Evaluating Waterborne Pathogen Risks for a Stronger Water Management Plan

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An effective water management program is vital to protecting patients from dangerous waterborne pathogens. In fact, one  CDC study found that about 21 percent of healthcare-associated infections (HAIs) can be transmitted via water. Yet many hospitals have struggled with developing and implementing a comprehensive water management program.

Many opportunistic pathogens, such as Mycobacterium and Pseudomonas, can silently thrive within facility water systems, leading to infections that threaten the most vulnerable patients. Mycobacterium have proven to be problematic in healthcare-facility water systems, causing a range of diseases through exposure to wounds and contamination during surgical procedures. Pseudomonas bacteria, found in soil and water, are another common pathogen that can be fatal upon infecting immunocompromised patients.

By understanding where these microorganisms originate and how they spread, their impact can be dramatically reduced through the mitigation of their sources and pathways. Healthcare teams can dramatically reduce risk and safeguard both patient safety and facility reputation.

The Goal of a Water Management Plan: Identifying Waterborne Pathogens

Waterborne bacteria are ubiquitous. They typically grow in stagnant water, or water that is between 68- and 124-degrees Fahrenheit and are commonly found in a variety of water systems such as cooling towers, condenser water systems, storage tanks, showers, faucets, air conditioning units, and ice machines. When the growth of these bacteria go undetected, hospital patients can breathe in airborne mist from water droplets containing the bacteria, potentially leading to a deadly infection.

The first step to addressing waterborne pathogen risks is understanding common sources and pathways. Stagnant water is a common source of waterborne pathogens in healthcare facilities, occurring when water systems experience underuse, such as a rarely used shower in an ICU, or after a wing or facility closure. The environment also becomes ripe for bacterial growth when water-using systems are not appropriately maintained. For example, ice machines that are not regularly disinfected or adequately maintained can lead to a buildup of biofilm that supports bacteria, mold, and other pathogens.

Construction work can create sources of stagnant water or pathways for contamination. Most major new construction or renovation projects either require turning off the water or connecting it at some point to a system that may not have been properly disinfected. Additionally, construction activities may disturb piping systems, altering water quality. A pre-construction risk assessment should include waterborne pathogen control mechanisms.

How to Create a Water Management Plan

Because water is a high-risk source of healthcare-associated infections (HAIs), the Center for Medicare & Medicaid Services (CMS) now requires Medicare-certified healthcare facilities to implement water management policies and procedures. Compliance should align with ASHRAE Standard 188, the national consensus standard for Legionella risk assessment and mitigation, and the CDC’s Developing Water Management Program to Reduce Legionella Growth & Spread in Buildings toolkit.

While ASHRAE 188 focuses on Legionella, facilities should consider expanding their programs to monitor and control other waterborne pathogens through broader surveillance, water-quality monitoring, and corrective actions to protect patients and staff. Additionally, although not yet adopted by the Joint Commission (JC), facilities should consider adopting AAMI ST-108, which recommends including critical water used for medical device reprocessing in water management plans. The JC provides further guidance on how to create an effective water management plan through its water management program standard for Hospital (HAP), Critical Access Hospital (CAH), and Nursing Care Center (NCC) accreditation programs.

The JC previously had a single requirement: to minimize “pathogenic biological agents in cooling towers, domestic hot- and cold-water systems, and other aerosolizing water systems.” The JC’s standard, which went into effect January 1, 2022, has four Elements of Performance (EP) that include specific requirements outlining JC expectations for what that program should include. The four EPs require a team or designated individual responsible for:

• Oversight and implementation of the water management program. The program must include a written plan and diagram of all water supply sources, treatment systems and control measures, processing steps and all end-use points.
• Development of specific program components. These include, but are not limited to, a water risk management plan, a plan for addressing stagnant water, and water monitoring protocols.
• Documenting water monitoring protocols and acceptable ranges for control measures, corrective actions and procedures to follow if measurements fall outside of those ranges and when a probable or confirmed waterborne pathogen case is identified.
• Updating and maintaining the program. Updates must address new risks such as changes to the water system that may add hazard points or the addition of new equipment.

While many healthcare facilities were already meeting some of these requirements before the standard went into effect, this more prescriptive update provides clear regulatory expectations, making robust, documented water management plans a sustained focus for JC compliance. The updated standard emphasizes implementation, ongoing program assessment, and documentation.

The JC now looks at how facilities assess the risk associated with water quality and evaluate the use of water management plans in practice, while monitoring surveillance data and taking corrective action if metrics such as water temperatures fall out of range. This ensures that water management programs are active, effective, and focused on ongoing patient safety, rather than just sitting on the shelf.

Build a Reliable Subject Matter Expert and Management Team

To ensure compliance with this requirement, allocate time to build a knowledgeable water management team. With a multi-department team in place, healthcare systems can develop a plan to proactively mitigate risks and rapidly respond if a problem occurs. Members may include representatives from engineering, nursing, quality and risk management, and infection control. Also included are the medical director of epidemiology, a senior-level support services director, a representative from clinical labs and environmental services, and the facility manager. Within your water management team, you’ll need to assign clear roles and responsibilities.

Ensuring that your entire facility understands why following water management procedures is important for maintaining the health and safety of hospital patients. EH&E can help you make this happen, assisting in developing your plan and making it a reality. If you’d like expert guidance in development of your water management plan, contact us today to speak with one of our experts.

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