Water Quality and Conservation

By Richard Dixon and David W. Koenig, PhD

This article originally appeared in the December 2023 issue of Healthcare Hygiene magazine.

Water is vital for life on this planet. Some organisms have up to 90 percent water by body weight. Humans contain up to 60 percent water. Water is also critical in the survival and transmission of pathogens in the healthcare environment. Microorganisms require water to grow and reproduce.

Water requirements for growth are best defined in terms of water activity, aw, of the substrate rather than as water concentration. The water activity of a solution is expressed as aw = P/Po, where P is the water vapor pressure of the solution and Po is the vapor pressure of pure water at the same temperature. Addition of a solute to an aqueous solution in which a microorganism is growing will have the effect of lowering the aw, with a concomitant effect upon cell growth.

Every microorganism has a limiting ‘aw’ below which it will not grow, e.g., for streptococci, Klebsiella spp., Escherichia coli, Clostridium, and Pseudomonas spp. the value is 0.95. Staphylococcus aureus is the most resistant and can proliferate with an aw as low as 0.86. Some fungi can grow with an aw of 0.7. Therefore, wet environments favor the survival and therefore transmission of fomites.

Water is also key to the cleaning and disinfection of these surfaces. Cleaners and disinfectants are mostly water based either being used as a ready-to-use (RTU) or diluted with water at the point if use. Taken together water is critical for life, critical for pathogen transmission and survival, and critical for infection control. Therefore, it is important to understand water as it enters the healthcare facility and all the forms it can be encountered in that facility.

Water Quality
In the United States potable water or drinking water is regulated by the Environmental Protection Agency (EPA). The EPA sets the legal limits on more than 90 chemical and microbial contaminates for drinking water. The EPA mandates that any water treatment technology must meet a disinfectant standard and that the resulting product is free of pathogens.

Although potable water standards ensure safe drinking water, the water is not sterile. Following EPA standards ensures that drinking water has a low probably of containing at risk organisms. The disinfectant is added at the treatment facility and is at a level that allows for preservation of the drinking water through the potable water distribution system to point of use. The level of disinfectant can be relatively low at the point of use dependent on the demand in the distribution system. The disinfectant added is not sufficient to control contaminates that may be introduced into the distribution system due breaks in the system. Once the water is removed from the distribution system, that level can decrease rapidly due to demand. Importantly for infection control measures, the design of the buildings’ water distribution system can significantly alter water quality. The water in the building can pass into water heaters, heat exchangers, faucet aerators, and lie stagnant in dead legs before use. Ice machines can be a challenge for microbial control. Furthermore, in older buildings, mixed metals and plastics used in the distribution system due to renovations and building additions can impact mineral build-up and biofilm development. Water systems that are not managed appropriately allow waterborne pathogens to increase in types and numbers resulting in infections in susceptible individuals.

Innovations for optimizing water quality, safety and conservation in a healthcare facility are insightful, forward-thinking, and necessary. By employing a holistic approach to water management, facilities can not only enhance operational efficiency and reduce the cost of the water supply from the local municipality but also contribute to environmental sustainability and most importantly patient, staff, physician, and visitor safety. The next sections will review those processes and provide insights in optimizing water usage while reducing pathogen transmission risk.

Water Microbiology: The main risk of bacteria in drinking water is usually due to contamination events that introduce human fecal organisms to the water distribution system. The most common problem organisms associated with drinking water are Vibrio cholerae, Vibrio parahaemolyticus, Salmonella enterica, Shigella dysenteriae, Shigella flexneri, Shigella boydii, Shigella sonnei, Escherichia coli, and Campylobacter sp. Problem viruses include adenovirus, astrovirus, hepatitis A and E viruses, rotavirus, norovirus, and enteroviruses, including coxsackieviruses and polioviruses. Other bacteria associated with water and infection include Mycobacterium, Legionella, Burkholderia, Klebsessia, and Ralstonia. Fungi can be isolated from tap water distribution systems, but their types and numbers are poorly defined. The most detected fungi are Aspergillus, Cladosporium and Penicillium. Giardia and Cryptosporidium are the most problematic protozoans found in water systems.

Point-of-Use Water Disinfection Technology

Reactive Oxygen Species (ROS): An innovative method of reducing pathogens in water is the use of point-of-use (POU) of ROS such as superoxide radicals, hydrogen peroxide, and hydroxyl radicals, are molecules that can cause oxidative stress and damage to pathogen cellular components. Water, on the other hand, is a fundamental molecule that supports life and biochemical processes by acting as a solvent and facilitating various reactions within cells but does not kill any bacteria.

Germicidal Ultraviolet Light: The most effective systems are those ultraviolet lights with the C wavelength (UVC) at 254 nanometers, which can easily disinfect the incoming or return water lines.

Copper-Silver Ionization: The proposal of using hot water produced at the central boiler room, treated through a copper/silver ionization system for bacterial control, is a proactive step to ensure safe water distribution. This measure, particularly in combating bacteria like Legionella, is both prudent and necessary, for safeguarding the well-being of all stakeholders in a healthcare facility.

Hand Hygiene Sinks That Use Ozonated Water: A smart flow sink that uses ozonated water to eliminate bacteria both on hands and on the sink, itself is a truly an easy way to eliminate harmful pathogens that collect in the P-trap below hand hygiene sinks. Ozonated water has been shown to be more effective than soap and water for bacterial removal from hands. This sink also provides a source of ozonated water for general cleaning and sanitizing. Convenient and twice as powerful as bleach. The sink is programmed to disinfect itself automatically, every hour, eliminating CPOs (Carbapenem-producing organisms, like Kleb’s pneumonia and E. coli) and preventing biofilm formation in the P-trap to prevent CPO outbreaks in a healthcare facility. And the system does not generate ozone into the air.

Engineering and Process Control Steps to Maintain Water Quality
Water Quality Measurement: Incorporating technology to monitor water quality parameters like hardness, pH, and total dissolved solids (TDS) is a crucial step toward ensuring the safety and suitability of water for various purposes. By setting and adhering to quality standards, you’re building a foundation for a consistent and reliable water supply throughout the facility.

Eliminate Dead-End Piping: Toward this end, it is important that a healthcare facility identify dead-end piping systems and segregate them from the active water lines. Keep in mind that most water distribution systems flow through copper pipes.

Eliminate Aerators on Sink Faucets: Aerators on sink faucets collect minerals and pathogens so their use should not be allowed on any sink in the healthcare facility.

Eliminate the Traditional P-Trap Under Sinks: An innovative approach to significantly reducing pathogen containing wet and dry biofilms in a traditional sink P-trap is to eliminate this 140-year-old method of sewer gas control with a straight vertical drainpipe. The sewer gas control is accommodated by using an automated negative pressure system from the drain piping air vent with exhaust to the facility roof. In addition, gate or ball shut off valves on the horizontal drain piping can be closed off periodically to have disinfectants poured into the sink drains with an appropriate amount of dwell time to kill the pathogens and the piping then re-opened back up for regular use. Also never dump patient medications, fluids, feces in a sink. Always follow the facility’s standard operating procedures for these components.

Ice Machines Cleaning and Disinfection: These units commonly used for producing ice cubes and crushed ice can become contaminated if not properly maintained, cleaned and disinfected. Contamination of ice machines can pose health risks, as the ice produced may encounter harmful microorganisms and impurities. Here are some potential sources of contamination and steps to prevent it:

Microbial Contamination: Bacteria, molds, and yeast can grow in the water supply, ice bin, and ice-making components of the machine. These microorganisms can multiply and contaminate the ice cubes.

Prevention: Regularly clean and sanitize the ice machine according to the manufacturer’s recommendations. This includes cleaning the ice bin, water lines, and ice-making components. Use approved cleaning agents to eliminate microbial growth. Even better, ultraviolet light systems with the C wavelength (UVC) at 254 nanometers, can easily disinfect the incoming water line. Another innovation would be to use modular ozonated water systems. An ozone generator system regularly sanitizes the water supply and kills bacteria, mold, and yeast. It produces an effective but safe amount of natural sanitizer that treats the machine interiors and sanitizes the remote storage bins and drains. No aerosolized ozone is dissipated into the air through this process.

Mineral Buildup: Over time, minerals from the water can accumulate in the ice machine, leading to scale buildup. This can affect the quality of the ice and the efficiency of the machine.

Prevention: Use a water filtration system to reduce mineral content in the water supply. Regularly descale the ice machine to remove mineral build-up. Follow the manufacturer’s instructions for use and de-scaling procedures plus the frequency.

Cross-Contamination: Improper handling of ice scoops and containers can lead to cross-contamination. If hands, containers, or utensils that are not properly sanitized encounter the ice, it can lead to contamination.

Prevention: Train staff in the proper hygiene practices when handling ice. Provide separate scoops for ice and other food items to prevent cross-contamination.

Airborne Contaminants: Airborne particles, dust, and debris can enter the ice machine and settle in the ice bin, leading to potential contamination.
Prevention: Keep the ice machine in a clean environment and regularly clean the surrounding area. Use air filters to minimize airborne contaminants entering the machine.

Improper Storage: Storing ice for extended periods without proper protection can lead to contamination from external sources.

Prevention: Use covered ice bins to protect ice from airborne contaminants. Dispose of ice that has been exposed for too long.

Water Quality: Poor water quality, including high levels of impurities or contaminants, can lead to poor-quality ice.

Prevention: Use water filtration and softening systems to improve the quality of the water used in the ice machine.

Inadequate Maintenance: Neglecting regular cleaning, maintenance, and inspection of the ice machine can increase the risk of contamination.

Prevention: Develop a predictive and preventative maintenance schedule and follow the manufacturer’s guidelines for cleaning and maintenance. Train staff on proper cleaning procedures

Water Conservation

AI-Driven Efficiency in Water Heating: Integrating artificial intelligence (AI) technology into zone booster heaters to manage hot water distribution effectively is a testament to the facility’s commitment to efficiency. By providing hot water precisely where and when it’s needed, you not only minimize wastage but also optimize energy usage. This thoughtful approach showcases the potential of technology in streamlining resource allocation. This can be achieved by heating the water in the central mechanical room at a lower temperature and using booster heaters at locations where hot water consumption is minimal or varied.
Waste Disposal Systems: A suggestion to eliminate macerator waste disposal systems is well-founded. By replacing processes that contribute to clogging municipal waste filtering systems, you’re fostering smoother waste management operations and potentially reducing maintenance costs. This proactive shift reflects a practical and sustainable approach to waste disposal.

Reverse Osmosis (RO) Water: This can be an eco-friendly and cost-effective approach, as RO systems waste a significant amount of water during the filtration process. Here are some ways you can reuse RO water:
 Landscaping: One of the most common uses for reused RO water is for watering plants and gardens. Since RO water is free from many contaminants, it can be suitable for your plants. Be cautious, however, not to overdo it with sensitive plants, as RO water might lack some minerals that are beneficial for plant growth.
 Humidifiers and Chillers: Reused RO water can be used in this type of equipment as it doesn’t contain minerals that can lead to scaling or deposits in these appliances. RO water for use in cooling towers, allows for less chemical use, and allows water to be re-used for significantly less cycles than municipal water.
 Waste RO Water: Instead of putting the waste RO water into the sanitary drain system, it can also be disposed of into the storm sewar stream with permission of the local municipality. They also may be able to provide a tax credit using this disposal system as the water that goes into a sanitary system requires municipal processing.
 Toilets: A very innovative process is to channel RO water for use in toilet flushing.

Compressing Municipal Water Supply: It’s a simple fact that along with the volume of water passing through your water meter is a volume of air. The volume of that air will vary as the water pressure fluctuates between static and dynamic pressure. The problem is that more than 99 percent of water meters are measured by volume, regardless of whether that volume is liquid or gas. A smart valve that compresses the municipal water before passing through a facility water meter takes long established principles of pressure and fluid dynamics, such as Boyle’s Law regarding gas pressure and volume, and Le Chatelier’s Principle of volumetric dynamics, and applies them in a new and financially rewarding application. This innovative process eliminates most of the air bubbles in the water and thus the volume is reduced and so is the cost.

Leak Detection Technologies: Smart meters and sensors can identify leaks and potential contamination points in water distribution systems, helping to reduce water losses and save money too. Leaks, even small ones, can waste significant amounts of water over time. Implement a proactive leak detection and repair program to fix leaks as soon as they are identified.

Educational Campaigns: Public awareness and education campaigns in the healthcare facility can promote water-saving behaviors and encourage individuals and communities to adopt water-efficient practices.

Water Audits and Monitoring: Conduct regular water audits to identify areas where water is being wasted. Install zone water meters to track usage in different parts of the facility and identify trends or anomalies.

Water-Saving Technologies: Consider installing water-saving technologies such as sensor-operated faucets, dual-flush toilets, and waterless urinals to reduce water usage.

Water Reduction Goals: Establish specific water reduction goals for your business and track progress regularly. Encourage departments to compete and collaborate on water-saving initiatives. Reward suggestions to employees who have innovative ideas to conserve water usage.

Regularly Review and Improve Strategies: Continuously monitor and assess your water conservation efforts. Regularly update your water conservation plan to incorporate new technologies and best practices. These innovations, along with healthcare policy support and public engagement, play a vital role in reducing water usage and ensuring the sustainable management of this precious resource. The key to successful water conservation in a healthcare facility is a combination of awareness, efficient technology, employee involvement, and a commitment to continuously improve your practices.

Other practical and novel conservation strategies
 Rainwater from roofs or parking garage top floors can be reused for landscaping as well if it can be collected into a storage tank.
 Smart irrigation systems use sensors, weather data, and soil moisture information to optimize irrigation schedules and flow amounts. Low-flow faucets, toilets, and showerheads use less water without sacrificing performance.
 Smart meters and sensors can identify leaks in water distribution systems, helping to reduce water losses.
 Public awareness and education campaigns in the healthcare facility can promote water-saving behaviors and encourage individuals and communities to adopt water-efficient practices.
 Conduct regular water audits to identify areas where water is being wasted by using zone water meters.
 Even small leaks can waste significant amounts of water over time. Fix all leaks promptly.
 Consider installing water-saving technologies such as sensor-operated faucets, dual-flush toilets, and waterless urinals to reduce water usage.
 Establish specific water reduction goals for your facility and track progress regularly.
 Reward suggestions to employees who have innovative ideas to conserve water usage.
 Continuously monitor and assess your water conservation efforts.
 Regularly update your water conservation plan to incorporate new technologies and best practices.
Water quality, safety and conservation can be achieved if we all work together.

David W. Koenig PhD, is chief technology officer of DKMicrobios as well as a board member of the Environmental Services Optimization Project (EvSOP). He may be reached at dkmicrobios@gmail.com or (920) 527-8243.

Richard Dixon is the co-founder and board member of the Coalition for Community & Healthcare Acquired Infection Reduction (CHAIR). He may be reached at DixonConsulting@gmail.com or (772) 269-6491.

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Engineered Infection Prevention: A New World of Better Disinfection of Air, Water and Surfaces

By Richard Dixon

This article originally appeared in the November 2023 issue of Healthcare Hygiene magazine.

Most people in the Middle Ages believed the world was flat. Brave adventurers such as the Vikings sailed across the ocean to the Atlantic seaboard, and the Chinese journeyed across the Pacific. They began the process of challenging this supposition. It then took several hundred years of voyages of discovery to map out the perimeter of North and South America in addition to inland expeditions such as the mapping experiences of Lewis and Clark in the U.S. and the Hudson Bay Company in Canada to define the nature of this vast land mass.

We do now believe the earth is round, humans have set foot on the moon, probes have landed on Mars, and a trip on a Boeing 787 Dreamliner from Seattle to Paris takes only 11 hours while we sit in comfort sipping a glass of wine. The moral of this story is that new ideas take time to become accepted, practiced, become the new normal and pave the way for the next new idea.

Many healthcare-acquired infections (HAIs) are caused by building-related environmental impacts of air, water, and surfaces, such as high-touch surfaces containing bacteria that are potentially harmful to patients and their subsequent transmission by people from surface to surface. Aerosols can also act as vehicles of microbial transmission. While we once thought medical procedures generated large amounts of aerosols, we now know that common actions like talking, shouting, singing, and coughing, generate far more aerosols than any medical procedures. Even the simple act of flushing the toilet can liberate dangerous pathogens with every use. Recent articles have nicely illustrated that aerosols from toilet plume can be potential vehicles for Clostridioides difficile and norovirus with deposition of infectious particles on bathroom or patient room touch surfaces. While handwashing and daily environmental cleaning have been the mainstays of environmental infection control for the past 170 years, today’s healthcare environments need new innovative processes in the battle with newer, more aggressive bacteria, viruses, and molds, such as the emerging threat of Candida auris.

The new ‘round’ world is about the use of engineered infection prevention (EIP) technologies, materials, automation, and strategies that are adjuncts or even replacements for traditional disinfection of air, water, and surfaces. One of most important risk assessment tools today is the quantitative microbial risk assessment (QMRA)1:

 What level of bacteria/virus reduction is needed to result in a significant risk reduction?
 What routes of exposure cause the greatest risk of infection?
 What activities cause the greatest amount of exposure to pathogens?
 How do pathogens spread via hands and surfaces and aerosolization in different environments? E.g., hospitals, outpatient clinics, urgent care, long-term care, etc.
 Where does the greatest exposure occur?
 How effective are hygiene products in reducing infection risks?
 What is the impact of the number of persons in a facility that practice good hygiene on the other persons in the facility (herd hygiene)?
 What is the impact of a product or process in practice on disease transmission in each environment?
 What is the cost/benefit assessment of prevention interventions?

The tendency to reject new evidence or new paradigms such as EIP because it contradicts established norms, beliefs or paradigms is ironically known as the Semmelweis Reflex.2 Ignaz Semmelweis, of course, went to his grave unable to convince his fellow doctors of the need for hand hygiene to prevent hospital-acquired infections.

Here are some practical, safe, cost effective and sustainable examples of EIPs in our new ‘round’ world:

Germicidal ultraviolet (UV-C) light is a common type of UV well known for one hundred years for its ability to disinfect bacteria, viruses, and mold. Covering the span of invisible light from 200 to 280 nm, the most common and cost-effective wavelength is 254 nm. UV-C photons fuse neighbouring thymine and cytosine molecules on DNA strands preventing replication.

UV-C disinfection is commonly used for:
1. Water:
a. Water treatment
b. Wastewater treatment.
c. Potable drinking water systems
d. Ice machines
2. Air:
e. “Coil Cleaners” - Industrial and hospital HVAC air handling units to prevent mold, bacteria and biofilm formation in cooling coils, filters, and evaporation pans; very inexpensive and energy-efficient.
f. “In-Duct” - Hospital and office tower in-duct air disinfection systems designed to reduce pathogens, especially in recirculated air, which cause HAIs and Sick Building Syndrome, typically up to 99 percent.
g. Air Purifiers – Either stand-alone devices or located within devices downstream of HEPA or other filters; often ceiling-mount or portable; typically, 99 percent or higher reduction.
h. Upper Air Disinfection - UV-C fixtures installed near the ceiling to create a field of UV-C across the upper part of a room (above 7’6”). The efficiency of the system can be enhanced with ceiling fans that actively draw air into the UV-C field and circulate the air throughout the room.
3. Surfaces:
i. Mobile – Typically one, two or three UV-C towers on wheels that are manually placed in unoccupied rooms to disinfect spaces between occupancies; especially used in hospitals for “terminal cleans” between patients,
j. Built-In – Also known as “AutoUV,” devices that use redundant occupancy sensors, door contacts and smart algorithms to automatically disinfect spaces when unoccupied 10, 20, 30 times or more per day; typically used in hospital bathrooms, equipment rooms and utility rooms.
k. Robot systems - That autonomously or semi-autonomously disinfect important surfaces in hospitals, pharmaceutical plants, and laboratories.
l. Tunnel Systems – High-speed conveyor-based disinfection systems used in food processing facilities, medical device manufacturers, biohazardous waste recyclers, distribution centres, luggage handling, and secure government mail processing centers.
m. Personal items - Portable UV-C ‘box’ disinfectors have become popular for disinfecting small personal devices including smartphones, keys, masks, etc., especially since the onset of the COVID-19 pandemic.

UV-C is invisible and can cause sunburn or welder’s eye in just a few seconds so it is especially important that systems are designed to protect users against accidental exposure. Only purchase and use UV-C devices from reputable sources that haver registrations and certifications for UV-C from the U.S. EPA3 and Health Canada. 4

Relative Humidity (RH) in patient care is particularly important. RH in the range of 40 percent to 60 percent5 is optimal for the health of patients and is the sweet spot where growth and survivability of microorganisms is lowest. Infection rates double when RH drops from 30 percent to 40 percent, patients can also suffer from dehydration and impaired mucous membranes. More than 60 percent RH leads to mold and bacterial growth and can be uncomfortable for patients.
Ideally, for optimal comfort and infection control, RH should be maintained at 50 percent, plus or minus 5 percent. This may be harder to control in an older facility than a newer one with more sophisticated building automation system controls and better building envelope.6

Ozonated Water (OW) refers to the strong oxidative species often generated by splitting water molecules in the presence of energy and a catalyst in the new ‘round’ earth. OW is exceptionally good at disinfection and penetrating and preventing biofilms. sanitizer that can be used in the presence of people. In fact, OW is generated and used in our own cells. OW could be used as part of daily cleaning and disinfection process by Environmental Services staff. There are also hand hygiene sinks that generate up to 5 ppm ROS to safely disinfect hands, bowl and drain with each use, preventing microbial growth and the release of pathogenic bioaerosols.7

Antimicrobial Copper is registered as a biocide in the U.S. by the Environmental Protection Agency (EPA) in 2009 (including recently as effective in reducing coronavirus8) and in Canada with Health Canada’s PMRA9 in 2014. Both organizations recognize that when cleaned regularly, antimicrobial copper alloys surfaces kill greater than 99.9 percent of specific bacteria within two hours and continue to kill more than 99 percent of these bacteria even after repeated contamination. Since that time, numerous companies around the (round) earth have contributed to the research and manufacturing of different alloys for various high-touch surfaces:
Touch surfaces: One of the most common applications of antimicrobial copper is on touch surfaces in healthcare facilities, public spaces, and transportation. This includes items like doorknobs, handrails, bedrails, faucets, and elevator buttons. When these surfaces are made of copper or copper alloys, they can help reduce the transmission of pathogens through touch.
Overbed tables: These are the most touched surfaces in healthcare, used throughout each day for patient’s personal items, food serving, and clinical services like wound treatment, IVs, catheters, and phlebotomy. Overbed tables are virtually never cleaned or disinfected during a patient’s stay because environmental services staff are reluctant to remove medical devices or a patient’s personal belongings. In a perfect world, all overbed tables would be made of antimicrobial copper.
Countertops and work surfaces: In settings where hygiene is critical, such as laboratories and food preparation areas, copper countertops and work surfaces are used to inhibit the growth of bacteria and other microorganisms.
Medical equipment: Copper and copper alloys can be incorporated into various medical devices and equipment, including hospital bedrails, IV poles, and dental instruments, to reduce the risk of HAIs.
Personal protective equipment (PPE): Copper-infused fabrics and materials are sometimes used in the production of PPE, such as face masks and gloves, to provide an additional layer of protection against pathogens.
Handrails and guardrails: In public transportation systems like buses, subways, and trains, as well as in crowded public spaces, copper or copper alloy handrails and guardrails can help reduce the spread of germs from hand contact.
It is important to note that while antimicrobial copper can help reduce the presence of harmful microorganisms on surfaces, it is not a substitute for regular cleaning practices. Proper cleaning and hygiene protocols should still be followed in conjunction with the use of antimicrobial copper to ensure the highest level of safety and cleanliness. The effectiveness of antimicrobial copper may vary depending on factors such as the specific copper alloy used, surface morphology, and maintenance. However, it remains a valuable tool in the fight against the spread of infectious agents in various settings.

Silver: This metal has been used for centuries for its antimicrobial properties, and it continues to be used in various medical and industrial applications. Some common uses of silver in this context include:
Silver dressings: Silver-impregnated dressings are used in wound care to help prevent infection and promote healing. They release silver ions slowly, which can kill or inhibit the growth of bacteria in the wound.
Silver coatings: Silver coatings or nanoparticles are used in medical devices, such as catheters and implants, to reduce the risk of bacterial colonization and infection.
Water purification: Silver is sometimes used in water purification systems to disinfect water by killing harmful microorganisms.
Antimicrobial textiles: Silver nanoparticles can be incorporated into textiles, such as clothing and bed linens, to provide antimicrobial properties and reduce odors.
It is important to note that while silver can be effective against a wide range of microorganisms, including antibiotic-resistant bacteria, its use is not regulated and controlled due to potential toxicity or overexposure of silver ions. Additionally, ongoing research is being conducted to better understand the mechanisms of silver's antimicrobial action and to develop safe and effective silver-based products.

HVAC System Design Be aware that most older hospitals in the U.S. and Canada use recycled air in their HVAC systems with only recent builds that use 100 percent fresh air. This use of recycled air was for purely ‘energy’ savings while the newer designs focus on ‘infection prevention’ savings. Ironically though, the most energy efficient hospital HVAC system in Canada, Humber River Hospital, uses 100 percent outside air. HVAC systems that are designed with 100 percent fresh air supply also benefit from the use of High Efficiency Particle Air (HEPA) rated filters. True HEPA filters must capture at least 99.97 percent of particles that are 0.3 micrometers in size or larger. These filters are commonly used in medical facilities, cleanrooms, and applications where extremely high air quality is essential. The types of hospital environments where the benefit is most useful are operating rooms, intensive care units, clean rooms, decontamination, and medical equipment processing departments, burn and bone marrow transplant units.

Other types of filters called MERV (Minimum Efficiency Reporting Value) are also useful in different critical environments of a healthcare facility.
MERV 8: Often used as a pre-filter, MERV 8 filters capture small particles such as dust and mold spores with little restriction to flow. MERV 12 - 13: Improved filtration, effective against fine particles like smoke and some bacteria.

In summary, EIP technologies, materials, and strategies are adjuncts to cleaning and may be either adjuncts or replacements to traditional disinfection of air, water, and surfaces. Change is quite often slow to happen, but the COVID pandemic has proven that traditional cleaning and disinfection processes do not work well enough by themselves. EIP is therefore part of the ‘round’ world of new strategies to reduced healthcare and community-based infections and death. Infection prevention is everyone’s responsibility, so let us change together and use EIP to the maximum. Our lives depend on it.

Richard Dixon is co-founder and board member of the Coalition for Community and Healthcare Associated Infection Reduction (CHAIR). Read more at CHAIRcoalition.org

References:
1. https://www.sciencedirect.com/science/article/abs/pii/S0924224421003320

2. https://www.psychologytoday.com/ca/blog/machiavellians-gulling-the-rubes/202301/the-semmelweis-reflex-truth-is-hard-on-the-ears-0

3. https://www.epa.gov/sites/default/files/2020-10/documents/uvlight-complianceadvisory.pdf

4. https://gazette.gc.ca/rp-pr/p2/2022/2022-05-25/html/sor-dors99-eng.html Note: Canadian Registration content is currently under review in 2023/24

5. https://www.ashrae.org/file%20library/professional%20development/tech%20hour/tech-hour-ppt_stephanie-taylor_november-2019.pdf

6. https://www.ashrae.org/file%20library/professional%20development/tech%20hour/tech-hour-ppt_stephanie-taylor_november-2019.pdf

7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5432778

8. https://www.epa.gov/newsreleases/epa-registers-copper-surfaces-residual-use-against-coronavirus

9. https://www.canada.ca/en/health-canada/services/consumer-product-safety/reports-publications/pesticides-pest-management/decisions-updates/registration-decision/2014/metallic-copper-rd2014-15.html

 

Healthcare Sinks as a Source of Pathogens and a Potential Solution

By Richard Dixon and David Koenig, PhD

This article originally appeared in the September 2023 issue of Healthcare Hygiene magazine.

Authors’ note: The purpose of this document is to stimulate a discussion on an innovative new concept to clean and disinfect healthcare sink drains that are a common source of pathogens. It is not intended to claim any outcomes.

Antimicrobial resistance (AMR) is among the World Health Organization (WHO)’s top 10 threats for global health. The rise of AMR was initially driven by the misuse of antimicrobials in livestock, crops, and humans. The rise in AMR microbes has reduced or eliminated the effectiveness of many antibiotics used to treat infections such there are limited alternatives. Lack of treatment is predicted to lead to a tenfold increase in AMR associated deaths by 2050. AMR microbes and associated health impacts are expected to become burden on the global economy leading to a rise in poverty.

Prevention is at the core for stopping AMR emergence. It is well known that the environment plays a key role in the development and transmission of AMR microbes. Conversely, the environment is a key area for active prevention of AMR. In the hospitals, the sink has been shown to contribute to the rise of AMR. Not only is the sink a source of hospital-acquired infections (HAIs) but is also a source for dispersal of AMR microbes into the community. Therefore, eliminating the sink as a source of HAIs and AMR microbes will greatly help in the quest for controlling AMR globally.

Sinks and Drains
Researchers all over the world have been investigating sinks and drains as a source of HAI microorganisms, especially carbapenem-resistant Enterobacteriaceae (CRE). CRE infections are of particular concern because of their ability to transfer their AMR genetic elements from one bacterial species to another, for example from carbapenem-resistant Klebsiella pneumoniae to Escherichia coli. In 2000, a paper in Current Opinions in Microbiology posed the question, “Is the emergence of carbapenemase a problem waiting to happen?” Almost 20 years on, the problem is here.

Reports that suspected sinks and drains could be the source of CRE that caused HAIs began to emerge in 2003. In a 2017 review, The Hospital Water Environment as a Reservoir for CRE Causing Hospital-Acquired Infections, 17 studies identified sinks as a potential source of microorganisms causing HAI outbreaks, often in the Intensive Care Unit (ICU). Additionally, AMR microbes can colonize sinks and associated plumbing allowing for the transmission of AMR genes to non-AMR microbes, increasing the AMR problem exponentially. In that the waste stream from a sink ultimately reaches the municipal wastewater facilities, AMR microbes and other pathogens can be released into the community.

Sink design directly drives the environmental conditions that favor microbial growth on plumbing line surfaces and ultimately favor AMR development. To prevent sewer gases being released into the room, sinks use water traps. These traps were first invented by Alexander Cumming in 1775, the S-bend trap. Eventually, P-trap (Figure 2) design was adopted that added a 90-degree fitting on the outlet side of a U-bend. The P-trap was popularized by Thomas Crapper in the 1880s and remains in use today. By design the P-trap allows for the sink lines to remain wet, but as was probably underappreciated in 1880 these conditions allow for the rapid growth of biofilms that will harbor pathogens and AMR microbes.

AMR microbes can spread along waste lines connecting sinks and colonize the P-trap. Once there, they form a biofilm which can grow upwards to reach the sink strainer at a rate of up to 2.5 cm a day. When the water from the faucet hits the sink strainer there is splashing that carries pathogens (HAI) and AMR microbes in droplets onto surrounding counters and the floor up to 1 meter away. Patient-care and personal items left around the sink can become contaminated, increasing the chance of transmission of pathogens to patients. Additionally, superbugs contained in sink biofilms can be flushed out of the sink into the municipal water treatment system contaminating the outside world, leading to community AMR infections. Sink design has been virtually unchanged for more than 140 years, going back to the days of Alexander Cumming and Thomas Crapper. It is time to change this plumbing.

To date, healthcare facilities have tried a wide range of interventions to stop outbreaks associated with sinks. A few of these are listed here:
• Replacing the entire contaminated sink or replacing the downpipes and p-traps.
o Still using the Crapper design, problem reoccurs soon after replacement.
• Correct defective conditions in water systems such as dead ends, low water use areas, temperature, and pressure fluctuations.
o Helpful in simplifying water flow but the P-trap is still there, maintaining the primary driver for biofilm development.
• Placement of an offset sink drain in hand hygiene sinks.
o Will reduce splashing from the sink strainer.
o P-trap is still in place allowing for biofilm growth.
• Changing to deeper sink basins to prevent cross-contamination of hands and adjacent surfaces.
o Does not eliminate splashing or biofilm growth.
• Regularly pouring disinfectants such as sodium hypochlorite, hypochlorous acid, hydrogen peroxide, acetic acid, octanoic acid, or peroxyacetic acid down sink
o Significantly decreases bioburden, but regrowth happens within a few days.
• Blocking the drain line and allowing the disinfectant to sit in the P-trap.
o More successful than just pouring disinfectant down drain.
o Regrowth will still occur.
• A device that heats and/or subjects the downpipe to ultrasound to kill and remove the biofilm.
o There will be biofilm regrowth after treatment.
o Units require a power source near the sink.
• Unit on sink that generates ozonated water via the faucet to disinfect the P-trap and drain at each use.
o Shown to be effective at decreasing Pseudomonas aeruginosa and Candida auris contamination.
o Due to rapid decomposition of ozone, water left to sit for long period of time in P-trap will become contaminated and form biofilms.
o Units require a power source near the sink.
o Ozone generators require engineering controls to ensure no release of ozone into occupied spaces.

It seems clear that there is no silver bullet that will eliminate the risk of pathogen (HAI), and particularly CRE transmission (AMR microbes) due to ancient design of sink P-traps and drains. Some interventions resulted in the end of outbreaks but didn’t fully eliminate CRE from the P-trap or drain and the potential of a CRE infection occurring. Others were not successful at eliminating the outbreak at all. We therefore propose a very different plumbing configuration to address sink biofilms and splash transmission of HAI and AMR microbes to the hospital-built environment.

EasyFlow Concept
All the interventions to date have missed the obvious, the ancient P-traps drain design is the key to biofilm development. Thus, the necessity of the immense problem lies in a new radical approach to the design called EasyFlow (Figure 3). This design eliminates the P-trap. The P-trap encourages biofilm growth by simply providing the water needed to build luxurious biofilms that will harbor AMR microbes and pathogens (HAIs) in conditions that are hard to treat and remove. The water in the P-trap furthermore provides the necessary water of activity (aw) conditions in the waste lines from the P-trap to the sink strainer allowing growth of biofilm on all surfaces. Ultimately providing the source of microbes to be splashed into the hospital-built environment. Removal of the P-trap allows for reducing the aw in the sink lines such that luxurious biofilms will not form, significantly reducing the risk of splashing microbes into the hospital-built environment.

The key to EasyFlow is eliminating the P-trap. To do this an offset sink drain line is routed straight down or at any angle equal or less then 45 degrees from the bottom of the sink. After which the drain line is routed 90o or less to the discharge line (Figure 3). Sewage odors are mitigated by installing a negative pressure fan on the vent pipe to pull the air gases continually out of the entire system. Negative pressure fans will have the ability to adapt flow rate to ensure appropriate operation in concert with room fluctuations of the heating, ventilation, and air conditioning (HVAC) systems air flow and pressures. All fans are connected via a low voltage control wire to the healthcare facility Building Automation System (BAS) so that if a fan fails, the engineering department can receive the failure signal and repair or replace the fan/motor immediately. A hatch is required for access by engineering. The advantage of this system is that unlike the “Crapper” design this system will substantially reduce the moisture in the waste system lines thereby minimizing dangerous wet biofilms. Dry biofilms are still expected to persist but will be treated using disinfectant applications.

A horizontal drain line will be installed at an applicable distance away from the sink or varying number of sinks on the front end of the drain system. These lines will have a closure gate or ball valve that can isolate the drain for short periods of time (Figure 3). This allows for completely filling the system with the appropriate disinfectant. The goal of this procedure is to remove any dry biofilm that may propagate in the waste lines. The valve should be placed such that there is an easy to locate access hatch that is appropriately marked as such. Conversely, a remote-control valve can be used to allow for energization of the circuit without manual interventions. It is also possible to install a remotely controlled ice plug device at the point required for fluid restriction as a redundant feature. It is also possible to use these valves to close off the drain line in the case of a negative pressure fan failure stopping sewer gas escaping into the room, during fan repair.

To ensure appropriate function of the system regular auditing of the drain lines via ATP tests, protein tests, or microbial culture are recommended to ensure there is no or very little dry biofilm in the section of the drain line closest to the sink(s). Remember a dead biofilm that is still on the surfaces will enhance the regrowth of new biofilm.

The advantage of the EasyFlow concept over the “Crapper” design is:
1. Proactive biofilm through engineered infection prevention
2. Continuous drying of waste drain lines
3. Efficient removal of dry biofilms
4. Redundancy
5. Process control monitors
6. Active reduction of AMR bacterial dispersal to the hospital-built environment and community

Summary
For 140 years the same design for sinks has been used that enhances the growth biofilms. These biofilms will harbor bacteria and fungi. The microbes in the biofilms will share genetic elements allowing for transfer of AMR between divergent species and enhance the growth of HAI microbes. Sink biofilms drive the transfer of HAI and AMR microbes into the hospital-built environment through splashing as well as dispersal into the community by release into the municipal waste stream.

The EasyFlow concept removes the P-trap greatly reducing the ability of biofilms to form by lowing the aw on the surfaces of associated sink and drain lines. This will reduce the ability of microbes to transfer AMR elements to others and eliminate the biofilm on the sink strainer abolishing dispersion of pathogens into the hospital-built environment. Ultimately enhancing the lives and wellbeing of both patients and care givers.

Richard Dixon is board member and co-founder of the Coalition for Community & Healthcare Acquired Infection Reduction (CHAIR); a Canadian Standards Association former standards writer: Vice-chair Infection Control During Construction, Renovations & Maintenance of Healthcare Facilities. chair, Cleaning and Disinfection of Health Care Facilities, Member Health Care Facilities (building new health care facilities), Special Requirements for Plumbing Installations in Health Care Facilities; and a research consultant for Vancouver Coastal Health (Environmental & Patient Care). He may be reached at: DixonConsulting@gmail.com or (226) 698-1768 (Canada) or (772) 269-6491 (U.S.)

David Koenig, PhD, is currently chief technology officer of DKMicrobios and a board member of the Environmental Services Optimization Playbook (EvSOP). He is formerly a research technical leader with Kimberly Clark Corporation (infection control, human microbiome, and skin health), as well as a former microbiologist for the NASA Johnson Space Center (ISS environmental and water subsystems, ISS Crew Health subsystem, Lunar/Mars Regenerative life support systems), and formerly a microbiologist for Betz Paperchem (biofilm control). He may be reached at: dkmicrobios@gmail.com or (920) 527-8243.

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Volling, C., Thomas, S., Johnstone, J., Maltezou, H.C., Mertz, D., Stuart, R., Jamal, A.J., Kandel, C., Ahangari, N., Coleman, B.L. and McGeer, A., 2020. Development of a tool to assess evidence for causality in studies implicating sink drains as a reservoir for hospital-acquired gammaproteobacterial infection. Journal of Hospital Infection, 106(3), pp.454-464.
Weinbren, M. and Inkster, T., 2021. The hospital-built environment: biofilm, biodiversity and bias. Journal of Hospital Infection, 111, pp.50-52.
Weinbren, M.J., 2020. Dissemination of antibiotic resistance and other healthcare waterborne pathogens. The price of poor design, construction, usage and maintenance of modern water/sanitation services. Journal of Hospital Infection, 105(3), pp.406-411.
WHO. 2021. Antimicrobial resistance. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance

 

Call to Action: A Team-Based HAI Response

By Richard Dixon

This article originally appeared in the July 2023 issue of Healthcare Hygiene magazine.

A good risk management question to ask in a healthcare facility is: Who is responsible for safety? The most likely response would be “everybody.” Great answer! What about: Who is responsible for reducing healthcare-acquired infections (HAIs)? Answers typically are infection prevention and control (IP&C), environmental services (EVS), or nurses and doctors. Let’s take a closer look at the clinical and environmental issues and answer this important question properly.

IP&C staff monitor antibiotic use, assist in the policies for EVS and chemical selection, monitor HAI statistics with a watchful eye on outbreaks, provide education on prevention on many typical issues, guide contractors through the difficult processes of renovations in the facility, product review and evaluation, manage HAI outbreaks and more.

EVS is clearly responsible for the cleaning and disinfection in most healthcare facilities, with daily attention to horizonal and vertical surfaces, and special attention to high-touch surfaces plus a variety of waste management and recycling functions, pest management, laundry, and a wide variety of other areas.

Specialized cleaning and disinfection also take place in the food service department (food preparation, storage, serving, waste management), and in facilities management (ducts, cooling towers, HVAC equipment, and more).

Medical device reprocessing plays an important role in the operating and procedure rooms, as cleaning, disinfection, and sterilization of the many pieces of equipment and instruments -- some of which are extremely difficult to achieve 100 percent efficacy, such as endoscopes.

Nurses do their best to clean up blood and other fluid spills in medical and surgical inpatient units plus in ambulatory departments like endoscopy units.

Laboratory personnel, especially microbiology staff, identify bacteria, virus and fungal pathogens with incredible accuracy and speed but seldom are involved in the outcomes and trends of the patients that these tests are concerning.

A healthcare facility is therefore a complex web of different departments within an environment of multi-factorial issues that inevitably causes HAIs.

Let’s take the example of a patient in an older-style double room. Patient A is recovering from a respiratory illness and patient B is recovering from an abdominal issue who will test positive two days later for Clostridioides difficile (C. diff) from an endoscopy procedure. In the meantime, Patient A starts off with a mild diarrhea, uses the ensuite bathroom with the door partly open, and to complicate this issue, the bathroom’s negative-pressure vent is hardly drawing in any air, so the flushing of the toilet results in a plume of air containing fecal particles with C. diff bacteria to be distributed to Patient A whose bed is adjacent to the bathroom door. In the meantime, EVS staff try to clean and disinfect the room and bathroom, although both patients have personal items on the sink, overbed and bedside tables, so those surfaces don’t get any attention – it’s the same with the bedside rails because both patients are sleeping or have frequent visitors. As you can see, a perfect circumstance for Patients A and B to both contract as HAI, with further potential transmission beyond that patient room.

So, you can see in this over-simplified example, that HAIs are multi-factorial, and a different approach is required by all the separate departments who reside in their own silos. Here is just a sampling of these multi-factorial issues:
• Patient acuity
• Hand hygiene practices and auditing with consideration of the Hawthorne Effect
• Antibiotic stewardship programs
• Clinical practices
• Fecal waste management
• Environmental cleaning and disinfection practices, plus education
• Patient and visitor education
• Visitor restrictions
• HAI statistics availability and future predictions
• Personal protective equipment (PPE)
• Auditing of routine and specialized practices
• Recognition of transmission routes and challenges
• Facility design
• Facility audit of positive and negative pressures, water temperatures
• Clinical glove use policy
• Training and education
• Budgets to maintain within only a focus on initial control, not long-term prevention, and risk adverse interventions.

The bottom line is that the typical healthcare system of silos does not function properly to the benefit of patient care. However, the first clue is that when an outbreak occurs, the entire group of departments gets together to work through the cause, effect, and resolution issues to a successful conclusion, and hopefully put into future processes of the lessons learned. Let’s then not miss the biggest learning opportunity of all. Teamwork among the silo partners resulted in a positive patient-care solution. Why would or should the silos be maintained as status quo?

A few answers would be “We have always done it that way” or “I don’t want to change the process as it would be too hard,” or “I don’t like change.” The best way may be to start with the concept of a patient care multi-disciplinary team (PC-MDT) taking full responsibility for the entire scope of processes on a patient-focused basis. Here are some suggestions on membership of the PC-MDT:
- Infection Prevention & Control
- Environmental Services
- Microbiology and/or Laboratory
- Food Services
- Facilities Management
- Quality & Risk Management
- Nursing (inpatient and outpatient)
- Administration
- Medical Device Reprocessing
- Infectious Disease Physicians/Epidemiologists
- Occupational Health & Safety
- Other stakeholders as required

Let’s also look at some of the initial tasks the PC-MDT can address in the short and long term:
- EVS is on the front lines of defense of HAIs and should be recognized for their heroic efforts with addition budget support for training and education
- HAI statistics (facility, community, regional, national, etc.)
- IP&C staff attend clinical rounds
- Policies and procedures blended for an integrated approach
- Key performance indicators of success
- IP&C also focuses on an ‘interventional’ focus via a learning and problem-solving approach
- Observational auditing (visual, marker, ATP, microbial culture) including when who, how, cost, etc. and use the outcome in trending analysis, celebrating success and learning
- Organizational audits of departments or significant multi-faceted processes
- Specialized audits targeting potential sources of transmission (sinks and drains)
- Chemical products (manufacturer’s use requirements, safety, fit for the desired outcome, PPE use, etc.)
- Terminal, shared equipment and specialized cleaning
- Engineered infection prevention solutions such as ultraviolet light, ozonated water hygiene sinks, self-sanitizing surfaces like copper alloys
- Patient, visitor, physician, and staff surveys
- Building trust and success, not fault or punitive measures
- Target typically higher rates of common HAIs (VRE, C. diff, MRSA, CPO), and be on the outlook for fungal infections (Candida auris, Aspergillosis) and more impacts of SARS-CoV-2 variants
- Collaborate with local healthcare facilities on regional learning and cooperation
- Attending professional conferences with a cross representation of attendance
- Seek out local, regional, national, and international standards relevant to the facility’s needs.
- Recommendations to administration on operational changes and capital equipment or facility changes that have a positive impact on patient care (Tip: while the upfront costs are very important, the real issue is what a proposed change can do to reduce HAIs, noted as a return on patient care investment and a strong perspective that HAIs cause illness and death) and financial issues for the facility
- Communication strategy to healthcare stakeholders
- Use science- and evidence-based decision-making
- Randomized clinical trials in environmental assessments do not do well in some multi-factorial HAI-related issues, but rather a practical approach of quantitative risk management assessment (QMRA) which has its roots in food services risk management and safety. This is about assessing the risk of transmission and developing changes to lessen the risk.

Did this whole discussion not start about who is responsible for safety? We are all responsible for HAIs and should dedicate our resources and trust in a PC-MDT to lead the way to safer environment for patients, staff, physicians, and visitors. Remember, the word “team” has four letters that can spelled also as mate; thus, we are all teammates.

Richard Dixon is the co-founder and a board member of the Coalition for Community & Healthcare Acquired Infection Reduction (CHAIR). He has 40 years of experience in senior administration, planning, design, construction, commissioning plus infection prevention and control in healthcare facilities in Canada and across the globe.

 

The Business Case for Hospitals to Expand Their CMS Reimbursement Potential

By John Scherberger, FAHE

This article originally appeared in the January 2023 issue of Healthcare Hygiene magazine.

Doing more with less – including lower reimbursement rates, fewer staff and smaller budgets – has become healthcare institutions’ new normal as the nation emerges from the pandemic while addressing continued challenges related to evolving patient populations, increased expectations around infection prevention, and the need for the C-suite to manage fiscal operations while meeting the IHI’s Triple Aim initiative of improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of healthcare. Additionally, the implementation of the Patient Protection and Affordable Care Act and the Centers for Medicare and Medicaid Services (CMS)’ Hospital Value-Based Purchasing Program presents both challenges and opportunities.1

In the interim, the world experienced the effects of the SARS-CoV-2 pandemic. Millions died worldwide, shook national economies to their foundation, and hospitals experienced challenges for which they were unprepared. The U.S. government stepped forth with a double-edged sword to combat the pandemic and save lives. The success or failure of the efforts remains controversial. As never seen before, an infusion of federal funds was one edge of the sword.

Hospitals are now experiencing the effects of the other edge of the sword. With the declaration of the end of the COVID-19 pandemic, drastic cuts to federal funds took place, hospitals are facing 2022 ending with the worst financial results, and 2023 may not show an economic turn-around. The fatted calf was laid on the altar of economic expedience, and there is not another one waiting in the wings.

In May 2021, one healthcare industry news outlet2 shouted, "Post-COVID-19 era hospital revenues plummet." In September 2022, they proclaimed 2022 "the most financially difficult year for hospitals and health systems since the start of the pandemic."

Times have changed, things have changed, and operations must change.

With the financial disasters facing healthcare because of the pandemic, it is time for chief financial officers and Medicare billing departments, along with their Medicare administrative contractors, to broaden their approaches realistically, ethically, and financially to maximize their CMS reimbursement opportunities.

They must revisit their approach to the Medicare Provider Manual, Part 1, Chapter 21 (Rev. 454). Specifically, Chapter 102.2 Costs Related to Patient Care, Section 2135 Purchased Management and Administrative Support Services, subsection 2135.1 General, and 2135.2 Evaluation of the Need for Purchased Management and Administrative Support Services.
(https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021929) Then click on Chapter 21 -- Costs Related to Patient Care.
An additional source for information is https://portal.cms.gov/portal/

Allowability of costs is subject to the regulations prescribing the treatment of specific items under the Medicare program.

Long-term adjustments, not knee-jerk reactions, must occur. Hospitals must recognize a paradigm shift for doing business, a new method (a late Middle English word meaning, in a sense, “prescribed medical treatment for a disease.” Derived via Latin from the Greek “methodos” meaning a pursuit of knowledge, from meta- (expressing development) plus “hodos” meaning way.)

Environmental, Social and Governance (ESG)

Hospitals and hospital systems face a new challenge in this post-pandemic time -- environmental, social, and governance (ESG) programs. With the financial difficulties incumbent upon their survival, ESG is demanded of them. They can no longer give lip service to sustainability or "reduce, reuse, recycle" campaigns. Hospitals must look beyond the healthcare environment; they must seek to do what is best for the environment and community in which they live and serve.

For example, hospitals are the most significant contributors to their community landfills and have it within their power to reduce their negative ecological footprint. They must look at how to incorporate reusable, sustainable products and recognize that the disinfectants and chemicals they use to keep their facilities hygienic are also polluting their environment. The same disinfectants they use damage the surfaces of their healthcare environment – equipment, floors, surfaces, mattresses, and countless other valuable and costly possessions.

Most importantly, they are endangering the health of their staff and patients with antiquated disinfectants (pesticides). They needlessly contribute to putting tons of waste into landfills that will never decompose. Disposable isolation gowns and plastic containers that hold disinfectants now find new "forever homes" in landfills because they cannot recycle them. (https://www.epa.gov/pesticide-worker-safety/containers-containment-storage-and-disposal-pesticides). Billions (and still counting) of disposable, single-use wipes and wipers contaminated with disinfectants are populating landfills regardless of manufacturers' claims that they are "recyclable."

What does ESG have to do with possible CMS reimbursement? Disposable products are not "reimbursable" events but a direct expense to hospitals. Hospitals must reduce their direct costs effectively, efficiently, and in ecologically sound manners. Thinking outside the proverbial box with CMS as a partner will bring rewards. Why have hospitals been reticent to go outside of the box? Maybe because it has yet to be done.

With the implementation of the Patient Protection and Affordable Care Act, CMS Value-Based Purchasing, and the financial wreckage healthcare providers are facing, healthcare must understand that times have changed, things have changed, and operations must change. The CMS Roadmap for Implementing Value Driven Healthcare in the Traditional Medicare Fee-for-Service Program opens with the following paragraph: "Given that CMS policies have a transformative impact on the healthcare system, it is important to develop the tools necessary to create rational approaches to lessen healthcare cost growth and to identify and encourage care delivery patterns that are not only high quality but also cost-efficient."

Healthcare facilities must go beyond using the best and most appropriate DRG to apply to a procedure to capture the highest reimbursement, participating in group purchasing organizations (GPOs), or utilizing just-in-time inventory. They must "develop the tools necessary to create rational approaches to lessen healthcare cost growth and to identify and encourage care delivery patterns that are both high quality and cost-efficient."

To quote Thomas Pynchon: "If they can get you asking the wrong questions, they don't have to worry about answers."

John Scherberger, FAHE, is principal of Healthcare Risk Mitigation.

References:

1. Scherberger J. The Case for Moving Infection Prevention Textiles to the Linen/Laundry Department. Infect Control Today. Sept. 9, 2019. Accessible at: https://www.infectioncontroltoday.com/view/case-moving-infection-prevention-textiles-linenlaundry-department

2. Becker's Hospital CFO Report. Post-COVID-19 Era Hospital Revenues Plummet. May 31, 2022,.

3. Becker's Hospital CFO Report. Sept. 16, 2022.