Raising Awareness About Water Safety During Construction

Healthcare facilities with concerns about immuno-compromised patients have been early adopters of water safety standards to maintain a healthy built environment. With the Centers for Medicare and Medicaid (CMS, 2017) publication of Memo 17-30, healthcare facilities are now required to establish a water management program (WMP) per ANSI/ASHRAE Standard 188: Legionellosis: Risk Management for Building Water Systems to reduce waterborne pathogens and ensuing disease. Since the CMS Memo 17-30 references utilization of ASHRAE 188, design and construction professionals, as the “designee,” are to work cooperatively with the designated water management team to develop a WMP for every project (renovation, expansion, or new construction) through commissioning activities. This is a lofty goal when there has been minimal training of design and construction professionals about impacts of their work on waterborne pathogens. Additionally, there has been a minimal effort to identify appropriate methods for controlling the hazards of construction activities associated with waterborne pathogens. This includes a lack of understanding about locations for controls, monitoring procedures, establishing control limits, and corrective actions. ASHRAE 188 affords plumbing design and construction professionals an opportunity to be part of the public health mission to mitigate waterborne pathogens from premise plumbing as a part of the global effort to improve water safety within the built environment. The pathway forward to mitigate waterborne pathogens associated with construction activities may lie in examining the changes that mechanical engineering experienced for the protection of patients from toxic airborne pathogens during construction activities through the development of Safety Risk Assessments (SRA) –also commonly referred to as Infection Control Risk Assessments (ICRAs).

BACKGROUND REGARDING THE DEVELOPMENT OF ICRA/SRA FOR AIR SAFETY

In the early 2000s, designers, contractors, and building owners found themselves increasingly in the cross-hairs of litigation involving construction projects associated with illness and death of patients in healthcare facilities (Riley et al., 2004). Unprotected construction environments transferred toxic construction dust through air vents into patient care units spreading Aspergillus spores. Immuno-compromised patients inhaled the spores only to develop pneumonia like symptoms and die. One such example was a California hospital which failed to protect patient care areas during a three-month construction project (Clark, 2000). Sixteen patients were found to have the Aspergillus fungus and six died of severe Aspergillus broncho-pneumonia of the lungs. Incidences similar to these patient deaths from exposure to environmental toxins during construction led to a decade of improvements in policy and procedures to reduce the likelihood of acquiring a severe hospital infection from construction activities. Healthcare owners began a crusade to enforce environmental protections during construction to limit exposure of patients to toxic dust using an ICRA/SRA. Infection prevention/control professionals, in conjunction with healthcare facility management departments, began to require changes to contractors’ general conditions and specifications, mandating that all construction personnel be trained in construction methods of infection prevention and control to minimize risks to building occupants from construction activities (Bartley et al., 2010). This in turn required mechanical engineering and construction related personnel to develop air safety plans during construction, especially for renovations within healthcare facilities.

In 2014, the Facility Guidelines Institute incorporated language mandating the use of an ICRA/SRA during planning, design, and construction for all healthcare construction projects (Taylor, 2013). Compliance with an ICRA/SRA requires design professionals and healthcare providers to follow a multi-step process to determine the appropriate class of cautions and methods for infection prevention and control. Recommendations are based on analyzing: 1) the type of construction to be undertaken; and 2) the patient risk groups to be impacted (Bartley, 2009; Health Canada, 2001). First, the team must identify the type of construction activity (A, B, C, or D), ranging from low activity (Type A = inspection and non-invasive activities) to high activity (Type D = major demolition and construction projects). Second, the patient risk groups associated with the project are identified (low, medium, high, and highest). Third, the team aligns the class of precautions (Class I, II, III, IV) for required infection prevention/control on the project in a matrix with the type of construction and the patient risk group categories. Each class of precautions contains a prescriptive checklist of methods and procedures deemed necessary by the healthcare facility to be undertaken throughout the phases of construction and at the completion of the project. Some examples of specific methods within each class include: Class I: immediately replacing ceiling tiles displaced during visual inspections; Class II: blocking off and sealing air vents; Class III: removing or isolating HVAC systems in areas of construction, maintaining negative air pressure within work site utilizing HEPA filtration units, and containing construction waste before transport in tightly covered containers; and Class IV: requiring personnel entering work sites to wear shoe covers. The healthcare facilities infection control matrix aligns construction project type with patient risk groups to determine the appropriate class of methods for infection prevention and control. This matrix is then typically adopted as an institutional policy of the infection prevention and control department and enforced through facilities maintenance and engineering. Although the ICRA/SRA documentation for healthcare construction is intended to be comprehensive protection of patients from various contaminants, the ICRA/SRA’s have primarily focused on air quality and safety to reduce exposures to toxic particulate matter – not water safety.

THE NEED FOR A PARALLEL ICRA/SRA FOR WATER SAFETY

Protection of the water system is essential during renovation and new construction for occupants of the primary building under construction, any adjacent departments to a renovation area, and surrounding buildings at a construction site. The CDC (2016) suggests 35 percent of issues concerning water safety in buildings comes from sources outside of the building owner’s control, citing compromises to the municipal water system in the form of water main brakes and construction. “Vibration and changes in water pressure can dislodge biofilm and release Legionella or other waterborne pathogens” (CDC, 2018, Item 3) into the piping system. Breaks in the water main or soil from the construction site can introduce sediment and other materials into the water supply. Sediments are nutrients for the growth of biofilms – a slimy layer in pipes in which pathogens can live and proliferate into the water supply. Key activities of construction associated with Legionellosis cases and outbreaks include:

Excavation
Structural foundation excavation at a construction site has been associated with Legionella cases and outbreaks (Mermel et al., 1995). Excavation activities can aerosolize Legionella from the soil into the air drifting into cooling towers or air intake systems, leading to direct inhalation of the pathogen. Legionella and other pathogens present in soil can contaminate new water piping left open at excavation sites, as well as pipes that are cracked or broken during construction activities. Once piping containing sediment is installed and water is activated in the system, biofilms can begin to grow.

Time Delays
The time between building commissioning and owner occupancy can create unsafe water conditions (Srivatava et al., 2011). Several weeks, months, or even a year can pass from the time the contractor releases the building to the owner with an active water system and the day the owner operates the building at full capacity. Extensive time delays between completion of construction and the owner’s building operations create water stagnation. Water stagnation during these time periods have been associated with confirmed cases of Legionellosis in a newly constructed long-term care facility (Stout et al., 2002), a newly renovated Hematology-Oncology Unit (Watkins et al., 2017), and an apartment complex (Krojgaard et al. 2011).

Re-pressurization of Water Lines
During renovation and new construction, water lines are often shut down and reactivated. To deal with piping additions or subtractions from the system, water shut downs are a necessary part of construction activities. When the supply water lines are re-activated and re-pressurized, it is possible for biofilms within the existing piping to launch downstream, creating Legionella exposure risk to occupants utilizing building areas adjacent to construction activities (Mermel et al., 1995).

Vibration
Larger scale construction not only involves the dangers of soil excavation, but also vibration from structural techniques known as pile driving used to find stable foundation levels. Vibration from structural system work has been hypothesized to be associated with Legionella cases and outbreaks at an academic medical center in Rhode Island (Mermel et al., 1995).

Dust Control and Fire Hydrants
In some regions, large water storage tankers are used to spray water across the construction site to control dust. However, water in vehicle storage tankers can become stagnant, losing residual chlorine levels and creating an environment for developing waterborne pathogens. In Western Canada during 2012, a three-week period of intensive construction across multiple sites and fire hydrant water releases were associated with a community outbreak of Legionellosis (Knox et al., 2017). An epidemiological study traced the eight cases of Legionellosis to a local business and residential district.

Even though epidemiological studies dating back into the mid-1990’s have identified various known hazards connecting the dangers of construction activities with water safety, there has been minimal research focusing on identification of control locations, determination of control limits, development of monitoring procedures, and determination of corrective actions for construction activities. Health Canada (2001) has been more progressive in trying to address controls for construction activities associated with developing waterborne pathogens and might have a list of recommendations to consider for additional research. But it is unclear if any verification or validation of control methods, which are required in a WMP per ASHRAE 188, are occurring.

WATER MANAGEMENT PROGRAM STANDARDS ADOPTED INTO POLICY AND LAW

ASHRAE 188, Section 8 appropriately addresses the design and commissioning of the building’s water system, but does not explicitly address protections from construction activities within the WMP. The focus of the document tends to be on internal aspects of an existing building – hot and cold-water processing, faucet flow restrictions, ice machines, and decorative water fountains, among others, which are equally important, but not exclusive items of concern. Procedures for flushing and disinfection are described once the piping system is activated with water. ASHRAE 188, Annex A specifically addresses healthcare facilities and is slightly more specific about updating WMPs as the building changes over time through renovation and expansion. Annex A requires every healthcare organizational leadership and their designee to “conduct an evaluation and estimate of the likelihood of Legionellosis in a risk management plan (RMP) as necessary for the project: 1.) during early planning; 2.) during each phase of design and construction; and 3.) during commissioning.” The Legionellosis RMP has several detailed steps identical to developing a WMP; however, this must be conducted on a project-by-project basis. How to go about this or the types of controls or corrective actions effective during construction are not yet identified. Therefore, the parallel controls and corrective actions (like an ICRA for mechanical air ventilation) are not yet formulated for inclusion within the healthcare provider’s comprehensive ICRA/SRA policy and procedures. This gap is an opportunity for plumbing engineering and construction professionals to develop a class of precaution levels (paralleling mechanical ventilation), which would contain prescriptive checklists of methods and procedures.

SUMMARY FOR MOVING FORWARD

Since the early 2000s, mechanical engineering design and construction professionals have been involved in reducing infections in healthcare construction projects from construction activities. An entire process for ICRA/SRA has been established, accepted, and included in building codes and contracts for protecting patients from toxic air matter. With the introduction of CMS Memo 17-30 and the establishment of ASHRAE 188, it is imperative that more specific methods, policies, and procedures for water safety must be added to address construction activities. Although healthcare building owners have been the early adopters of such ICRA/SRA policies, note that other building types with public exposure risk will most likely follow. As our population ages and technology allows vulnerable patients to leave the traditional hospital like settings, we will see concerns for air and water safety escalate in other environmental settings, such as senior living centers, schools, airports, commercial settings, and hotels. Plumbing design
and construction professionals who incorporate knowledge about the impacts of construction activities on waterborne pathogens in premise plumbing will gain an advantage in competitive work contracts and will also be serving a greater public health mission for water safety in the built environment.

REFERENCES

1. Bartley, J. M., Olmsted, R. N., & Haas, J. (2010). Current views of health care design and construction: Practical implications for safer, cleaner environments. AJIC: American Journal of Infection Control, 38(5), S1-S12. 10.1016/j.ajic.2010.04.195
2. ASHRAE (American Society of Heating Refrigeration Air Conditioning Engineers). (2015) Standard 188-2015 – Legionellosis: Risk Management for Building Water Systems (ANSI Approved), Product Code: 86603, 1-16. Available at: https://www.ashrae.org/resources–publications/bookstore/ansi-ashrae-standard-188-2015-legionellosis-risk-management-for-building-water-systems
3. CDC (Center for Disease Control and Prevention). (2016) Vital Signs: Legionnaires’ Disease Use water management programs in buildings to prevent outbreaks. Available at: https://www.cdc.gov/vitalsigns/pdf/2016-06-vitalsigns.pdf
4. CDC (Center for Disease Control and Prevention). (2018). Legionella: Health Water Management Programs Frequently Asked Questions. Available at: https://www.cdc.gov/legionella/water-system-maintenance/healthcare-wmp-faq.html
5. CMS (Center for Medicare and Medicaid Services) Memo (2017). Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (LD). S&C 17-30Available at: https://www.cms.gov/Medicare/Provider-Enrollment-and Certification/ SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-30.pdf
6. Health Canada. (2001). Construction-related nosocomial infections in Patients in Health Care Facilities: Decreasing the Risk of Aspergillus, Legionella, and Other Infections. ISSN 1188-4169, CCDR (2752), 1-55.
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13. Taylor, E. (2013) Designing for Safety. FGI Guidelines Update Series, (Update #1), 1-7. Available at: https://www.fgiguidelines.org/resource/designing-for-safety