Att 14_Infection Control Clinician_Test materials

DEVELOPING A LEGIONELLA WATER MANAGEMENT PROGRAM

Special Considerations for
Healthcare Facilities
ELEMENTS OF A WATER MANAGEMENT PROGRAM
Developing and maintaining a water management program in healthcare facilities requires a few more
considerations than the ones explained on page 6. All healthcare facilities should have a Legionella water
management program.

Include all areas where hazardous conditions may contribute to
Legionella growth and spread:
• Patient care areas (such as patient rooms and ICUs, but don’t forget
other places like dialysis, respiratory therapy, and hydrotherapy)
• Clinical support areas (including dietary and central supply) which
could contribute to spread by aspiration

The team should include
someone who understands
accreditation standards and
someone with expertise in
infection prevention

1
Establish a water
management
program team

Include all components and devices that can contribute to Legionella
growth and spread, as listed in the glossary on page 3. Think about all
of the places where patients can be exposed to contaminated water.
Don’t forget about ice machines, heater-cooler units* and respiratory
therapy equipment.

2
Describe the building
water systems using
text and flow diagrams

4
5

Establish ways to
intervene when
control limits
are not met

3
Identify areas where
Legionella could grow
and spread

Decide where control
measures should be
applied and how to
monitor them

Think about:
• Areas where medical procedures may expose patients to water
mists, such as hydrotherapy and respiratory therapy devices
• Areas where patients are more vulnerable to infection, such as bone
marrow transplant units, oncology floors, or intensive care units

6
Make sure the
program is running
as designed and
is effective
*Devices that are commonly
used during cardiac surgical
procedures to warm and
cool a patient’s blood during
cardiopulmonary bypass

7
Document and
communicate all
the activities

Continuous program review (see page 6)

Reference: ASHRAE 188: Legionellosis: Risk Management for Building Water Systems June 26, 2015. ASHRAE: Atlanta. www.ashrae.org
Note: ASHRAE 188 Normative Annex A applies to accredited healthcare facilities that have a Certification Board of Infection
Control and Epidemiology (CBIC) certified infection preventionist or a master’s-level epidemiologist.

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DEVELOPING A LEGIONELLA WATER MANAGEMENT PROGRAM

IDENTIFYING & INVESTIGATING LEGIONNAIRES’
DISEASE CASES
Healthcare facilities are often uniquely positioned to identify and respond to cases of Legionnaires’
disease. A healthcare facility’s water management program to limit Legionella growth and spread should
include the actions to take when a patient is diagnosed with Legionnaires’ disease or environmental
triggers occur. If you decide to conduct a full investigation of the source of an infection, key elements
should be included, as noted below. A full investigation following a diagnosis of Legionnaires’ disease
can help determine whether the infection was acquired in the facility or the community.
Clinicians should test patients with healthcare-associated pneumonia for Legionnaires’ disease.
This is especially important among patients at increased risk for developing Legionnaires’ disease
(see Appendix A), among patients with severe pneumonia (in particular those requiring intensive care),
or if any of the following are identified in your facility:

6 Patients with Legionnaires’ disease, no matter where they acquired the infection
6 Positive environmental tests for Legionella
6 Changes in water quality that may lead to Legionella growth (such as low chlorine levels)
The preferred diagnostic tests for Legionnaires’ disease are culture of lower respiratory secretions on
selective media and the Legionella urinary antigen test.

Perform a full investigation for the source of Legionella when:

6 ≥1 case of definite healthcare-associated Legionnaires’ disease (a case in a patient who spent the
entire 10 days prior to onset of illness in the facility) is identified

6 ≥2 cases of possible healthcare-associated Legionnaires’ disease (cases in patients who spent
part of the 10 days before symptoms began at the same facility) are identified within 6 months of
each other

Key elements of a full investigation include:

6 Working with local and/or state health department staff
6 Reviewing medical and microbiology records
6 Actively identifying all new and recent patients with healthcare-associated pneumonia and testing
6
6
6
6
6
6
6

them for Legionella using both culture of lower respiratory secretions and the Legionella urinary
antigen test
Developing a line list of cases
Evaluating potential environmental exposures
Performing an environmental assessment
Performing environmental sampling
Subtyping and comparing clinical and environmental isolates
Decontaminating environmental source(s)
Reviewing and possibly revising the water management program

Reference: ASHRAE 188: Legionellosis: Risk Management for Building Water Systems June 26, 2015. ASHRAE: Atlanta. www.ashrae.org
Note: ASHRAE 188 Normative Annex A applies to accredited healthcare facilities that have a Certification Board of Infection
Control and Epidemiology (CBIC) certified infection preventionist or a master’s-level epidemiologist.

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