By Gary Evans, Medical Writer

A recent strongly worded directive by the CMS to implement water management programs to prevent Legionella infections in hospitals and long-term care facilities is the subject of much conversation and consternation in Portland at the annual meeting of the Association for Professionals in Infection Control and Epidemiology (APIC). Bottom line: If you don’t have a water system management plan for this increasing threat, you’d better start collaborating with other key departments and get one in process.

The CMS listed “immediately” as the effective date.

We sought out one of the top Legionella experts at the APIC meeting, Janet Stout, PhD, president of the Special Pathogens Laboratory in Pittsburgh. Stout has been researching this waterborne bug since it first emerged in a dramatic 1976 outbreak at a Philadelphia hotel.

“What I see the CMS doing is really putting their feet to the fire because they control funding for hospitals,” she tells Hospital Infection Control & Prevention. “The language in the CMS memorandum was pretty dramatic. It said implement a risk assessment, do a water management plan, evaluate the effectiveness of the plan through testing. The language then said if you don’t, you will be cited and funding may be affected. Well, this is like [the commercial], ‘when E.F. Hutton talks, people listen.’ When CMS says something like this people jump to it. So I see it having a pretty dramatic effect on implementation. People will start doing what, in my opinion, they should have done a long time ago. But better late than never.”

With federal health officials reporting a striking surge in healthcare associated Legionnaires’ disease (LD), the Centers for Medicare and Medicaid Services issued the memo to its inspectors on June 2, 2017.

“In a recent review of LD outbreaks in the United States occurring in 2000–2014, 19% of outbreaks were associated with long-term care facilities and 15% with hospitals,” CMS said in the memo. “The rate of reported cases of legionellosis, which comprises both LD and Pontiac fever (a milder, self-limited, influenza-like illness) has increased 286% in the U.S. during 2000–2014, with approximately 5,000 cases reported to the Centers for Disease Control and Prevention (CDC) in 2014. The CMS expects Medicare-certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems.”

The regulatory move was supported by the CDC at a recent press conference, where the consensus was that the threat of healthcare-associated LD warrants action beyond voluntary efforts like those recommended in a CDC toolkit on the issue. The CDC toolkit was modeled on a 2015 standard by the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE).

“Hospitals have been aware of the ASHRAE standard since June of 2015, so the whole concept of looking at Legionella in water systems is not new,” Stout says. “But that was a voluntary standard so there were kind of early adopters and others taking their time – ‘I don’t have to, so I am not going to do it.’”

With the exception of VA hospitals already in compliance, many facilities will have to develop policies now. The increase of this bug – which first appeared when Rocky won the Oscar for best picture – may be explained in part by an aging population and more testing for Legionella as a cause of pneumonia. But the truth is many cases of healthcare-associated LD are missed because lengths of stay now average only about half of the 10 days needed to confirm a nosocomial case, Stout notes.

Born in Philadelphia, Legionella is still in the ring. IPs are going to have to answer the bell.

For more on this important development see the next issue of Hospital Infection Control & Prevention. 

Gary Evans has written about infectious diseases, occupational health, medical ethics and a variety of other healthcare issues for more than 25 years. His writing has been honored with five awards for interpretative and analytical reporting by the National Press Club in Washington, DC.