Health Care Facility Environmental Exposures: Unique Concerns and Controls

RISK BULLETIN

Health care facilities contain a diverse population of potential pathogens and unique environmental hazards in addition to more commonly recognized facility environmental exposures (e.g., underground storage tanks, hazardous materials, wastes, etc.). This alone makes health care facilities prime candidates for intensive environmental control. Combine the number of potential hazards with an increased number of high risk individuals (infants, elderly, immunosuppresed, etc.) and the result is an environment that requires a complex compilation of procedural and environmental controls. Exposure to either biological or chemical hazards can occur via surfaces, air, and water and can be exacerbated by construction activities within the facility. Pollution liability insurance coverage, contractual agreements and other risk transfer mechanisms are advisable; however, a strong risk management program is essential in minimizing third party liabilities and claims at health care facilities.

There are more than 6,000 hospitals in the United States with over 1 million beds. Approximately 75% of health care-associated construction projects focus on renovations of existing outpatient facilities with an annual price tag of almost $14 billion dollars (1). With the aging of health care facilities and advancement of technology comes an ongoing need for repair and remediation work (e.g., installing wiring for new systems, removing old sinks, repairing elevator shafts, etc.), all of which can introduce contamination to the air and water. Aging mechanical equipment and lack of proper maintenance can provide an additional mechanism for contamination in patient areas. Examples of some controllable environmental risks include: transmission of infections due to inappropriate or inoperable air-handling systems; fungal infections due to lack of environmental controls during periods of health care facility construction; and disease outbreaks due to compromised water and aqueous solutions. This technical bulletin will address: mold and fungal infections; Legionella and other water-borne pathogens; indoor air quality issues; and the effect on each of construction/renovation projects.

Mold and Fungal Infections

Fungi are one of the most commonly found organisms on the planet. In general, fungi are not considered highly pathogenic; however, there are a few health care populations that have an increased susceptibility to fungal infections. These populations typically have some form of general (e.g., HIV, transplant patients, etc.) or localized (e.g., lung due to steroid inhaler use) immunosupression. One of the most prevalent fungal pathogens belongs to the genera Aspergillus. Aspergillus species are ubiquitous and occur in soil, water and decaying vegetation. Spores of Aspergillus can survive for extended periods of time (hundreds of years) in air, dust and water. Infections in immunosuppressed patients have been documented following renovation and construction work and in contaminated potable water systems. The presence of Aspergillus species in the high risk locations of a health care facility environment can be a substantial risk factor for invasive aspergillosis.

Site renovations and construction activities can disturb Aspergillus-contaminated dust or fungal colonization of moisture-impacted building materials and increase the levels of airborne spores within the facility. Airborne spores can impact patients directly or indirectly. For example, infections have been documented as a result of contaminated medical devices that were stored near a renovation or construction area. In addition to Aspergillus species, several other molds such as Rhizopus species, Fusarium species and Penicillium species have also been implicated in outbreak clusters in health care facilities. These other fungi are usually associated with contaminated dust or water-impacted building materials. As such, it is vital for a health care facility to develop and implement water intrusion management plans and infection control protocols that address renovation and construction projects. These programs should include a detailed training program for both contractor and hospital staff. All contractors working at a healthcare facility should understand the importance of developing and adhering to an infection control plan.

In addition to the impact by the common fungal organisms mentioned above, health care facilities in certain geographic locations may also have the potential to be impacted by a group of fungi which are considered to be relatively unusual. Infections due to Cryptococcus neoformans, Histoplasma capsulatum (endemic in the soil of the central river valleys of the United States) or Coccidioides immitis (endemic in the southwestern desert regions of the United States) can occur in health care facilities if the nearby soil is disturbed and the spores are passed into the ventilation system. In addition to disturbing soils, C. neoformans outbreaks have been associated with disturbing bird droppings, particularly from pigeons, that occur near air intakes. Therefore, when renovation, construction or maintenance is conducted, it is essential that the work be coordinated with the infection control department and that appropriate controls (dust suppression methods, wetting bird droppings prior to cleanup, HVAC inspections and filter replacement, etc.) are in place prior to initiation of the project.

Current data suggests that the risk of disease is influenced not by the quantity of Legionella present in one given (sample) location, but rather the extent of contamination – the number and percentage of sites testing positive in a building. An individual may be exposed by inhaling aerosols, fine sprays, mists or other microscopic droplets of water contaminated with Legionella. Exposure may also occur when choking spontaneously during drinking, ingesting, and swallowing (aspiration), which is a greater risk in a health care setting. Legionnaires’ Disease is not known to pass from person to person.

Waterborne Pathogens

Water systems and aqueous solutions used in a health care facility have the potential to serve as reservoirs for a number of microorganisms. These microorganisms can then infect a susceptible host by: direct contact (e.g., washing an open wound); ingestion of water; indirect contact (e.g., a medical device washed with contaminated water); and inhalation of aerosols dispersed from water sources. The first three modes of transmission are commonly responsible for infections by gram-negative bacteria and nontuberculous mycobacteria. Aerosols generated by water sources are typically responsible for the transmission of Legionella.

Legionellosis or Legionnaires disease are terms used to describe infections caused by Legionella species. Legionella is commonly found in various aquatic environments such as cooling towers, evaporative condensers and heated potable water systems. In a number of documented hospital outbreaks, Legionella has been traced back to cooling towers, showers, faucets, respiratory therapy equipment, and humidifiers. Lack of maintenance of a facility’s hot water system can increase the likelihood of finding the bacteria in the system. Legionella thrives in water temperatures between 77 and 107o F, stagnant water, and water heaters with a large amount of scale and sediment. Like fungal infections, individuals with compromised immune systems are at a higher risk for contracting the disease.

Health care facilities should have a written waterborne pathogens prevention program and maintenance plan that provides for periodic maintenance of the various water systems (e.g., water heaters, cooling towers, hot tubs, atriums and water features, etc.) in the facility. Legionella is easily controlled with diligent preventative maintenance. Maintenance can be as simple as periodic flushing of systems with hot water and preventing the build-up of sediments in the systems. Neglected systems may require sanitization with high levels of chlorine prior to development of a maintenance and monitoring system. A waterborne pathogens prevention program should address ongoing water system operation, maintenance, and monitoring.

Potable water systems can also be a source of other opportunistic organisms. Pseudomonas aeruginosa, Burkholderia cepacia, Ralstonia pickettii, Stenotrophomonas maltophilia, and Shingomonas species have all been linked to outbreaks in health care facilities. As with most of the pathogens discussed, immunosuppresed patients are at the highest risk for developing an infection. The mode of entry into the potable water system can vary depending on the system; however, one of the more common modes is through introduction of soils and other contaminants during construction or plumbing repair.

Another group of water-borne bacteria that is of particular concern to the immunosuppressed population of health care facilities is Nontuberculous Mycobacteria (NTM). The four most common forms of human disease associated with NTM are: pulmonary disease in adults; cervical lymph node disease in children; skin, soft tissue and bone infections; and disseminated disease in immunosuppressed patients. NTM is spread via all modes (contact, indirect contact, ingestion and aerosols) of transmission associated with water. NTM can be isolated from both natural and man-made environments that include municipal systems, hospital water systems and storage tanks. Some NTM species can survive water temperatures up to 113o F and have been isolated from hot water taps, which can pose a problem for hospitals that lower the temperature of their hot water systems. In addition to NTM’s ability to survive in hot environments, many species have a high resistance to chlorine. As such, these organisms can form biofilms at fluid-surface interfaces (e.g., inside of pipes). NTM has also been found to enter drinking water systems inside of waterborne protozoa. To reduce the risk of infection to immunosuppressed patients, hospitals are encouraged to add filtration or sterilization systems to plumbing lines feeding high risk areas like Operating Suites and Intensive Care Units.

Indoor Air Quality

In addition to the number of biological pathogens, other indoor air quality (IAQ) issues may pose potential hazards to health care facilities. These hazards consist of irritants, allergenic agents, anesthetic gases and aerosolized medications, and laser plumes and surgical smoke.

Irritants are a class of chemicals that will typically cause minor discomfort such as burning of the nose, throat and eyes. Some of the irritants commonly found in health care facilities include ethylene oxide (used in the sterilization process), glutaraldehyde (used in sterilization and water treatment), formaldehyde (used to disinfect surfaces and in laboratory processes) and hexachlorophene (antimicrobial wipe). Unfortunately, many of these irritants are needed to maintain sterile surfaces in the health care setting. However, it is important that health care facilities keep an accurate record of all of the chemicals that are being stored and used in each area. To reduce the number of patient and staff complaints, HVAC inspections should be conducted regularly to ensure that the systems are working properly. These inspections should verify that the number of air changes in an area meets ASHRAE recommendations (2).

Health care workers and patients may have a particular susceptibility to allergen contaminants from products used in a health care facility. Latex allergens from gloves and other latex-containing products have received a lot of attention from the health care industry, but there may also be more common allergens (dusts, molds, etc.) that can cause problems. A plan should be developed by the facility that provides guidelines to help identify patients or staff with allergies, the measures to be taken when an individual is identified with an allergy, and the education needed to alert health care providers about potential problems.

Anesthetic gases and aerosolized medications (e.g., ribavirin, pentamidine, and aminoglycosides), laser plumes and surgical smoke are considered some of the emerging potentially hazardous exposures to health care workers and patients. Procedures that utilize lasers for the transfer of electromagnetic energy into tissues result in the release of a heated plume that includes particles, gases, tissue debris, microbes and offensive odors. Facilities should have detailed health and safety plans and indoor air quality controls that protect employees and third parties. Periodic monitoring and exposure assessments should be conducted to document exposure levels of these hazards.

Regulatory Standards

With the exception of those issues covered by occupational safety standards (i.e., OSHA standards), control of the hazards discussed in this paper are left to the discretion of the facility itself. The Joint Commission is responsible for overseeing hospital accreditation, but is not prescriptive in their guidance manual section entitled “Surveillance, Prevention, and Control of Infection” where they outline nine standards (3). These somewhat vague standards are as follows:

• IC.1.10 – The hospital uses a coordinated process to reduce the risks of nosocomial infections in patients and health care workers;
• IC.1.20 – The infection control process is managed by one or more qualified individuals;
• IC.2.10 – Case findings and identification of demographically important nosocomial infections provide surveillance data;
• IC.3.10 – When appropriate, the hospital reports information about infections both internally and to public health agencies;
• IC.4.10 – The hospital takes action to prevent or reduce the risk of nosocomial infections in patients, staff, and those who come into the organization;
• IC.5.10 – The hospital takes action to control outbreaks of nosocomial infections when they are identified;
• IC.6.10 – The hospital’s infection control process is designed to lower the risks and to improve the rates or trends of epidemiologically significant infections;
• IC.6.20 – Management systems support the infection control process;
• IC.6.30 – The infection control process includes at least one activity aimed at preventing transmission of epidemiologically significant infections between patients and staff.

Because of the flexibility provided in implementing the Joint Commission standards, it is incumbent upon the facility itself to identify the various hazards and provide an appropriate risk management plan.

Litigation associated with exposure to the hazards outlined in this paper varies depending on the risk itself. For example, lawsuits brought on behalf of victims of latex protein toxic syndrome are becoming increasingly numerous nationally. There have also been some suits filed for Aspergillus infections associated with construction activity and Legionella infections due to contaminated hot water systems. However, most of the other infections and exposures addressed in this overview have not been the center of intense litigation. This is in part due to liability waivers in place at most health care facilities that indicate infections are an acceptable risk of health care procedures. However, with changes in Medicare and Medicaid coverage for “never events” (conditions that are preventable and should never occur), this may hold hospitals to higher quality standards and increase their liability and susceptibility to litigation. Risk managers should work with legal counsel to understand what exposures are covered under various insurance policies and those which should be addressed via liability waivers and other contracts.

Construction Activity

Construction activity in a health care facility can be categorized as either external construction or internal construction. External construction can include activities from construction of a new building to re-design of the exterior landscape. There are several issues that need to be addressed prior to any type of external demolition or construction. These issues include, review of the proximity of the air intake system to the work site, adequacy of window and door seals, along with a determination of the proximity of these areas to areas frequented by immunocompromised patients. Minimizing the entry of outside dust into the HVAC system is crucial in reducing the risk of airborne contaminants. Air handling units that may be impacted by dust from construction projects should either be shut off or the filtration of the air through the unit should be increased. It is important that this work be conducted by an HVAC engineer to ensure that operational changes do not adversely impact pressure differentials and other controls in the building.

Interior construction activity includes all processes from changing ceiling tiles and painting to full-scale renovation. During periods of demolition, construction, renovation or repair inside of the facility, a properly developed infection-control program should be implemented. This program at a minimum should include: education of construction and hospital staff on plan implementation; proper preparation of the site (e.g., construct appropriate barriers or temporary walls); proper notification to staff, patients and visitors of the pending construction; relocation of high risk patients; monitoring of the control measures during construction; daily cleanup procedures; and ensuring the integrity of the water system during and after construction. It is imperative that all contractors and maintenance personnel are in contact with the infection control department when any type of renovation activity is undertaken to evaluate the associated risk of materials and activity to the patient population. Simple projects such as replacing a ceiling tile can have serious implications if conducted around high-risk populations.

Conclusions

In conclusion, health care facilities contain a complex range of environmental hazards. To reduce the risk to patients, staff, visitors, and contractors, it is imperative that the facility design and implement a comprehensive management plan. The plan should include, at a minimum, a detailed description of the issue, required training, assessment and audit procedures, and communication requirements. A comprehensive written program should be implemented to address water intrusion and mold prevention, infection control, waterborne pathogens, and operation and maintenance of systems associated with indoor air quality. Formal programs will help establish a standard of care, prevent problems, and minimize liabilities and claims.

References

1. American Hospital Association – www.aha.org – Redefining Hospital Capacity.
2. American Society of Heating, Refrigerating and Air-Conditioning Engineers, Inc, Standard 62.1-2007 – Ventilation for Acceptable Indoor Air Quality
3. The Joint Commission - www.jointcommission.org – Hospital Accreditation Standards 2004.

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Information accurate as of October, 2008.

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