Advanced management and control of a Legionella outbreak in a full service hospital clinical and technical collaboration.

Transcription

1 Advanced management and control of a Legionella outbreak in a full service hospital clinical and technical collaboration. Dr Vyt Garnys 1, Paul Bartley 2, Raghuram Muguli 3 1 CETEC Pty Ltd, Melbourne, Australia 2 The Wesley Hospital, Brisbane, Australia 3 CETEC Pty Ltd, Sydney, Australia

2 WE WILL LOOK AT Limitations of published remedial options Monitoring strategies Rectification strategies Case study Path to regulation

3 BIOFILM IN PLUMBING SYSTEM. All cold, hot and warm water designs have the potential to house microbially active matter due to their complex design, fittings and intermittent use

4 HEATED WATER DESIGN INITIALLY SIMPLE. DEWHA 2008

5 . POTABLE WATER DELIVERY NOW INCREASINGLY COMPLEX

6 . EVEN ACCESS IS NOW INCREASINGLY DIFFICULT AND DEPOSITION LOCATIONS MORE FREQUENT

7 KEY BACTERIAL BREEDING POINTS. Dead Legs, Pipe walls, TMV s, Taps, Showers Washers, o-rings, ABS plastic, flexible hoses Storages, cold and warm systems

8 EVEN COLD WATER IS CONTAMINATED Often neglected as a repository of biofilm Can be contaminated by earthworks, repairs and other water supply quality issues and can seed cold and warm water system either directly or through thermal mixing values (TMV) Cold water pipes adjacent to warm water pipes, refrigeration, ceilings and/or heating systems, ie. can be warmed Active Legionella breeding is found in cold side of TMVs Need to disinfect both hot and cold water systems Need to maintain disinfection.

9 . THERMAL MIXING VALVE

10 Control Options (WHO) Method Advantage Disadvantage Periodic flushing with hot water at C Simple, Effective, easily monitored Not applicable to cold water systems Requires protection against scalding Must be maintained and inspected to achieve consistent control Recolonization occurs within days

11 Chemical Options (WHO) Method Advantage Disadvantage Dosing with Sodium Hypochlorite Dosing with monochloroamine Proven, effective disinfection technique Simple to use Relatively cheap More persistent than chlorine Simple to use in mains distribution Penetrates into Biofilm Formation of trihalomethanes Needs protection for dialysis patients Toxic to fish Affects taste and odour Not stable, especially in hot water Increases corrosion of copper Needs protection for dialysis patients Toxic to fish Affects rubber components Limited commercial kits available

12 Chemical Options - Cont (WHO) Method Advantage Disadvantage Formation of chlorite Dosing with Chlorine dioxide Ultraviolet disinfection Proven disinfection technique Simple to use Proven disinfection technique Simple to use Needs protection for dialysis patients Safety considerations (dependent on method of generation) Effective only at point of application (no residual) Not suitable for turbid waters No effect on Biofilm formation

13 CASE STUDY

14 TREATMENT HISTORY Several heat treatment cycles (70 Deg C) conducted internally for 2 weeks Presence of Legionella (2x 10 days) still confirmed following heating CETEC contracted to provide expert advice and resolve issue to allow hospital to RAPIDLY return to full operation

15 MANAGEMENT STRATEGY Daily meeting of all key sector managers Establish multidisciplinary expert panel Establish physical remediation task group Establish expert communications task group Regular staff assembly progress briefings Ambulance bypass and no new patients (20% occupancy) Maintain ICU and dialysis operations on bypass water Dry washing and bottled drinking water Train and use 50 underemployed nurses to assist in remediation (tap flushing and testing)

16 CHALLENGES Understanding plumbing networks & condition Backflow water prevention to isolate buildings Not cutting all water to the hospital whilst installing backflow equipment (e.g. Maintaining water supplies) Management of occupants and critical patients within facility during treatment In this case, each of 5 hospital buildings were vacated in rotation but critical facilities were operated during remediation.

17 WATER & CLINICAL MONITORING A baseline was established for both Legionella & HCC plate count Implemented rapid same day microbial enzyme analysis technique (Mycometer - Bactiquant Water) Patient management, diagnosis, treatment & reporting requirements occurred concurrently.

18 RAPID REMEDIATION PROGRAM No single silver bullet therefore Integrated program of biofilm remediation required consisting of: chemical cleaning & hyper disinfection of pipework Ongoing chlorine disinfection of potable water ongoing removal of dead legs Ongoing monitoring 1-2 days remediation treatment per building

19 BIOFILM and DEPOSIT CLEANING OF PIPEWORK - STEPS

20 . CHEMICAL AND CHLORINE DOSING

21 REMOVAL OF BIOFILM WITH ALKALINE DETERGENT.

22 . MAIN TANK STORAGE AND MAINTENANCE DOSING POINT

23 Examples of results # Pre Treatment (cfu/ml) Post Treatment (cfu/ml)** Area *HCC Legionella (SG1) HCC Legionella (TL & SG1) 1 36, <10 < ,000 <10 <10 <10 3 1, <10 < ,000 >30,000 <10 <10 # Approximately 3000 samples, 5 buildings, 560 beds A range of Species identified periodically, ** >99% at <10cfu/ml

24 OUTCOMES New admissions were made to the hospital in 13 days, full operation in 29 days from 20% occupancy Where reoccurrences of Legionella occurred, these allowed detection of dead legs which were subsequently removed Following removal of dead legs, and >3 months later, no reoccurrence of Legionella or HCC Rapid Mycometer HCC testing allowed for on-site control of efficacy of the decontamination and post treatment Invited to join Technical advisory panel (TAP) formed by Queensland state government in June TAP released Preliminary Guidelines for Managing Microbial Water Quality in Healthcare Facilities on the 24 th October 2013 Guidelines incorporate CETEC decontamination method and WQRMP

25 Released 24 th October 2013

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30 ACKNOWLEDGEMENTS Richard Royle and all of the magnificent Wesley Hospital and Uniting Care team All of the CETEC and Foray Laboratories Team Glen Pinna and the Biotech Labs Team The Nalco water treatment Team Alex Mofidi and the AECOM water engineering Team Nicolas Massey and the Queensland Health Team Reviewers and Queensland HHS regional staff

31 THANK YOU, QUESTIONS? Queries to: Dr Vyt Garnys