Protecting Patients from Legionnaires’ Disease: 7 Steps to Creating a Water Management Program

Posted on by CDC's Safe Healthcare Blog

Jonathan J. Flannery, MHSA, CHFM, FASHE, FACHE
Jonathan J. Flannery, MHSA, CHFM, FASHE, FACHE
Senior Associate Director of Advocacy for the American Society for Healthcare Engineering of the American Hospital Association
Guest Author: Jonathan J. Flannery, MHSA, CHFM, FASHE, FACHE
Senior Associate Director of Advocacy for the American Society for Healthcare Engineering of the American Hospital Association

Legionnaires’ disease is a serious type of pneumonia that people most commonly get by inhaling mist that contains Legionella bacteria. People can less commonly get this disease by aspirating contaminated water. In health care facilities, such as hospitals and long-term care facilities, exposure sites can include showerheads, therapy spas and baths, cooling towers, decorative fountains, and certain medical equipment (e.g., bronchoscopes, heater-cooler units). In addition to Legionella, other water-related pathogens pose a threat to patients in healthcare settings. This makes it even more important for healthcare leaders to ensure the water in their facilities is safe for their most vulnerable patients.

ASHRAE Standard 188: Legionellosis: Risk Management for Building Water Systems establishes minimum legionellosis risk management requirements for building water systems. Creating a water risk management plan can help hospitals comply with this standard and mitigate risk as much as possible. Here are 7 steps for creating a water risk management plan:

  1. Create a team: ASHRAE 188 requires a team—called the “Designated Team”—to write water management programs and procedures and to oversee the implementation of the water risk management plan. Who should be at the table? The health care facility Designated Team should include infection control practitioners, hospital administrators, facility management staff and quality assurance staff. Additionally, consider adding team members from nursing management, occupational and environmental safety, or other areas such as representatives from high-risk patient care areas.
  2. Map the water system: The Designated Team should develop a water system flow diagram of the entire building’s water system. This map will help the team identify potential hazard conditions and high-risk patient care areas. You can consider using up-to-date plumbing drawings if available, but those are often too complicated for the team to use for risk assessments. Simplified drawings are often more practical. A helpful example can be found in the publication Water Management in Health Care Facilities: Complying with ASHRAE Standard 188.
  3. Identify risks: The Designated Team should systematically evaluate the water flow diagram to identify potential risks. Look for areas where there is slow or stagnant water. Consider areas with at risk patients including adults 50 or older, current or former smokers, and those with weakened immune systems. It is important to identify both the patient populations at risk and the potential exposure sites (i.e., medical equipment and building water systems) to get a full picture.
  4. Develop strategies to mitigate the risks: The Designated Team should use a risk management approach to identify control locations and limits. Control limits could refer to characteristics such as water flow rate, water temperature, disinfectant residual, concentration of pathogen, or any other identified measurements.
  5. Monitor and respond: The Designated Team should develop monitoring procedures, which include reviewing the control limit data. If there are deviations outside of the set control limits, the Designated Team can consider response methods, such as:
    • Disinfectant
    • Heating
    • Cooling
    • Filtering
    • Flushing water

    A full list of treatment options is available in the Water Management in Health Care Facilities publication. The team should develop standard operating procedures to help reduce risks.

  6. Review periodically: The Designated Team should create procedures that will confirm that the risk management plan is working as planned. This confirmation can be as simple as a spreadsheet that shows specific steps of the water management plan that are reviewed with the team whenever anomalies occur. A full program review should be completed at least annually.
  7. Document, document, document: From the first step through the last, all activities should be documented. Documentation should include all parts of the plan, and must be maintained and kept current.

For more detailed information on complying with ASHRAE 188, download the Water Management in Health Care Facilities monograph or attend the ASHE Annual Conference in Indianapolis August 6–9, 2017. Also, download CDC’s toolkit: Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings and view the latest CDC Vital Signs report on health care-associated Legionnaires’ disease.

Guest Author: Jonathan Flannery, MHSA, CHFM, FASHE, FACHE is the Senior Associate Director of Advocacy for ASHE of the American Hospital Association playing a key role in ASHE’s advocacy program which works for better codes and standards affecting health care facilities. Jonathan has 28 years of health care engineering experience and continues to serve as part of ASHE’s educational faculty. He serves on national panels and committees that develop regulations for the design and construction of health care facilities such as the ICC’s Ad Hoc Committee on Healthcare, ASHRAE SSPC 170 Ventilation of Health Care Facilities, ASHRAE SSPC 189.3 Design, Construction & Operation of Sustainable High Performance Health Care Facilities and NFPA AIC-AAA Committee for NFPA Standards 90A & B.

Posted on by CDC's Safe Healthcare Blog

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Page last reviewed: June 15, 2017
Page last updated: June 15, 2017