succeed, try to figure out the lesson behind the failure to make a better choice/strategy/etc. moving forward. The blog covers things more elegantly than I did here, but I guess my closing thought would be to have the courage (maybe “luxury” is the better term) to really learn from your mistakes—if we were perfect, there would never be a need for improvement.

Breathe deep the gathering gloom…

As part of our (seemingly) never-ending quest to find topics of interest for you folks, we turn to the fascinating world of utility systems management, in particular, the management of aerosolizing water systems. As a safety generalist, I am always on the lookout for resources that will help increase my understanding of certain subjects and I try to pass on to you those that I find most useful (particularly over time). That said, I feel I have been somewhat remiss in not alerting you to a resource that I have been following for a fairly long time (it might even extend back to my days as a hospital safety manager—so we’re talking well into the safety Mesozoic era—love those birdsongs!). While the focus is Legionella prevention and education, there’s a lot of information regarding the management of risks associated with the aforementioned aerosolizing water systems—possibly the most risky (in terms of potential impact on patients, staff, and visitors) of the various high-risk utility systems.

The resource of which I am speaking is HCInfo; one of the highlights (at least for me) is that you can sign up for periodic e-mail updates; I find the updates, at the very least, to be thought provoking. The most recent blog posting on the site covers the potential impact on litigation relative to cases of Legionnaire’s disease in the wake of CDC’s release of its guidance for developing a water management program to reduce Legionella in buildings (you can find that august offering here). As noted in the blog entry, the CDC has come up with some very specific recommendations that could very well be the next bludgeon used by our regulatory friends. While the focus of the blog is on the litigious nature of things, there are a couple of take-home messages:


  1. “You should develop a water management program to reduce Legionella growth and spread that is specific to your building” (page ii of the CDC toolkit);
  2. “Legionella water management programs are now an industry standard for large buildings in the United States (ASHRAE 188: Legionellosis: Risk Management for Building Water Systems June 26, 2015. ASHRAE: Atlanta).”
  3. “This toolkit will help you develop and implement a water management program to reduce your building’s risk for growing and spreading Legionella.” (page ii of the CDC toolkit)
  4. “Environmental testing for Legionella is useful to validate the effectiveness of control measures.” (page 21 of the CDC toolkit)


So, while not quite “marching orders,” there is enough certainty lurking within the pages of the toolkit to push for having some sort of plan in place for the management of your aerosolizing water systems (TJC has had a long-standing requirement to minimize pathogenic biological agents in aerosolizing water systems, the CDC toolkit may increase specific focus on this area). The one area that would seem to represent something of a sea change is the “useful”-ness of environmental testing for Legionella. Back in 2003, when CDC published its Guidelines for Environmental Infection Control in Health Care Facilities, there was just enough wiggle room to more or less dismiss the need to do environmental testing for Legionella (to test or not to test, that is the question—and it appears to hinge on what one might consider due diligence). I think partially due to the amount of bureaucratic language in the recommendations section, the sense was that the regular testing was not only just optional, but not really recommended (again, lots of room for interpretation). The current toolkit language definitely makes the case for testing as a means of validating the effectiveness of your control measures. But (as always appears to be the case), it is up to the individual facility to determine frequency, etc. But there is a way to get to that:


One of the key components of the CDC toolkit is (wait for it…) a risk assessment of your facility to help determine the applicable risks in your facility. The question then becomes: how long before our regulatory fiends (oops, friends!) start asking pointed questions about what we’ve been doing in this regard. As always, I provide this as information, but as the survey process continues to evolve (mutate?) in how infection prevention concerns are covered, this one really feels like something we need to button down as soon as possible. No doubt there are those of you who have already embarked upon this journey, so if you have any useful war stories that you could share, I’m sure everyone would benefit from your insight. I think this stands a good shot at being next in the line of hot button survey topics—and it’s an important one. My prediction is that everyone will be in reasonably good stead relative to the recommendations in the toolkit (this could be a very timely—and useful—performance improvement initiative for the EOC Committee), but I would encourage you to take whatever steps are required to be certain that you are in good shape.

Come together, right now over…more heavy breathing

Talk about your regulatory supergroups: it’s almost like the second coming of Crosby, Stills, Nash, Young and all manner of goodness or maybe the Fantastic Four (or in this case, the Spectacular Six)! Back on September 21, the modern healthcare environment equivalent of the Justice League (AAMI, ASHE, AORN, ASHRAE, APIC, and FGI) published a Joint Interim Guidance (JIG) on HVAC in the Operating Room and Sterile Processing Department. The intent of this JIG (sometimes acronyms can be fun) is to address what the Spectacular Six deem “the biggest challenge for owners and designers of health care facilities,” which is “to understand the purpose and scope of the various requirements” of the “conflicting and sometimes unclear” standards and guidelines for the management of heating, ventilation, and air-conditioning (HVAC) so “patient and staff safety and comfort can be managed.” You can check out the JIG document here.

Without spoiling too much of your interest in discovering all the particulars, the JIG speaks to the dichotomy inherent between the minimum design requirements and criteria that are used to construct an HVAC system (the FGI/ASHRAE/ASHE side of the equation) and the guidelines that “are intended to guide the daily operation of the HVAC system and clinical practice once the health care facility is occupied (this is where AAMI/AORN/APIC come in). As any number of you have experienced in real (and sometimes really painful) time, this dichotomy is very much at the heart of the regulatory survey process at the moment (somehow in my heart of hearts I knew that we could be continuing this conversation). But mayhap there is a light at the end of the tunnel (that is not an oncoming train!): the Spectacular Six have begun working towards a harmonization of the HVAC guidance in the various standards. They’ve been working on this since late April and the JIG is, for all intents and purposes, their first work product. I think it’s an excellent start and I hope that their work is allowed to continue with minimal interference from outsider influences (who that could be, I have no idea…).

An important part of the JIG is their advice to healthcare organizations (it’s on p. 2 of the document—I’ll let you reflect on it in your spare time) and those of you who’ve been following this space for a while will guess that my fave-o-rite topic is going to feature quite prominently in this movement: our old friend, the risk assessment! (Admit it, you knew it was going to go that route!) The goal of the assessment is to make a determination of HVAC operating parameters for critical areas that meet patient, personnel, and product storage needs, with an eye towards the identification of appropriate corrective measures to mitigate risk, etc. I think we’ve been honking this horn a bit as we’ve traversed this landscape, but I think the critical opportunity/challenge is going to be based on the Spectacular Six’s intent to communicate/advocate directly with the regulatory folks in this regard. I haven’t yet seen anything official from CMS in this regard, but based on its adoption of the tenets of the Joint Quality Advisory from January of this year (again, a number of web locales for info, including this one), I think we can reasonably anticipate some level of guidance to the surveyor corps in the not-too-distant future.

So perhaps we can work through this in relatively straightforward fashion; at the end of the day, our charge is to ensure that we are providing the safest possible environment for patients, staff, and visitors. But in meeting that charge, we also need to make sure that we are not writing checks that our building systems can’t cash. We should be able to identify appropriate, safe performance parameters that appropriately address all the risk factors and identify a response plan that we can effectively implement when we have conditions that increase the risk to unacceptable levels. If you ask me, that sounds like business as usual…

This one belongs on your shelf…big time!

In the nearly six months I’ve been back in the consulting world, one trend during Joint Commission surveys stands out as the most likely to result in survey heartache (and heartburn). And that trend, my friends, has everything to do with the management of environmental conditions in surgical (and other environments). Clearly, the folks at TJC have struck a motherlode of potential findings—and I have no reason to think that these strikes will be abating any time soon. My advice to you is to start cracking the books—one tome in particular (okay, not so much a tome because it’s really not quite long enough, but if we were to somehow measure its impact…).

For those of you who have not yet procured a copy of the American Society of Heating, Refrigeration and Air-Conditioning Engineers ASHRAE-170 Standard for Ventilation of Health Care Facilities, I cannot encourage you too much to bite the bullet and get yourself a copy of this august standard. I can almost guarantee that doing so will decrease the likelihood of survey ugliness, perhaps even for the foreseeable future.

Now, this volume—a mere 14 pages in length—contains a lovely table (pages 9-12, for those of you keeping score at home) that identifies all the areas in a hospital (hey, maybe even your hospital…imagine that!) in which there are specific design parameters for temperature, humidity, air flow, air exchange rates, pressurization. Pretty much everything that is causing so much pain during TJC surveys of late (I’ve seen a significant increase in the number of Condition-level TJC survey results, which is almost exclusively the result of managing these conditions).

Once you have this volume in your hot little hands, turn to page 9 and start looking at all the places where you can expect scrutiny (word to those facing survey in the near future, there is an indication that the focus is expanding to include any areas in which invasive procedures are performed. Can you say interventional radiology and IVF? I knew you could.). My recommendation is to start working through the list (and, rest assured, it’s a pretty lengthy list) and identify where you are compliance-wise relative to the design parameters listed. And if you should find that you have some compliance vulnerabilities in these areas, please, please, please reach out to your infection control practitioner to start working on a risk assessment/response protocol to manage the risks associated with those non-compliant conditions. It may be the only thing standing between you and an awful journey into the darkness of a condition-level finding—a journey none of us would want to make.

It’s not the heat, it’s the humidity (no, really…)

Good news for those of you who might be struggling a bit with low humidity levels (below 35%) in your surgical procedure areas. CMS issued a categorical waiver based on the recent changes to the FGI Guidelines for the Design and Construction of Health Care Facilities (including the recently updated ASHRAE 170 standard) that allows for relative humidity (RH) values in surgical procedure areas down to a 20% level. Could this be an example of science triumphing over bureaucracy? Only time will tell.

As always, there are some caveats involved: the waiver does not apply if more stringent humidity levels are required under state or local law or regulation or if the reduction of the RH would negatively affect ventilation system performance (which means you need to “know” where you stand relative to state/local requirements as well as the design specifications for your HVAC equipment—and if that sounds like a risk assessment, quack quack!).

Also, the waiver does not specifically establish an upper limit for RH in these areas; it does, however, strongly recommend that an upper level of 60% be maintained based on ASHRAE keeping that upper limit. So I guess those of you in more swampy areas of the world are going to have to keep on keeping on with that. Make sure you’ve got your response to out-of-range values process in good working order.

Administratively, while you will not have to apply in advance for the waiver or wait until you’ve been cited (which is always a fun thing), you must document that you’ve decided to use the waiver. Also, be prepared to notify the survey team assessing Life Safety Code® compliance at the opening conference of the survey that you have decided to use the waiver. Failure to provide documentation of your prior decision to use the waiver could result in a citation.

I guess this is just one more step on the road to the adoption of the most contemporary of codes and regulations. Can you say 2012 edition of NFPA 101? Sure you can! And hopefully, we’ll all be able to say that before too very long…