Waterborne pathogens: Give them special attention or the lawsuits will soon follow

Risk managers must work with engineers, infection control to minimize risk

The water sitting in the pipes in the walls throughout your facility could pose a liability risk you’ve never considered — waterborne pathogens can grow in your water system and provide unique opportunities for infecting your patients.

When those opportunities present themselves, you can be certain a lawsuit will follow.

Most common among the likely pathogens is Legionella, the bacteria that can cause Legionnaires’ disease. But there are steps you can take to make such an outbreak unlikely. The risk manager’s role, some experts say, is to make sure your maintenance and infection control departments are taking the necessary steps to prevent such problems. If you don’t, you’ll be the one dealing with lawsuits that some consider a slam-dunk for plaintiffs.

The risk of Legionella and similar waterborne pathogens is not unique to health care facilities, but they are at more risk than other types of organizations, says J. Glenn Morris Jr., MD, MPH, chairman of the department of epidemiology and preventive medicine at the University of Maryland School of Medicine in Baltimore, and chairman of a task force that studied nosocomial Legionella recently in Maryland.

"Legionella infection can occur in many health care settings, but the risk is highest in acute-care hospitals that treat patients who are already suffering from a serious chronic disease or a suppressed immune system," Morris says.

Legionella bacteria were first recognized with an outbreak of pneumonia that occurred among attendees of an American Legion convention in 1976. Since then, more than 39 species and 61 serogroups of Legionella bacteria have been recognized. More than half of these species/subgroups have been associated with human disease. Legionella pneumophila, the first Legionella bacteria species identified, accounts for approximately 90% of infections.

Legionella can cause Pontiac fever, an often undiagnosed and generally mild and self-limited respiratory illness, but it also can cause Legionnaires’ disease, a potentially severe bacterial pneumonia that is accompanied by fever, fatigue, and cough. The Centers for Disease Control and Prevention (CDC) estimates between 10,000 and 20,000 cases occur each year in the United States. Nosocomial infections leading to Legionnaires’ disease account for 23% of reported cases to the CDC. Nosocomial cases have a higher mortality rate than community-acquired cases.

The Legionella bacteria must be inhaled; ingesting it will not cause disease. That is why health care facilities can be such fertile grounds for Legionella outbreaks, Morris says. A health care facility presents many opportunities to inhale the bacteria from showers, whirlpools, humidifiers, and inhalation therapies. And, of course, a health care facility has a much higher proportion of weakened, susceptible patients than a typical business.

Extended-care facilities can be at especially high risk, says Tim Keane, president of Legionella Risk Management, a consulting firm in Chalfont, PA. Long-term care patients can be particularly weakened, and incontinence can expose the patient to more than the typical number of showers.

"It’s amazing, the lack of awareness in risk management in hospitals," Keane says. "A lot of people think it’s an infection control problem, so they don’t get involved."

Baltimore outbreak results in four deaths

Legionella outbreaks can quickly turn into a nightmare for risk managers. Keane says these lawsuits usually are an easy win for the plaintiff.

"It’s like asbestos in that if you get the disease, you can sue and you’ll win," he says. "But it’s better than asbestos. With asbestos, it’s tough to prove where you got it. With Legionella, they can test different sites like your workplace and the hospital. If they get a match, they have to prove negligence, that the engineering standards were not implemented. That’s usually not difficult."

The number of published trial results seems few, but that may be because, Keane says, "the lawyers I talk to always recommend that the defendants settle."

One terrible outbreak of Legionnaires’ disease in a health care facility occurred in Havre de Grace, MD, near Baltimore, in July 1999. Officials at the Harford Memorial Hospital reported that four patients diagnosed with Legionnaires’ disease died from the illness. The patients were among five originally diagnosed with the disease at the hospital, says Louis Sperling, JD, vice president for human resources and legal counsel for the health system Upper Chesapeake Health.

The problem was traced to the hospital’s hot-water system, though investigators never found the specific cause of the Legionella infiltration, Sperling says. Extensive testing found Legionella at several hot-water outlets throughout the facility. The infected patients were different in many ways, and they were not on the same unit or in nearby rooms, though most of them were immunocompromised.

The state health department recommended superheating the water supply, but the hospital continued to find positive test results after that treatment. Then the hospital started superchlorinating the system, and that eliminated the Legionella. Sperling says the hospital continues to superchlorinate the water system as a precaution and has had no positive results in a year and a half.

A Legionella outbreak is particularly difficult for a hospital because the public reacts with near panic at the mention of Legionnaires’ disease, Sperling says. Even the hospital staff were wary, he says.

"Risk managers have to be concerned about this," Sperling says. "Risk management has a responsibility to ensure that the lines of communication necessary to prevent this kind of outbreak are in place. It’s one thing for engineering to say they’ve got it under control, but our risk-management department ensures that, if there is any positive reading at all, that is relayed to risk management and to infection control. Risk management plays a coordinating role, making sure everyone is talking to each other."

Risk management should establish the level of caution that will be utilized within the facility, Sperling says. Engineering, for instance, may decide that the water should be tested twice a year and low-positive results can be ignored. There may be engineering standards that justify that decision, but risk management may determine that the organization needs to be much more cautious. Sperling and the risk manager at Harford Memorial, for instance, decided that they should do weekly testing for a while after the outbreak; now monthly testing is done.

"That was a risk-management decision that took us far beyond the engineering and clinical standards," he says. "We determined that there was reason for organization to be extraordinarily cautious now."

Death’s fallout

Investigations after the deaths never revealed any deficiencies in the hospital that could have caused the outbreak, Sperling says. Even when the Legionella outbreak occurs without any obvious cause, there is tremendous liability risk for the hospital, he says.

"There was a case filed after the deaths. There definitely is going to be legal fallout any time you have four people die," he says. "You’re going to have someone wanting to point the finger at you."

Sperling declined to say how the lawsuit was resolved. He confirmed, however, that "the liability risk is significant."

Another Legionella source was discovered in August 2000 at St. Joseph Medical Center in Towson, MD. Officials there banned showers and distributed bottled water to patients after an inspection of the hospital’s hot-water system revealed the presence of Legionella. The hospital, just north of Baltimore, began treating the hot-water system after tests revealed elevated levels of Legionella bacteria, according to hospital spokeswoman Linda Harder. No patients contracted Legionnaires’ disease, but one patient was confirmed as having Legionella and recovered.

Earlier, in 1998, two patients died and three others were ill with Legionnaires’ disease at a hospital in Tarbes, France. In that case, hospital officials reported that the bacteria were transmitted in the hospital by vapors rising from hot water used in physical therapy treatments.

After the outbreaks near Baltimore, a Maryland state health task force released recommendations to hospitals that included routinely testing water systems, giving doctors quick access to diagnostic tests and setting up Legionnaires’ response teams to deal with outbreaks. The CDC also issued guidelines for preventing nosocomial Legionnaires’ disease. They can be found at www.cdc.gov/ncidod/hip/pneumonia/2_legion.htm.

Problem addressed by Joint Commission

The Joint Commission on Accreditation of Healthcare Organizations makes it clear that hospitals must take the proper steps to protect patients from waterborne pathogens. But it has not specified exactly what they must do. In the utility standard, EC.1.7 (previously EC.1.9), the Joint Commission says accredited facilities must "reduce the potential for organizational acquired illness," but it is a utility equipment standard, not an infection control standard. Two new intent statements were added to the standard in 2001. Intent item "i" addresses water-based systems and requires that equipment for recirculating water be continuously properly designed, accurately installed, and adequately maintained.

Most frequently, Legionella grows in a water system that allows water to stand for too long at the temperature most favorable to the bacteria. The bacteria grow between at 86° and 110° F, so a big part of the solution is to keep hot water at a higher temperature and cold water pipes insulated to a lower temperature. Stagnation is another big threat, Keane says.

"Patient-care areas tend to have a lot more plumbing and outlets than your typical room, even your typical bathroom. If you convert that room to an office, suddenly all those pipes aren’t used any more and the water can just sit there," Keane says. "If you’re renovating and close down a unit for a week, you have to flush those pipes and make sure the water’s good before you use it again. Typically, nothing is done."

Engineering and infection-control professionals have extensive resources for the details of how to prevent waterborne pathogen outbreaks. Keane suggests that the risk manager should be the one overseeing the risk control by ensuring that the other departments are taking the necessary steps.

"Hospitals take for granted that water coming out of the faucet is clean, but that’s not necessarily the case," Keane says. "The water supplied by the city is clean enough for a healthy person to drink, but other things can happen in your own building."