Infection Control & Hospital Epidemiology
ability to test for LD in house using urine antigen tests (UAT), 21 respondents (72%) reported using respiratory culture, and 8 respondents (28%) reported using multipathogen molecular assays. However, 19 respondents (66%) indicated that routine LD testing for hospital-acquired pneumonia was limited to non– culture-based tests (eg, urine antigen tests or molecular assay), and only 4 respondents (14%) reported always conducting bac- terial culture in conjunction with nonculture tests. Moreover, 19 respondents (66%) had an established water management plan (WMP) for both potable and nonpotable water; 8 respondents (28%) reported a WMP was in development, 1 respondent (3%) had a WMP for nonpotable water only (with planning underway for potable water), and 1 respondent (3%) had no WMP. The facility without a WMP reported having no cases of LD in the past 5 years. To monitor potable water quality, 18 of 28 respondents (64%) reported routinely measuring disin- fectant levels (eg, residual chlorine), 17 respondents (61%) reported routinely measuring temperature, and 15 rsepondents (54%) reported routinely measuring pH level. In addition, 17 respondents (61%) reported routinely testing for Legionella pre- sence as part of their WMP. Having an existing WMP and per- forming routine tests on potable water were more frequently reported among larger facilities and those with transplant units, compared to those without (Table 1). Existing WMPs covering potable and nonpotable water were also more prevalent among the 9 facilities reporting a healthcare-associated LD case in the previous 5 years than in facilities not reporting a healthcare- associated case: 8 of 9 (88.9%) versus 11 of 20 (55%). Regarding personnel actively engaged inWMPdevelopment, the
most commonly reported domains of expertise were infection control (93%) and facilities and engineering (90%); risk
1471
management and public health staff were less frequently involved (Table 2). Although most facilities reported awareness of ASHRAE Standard 188 (97%) and the CDC toolkit (89%)—andusedthese to develop their facility's WMP—fewer were aware of the American Industrial Hygiene Association (AIHA)'s Legionella guidelines from 2015. Moreover, 24% of facilities reported not having conducted a risk assessment to identify areas within their infrastructure sus- ceptible to Legionella growth, as outlined in these standards.
Discussion
In this sample of acute-care hospitals, the reported prevalence of established WMP and awareness of key LD prevention guidance documents was high. Nearly two-thirds of facilities reported already having established a WMP covering both potable and nonpotable water, though we did not determine their adequacy or comprehensiveness. This is substantially more than the 27% of hospitals in Minnesota that reported having a WMP before the release of the CMS directive in June 2017.6 Close to 60% of respondents reported having conducted a risk assessment for Legionella since 2014, yet some of these assess- ments likely occurred before publication of new prevention guidelines. As facilities continue refining their WMP, conducting periodic risk assessments with emphasis on Legionella prevention will be a continued priority. For diagnosing LD, the UAT was the most prevalent diag-
nostic, with 86% indicating capacity to conduct UATs at their facility. This proportion is substantially higher than the 18.8% of acute-care hospitals reporting this capability in 2013.7 Although this increase could signal general improvements in LD diagnostic
Table 1. Differences in Legionella Prevention Activities by Presence of Transplant Unit, Facility Size and Facility Type, 29 SHEA Research Network Respondents, October–November 2017
LD related activity WMP is in place
Cultures for routine diagnostics Always/Sometimes Rarely/Never
LD identified within 5 y
Routine potable water testing includes:c pH
Temperature Legionella presence
L. pneumophila presence only Aware of ASHRAE 188c Aware of CDC tool kitc Aware of AIHA guidancec
Transplant Unit, No. (%) 14 (78) 2 (33) Facility Bed Size, No. (%) 8 (80) 10 (77) Hospital Type, No. (%)
No (n=11) Yes (n=18) 100–249 (n=6) 250–459 (n=10) ≥500 (n=13) Academica (n=17) Otherb (n=12) 6 (55)
13 (76)
6 (54) 5 (45) 9 (82)
4 (40) 5 (50) 5 (50) 3 (30) 9 (90) 9 (90) 5 (50)
14 (78) 4 (22)
15 (83)
11 (61) 12 (67) 12 (67) 4 (22)
18 (100) 16 (89) 11 (61)
5 (83) 1 (17) 4 (67)
3 (50) 4 (67) 2 (33) 2 (33)
6 (100) 6 (100) 4 (67)
Industrial Hygiene Association. aAcademic medical center or university-affiliated academic medical center. bCommunity teaching hospital with academic affiliation, community hospital, federal non-military hospital. cOnly 28 respondents to these questions.
6 (60) 4 (40) 8 (80)
5 (56) 6 (67) 7 (78) 1 (11)
9 (100) 8 (89) 5 (56)
9 (70) 4 (31)
12 (92)
7 (54) 7 (54) 8 (62) 4 (31)
12 (92) 11 (85) 7 (54)
14 (82) 3 (18)
14 (82) 9 (53)
10 (59) 11 (65) 4 (24)
17 (100) 15 (88) 10 (59)
7 (58)
6 (50) 6 (50)
10 (83)
6 (55) 7 (64) 6 (55) 3 (27)
10 (91) 10 (91) 6 (55)
Note. SHEA, Society for Healthcare Epidemiology of America; LD, Legionnaires’ disease; WMP, water management plan; CDC, Centers for Disease Control and Prevention; AIHA, American
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