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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.

My heart is black and my lips are cold

Crash carts on flame with rock and roll!

I figured I’d start out the newly minted 2017 with a few brief items of interest: a device warning from FDA, some thoughts regarding post-Joint Commission survey activities, and a free webinar that some of you might find of interest.

On December 27, the Food & Drug Administration (FDA) communicated a warning letter to healthcare providers regarding potential safety issues with the use of battery-powered mobile medical carts. The warning is based on FDA’s awareness of reports of “explosion, fires, smoking, or overheating of equipment that required hospital evacuations associated with the batteries in these carts.” Apparently, the culprits are those carts powered by high-capacity lithium and/or lead acid batteries and it also appears that there is a distinct possibility that you might just a few of these rolling around in your facility. Fortunately, the warning (you can see the details here) also contains some recommendations for how to manage these risks as a function of the preventive maintenance (PM) process for the battery-powered mobile medical carts; as well as recommendations for what to do in the event a fire occurs (might be a good time to think about testing your organization’s fire response plan as a function of response to a Class C electrical fire). The warning letter also contains some general recommendations for managing the mobile medical carts. So, if you were wondering whether you were going to have anything interesting to put on the next EOC Committee agenda, this one might just fit the bill. As a final thought on this, I think it very likely that our comrades in the regulatory surveying world might be interested in how we are managing the risks associated with these carts—and if you’re thinking risk assessment, I couldn’t agree more!

Moving on to the post-survey activity front, TJC division, for those about to be surveyed (I salute you!), I have some thoughts/advice for preparing yourselves for a slight, but nevertheless potentially dramatic, shift in what you will need to provide in your Evidence of Standards Compliance—a plan for ongoing compliance. Now I will admit that in some instances, being able to plot a course for future compliance makes a lot of sense; for example, managing pressure relationships in procedural areas. If you get tagged for that during a survey, I think it’s more than appropriate for them to want to know how you’re going to keep an eye on things in the future. But what about the million and one little things that could come up during a survey (and with the elimination of the C elements of performance, I think we all know that it’s going to seem like a million and one findings): doors that don’t latch, barrier penetrations, dusty sprinkler heads, etc. There already exist processes to facilitate compliance; are we going to be allowed to continue to use surveillance rounds as the primary compliance tool or is the survey process going to “push” something even more invasive? It is my sincere hope that this is not going to devolve into a situation in which past sins are held in escrow against future survey results—with compounding (and likely confounding) interest. Sometimes things happen, despite the existence/design/etc. of a reasonably effective process. As I’ve said before (probably too many times), there are no perfect buildings, just as there are no perfect plans. Hopefully perfection will not become the expectation of the process…

As a final note for this week, one of the bubbling under topics that I think might gain some traction the new year is the management of water systems and the potential influence of ASHRAE 188: Legionellosis: Risk Management for Building Water Systems. I know we’ve touched on this occasionally in the past and I think I’ve shared with you the information made available by our good friend at the Centers For Disease Control and Prevention (check it out, if you haven’t yet done so), but in the interest of providing you with some access to a little more expertise than I’m likely to muster on the topic, there is a free webinar on January 19 that might be worth your time. In the live online event, “Following ASHRAE 188 with Limited Time, Money, and Personnel: Pressure for Building Operators and Health Officials,” respected expert Matt Freije will briefly discuss the pressure facing building operators as well as health officials regarding compliance with ASHRAE 188 to minimize Legionella risk, suggest possible ways to reduce the pressure, and then open the conversation to the audience. The 60-minute webcast begins at 1 p.m. EST. It’s free but space is limited; you can register here.

So that’s the scoop for this week. I hope the new year is treating you well. See you next week!

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.