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A water disruption or contamination situation can wreak havoc on health care facilities, imperiling patients and causing major headaches for infection control professionals. But as a practical matter, there is likely to be an initial burning issue in the minds of health care workers.
"What first started this for me was walking in and saying, Can we drink the coffee?’" recalls Janette Drapchak, RN, CIC, infection control manager at Rahway (NJ) Hospital.
That and many other questions had to be answered after Hurricane Floyd flooded North-west New Jersey in 1999. The same area had been hit by a complete tap water loss in 1995 when a water main broke. Using knowledge gained from both experiences, Drapchak and colleagues developed a disaster plan to prepare health care facilities when water is everywhere or not to be found.1 (See "Water disaster infection control," in this issue.) The plan is particularly insightful in that it reflects firsthand experience with both a complete water loss and a severe flood caused by a pounding hurricane.
"Hurricane Floyd hit New Jersey in a rather odd way," says Anthony Monaco, BBA, MA, one of the developers of the plan and an environmental scientist with the New Jersey Department of Health in Trenton. "It swung around to the west-northwestern side of New Jersey and hit the northern and northwest counties really hard. We had massive flooding. It took out a couple of major water companies, actually flooded them. We ran a boiled-water order for almost a week."
With the water supply potentially contaminated and appearing turbid, surveillance was stepped up for waterborne pathogens such as cryptosporidium and E. coli. (See "Focus surveillance on waterborne pathogens," in this issue.) Health officials and ICPs monitored the hospital emergency departments for any significant increase in diarrhea. Local health departments checked the pharmacies for any signs of depleting antidiarrheal medications. Overall, water quality was questionable in an area that included about 4 million people and many health care facilities.
"Information was poor and was changing rapidly," Monaco says. "The phone lines were out, and we couldn’t get to the health departments. I gave the latest updates to the northern chapter of APIC [Association for Professionals in Infection Control and Epidemiology] so they could bring it back to their hospitals."
While the area survived the hurricane without a major waterborne outbreak, another hard lesson had been learned on the heels of the 1995 water outage. In that situation, water was lost to about six hospitals and 1 million people.
"After [both incidents], we sat down and discussed it with the infection control professionals," he says. "They [suggested] developing a plan that all health care facilities could use as a model or at least as talking points when they are in their emergency planning meetings."
At the onset, the guidelines emphasize that procurement of water from alternate sources is a planning function — not something to think about after a disaster has occurred. Contracts should be established and maintained so that potable water will be available immediately in the event of a disruption. Bulk water (tanker truck) contracts should be in place with two or three companies that have the capability to transport potable water in sanitary, food-grade vehicles, the guidelines recommend.
As for bottled water, the amount of water needed for patients and personnel was estimated at about 1-2 liters per person per day, depending on the patient population. Contracts should be established with two or three companies to ensure the availability of bottled water in a widespread emergency, the guidelines stress. An emergency supply of bottled water should be maintained on the premises, then additional supplies of bottled water for drinking obtained as necessary. How-ever, even unopened bottled water cannot be kept indefinitely so stocks have to be changed out.
"Did you know that bottled water has a two year expiration date?" Drapchak asks. "I didn’t know that." And of course, as the ICPs mulled such newfound facts about water, they discussed its critical role in infection control: hand washing. We talked about using the alcohol-based [waterless] products and making sure you had enough available."
While such products are essential — particularly if there is no water to wash with — a contaminated water situation may allow washing to continue. During the flooding, health officials decided to recommend that health care workers continue hand washing with the tap water if no alternative was available. The decision was based in part on the fact that they had not been finding high counts of contamination in the water, Monaco says.
"We thought that hand washing was far more important, and the antimicrobial soap that they were using could [clear contamination]," he says. "The only problem we had was that we were also telling the health care population that it was unsafe to drink. Yet you are telling them to wash their hands. It’s a double standard, and people don’t understand that. It’s a mixed message"
For water-dependent patients, such as those in hemodialysis, the best-case scenario is to leave a water disaster area and seek treatment where water availability and quality is not in question. If that is impossible and a clean water source is not available, potentially contaminated water can be used because dialysis machines should filter out the impurities, he adds. In the 1995 water outage, water trucks were brought in for dialysis patients, Monaco says.
"If you have hemodialysis patients, you have two choices: either move them out to a nonaffected area, which is a major task, or get water to them," he explains. "The dialysis machines use water to mix the dialysate to draw the impurities out of the blood. Everything is water based. In that situation, you would actually have to get tankers hooked up to the existing pipes and deliver water to these areas. Dialysis was our No. 1 concern right from the get-go."
The loss of water also crippled another aspect of the hospitals that was something of a shock to investigators. "One thing I didn’t realize — and was it was one of the first glaring things — was that [water loss] knocked out the X-ray machines because the developers are dependent on water. So we needed to get water into those developers in order to have X-ray abilities for [the emergency department]."
Sterilizers are a similar problem if they need water to create steam, he adds. Again, it was felt they could be run in the flood situation because any water contamination should be killed in the process of creating steam.
Adequate preparation, using the lessons learned from those who dealt with such experiences, could help many an ICP faced with a water crisis. "Water problems can happen at any time for a number of reasons," Monaco says. "When they do happen, even though hospitals are supposed to have emergency plans, there was really no plan on how to deal with significant episodes like these."
Now that plan is available, detailed right down to the coffee question. In that regard, the guidelines state that coffee makers can be used in a potentially contaminated water situation if they can be brought to and maintained at a temperature of 170 degrees F for three minutes. Some coffee makers have built-in temperature gauges, but if not, devise a method to ensure the time and temperature recommendations are being met, the guidelines recommend.
"You wouldn’t think of coffee," Monaco says. "But it was a major issue with employees."
1. Drapchak J, Ferrer L, Leschek J, et al. Recommendations for Safe Practices during Water Supply Disruption and/or Contamination in Healthcare Facilities. New Jersey; 2001.