ASHRAE SPC 188 and What that means for Healthcare
ASHRAE SPC 188 and What that means for Healthcare
ASHRAE SPC 188 and What that means for Healthcare
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<strong>ASHRAE</strong> <strong>SPC</strong> <strong>188</strong><strong>and</strong><strong>What</strong> <strong>that</strong> <strong>means</strong> <strong>for</strong> <strong>Healthcare</strong>South Carolina Society of<strong>Healthcare</strong> EngineersMay 6, 2011Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
Who is Garratt Callahan?Largest privately owned watertreatment companyFormed in 1904 – family owned <strong>and</strong>operated – 4 th generationUSA, Mexico, Caribbean, AsiaConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
ExperienceTen years doing secondarydisinfection – started in WisconsinPreferred vendor to nationalhealthcare GPOs:Premier, Novation, Amerinet, MedAssets, Catholic Health <strong>and</strong> moreMember: National ASHEConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Presentation Introduction Legionella, Biology, Mitosis Sources of Legionella Risks Cooling Water Domestic WaterConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Presentation <strong>ASHRAE</strong> HACCP Identify an Ideal Biocide Choices <strong>for</strong> Domestic Water Relative Per<strong>for</strong>mance Equipment Design / Method Q & AConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Legionella p. (gram-negative)Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
Legionella pneumophila• Thin, flagellated Gram-negativebacterium of the genus Legionella.• L. pneumophila is the primaryhuman pathogenic bacterium inthis group <strong>and</strong> is the causativeagent of Legionellosis orLegionnaires' diseaseConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Legionella pneumophila• 54 genetic strains (serogroups)• Legionella pneumophila(serogroup 1) is the most lethallstrain• Protozoonotic - can live <strong>and</strong>reproduce within amoebae,paramecia (protective habitat)Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
Time <strong>for</strong> a Short Biology LessonConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
But First…A Math Question:“Chess Board For Sale”‣ 64 Squares‣ Price Increases in GeometricProgression (2X)‣ $0.01 <strong>for</strong> the first square‣ $0.02 02 <strong>for</strong> the second square‣ $0.04 <strong>for</strong> the third square‣ <strong>and</strong> so on…‣ How Much <strong>for</strong> the Board?Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
Total Cost….$184,467,440,737,095,000.00467 440 737 095 000 00$184 Trillion <strong>and</strong> ChangeConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Legionella pneumophilaConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Bacteria Cell Some bacterium can divide every20 minutes, others 18 secondsLet’s s say conditions are not idealMitosis takes place every hour…Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
Growth Rate One cell at the StarttAt end of the first hour – 2 cellsEnd of second hour– 4 cellsAt the end of six hours – 64 cellsConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Growth Continues…At 18hours – 262,144 CellsIn Only One Day…16,777,216 CellsConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Bacteria Cells in WaterPlanktonic: free-floatingSessile: attached, <strong>for</strong>ming slimeSlime: cells buried in polysaccharideConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Bacterial SlimesConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Where is Legionella Found in aTypical Outbreak? USCDC100%90%80%70%60%80% fromDomestic Water(Potable)50%40%30%20%10%20% fromCoolingWater0%Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
In which Facilities doesLegionnaire's Disease appear?56% from all Others21% Hotels23% <strong>Healthcare</strong>Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
How does it enter the body?Aerosol water droplets must beinhaled (aspirated)Legionellosis develops as apneumonia-like infection in thelungsConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Areas of Highest Risk• Hot <strong>and</strong> cold water systems– Pipes, faucets, electronic faucets, shower heads, ice makers• Nebulizers• Cooling towers <strong>and</strong> evaporativecondensers• Humidifiers <strong>and</strong> air washers• Pools <strong>and</strong> spas• Air conditioningConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Medical Treatment?Presents as pneumonia – treatmentis penicillinPatient get worse – doctors increasethe penicillin dosePatient can die…Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
Treatment <strong>for</strong> LegionellosisWhen the doctor knows it isLegionellosis:The treatment protocol changes to a“mycin”, penicillin doesn’t workConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Medical Best PracticePatient can die unless urinaryantigen, culture, serology or DFA<strong>for</strong> Legionella was run <strong>and</strong> properdiagnosis <strong>and</strong> treatment isprovided.USCDC directs healthcare to:“maintain high index of suspicion<strong>for</strong> Legionellosis” where patientsare at risk.Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
Legionella in Cooling Water100%90%80%70%60%50%40%30%20%10%20% fromCoolingWater0%Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
Cooling TowersConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Cooling TowersConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Cooling Water Ideal Temperature <strong>for</strong> Growth–68 o F to 105 o F Lots of Food – air is washed Biocide Choices are Important Must Penetrate t SlimesConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Cooling WaterMust KILL Be<strong>for</strong>e being dumped Must Know the Wash Out Rate Alternating Oxidizer with Non-Oxidizer is highly recommended(<strong>ASHRAE</strong>, ASHE, USCDC, CTI…)Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
Non-Oxidizing Biocides Isothiazolone Glutaraldehyde Organo-sulfur DBNPATHPSTerbuthylazinebl iConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Oxidizing Biocides Alternate with Non-OxidizingBiocide Must be USEPA Registered Must be used per the LabelConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Oxidizing Biocides Hypochlorous Acid (Bleach) Ozone Bromine (activated by chlorine) Bromine chloride Chlorine (gaseous) Chloramines Chlorine dioxideConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Oxidizing Biocides - SelectionHypochlorous Acid (Bleach) Not effective at pHabove 8.3, 30 minute kill timeOzone Not very soluble in waterBromine (activated) Good Choice, requirescontrolled mixingiBromine chloride Very Good Choice in manyapplicationsChlorine (gaseous) Dangerous, requiresconstant attentionChloramines Requires ammonia mixed withchlorineChlorine dioxide Excellent but can be morecostly, 99% kill in one minuteConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Legionella in Domestic Water100%90%80%70%60%50%40%30%20%10%0%80% fromDomestic Water(Potable)Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
Domestic Water SystemsConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Domestic Water Pipe withBacterial SlimeConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Bacterial SlimesConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
<strong>ASHRAE</strong> 12-20002000• Recommendations <strong>for</strong> BestPractices• Widely Ignored Due to Direct Costswith little perceived benefit• No support from USCDC, ASHE,CTI, USEPA, Joint CommissionConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Why is Europe ahead of US? Water Quality is Regulated Specific En<strong>for</strong>cement Department Strict Limits Fines <strong>and</strong> PrisonIn USA: Quality Measured, not RegulatedConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
<strong>What</strong> is changing here in theUSA?<strong>ASHRAE</strong> <strong>SPC</strong> <strong>188</strong>Work started in 2008Due <strong>for</strong> publication later this yearJune Meeting….Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
Organizations Supporting<strong>ASHRAE</strong> <strong>SPC</strong> <strong>188</strong>The following have been involved inshaping the St<strong>and</strong>ard d <strong>SPC</strong><strong>188</strong> <strong>and</strong> haveindicated support:1. ASHE2. USCDC - HICPAC3. USEPA4. Joint CommissionConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
<strong>ASHRAE</strong> St<strong>and</strong>ard <strong>188</strong>• Covers Legionellosis as did<strong>ASHRAE</strong> 12-2000• No Longer Just a Suggestion• Failure to Comply will beconsidered d Negligence• Expected to Require a HACCP be<strong>for</strong>medConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
<strong>What</strong> is HACCP?• Hazard Analysis & Critical ControlPoints• World Health Organization (1997)• Found in USEPA – HACCPStrategies (2007)Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
HACCP PROCESS – initial steps1. Assemble a Team – Operations,Consultants, Engineers, Vendors2. Describe the end product3. Document the intended use4. Construct a Flow Diagram5. Validate the Flow DiagramConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
HACCP – Seven Principles1. Conduct Hazard Analysis2. Identify Critical Control Points3. Establish Critical Limits4. Identify Monitoring Procedures5. Establish Corrective Actions6. Validate/Verify the HACCP Plan7. Establish Documentation <strong>and</strong>Record KeepingConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Next Step: Proactive Approach1. Form a HACCP Team2. Cover all areas of Expertise3. Your Product is Water4. Produce a Flow Diagram5. Assess the Risks6. Identify Control Points7. Establish Control Limitsit8. Identify Monitoring Process9. Establish Corrective ActionsConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
<strong>What</strong> are your Products?Water: used <strong>for</strong> drinking, showers,cooling water, cooking, icemaking, medical treatmentsCooling Water <strong>for</strong> HVACDomestic Cold <strong>and</strong> Hot WaterConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Hazard Identified in Std <strong>188</strong>Presence of Legionella pneumophilaIn Potable Water1. Domestic Cold Water2. Domestic Hot Water3. Cooling Water4. Water Features (fountains, etc.)Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
Your Goal should be PreventionLegionellosis as a Hospital AcquiredInfection (HAI) can be activelyfought using secondarydisinfection of potable water withinthe healthcare facility <strong>and</strong> a goodbiocide program in cooling waterConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Economic MotivatorsMedicare <strong>and</strong> many InsuranceCompanies will not pay <strong>for</strong> HAIsBad Publicity sends potentialpatients elsewhere – loss ofrevenueLawsuits can cost millions - $$$Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
LawsuitsSimple Wrongful Death - $100,000 to$200,000 rangeWith Negligence - $1,000,000 to$2,000,000With Gross Negligence - $10,000,000 000 000to $600,000,000Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
Why Doesn’t the Water AuthorityTake Care of the Problem?Most Public Water Authorities useSodium hypochlorite (Bleach)Biocidal Action comes from the<strong>for</strong>mation of:Hypochlorous Acid (HOCl)Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
THMs <strong>and</strong> HAAsUsing bleach <strong>for</strong>ms:Tri-halomethanes (Chloro<strong>for</strong>m) <strong>and</strong>Haloacidic Acids by-productsThese are identified as cancercausing <strong>and</strong> limited it to 1.0 ppm indrinking water by USEPAConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Soft Water vs Hard WaterHard Water causes scale <strong>and</strong> underdepositcorrosioncomes from wellsincreased cooling water usagesofter water source is desirableSoft Water comes from lakes <strong>and</strong>rivers – surface waterscontains more organic pollutantsdirt <strong>and</strong> debrisConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Effect of pH on HOClAt pH of 7.5 only 50% of Bleach<strong>for</strong>ms HOCl ( 50% remainder isorders of magnitude less effectiveas biocide )At pH of 7.5 a Double-Dose isrequired to get a KillHOCl 99% Kill Time is 30 minutesConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Criteria <strong>for</strong> an Ideal Biocide High Per<strong>for</strong>mance Environmentally Friendly Safe to Use Make Economic SenseConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Evaluate Per<strong>for</strong>mance Speed of Kill Selective – kills target organisms Low LC50 – lethal concentration Penetrates Slimes Not Consumed by Material ofConstruction Effective over wide range ofOperating ConditionsConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Environmentally Friendly Minimal by-products of reactions Residues do not Persist By-products do not Persist Consumables recyclableConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Safe to H<strong>and</strong>le Manageable Quantities Releases non-reportable (spills) Controllable Form Normal PPE <strong>for</strong> H<strong>and</strong>ling Minimized Storage RequiredConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Economically Feasible Appropriate Cost/Benefit Effective at Low Dosage Controlled Consumption Minimal Wasted Product Reliable Delivery Od Order/Inventory ControlConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
<strong>What</strong> are the Choices <strong>for</strong>Domestic Water Disinfection?1. Superheat <strong>and</strong> Flush2. Periodic Hyper Chlorination3. Continuous Chlorination4. Chloramines5. Ozone6. Copper-Silver Ionization7. Ultraviolet Light8. Chlorine Dioxide (ClO 2 )Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
SUPER HEAT & FLUSH• Proven effective, but…– Hot Water not available during disinfection– Risk of scalding (return at 124 o F)– No residual effect once cooled– Rapid re-growth (not effective againstslimes)– Cold water mixes at point of use (>68 o F)– Cold water carries the bacteria– Resource intensive - expensiveConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Biofilm vs CaCO 3 as an InsulatorWaterBiofilmScale5mm1 mmHeat Transfer Surface5 Times Equivalent Reduction in Heat5 Times Equivalent Reduction in HeatTransfer Rate
CHLORINATION• Hyper-chlorination is effective, but…– Resource intensive - labor– Does not penetrate slimes– Re-growth occurs quickly– High corrosion rates in copper pp pipes– pH sensitive (50% wasted at 7.5 pH)– Taste <strong>and</strong> odor– THM’s <strong>and</strong> HAA’s (carcinogens)Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
Continuous Chlorination• Requires feed <strong>and</strong> control system• Will not penetrate slimes•“Burns” the Polysaccharide slime• Consumed on non-living things• Oxidizes anything – corrosive• Adds THMs <strong>and</strong> HAAs• Is depleted as it flows throughsystemsConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Chloramines• Appears to work well• Adds ammonia (NH 4 ) to chlorine• Requires ammonia gas hazard onsite• Used in some city water plants• Not safe in a hospitalConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
OZONE• Effective against planktonic <strong>and</strong> sessilebacteria (O 3 , a gas)• Sparingly soluble, difficult to control• Must be generated close to point of use• High maintenance – corona• High maintenance – molecular sieve• High energy use• Works best at low pH• EH&S issues (toxic gas)Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
Copper/Silver Ions– 2006 EPA classified as biocide (toxic metals)– Still not registered with USEPA– Show >40% users still have positives instudy of 16 hospitals (Janet Stout, t Victor Yu)– High capital costs ($90,000 average)– Sensitive to pH (
Ultra-Violet LIGHT• Excellent disinfection technique when water isclear (low NTUs - ultrapure)• Effective over very short range when thin film(< 3mm) is used• Bulbs become coated, effectiveness lost• Frequent bulb replacement• No residual, localized disinfection only• Not effective on open-recirculating coolingtower waterConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
GC Selected This MoleculeChlorine Dioxide (ClO 2 )5HCl + 5NaClO 2 4ClO 2 + HCl + 2H 2 OStoichiometric Reaction (equal volumes)“Best Available ab Technology”ogyConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Water Pipe after Treatment withClO 2Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
Evaluate Per<strong>for</strong>mance Speed of Kill Selective – kills target organisms Low LC50 – lethal concentration Penetrates Slimes Not Consumed by Material ofConstruction Effective over wide range ofOperating ConditionsConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
ClO 2 Per<strong>for</strong>mance 99.999% Kill in 60 seconds Very low dosagePolluted Water Study: 1 PPM ClO 2 Compares to almost 40 PPM Cl 2 Selective Oxidizer Same Kill Rate at pH 6.5-8.5 LC 50 = 293 ppm in airConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
ClO 2 Environmental ImpactNot regulated under CERCLA(Comprehensive EnvironmentalResponse, Compensation <strong>and</strong>Liability Act of 1980)Not regulated under SARA Title III,Section 304Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
ClO 2 Safety No Reportable Spill Quantity USEPA Approved <strong>for</strong> PotableWater at 0.8 PPM Normal PPE <strong>for</strong> ChemicalH<strong>and</strong>lingConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
ClO 2 Economics Low Dosage is Effective (0.1-0.3 ppm) Made on site from Precursors Simple operation Maintenance can be in-house Predictive Maintenance makesbudgeting easy Range of Generator CapacitiesMatched to NeedConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Grundfos Equipment More than 30 years in Europe World Class Pump Manufacturer Simplest Method – KISS Easy Set up <strong>and</strong> Maintenance No membranes to scale or fail Straight<strong>for</strong>ward control ClO 2 gas is always in solutionConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Grundfos Method Add in Water Add in diluted hydrochloric acid Add in diluted sodium chlorite Add in more dilution water Allow to React Gravity Feed to Reservoir Pump to System on Dem<strong>and</strong>Confidential <strong>and</strong> proprietary to Garratt-Callahan Company
Data Collection <strong>and</strong> Alarms Multiple Data Points Alarms with e-Mail Out Tracking <strong>and</strong> Trend dAnalysis Automatic Report Generators Visible in Real Time from Offsite Designed to satisfy regulators Reduces Labor RequiredConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Operating In<strong>for</strong>mation Needed Annual Water Throughput Estimate How Water Usage Estimate t Peak Flows Water Quality Hot Water Temperature & Flow Pipe Sizes Materials of ConstructionConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Review1. Legionellosis Can Kill2. Form a HACCP Team3. Hire a Consultant Expert4. Identify Risks5. Make a Plan6. If Secondary Disinfection isNeeded, Choose CarefullyConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
Questions?Thank YouConfidential <strong>and</strong> proprietary to Garratt-Callahan Company
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