ashrae spc 188 and what that means for healthcare · pdf fileashrae spc 188 and what that...

ASHRAE SPC 188andand

What that means for Healthcare

South Carolina Society of H lth E iHealthcare Engineers

May 6, 2011

Confidential and proprietary to Garratt-Callahan Company

Who is Garratt Callahan?Who is Garratt Callahan?

Largest privately owned water treatment companyp y

Formed in 1904 family owned andFormed in 1904 – family owned and operated – 4th generation

USA, Mexico, Caribbean, Asia


ExperienceExperience

Ten years doing secondary disinfection – started in Wisconsin

Preferred vendor to national healthcare GPOs:healthcare GPOs:

Premier, Novation, Amerinet, Med Assets Catholic Health and moreAssets, Catholic Health and more


Member: National ASHE

PresentationPresentation

IntroductionLegionella, Biology, Mitosisg , gy,Sources of LegionellaRisksRisksCooling Water Domestic Water


PresentationPresentation

ASHRAEASHRAE HACCPIdentify an Ideal BiocideChoices for Domestic WaterRelative PerformanceEquipment Design / MethodEquipment Design / MethodQ & A


Legionella p. (gram-negative)Legionella p. (gram negative)


Legionella pneumophilaLegionella pneumophila

• Thin flagellated Gram-negativeThin, flagellated Gram-negativebacterium of the genus Legionella.

• L pneumophila is the primary• L. pneumophila is the primary human pathogenic bacterium in this group and is the causativethis group and is the causative agent of Legionellosis or Legionnaires' diseaseLegionnaires disease



• 54 genetic strains (serogroups)• 54 genetic strains (serogroups)• Legionella pneumophila

( 1) i th t l th l(serogroup 1) is the most lethal strain

• Protozoonotic - can live and reproduce within amoebae, paramecia (protective habitat)


Time for a Short Biology LessonTime for a Short Biology Lesson


But First…A Math Question: “Chess Board For Sale”Chess Board For Sale

64 SquaresPrice Increases in Geometric Progression (2X)g ( )$0.01 for the first square$0 02 for the second square$0.02 for the second square$0.04 for the third squareand so on…How Much for the Board?


Total Cost….Total Cost….

$184 467 440 737 095 000 00$184,467,440,737,095,000.00

$184 Trillion and Change


Bacteria CellBacteria Cell

Some bacterium can divide every 20 minutes, others 18 seconds,

Let’s say conditions are not idealLet s say conditions are not ideal

Mitosis takes place every hour…


Growth RateGrowth Rate

O ll t th St tOne cell at the Start

At end of the first hour 2 cellsAt end of the first hour – 2 cells

End of second hour – 4 cellsEnd of second hour 4 cells

At the end of six hours – 64 cells


Growth Continues…Growth Continues…

At 18hours – 262,144 Cells

In Only One Day…

16 777 216 Cells16,777,216 Cells


Bacteria Cells in WaterBacteria Cells in Water

Planktonic: free-floating

Sessile: attached, forming slime

Sli ll b i d i l h idSlime: cells buried in polysaccharide


Bacterial SlimesBacterial Slimes


Where is Legionella Found in a Typical Outbreak? USCDCTypical Outbreak? USCDC

100%

70%

80%

90%

80% from Domestic Water

(Potable)

40%

50%

60%

(Potable)

10%

20%

30%

40%

20% fromCooling Water


0%

10%

In which Facilities does Legionnaire's Disease appear?Legionnaire s Disease appear?

56% from all Others

21% Hotels

23% Healthcare


How does it enter the body?How does it enter the body?

Aerosol water droplets must be inhaled (aspirated)

Legionellosis develops as aLegionellosis develops as a pneumonia-like infection in the lungslungs


Areas of Highest RiskAreas of Highest Risk

• Hot and cold water systemsHot and cold water systems– Pipes, faucets, electronic faucets, shower heads, ice makers

• Nebulizers • Cooling towers and evaporative

condenserscondensers• Humidifiers and air washers

P l d• Pools and spas• Air conditioning


Medical Treatment?Medical Treatment?

Presents as pneumonia – treatment is penicillinp

Patient get worse doctors increasePatient get worse – doctors increase the penicillin dose

Patient can die…


Treatment for LegionellosisTreatment for Legionellosis

When the doctor knows it is Legionellosis:g

The treatment protocol changes to aThe treatment protocol changes to a “mycin”, penicillin doesn’t work


Medical Best Practice

Patient can die unless urinary antigen, culture, serology or DFA for Legionella was run and proper diagnosis and treatment is provided.

USCDC directs healthcare to:“maintain high index of suspicionmaintain high index of suspicionfor Legionellosis” where patients

t i kConfidential and proprietary to Garratt-Callahan Company

are at risk.

Legionella in Cooling WaterLegionella in Cooling Water

100%

60%

70%

80%

90%

30%

40%

50%

60%

20% from

0%

10%

20%

20% fromCooling Water


Cooling TowersCooling Towers


Cooling WaterCooling Water

Ideal Temperature for Growth –Ideal Temperature for Growth 68oF to 105oF

Lots of Food – air is washed

Biocide Choices are Important

M t P t t SliMust Penetrate Slimes


Cooling WaterCooling Water

Must KILL Before being dumped

Must Know the Wash Out Rate

Alternating Oxidizer with Non-Oxidizer is highly recommended (ASHRAE, ASHE, USCDC, CTI…)


Non-Oxidizing BiocidesNon Oxidizing Biocides

Alternate with Oxidizing Biocide

Must be USEPA RegisteredMust be USEPA Registered

Must be used per the LabelMust be used per the Label

Quaternary not effectiveQuaternary not effective


Non-Oxidizing BiocidesNon Oxidizing BiocidesIsothiazolone

Glutaraldehyde

Organo-sulfur

DBNPA

THPS

T b th l iConfidential and proprietary to Garratt-Callahan Company

Terbuthylazine

Oxidizing BiocidesOxidizing Biocides

Alternate with Non-Oxidizing BiocideBiocide

Must be USEPA RegisteredMust be USEPA Registered

Must be used per the Labelp


Oxidizing BiocidesOxidizing Biocides

Hypochlorous Acid (Bleach)Hypochlorous Acid (Bleach)OzoneBromine (activated by chlorine)Bromine (activated by chlorine)Bromine chlorideChlorine (gaseous)ChloraminesC o a esChlorine dioxide


Oxidizing Biocides - SelectionOxidizing Biocides SelectionHypochlorous Acid (Bleach) Not effective at pH

above 8.3, 30 minute kill timeOzone Not very soluble in waterBromine (activated) Good Choice, requires

t ll d i icontrolled mixingBromine chloride Very Good Choice in many

applicationsapplicationsChlorine (gaseous) Dangerous, requires

constant attentionChloramines Requires ammonia mixed with

chlorineChlorine dioxide Excellent but can be more


Chlorine dioxide Excellent but can be more costly, 99% kill in one minute

Legionella in Domestic WaterLegionella in Domestic Water

100%

60%

70%

80%

90% 80% from Domestic Water

(Potable)

30%

40%

50%

60%

0%

10%

20%


Domestic Water SystemsDomestic Water Systems


Domestic Water Pipe with Bacterial SlimeBacterial Slime


Bacterial SlimesBacterial Slimes


ASHRAE 12-2000ASHRAE 12 2000

• Recommendations for BestRecommendations for Best Practices

• Widely Ignored Due to Direct Costs ith littl i d b fitwith little perceived benefit

• No support from USCDC, ASHE, CTI, USEPA, Joint Commission


, ,

Why is Europe ahead of US?Why is Europe ahead of US?

Water Quality is Regulatedy gSpecific Enforcement DepartmentStrict LimitsStrict LimitsFines and Prison

In USA:Quality Measured, not Regulated


What is changing here in the USA?USA?

ASHRAE SPC 188ASHRAE SPC 188

Work started in 2008Work started in 2008

Due for publication later this year

June Meeting….


Organizations Supporting ASHRAE SPC 188ASHRAE SPC 188The following have been involved in

h i th St d d SPC188 d hshaping the Standard SPC188 and have indicated support:

1. ASHE2. USCDC - HICPAC3. USEPA4. Joint Commission


ASHRAE Standard 188ASHRAE Standard 188

• Covers Legionellosis as didCovers Legionellosis as did ASHRAE 12-2000

• No Longer Just a Suggestion• No Longer Just a Suggestion• Failure to Comply will be

id d N liconsidered Negligence• Expected to Require a HACCP be

formed


What is HACCP?What is HACCP?

• Hazard Analysis & Critical Control Points

• World Health Organization (1997)• Found in USEPA HACCP• Found in USEPA – HACCP

Strategies (2007)


HACCP PROCESS – initial stepsHACCP PROCESS initial steps

1. Assemble a Team – Operations, Consultants, Engineers, Vendors

2. Describe the end product3 Document the intended use3. Document the intended use4. Construct a Flow Diagram5 V lid t th Fl Di5. Validate the Flow Diagram


HACCP – Seven PrinciplesHACCP Seven Principles

1. Conduct Hazard Analysis2. Identify Critical Control Points3. Establish Critical Limits3. Establish Critical Limits4. Identify Monitoring Procedures5 E t bli h C ti A ti5. Establish Corrective Actions6. Validate/Verify the HACCP Plan7. Establish Documentation and

Record Keeping


p g

Next Step: Proactive ApproachNext Step: Proactive Approach1. Form a HACCP Team2 C ll f E i2. Cover all areas of Expertise3. Your Product is Water4. Produce a Flow Diagram5 Assess the Risks5. Assess the Risks6. Identify Control Points7 E t bli h C t l Li it7. Establish Control Limits8. Identify Monitoring Process


9. Establish Corrective Actions

What are your Products?What are your Products?

Water: used for drinking, showers, cooling water, cooking, ice making, medical treatments

Cooling Water for HVACCooling Water for HVAC

D ti C ld d H t W tDomestic Cold and Hot Water


Hazard Identified in Std 188Hazard Identified in Std 188

Presence of Legionella pneumophilaPresence of Legionella pneumophilaIn Potable Water

1. Domestic Cold Water2. Domestic Hot Water3 Cooling Water3. Cooling Water4. Water Features (fountains, etc.)


Your Goal should be PreventionYour Goal should be Prevention

Legionellosis as a Hospital Acquired Infection (HAI) can be actively ( ) yfought using secondary disinfection of potable water within pthe healthcare facility and a good biocide program in cooling waterp g g


Economic MotivatorsEconomic Motivators

Medicare and many Insurance Companies will not pay for HAIs

Bad Publicity sends potential patients elsewhere – loss ofpatients elsewhere loss of revenue

Lawsuits can cost millions - $$$


LawsuitsLawsuits

Simple Wrongful Death - $100,000 to $200,000 range

With Negligence - $1,000,000 to $2,000,000$2,000,000

With G N li $10 000 000With Gross Negligence - $10,000,000 to $600,000,000


Why Doesn’t the Water Authority Take Care of the Problem?Take Care of the Problem?

Most Public Water Authorities useMost Public Water Authorities useSodium hypochlorite (Bleach)

Biocidal Action comes from thef fformation of:

Hypochlorous Acid (HOCl)


THMs and HAAsTHMs and HAAs

Using bleach forms:

Tri-halomethanes (Chloroform) andTri halomethanes (Chloroform) and Haloacidic Acids by-products

These are identified as cancer i d li it d t 1 0 icausing and limited to 1.0 ppm in

drinking water by USEPA


Soft Water vs Hard WaterSoft Water vs Hard Water

Hard Water causes scale and under-deposit corrosioncomes from wellsincreased cooling water usagesofter water source is desirablesofter water source is desirable

Soft Water comes from lakes and i f trivers – surface waterscontains more organic pollutants


dirt and debris

Effect of pH on HOClEffect of pH on HOCl

At pH of 7.5 only 50% of Bleach forms HOCl ( 50% remainder is orders of magnitude less effective as biocide )

At pH of 7.5 a Double-Dose is required to get a Killrequired to get a Kill

HOCl 99% Kill Ti i 30 i tConfidential and proprietary to Garratt-Callahan Company

HOCl 99% Kill Time is 30 minutes

Criteria for an Ideal BiocideCriteria for an Ideal Biocide

High PerformanceEnvironmentally FriendlySafe to UseMake Economic Sense


Evaluate PerformanceEvaluate Performance

Speed of KillSelective – kills target organismsLow LC50 – lethal concentrationLow LC50 lethal concentrationPenetrates SlimesN t C d b M t i l fNot Consumed by Material of

ConstructionEffective over wide range of

Operating Conditions


Environmentally FriendlyEnvironmentally Friendly

Minimal by-products of reactionsResidues do not PersistResidues do not PersistBy-products do not PersistConsumables recyclable


Safe to HandleSafe to Handle

Manageable QuantitiesReleases non reportable (spills)Releases non-reportable (spills)Controllable FormNormal PPE for HandlingMinimized Storage Requiredg q


Economically FeasibleEconomically Feasible

A i t C t/B fitAppropriate Cost/BenefitEffective at Low DosageControlled ConsumptionMinimal Wasted ProductMinimal Wasted ProductReliable DeliveryO d /I t C t lOrder/Inventory Control


What are the Choices for Domestic Water Disinfection?Domestic Water Disinfection?

1. Superheat and Flush2. Periodic Hyper Chlorination3. Continuous Chlorination3. Continuous Chlorination4. Chloramines 5 O5. Ozone6. Copper-Silver Ionization7. Ultraviolet Light8. Chlorine Dioxide (ClO2)


8. Chlorine Dioxide (ClO2)

SUPER HEAT & FLUSH

• Proven effective, but…– Hot Water not available during disinfection– Risk of scalding (return at 124oF)– No residual effect once cooled– Rapid re-growth (not effective against

slimes)– Cold water mixes at point of use (>68oF)– Cold water carries the bacteria– Resource intensive - expensive


Biofilm vs CaCOBiofilm vs CaCO33 as an Insulatoras an Insulator

Water

BiofilmBiofilm ScaleScale5 mm

1 mm

5 mm

Heat Transfer Surface5 Times Equivalent Reduction in Heat5 Times Equivalent Reduction in Heat

Transfer Rate

CHLORINATION

• Hyper-chlorination is effective, but…– Resource intensive - labor– Does not penetrate slimes– Re-growth occurs quickly– High corrosion rates in copper pipesg pp p p– pH sensitive (50% wasted at 7.5 pH)– Taste and odorTaste and odor– THM’s and HAA’s (carcinogens)


Continuous ChlorinationContinuous Chlorination

• Requires feed and control system• Will not penetrate slimes• “Burns” the Polysaccharide slimeBurns the Polysaccharide slime• Consumed on non-living things

O idi thi i• Oxidizes anything – corrosive• Adds THMs and HAAs• Is depleted as it flows through

systems


y

ChloraminesChloramines

• Appears to work wellAppears to work well• Adds ammonia (NH4) to chlorine

R i i h d• Requires ammonia gas hazard on site

• Used in some city water plants• Not safe in a hospitalp


OZONE

• Effective against planktonic and sessile b t i (O )bacteria (O3, a gas)

• Sparingly soluble, difficult to control• Must be generated close to point of use• High maintenance – coronaHigh maintenance corona• High maintenance – molecular sieve

Hi h• High energy use• Works best at low pH


• EH&S issues (toxic gas)

Copper/Silver Ions

– 2006 EPA classified as biocide (toxic metals)Still t i t d ith USEPA– Still not registered with USEPA

– Show >40% users still have positives in t d f 16 h it l (J t St t Vi t Y )study of 16 hospitals (Janet Stout, Victor Yu)

– High capital costs ($90,000 average)S iti t H ( 7 6) d h d– Sensitive to pH (<7.6) and hardness

– Difficult to control desired residual– Sophisticated analytical techniques– High maintenance costs (cleaning)


– Source of corrosion in copper pipes

Ultra-Violet LIGHT

• Excellent disinfection technique when water is l (l NTU lt )clear (low NTUs - ultrapure)

• Effective over very short range when thin film (< 3 ) i d(< 3mm) is used

• Bulbs become coated, effectiveness lostF t b lb l t• Frequent bulb replacement

• No residual, localized disinfection only• Not effective on open-recirculating cooling

tower water


CHLORINE DIOXIDE

• EPA approved drinking water additive• OK to use on both hot and cold water• Effective regardless of water chemistry• Effective at very low levels 0 2 0 3 PPM• Effective at very low levels, 0.2 – 0.3 PPM• Controlled with Water Meter and ClO2 Analyzers (hot

or cold water)• Penetrates biofilm (polysaccharides) without reacting• Residual can be traced throughout facility• Low corrosion rates (very low affect on pH)• Low corrosion rates (very low affect on pH)• No THM’s or HAA’s, adds no taste or odor• Removed by normal Dialysis pre-filters


GC Selected This MoleculeGC Selected This Molecule

Chlorine Dioxide (ClO2)

5HCl + 5NaClO2 4ClO2 + HCl + 2H2O

Stoichiometric Reaction (equal volumes)

“Best Available Technology”


est a ab e ec o ogy

Water Pipe after Treatment with ClO2ClO2


Evaluate PerformanceEvaluate Performance

Speed of KillSelective – kills target organismsLow LC50 – lethal concentrationLow LC50 lethal concentrationPenetrates SlimesN t C d b M t i l fNot Consumed by Material of

ConstructionEffective over wide range of

Operating Conditions


ClO2 PerformanceClO2 Performance

99.999% Kill in 60 secondsVery low dosage

Polluted Water Study: 1 PPM ClO2

C t l t 40 PPM ClCompares to almost 40 PPM Cl2Selective OxidizerSame Kill Rate at pH 6.5-8.5LC50 = 293 ppm in air


LC50 293 ppm in air

ClO2 Environmental ImpactClO2 Environmental Impact

Not reg lated nder CERCLANot regulated under CERCLA (Comprehensive Environmental Response Compensation andResponse, Compensation and Liability Act of 1980)

Not regulated under SARA Title III, Section 304


ClO2 SafetyClO2 Safety

No Reportable Spill Quantity

USEPA Approved for Potable Water at 0.8 PPM

Normal PPE for Chemical H dliHandling


ClO2 EconomicsClO2 Economics

Low Dosage is Effective (0.1-0.3 ppm)

Made on site from PrecursorsSimple operationSimple operationMaintenance can be in-houseP di ti M i t kPredictive Maintenance makes

budgeting easyRange of Generator Capacities

Matched to Need


Grundfos EquipmentGrundfos Equipment

M th 30 i EMore than 30 years in EuropeWorld Class Pump ManufacturerSimplest Method – KISSEasy Set up and MaintenanceEasy Set up and MaintenanceNo membranes to scale or failSt i htf d t lStraightforward controlClO2 gas is always in solution


Grundfos MethodGrundfos Method

Add in WaterAdd in diluted hydrochloric acidyAdd in diluted sodium chloriteAdd in more dilution waterAdd in more dilution waterAllow to ReactGravity Feed to ReservoirPump to System on Demand


Data Collection and AlarmsData Collection and Alarms

Multiple Data PointsMultiple Data PointsAlarms with e-Mail OutT ki d T d A l iTracking and Trend AnalysisAutomatic Report GeneratorsVisible in Real Time from OffsiteDesigned to satisfy regulatorsDesigned to satisfy regulatorsReduces Labor Required


Operating Information NeededOperating Information Needed

Annual Water ThroughputAnnual Water ThroughputEstimate How Water UsageE ti t P k FlEstimate Peak FlowsWater QualityHot Water Temperature & FlowPipe SizesPipe SizesMaterials of Construction


ReviewReview

1 Legionellosis Can Kill1. Legionellosis Can Kill2. Form a HACCP Team3. Hire a Consultant Expert4. Identify Risksy5. Make a Plan6 If Secondary Disinfection is6. If Secondary Disinfection is

Needed, Choose Carefully


Questions?Questions?

Thank You


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