9/16/2014. Michelle Peninger, BSMT, CIC Inova Health System

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1 Michelle Peninger, BSMT, CIC Inova Health System Houston, Texas June 9,

2 Tropical Storm Allison June 9, 2001 Memorial Hermann Hospital flooded Evacuated over 500 patients in 36 hours Loss of all utilities Implementation of Disaster Plan Memorial Hermann Hospital 800 plus bed facility Tertiary care referral University affiliated Level I Trauma Center Burn Center Texas Medical Center 2

3 Tropical Storm Allison Major areas lost: Clinical Laboratory & Pathology State of the art Cath Lab Central Supply Linen Morgue Medical Records IT Department 3

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9 Infection Control Considerations Drinking water Hand hygiene Personal Protective Equipment Hazardous materials clean up HVAC systems Potable Water Infection Control Considerations Legionella Mold Sterile supplies Disinfection of equipment Immunizations/Employee illnesses Education and dispelling fear/rumors 9

10 First things first! Four fundamentals of life: Hand sanitization Drinking water Food Bathrooms 10

11 Hazardous Materials Clean Up Storm water release Laboratory considerations: Blood and specimens Cultures Chemicals Medical Records management Disinfection of equipment Hazardous Materials Clean Up Rule of thumb if it can t be cleaned or completely dried within 48 hours, discard Submerged in flood waters discarded everything Microbial and chemical contamination Clean water may require a less extreme approach Called in the experts 11

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13 Potable Water EPA National Primary Drinking Water Standards CDC Draft Guidelines for Environmental Infection Control in Healthcare Facilities TDH TNRCC City of Houston Potable Water Disinfection of water tanks Total coliforms Cryptosporidia Giardia Legionella Heterotrophic plate counts Viruses Non Tuberculous Mycobacteria 13

14 Potable Water Pressure wash potable water vessels 50 ppm chlorine Fill vessels with water 10 ppm chlorine Run water through all outlets Must achieve > 3 ppm at distal outlets Test for chlorine at each step Potable Water Shut down outlets System should sit for: 48 hours if 3 ppm achieved 32 hours if 5 ppm achieved Flush for 24 hours 14

15 Potable Water Test tank and outlets for: Chlorine Coliforms TDH must confirm coliform results Potable Water Hot water tanks superheated to achieve 170F for 1 hour at distal ports Check temperatures Legionella testing 15

16 Sterile Supplies Question: Are our sterile supplies okay? AORN and AAMI Temperature Humidity Package Integrity 16

17 HVAC Systems Air handler inspection Any component of the HVAC system that cannot be cleaned should be removed HVAC components such as insulation and filter media should be discarded HVAC systems above the water level collect moisture and can support microbial growth Isolate areas for inspection, cleaning and disinfection 17

18 HVAC Systems To bring HVAC back into operation consider Filtration capacity Ducted supply and return Test systems Monitor frequently HVAC Systems Insure compliance with ASHRAE standards regarding indoor air quality Insure compliance with ASHRAE Standard 170 Pressure differential Air changes per hour Temperatures and humidity 18

19 Medical Records Make copies and discard originals Restoration company 19

20 Mold Remediation CDC Draft Guidelines for Environmental Infection Control in Healthcare Facilities NYC Dept of Health Bureau of Environmental & Occupational Disease Epidemiology EPA University of Minnesota Streifel 20

21 Mold Remediation Standards or Threshold Limit Values (TLVs) for airborne concentrations of mold, or mold spores, have not been set No EPA regulations or standards for airborne mold contaminants CDC Draft Guidelines for Environmental Infection Control no recommendation Mold Remediation IAQ Plan Targets & thresholds Remediation plan Any subsequent monitoring Fungal Surveillance Utilities Management Policy 21

22 Mold Remediation Visual and olfactory inspection Detect and correct moisture/water problems Mold abatement 22

23 Mold Remediation Mold sampling Bioaerosol Bulk Air O Cell Particle counts Mold Remediation Stachybotrys chartarum Aspergillus Cladosporium Penicillium Alternaria 23

24 Mold Remediation Establish IAQ target Air sampling should entail simultaneous indoor and outdoor sampling Ratio of indoor mold/spores/particles to outdoor samples should be reflective of filtration Fungi (25 degree C) Colony Conc % Count (CFU/m3) Alternaria alternata 1 12 < 1 Aspergillus niger 1 12 < 1 Basidiomycetes Cladosporium 97 1, Curvularia geniculata 1 12 < 1 Curvularia lunata 1 12 < 1 Epicoccum nigrum 1 12 < 1 Fusarium oxysporum 1 12 < 1 Fusarium solani 1 12 < 1 Penicillium Total: 1,312 24

25 Outcomes No coliforms or Legionella cultured in our water system No subsequent HA infections with Legionella HVAC remediation, improvements and validation No employee infections HA mold infections reduced by half from previous year prior to flood 25

26 Conclusions Disaster planning to address contained and devastating flooding Know your resources Common sense works Choose consultants wisely TEAMWORK! TEAMWORK! 26

27 References: 1. Anonymous. Guidelines on Assessment and Remediation of Fungi in Indoor Environments. New York City, NY: New York City Department of Health, Bureau of Environmental & Occupational Disease Epidemiology (www.ci.nyc.ny.us/html/doh/html/epi/moldrpt1.html), November Anonymous. Indoor Air Quality Info Sheet. Berkeley, CA: Indoor Air Quality Section, Calirfornia Department of Health Services (http://www.caliaq.org/mold9803.htm), March Anonymous. Questions and Answers on Stachybotrys chartarum and other molds. Atlanta, GA: Centers for Disease Control and Prevention (http://www.cdc.gov/nceh/asthma/factsheets/molds/default.htm), March Anonymous. Mold Remediation in Schools and Commercial Buildings. Washington, DC: United States Environmental Protection Agency (www.epa.gov/iaq), March Streifel AJ. A holistic approach to indoor air quality in health care. HPAC: Heating/Piping/Air Conditiong 1998;October: Streifel A. Hospital air quality monitoring for infection control. Infection Control Today 1998;September: Anonymous. Building Air Quality: A Guide for Building Owners and Facility Managers. Washington, DC: United States Environmental Protection Agency (www.epa.gov/iaq), December References: 1. Anonymous. Current Drinking Water Standards. Washington, DC: United States Environmental Protection Agency (http://www.epa.gov/safewater), March Anonymous. Drinking Water Standards and Health Advisories. Washington, DC: United States Environmental Protection Agency (www.epa.gov), Summer Anonymous. Draft Guideline for Environmental Infection Control in Healthcare Facilities. Atlanta, GA: Centers for Disease Control and Prevention, Healthcare Infection Control Practices Advisory Committee (www.cdc.gov), Aronson T, Holtzman A, Glover N, et al. Comparison of large restriction fragments of Mycobacterium avium isolates recovered from AIDS and non-aids patients with those of isolates from potable water. J Clin Microbiol 1999;37(4): Griffiths PA, Babb JR, Fraise AP. Mycobactericidal activity of selected disinfectants using a quantitative suspension test. J Hosp Infect 1999;41(2): Burns DN, Wallace RJ, Jr., Schultz ME, et al. Nosocomial outbreak of respiratory tract colonization with Mycobacterium fortuitum: demonstration of the usefulness of pulsed- field gel electrophoresis in an epidemiologic investigation. Am Rev Respir Dis 1991;144(5):

28 References Since Allison 1. STORM, FLOOD, AND HURRICANE RESPONSE Recommendations for the Cleaning and Remediation of Flood Contaminated HVAC Systems: A Guide for Building Owners and Managers NIOSH Centers for Disease Control and Prevention. Mold Prevention Strategies and Possible Health Effects in the Aftermath of Hurricanes and Major Floods. MMWR 2006;55(No. RR 8). 3. CDC. Mold: prevention strategies and possible health effects in the aftermath of hurricanes Katrina and Rita. Atlanta: US Department of Health and Human Services, CDC; CDC. Remediation and infection control considerations for reopening healthcare facilities closed due to extensive water and wind damage. Atlanta, GA: US Department of Health and Human Services, CDC;

Water should be removed as soon as possible once the safety of the structure has been verified.

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