Infection Prevention

Leading the Way to Zero: Moving Purposefully Forward Together

By Sylvia Garcia, MBA, RN, CIC

This column originally appeared in the January 2020 issue of Healthcare Hygiene magazine.

At the opening of the 2006 annual meeting of the Association for Professionals in Infection Control and Epidemiology (APIC), then-APIC president Kathleen Arias said, “Zero tolerance is not a number—it’s a culture in which healthcare providers strive to prevent as many healthcare-associated infections as possible. We may never eliminate every infection, and many cannot be prevented, but infection control professionals should accept nothing less than the very lowest rates of infection.”

Back then, I sat in the audience and thought to myself, great idea, but is it achievable? Which infections should we prioritize? What are the key interventions? How do we get support from leadership and staff? (I wasn’t even thinking about the patient or their family at that point.)

There were already evidence-based guidelines available from Centers for Disease Control and Prevention (CDC) and other professional organizations on a variety of key topics. The next year, the Centers for Medicare & Medicaid Services (CMS) published payment reforms intended to increase emphasis on value-based purchasing which identified central line-associated bloodstream infections (CLABSI) and indwelling catheter-associated urinary tract infections (CAUTI) as “never events.” So, I knew CLABSI and CAUTI would be on leaderships’ list of priorities, but was this enough?

The answer would become clearer during 2008 when the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), APIC, and the Joint Commission worked together to create the Compendium of strategies to prevent healthcare-associated infections in acute-care hospitals. These documents focused on implementation of basic strategies to prevent the most common healthcare associated infections (HAIs) as well as providing special approaches when basic practices were not enough. They also recommended that accountability be assigned and proposed performance metrics to monitor quality improvement efforts.

Information from the CDC, the Compendium and other professional organizations soon became an even greater organizational priority when the Joint Commission added three new requirements to national patient safety goal (NPSG) 7: Reduce the Risk of Healthcare Associated Infection in 2009 and an additional topic area in 2012
• Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms (MDRO)
• Implement evidence-based practices to prevent CLABSI
• Implement evidence-based practices for preventing surgical site infections (SSI)
• Implement evidence-based practices to prevent CA-UTI

Today, the results of concentrated efforts to identify key interventions and reduce risk by implementing evidence-based practices are clear. Nationally, among acute care hospitals, significant progress has been made. For example, between 2017 and 2018, an 8 percent to 12 percent statistically significant decrease in CAUTI, CLABSI and hospital-onset C. difficile infections was reported. However, there was no significant decrease in SSI rates.

According to point prevalence surveys of hospitals conducted in 2011 and then again in 2015, there has also been a statically significant (p<0.0001) decrease in HAI amongst hospitalized patients: 1 in 25 (4 percent) versus 1 in 31 (3.2 percent), respectively. Pneumonia, gastrointestinal infections (most of which were due to Clostridium difficile) and surgical-site infections were the most common health care-associated infections infection identified.

As the following NPSGs are moved to standards effective July 1, 2020, organizations need to continue to implement evidence-based practices.
• NPSG.07.03.01—Multidrug-resistant organisms
• NPSG.07.04.01—Central line–associated bloodstream infections
• NPSG.07.05.01—Surgical site infections
• NPSG.07.06.01—Catheter-associated urinary tract infections

Organizations should also be aware that in November 2019, the CDC released a report about the threat of antibiotic-resistant organisms and the statistics are eye-opening: “…antibiotic-resistant bacteria and fungi cause more than 2.8 million infections and 35,000 deaths in the United States each year. That means, on average, someone in the United States gets an antibiotic-resistant infection every 11 seconds and every 15 minutes someone dies.”

To keep patients, visitors and staff safe, organizations should be ready to implement CDCs recommended containment strategies when these organisms are identified. This includes ensuring compliance with existing Joint Commission focus areas, including:
• Implementation of standard and transmission-based precautions
• Making appropriate personal protective equipment available to staff
• Training staff on selection, limitations, maintenance, donning and removal of personal protective equipment
• Enforcing use of appropriate personal protective equipment

Note: Examples of potential survey findings related to the aforementioned areas were published in the August 2019 edition of Perspectives, under the “Consistent Interpretations” section.

We are making progress but there is still much work to be done both for the common infections that occur in healthcare such as SSI, and those, such as antibiotic resistant organism and other high- consequence organisms, that loom on the horizon.

Each healthcare organization needs to look within and conduct an accurate risk assessment – and ask: where are the low hanging fruit and the biggest risks? Are leadership, staff, patients, their families and their significant others are involved? And, is everyone working together to prioritize, plan, implement, and monitor?
If we all hold ourselves and our colleagues responsible and accountable…together we can get to zero HAIs!

So, 14 years later, do I think that we can achieve zero HAIs? My answer is a resounding Yes!

Sylvia Garcia, MBA, RN, CIC, is director of infection prevention and control within the of Division of Healthcare Improvement at the Joint Commission.

1. Association for Professionals in Infection Control and Epidemiology. Prevention Strategist. 40 Years of Growth and Progress. Winter 2012.
2. Centers for Medicare & Medicaid Services (CMS), HHS. Medicare program: changes to the hospital inpatient prospective payment systems and fiscal year 2008 rates. Federal Register. 2007;72(162):47129–48175.
3. Centers for Disease Control and Prevention. 2018 National and State Healthcare-Associated Infections Progress Report. Available at:
4. Magill SS, Changes in prevalence of healthcare associated infections in U.S. Hospitals. N Eng J Med. 2018 Nov 1;379(18):1732-1744. doi: 10.1056/NEJMoa1801550
5. Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States – 2019. Available at: .
6. Centers for Disease Control and Prevention. Containment Strategy Responding to Emerging AR Threats. Available at:

Screening for Asymptomatic Bacteriuria: A Dangerous Intersection

By Barbara DeBaun, MSN, RN, CIC

This column originally appeared in the December 2019 issue of Healthcare Hygiene magazine.

It was a dark and stormy specimen. You know the story.  It begins with a well-meaning nurse who notices that the urine in the patient’s urinary drainage bag is dark in color. When the urine is drained from the bag, the nurse notes that the urine is not only concentrated but smelly. More likely than not, this nurse will collect a sample of the urine and request an order for urinalysis and culture. The nurse has seen this before and is confident the patient’s symptoms suggest a urinary tract infection.

Another twist on the story is the patient who presents in the emergency department (ED) and whose daughter or son insists that “When mom gets like this, it’s always a urinary tract infection.”  Sound familiar?

Asymptomatic bacteriuria (ASB) is the presence of one or more species of bacteria growing in the urine at specified quantitative counts (≥10⁵ colony forming units (CFU/mL or ≥10⁸ CFU/L regardless of whether there is presence of pyuria or signs/symptoms that are attributable to an urinary tract infection.

What do we know about ASB?

- Present in >30 percent of nursing home patients and 100 percent of those who are chronically catheterized

- 23 percent to 50 percent of antibiotic days for UTI are unnecessary treatment of ASB

- ASB is a benign condition that generally does not require treatment

Urine culturing misadventures often begin when a patient with a low pre-test probability of having a UTI is tested for one. It may start when a physician orders a urinalysis and culture on a patient who is unlikely to have a UTI, or in the scenario previously described, when a nurse obtains the specimen first and requests the order later. The integrity of the specimen including technique for obtaining and transporting it will impact the result.

Despite our best efforts, we still hear of urine samples being obtained directly from urinary catheter drainage bags. It is not unusual for a urine sample to be considered low priority for transfer to the lab therefore overgrowth of bacteria may result. The downstream impact of this includes additional work for the laboratory, increased costs for the pharmacy, and a negative impact on antimicrobial stewardship.  Infection Preventionists are tasked with reporting hospital onset catheter associated urinary tract infections (CAUTI) and are likely reporting cases that are not true infections despite meeting the NHSN case definition. Financial penalties and impact on reimbursement are impacted by a substandard culture of culturing. The ultimate negative impact of culturing patients for an infection that is probably not likely, is that patients receive antibiotics that are not necessary.

The Infectious Diseases Society of America (IDSA) recently issued a clinical practice guideline for the management of asymptomatic bacteriuria. These 2005 guidelines recommended that only pregnant women and those scheduled to have an invasive urologic procedure be screened for ASB. The updated guidelines provide additional guidance on children and specific adult populations such as those with neutropenia, solid organ transplants, and surgery that does not involve the urological tract. Much has been learned about the impact of testing for ASB in these settings therefore the Society has provided guidance that will ultimately impact antimicrobial prescribing and the emergence of antimicrobial resistance.

An all-too-common practice is for practitioners to test a patient who has been admitted to an acute-care hospital with an indwelling catheter. The temptation to screen may be based upon the pressure to “capture on admission” or prove that the patient was already “infected” at the time of admission.  The IDSA strongly advises against screening or treating ASB. As the screening of patients admitted with a catheter are likely to present in the ED, it is critical to partner with the ED providers and nurses so they are aware of the negative impact of performing urine screening in patients who are unlikely to have a UTI.

An additional strong recommendation is to avoid screening patients who are scheduled to undergo elective nonurological surgery for ASB. This is an area where the IP has tremendous opportunity to impact and drive change.  Pre-operative order sets commonly include “urinalysis” and it may be “because we have always done it and we’re afraid to stop doing it.”  We must have critical conversations with our surgical partners to discuss the impact of ASB screening to assure them that the risk of testing may outweigh the benefits.  A patient scheduled for a knee replacement will be far better off if s/he is not treated with an antibiotic for ASB. There are no data to support the benefit of urine screening for nonurological surgical patients, however there is an abundance of data to connect antimicrobial therapy with negative downstream effects such as multi-resistant organisms and C. difficile infection.

Our laboratory “culture of culturing” practices that discourage the screening of patients who have a low probability of having a UTI directly impact antimicrobial prescribing practices and patient outcomes.  This requires a partnership that connects the dots between laboratory stewardship and antimicrobial stewardship so that antibiotics are only prescribed when they should be.

Barbara DeBaun, MSN, RN, CIC, is an improvement advisor for Cynosure Health.




Education and Training of Frontline Infection Preventionists

By Matthew Hardwick, PhD

This column originally appeared in the November 2019 issue of Healthcare Hygiene magazine.

One of the most fundamental operations in any medical facility is cleaning. Cleaning critical areas such as patient rooms and surgical suites, as well as, less critical areas such as waiting rooms, hallways, cafeterias, kitchens, etc. are all apart of keeping medical facilities free of pests and, hopefully, pathogens. However, for the longest time, cleaning hospitals has followed the same basic principles as cleaning a hotel room -- clean visible soil. While there are cleaning protocols in place at nearly all medical facilities, the predominant feature of these protocols is routine cleaning with a focus on visible soil. It should come as a surprise to no one that pathogens do not always reside in visible soil. Indeed, many of the fluids and semi-solids that pathogens use to move from place to place are not readily visible to the naked eye (think sputum or fingerprint oils). Despite this fact, many cleaning protocols do not take invisible soil into account during both routine and specialized cleaning protocols. The responsibility for this lack of awareness belongs to all involved in healthcare. While environmental service (EVS) personnel, nurses and technicians are primarily responsible for keeping our medical facilities and equipment clean, they are only as good as they are trained to be.

From the Centers for Disease Control and Prevention (CDC) to the Association for the Healthcare Environment (AHE) to the Association for Professionals in Infection Control and Epidemiology (APIC), all agree that EVS personnel require extensive training to play their pivotal role in keeping healthcare environments free of pathogens. Indeed, each has dedicated significant resources to developing training programs for EVS workers. AHE has a suite of training programs aimed at frontline EVS workers to surgical suite cleaning to EVS management and leadership. Through funding from the CDC, APIC has developed training modules that run the gamut of cleaning from the basic principles, personal protective equipment, chemical safety, and techniques for cleaning and disinfection. In addition to these resources, vendors have developed their own extensive training for EVS workers. Such training is, perhaps, more individualized and often encompasses multiple days for training sessions and accompanied by annual refreshers for each worker.

  • Fluorescent markers – This tool was developed in order to provide “before” and “after” feedback for EVS workers. In short, an invisible fluorescent gel is applied to pre-determined surfaces prior to EVS cleaning. Following cleaning, a manager uses a black light to determine if the gel has been removed from all the spots. In this way, the manager can determine adherence to cleaning protocols. It should be noted, however, that this method does not determine the efficacy of removing pathogens from environment.
  • Adenosine Triphosphate (ATP) swabs – One way to determine if a surface is free of pathogens is to detect organic ATP (derived from biological organisms like bacteria, fungi and human cells) left on surfaces. ATP detection is performed only following cleaning, reducing the time needed for monitoring. In theory, this method will not only determine an EVS workers adherence to established cleaning protocols, it will also evaluate the protocol for pathogen removal. There is one big problem with this method, however. First, we do not know the half-life of biologically derived ATP, meaning that cells maybe dead (killed by auxiliary techniques such as UV and vapor) and still leave active ATP behind. In our laboratory, we have detected ATP signals in the absence of viable bacterial loads, more than 48 hours after exposure to UV light.

The development of fluorescent marker and ATP swab methodologies are a boon to the education and monitoring of EVS workers. However, given the limitations of both the current cleaning methodologies and these monitoring devices, we still have a long way to go before we have adequate tools to empower EVS workers.

While EVS personnel receive considerable training, nurses and technicians may only receive cursory training, if any at all, on how to clean medical equipment and how to use disinfectants. APIC’s training does include sections for healthcare professionals including a section on “roles and responsibilities” geared toward who cleans what in healthcare environments. Despite APIC’s efforts, there is clearly a gap in training for nurses and technicians. This education and training gap is critical, since these individuals are largely responsible for cleaning critical patient-care equipment such as blood pressure monitors and dialysis machines. Without understanding which disinfectant to use and the appropriate dwell times, as well as how to use wipers in order to reduce cross-contamination, we cannot begin to hope that healthcare surfaces will be cleaned properly.

In last month’s Healthcare Hygiene magazine, Linda Lybert and Caroline Etland described a comprehensive literature review commissioned by the Healthcare Surfaces Institute. As a part of this review, studies on current healthcare training and education were examined. Despite the availability of numerous training programs and studies to show that only 48 percent of healthcare surfaces are cleaned appropriately, no research studies were found to determine if these programs are effective. Rather, only a handful of research studies were focused on monitoring cleaning practices. This lack of scientific research into the effectiveness of EVS training is surprising and, frankly, appalling.

Given the rapidly evolving world of infection prevention, it is critical that all healthcare professionals – EVS workers, nurses, technicians – receive the education and training they need to fill their roles as frontline infection preventionists.

Matthew Hardwick, PhD is president/CEO of ResInnova Laboratories and is the president of the board of directors of the Healthcare Surfaces Institute. He is a thought leader in the field of infection prevention in the healthcare environment of care and is an expert in antimicrobial surface technologies.

When Prime Directives Collide: The Survival Wars

By Wava Truscott, PhD, MBA

This column originally appeared in the November 2019 issue of Healthcare Hygiene magazine.

The Prime Directive driving all humans is an internal instinct to survive.  Throughout the ages, man has struggled and adapted to protect himself, his family, and his tribe.  This core drive to survive has advanced weapons for protection, from crushing threats with rocks, to throwing spears, and on to more powerful weapons. To survive weather extremes, man huddled in caves, constructed lean-tos, and moved up to more permanent structures of wood, stone, and cement.

The same Prime Directive drives microorganisms to adapt or die. However, instead of innovative adaptations requiring thought, bacteria experience genetic mutations that may, or may not be helpful. Mutations that protect bacteria enable survival, while mutations that are not sufficiently protective die off with the bacteria.  For example, those bacteria that received successfully mutations allowing them to withstand temperatures up to 180 degrees F, continue to thrive in the hot springs and steam vents of Yellowstone.

The adaptive capacity of bacteria has been incredibly successful, especially considering they have been on earth for over 1.8 billion years. Most successful mutations are passed on vertically from generation to generation in a long looped single chromosome composed of double-stranded DNA residing in the nucleolus of the bacteria. The instructional information is passed primarily during cell division, enabling future progeny to survive in their environment. These traits include such capabilities as biofilm formation for tribe protection, the ability of a small number of bacteria to form one-occupant spores, and the inherited capability that a few bacteria possess to produce small colony variant (SCV) progeny that, in effect, are invisible to the human immune system.

Some protective mutations can be transferred horizontally to other bacteria unrelated to the original “mutant.” The genetic instructions are encoded in a much smaller double-stranded DNA loop, the plasmid. Plasmids can replicate independently producing as many as needed to “share” with other bacteria. Once a bacterium receives a plasmid, it in turn produces replicates to fortify its own protection and potentially to distribute to others. Plasmids are also vertically passed on to progeny during cell division, thus improving the odds of survival for their descendants.

Antibiotic resistance genes are very successful mutations located on plasmids. The mutations only work on specific antibiotic types and only by specific action modes. There are at least 10 different protection modes that have been successful:

Within the bacterial cell itself:

  1. Blocks entry of specific antibiotic types trying to enter bacterial cell
  2. Flushes the antibiotic out of the bacterial cell before it reaches their targets
  3. Produces enzymes that break apart antibiotics before they reach their targets
  4. Produce antibiotic modifying enzymes that render the antibiotic ineffective
  5. Modify the targets so they cannot be impacted by the antibiotic
  6. Make so many clones of the antibiotic targets, that the antibiotic is spent before destroying all the targets

Within the group-protective biofilm:

  1. Exo-enzymes distributed throughout the biofilm matrix like land mines in the battlefield, digest specific antibiotic types when contact is made
  2. Many bacteria in the center of the biofilm, are altered into persister cells that shut down (hibernate), not allowing anything in---including antibiotics
  3. Most biofilm founding-bacteria attract diverse bacterial types to increase the odds of biofilm survival through genetically diverse protective adaptations
  4. Proximity and purpose of the (a) peripheral bacteria in a biofilm “fortress” makes them the forward perimeter guards. It is there that plasmids for diverse means of protection are most liberally shared. For example, the more means of defeating antibiotics each defender possess, the more effectively broad the antibiotic resistance. Bacteria deeper in the matrix are responsible for (b) harvesting moisture and nutrients, (c) metabolic waste disposal, (d) hibernating as persister cells, and (e) transforming into “Supper-Surface-Grippers.”

U.S. Daily Human Cost: Each day, approximately 5,000 Americans acquire a serious antibiotic–resistant infection.  Of those, about 63 patients will die and a large percentage of survivors will suffer long term chronic consequences. By 2050, it is projected that untreatable antibiotic infections with overtake cancer as the number one cause of death globally.

U.S. Annual Financial Cost: Antibiotic-resistant infections add $20 billion in excess direct health care costs and up to $35 billion the additional costs to society for lost productivity.

As with any battle, attacking before the enemy can establish a foothold and fortify a reservoir of resistant pathogens is by far the easiest, most effective and least costly means of patient protection. It takes a team to do what’s needed including infection preventionists, OR and device reprocessing staff, environmental services, engineering, and clinicians.

Infection preventionists must have help to handle required reports, statistics and trending paperwork so they can be actively on the floors, teaching, advising, admonishing, finding solutions and supporting staff trying to do the right things under pressure.

Infection prevention efforts are becoming more and more imperative.  We are facing a clash of Prime Directives between patient and pathogen. Bacteria have almost a 2 billion-year proven record of adapting to survive.  We are losing the capability to treat more and more our patients’ infections.  We need to adapt tactics, techniques, technologies and responsibilities if we are to win the war for patient survival.

Wava Truscott, PhD, MBA, is principal of Truscott MedSci Associates, LLC.     

This article is from the October 2019 issue of Healthcare Hygiene magazine.

Legionella: Recognizing the Risk and the Resources

By Sylvia Garcia, MBA, RN, CIC

Every day, patients are at risk because healthcare facilities are not aware of hazards related to water systems and equipment that uses water, or they have not prioritized it as an important issue. It is estimated by the Centers for Disease Control and Prevention (CDC) that 9 out of 10 infections acquired in a healthcare setting could have been prevented if the facility had initiated a better water management system.

Shockingly, 1 in 4 patients who develop healthcare-associated Legionnaires’ disease will die, compared to one in 10 that will die from community-acquired pneumonia. Even more surprising is the fact that at least 80 percent of the Legionella cases that occur in healthcare facilities could have been prevented by implementing an effective water management program.

The most common sources of Legionella cases are showers, cooling towers, decorative fountains, and hot tubs but anything that can create droplets or aerosols could become a source. For example, putting tap water into a room humidifier could lead to infection. About half of Legionella outbreaks are linked to incidences associated with human error, such as a health care professional not following instructions for use of equipment.

Although Legionella is highly publicized, it is not the only risk related to health care water systems. At the Association for Professionals in Infection Control and Epidemiology (APIC) 2019 Conference, researchers reported that 22 percent of consultations conducted by the Division of Healthcare Quality Promotion (DHQP) were water related. Causes of patient infections were identified as preventable, had the healthcare organization properly utilized available information and followed procedures communicating the need for the organization to implement an effective water management plan. For example, use of consumer-grade humidifiers in an operating room was linked to an outbreak of nontuberculous mycobacteria. Yet, the 2003 CDC Guidelines for Environmental Infection Control in Health Care Facilities clearly state that this this type of humidifier has been linked to Legionella outbreaks.

As with other infection prevention and control challenges, organizations need to follow a standardized approach to reducing risk related to waterborne disease.

1. Regulatory Requirements. Organizations should know their state’s regulatory requirements. Sources include health department and building code requirement documents. New York has enacted state regulations that require hospitals and residential healthcare facilities to perform environmental assessments, implement sampling and management plans to sample their potable water systems for Legionella and institute control measures in the event of a Legionella exceedance. New York also requires cooling towers to be registered and monitored for Legionella. All states provide or employ Healthcare Associated Infection Liaisons to direct healthcare workers to relevant information.

It is also important to understand state reporting requirements for Legionella and to identify known or suspected outbreaks caused by waterborne pathogens. To meet these requirements, facilities must implement a system to identify and evaluate possible cases. A laboratory finding is usually the first step in identifying a possible case. However, the infection preventionist or other knowledgeable person is also needed to apply generally-accepted case definitions or create a case definition in the outbreak setting.

State building codes vary, but many states have adopted a version of the Facilities Guideline Institute (FGI). Organizations can gain access to relevant building codes or, depending on the year, can access the information directly via FGI’s read-only access. For example, FGI 2014 and 2018 state “provisions based on a risk-assessment plan shall be included in the heated potable water system to limit the amount of Legionella bacteria and opportunistic waterborne pathogens.” For the same reason, unsealed, indoor decorative fountains are prohibited in these versions. FGI also provides excellent references - including CDC Guidelines for Environmental Infection Control in Health Care Facilities, American National Standards/American Society of Heating, Refrigerating and Air-Conditioning Engineers Standard 188: Legionellosis: Risk Management for Building Water Systems, American Society of Heating, Refrigerating and Air-Conditioning Engineers Guideline 12: Minimizing the Risk of Legionellosis Associated with Building Water Systems and the American Society of Plumbing Engineer’s Legionella Control in Health Care.

2. Centers for Medicare and Medicaid Requirements. In July 2018, CMS updated its requirement to reduce Legionella risk in health care facility water systems to prevent cases and outbreaks of Legionnaires’ disease. The updated requirement makes certain that Medicare-certified hospitals, critical-access hospitals and long-term care facilities develop, implement and monitor the effectiveness of water-management programs to protect patients, visitors and staff from exposure to waterborne pathogens, including Legionella pneumophila.

3. Manufacturer Instructions for Use (IFU). Equipment that uses or is connected to water has specific plumbing, filter and/or maintenance requirements. For example: air gaps may be required for plumbing installations; cooling tower instructions-for-use may specify inspection criteria and biocides to maintain biological control; and equipment may indicate use of sterile water or specific frequency for maintenance. In addition, some equipment may specifically state that it is not appropriate for healthcare settings. Careful reading and compliance with IFUs are essential to preventing outbreaks.

4. Evidence-based guidelines and national standards (EBG). CDC, the American Society of Heating, Refrigerating and Air-Conditioning Engineers and many other organizations have created excellent resources for preventing waterborne illness. Key resources from CDC include 2003 CDC Guidelines for Environmental Infection Control in Health Care Facilities Guidelines for Environmental Infection Control in Health care Facilities and the Centers for Disease Control and Prevention Tool kit, which outlines elements of an effective water management system with focus on health care facilities. EGB will include the following key elements:
• Establish a water management team. There is flexibility in qualifications of team members. However, it is important to seek individuals with backgrounds in the following when forming a health care facility team: facilities management, microbiology, infection prevention, risk management and occupational health.
• Describe the building’s current water system. Create a diagram that highlights water points of entry, distribution, storage and use. Most facilities display building drawings that include their plumbing system, so that is a great place to start.
• Identify where Legionella and other pathogens can grow. Facilities should identify at-risk systems and equipment with respect to their components, installation, configuration, use and condition, as well as vulnerability of persons served by these systems.
• Determine control measures and standards for monitoring them. Control measures must be developed for each risk point. Facilities must determine what is planned to be checked to ensure that their control measures are effective. Examples include but are not limited to: monitoring compliance with routine maintenance, water temperature, pH, chlorine levels and cultures. Note: Routine culture testing for Legionella and other pathogens is not required by CMS but may be required by state or local regulation.
• Establish interventions when clinical limits are not met. The expectation is that facilities establish a plan for remedy if a suspected health care-associated case of Legionella is identified or suspected or if control measures are not being met.
• Make sure the program is functioning as designed and is effective. Validate that all control measures have been implemented as designed and procedures have been established to confirm the water management program is effectively controlling water-related hazards.
• Document and communicate. Facilities’ water management programs should be documented. It is important to inform those at risk of the facility plan in place. If a problem occurs, it is required that the incident is reported to the health department.

5. Create a Facility Water-Management Plan. Using the steps, create a team and sort through water management requirements. The Joint Commission looks for evidence of compliance by using following key elements:
• Facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. pseudomonas, Acinetobacter, nontuberculous mycobacteria, and fungi) could grow and spread, and to evaluate programs to protect the health and safety of patients. Relevant standards should be recorded for facility water systems or equipment containing or using water.
• A water management program that considers input from the following publications: American Society of Heating, Refrigerating and Air-Conditioning Engineers 188 and the CDC Toolkit. Developing a Water Management program to reduce Legionella growth and spread in buildings: a practical guide to implementing industry standards.
• Testing protocols and acceptable ranges for control measures, with results of testing and corrective actions taken when control limits are not maintained

The Joint Commission surveyors may ask to review IFUs for equipment that uses or contains water. They also may ask about circumstances that could put a facility’s cooling towers or water system at risk.

Surveyors may also ask for a facility’s plan to mitigate risk, which should include identifying:
• System startups and shutdowns
• Areas of the facility that are closed or have low census
• Changes to municipal water treatment
• Water main breaks
• Construction or renovation
• Fluctuations in source water temperature
• Cooling tower maintenance

A systematic approach will ensure that key requirements and prevention strategies are not missed when preventing waterborne pathogens. There is not one solution to this challenge. In fact, water management needs to be uniquely tailored to each health care facility’s building, equipment, water and conditions. Implementing an organized approach, maintaining correct background information and utilizing key resources will help keep people safe from waterborne pathogens.

Sylvia Garcia, MBA, RN, CIC, is the director of infection prevention and control in the Division of Healthcare Improvement. In this role, she is responsible for the oversight of infection prevention and control for The Joint Commission. She has more than 30 years of experience in infection control in both hospital and long term care settings, as well as eight years of clinical microbiology experience. Most recently, she served as the director of infection control at University of Chicago Medicine and was also an intermittent consultant for Joint Commission Resources for 10 years. Garcia has provided infection prevention and control consultation, assessment and education in a variety of healthcare settings including hospitals, health clinics, ambulatory surgery, and dialysis centers both domestically and internationally. Her specialty areas of interest include disinfection and sterilization, dialysis, infection prevention during renovation and construction, and control of Legionella. One of the highlights of her career has been training healthcare professionals in Saudi Arabia as infection preventionists. She served as a test writer and reviewer for the Certification Board of Infection Control and Epidemiology, and has also authored numerous articles and book chapters related to infection control including a chapter in the APIC Text and the Cleaning, Disinfection and Sterilization Chapter in The APIC/JCR Infection Prevention and Control Workbook, Third Edition. Garcia earned a degree in biochemistry and molecular biology from Northwestern University, a master’s of business administration from the Keller Graduate School of Management, and her nursing degree from Truman College.