When Proven Solutions Don’t Work

Preventing Infection From Unexpected Sources Happens With Clear Communication 

By Bryan Connors, MS, CIH, HEM

Healthcare facilities have made huge strides in improving infection prevention and control, yet the Centers for Disease Control and Prevention notes that, on any given day, one in 31 hospital patients may acquire a healthcare-associated infection (HAI). No matter how effectively an organization plans to mitigate common causes of HAIs, there remains the risk of exposure to unexpected or difficult-to-root-out pathogens. Eliminating these less well-known risks can be tricky. It requires careful planning and clear communication among infection prevention professionals, facilities staff, clinical caregivers, and environmental services (EVS) teams. 

Below, we offer three investigations that uncovered unexpected pathways of healthcare associated infections, less well-known sources of infections, and novel approaches to pinpointing and mitigating the root cause of infection. With this insight, healthcare professionals can find ways to partner more quickly, creatively, and effectively stop healthcare associated outbreaks.

Investigation 1: A change in process leads to unexpected infections from a novel source 

In 2021, healthcare facilities of all types were adapting their day-to-day operations to reduce the risk of spreading COVID-19. For one hospital’s critical care unit (CCU), that proved to be the beginning of a problem. 

The CCU treated a patient who brought a carbapenem-resistant Enterobacteriaceae (CRE) Klebsiella infection into the facility, ultimately leading to a second CRE infection in another patient. That seemed to be the end of the problem until, nine months later, another CRE infection abruptly arose in the unit, followed by still more cases, typically in a couple of specific rooms in the CCU. 

The facility soon averaged two infections a month as they reviewed and adapted routine infection prevention, cleaning, and care practices to break the chain, with no success. All told, over 20 patients were impacted by the outbreak before environmental sampling at last sourced it to biofilm in the sink drains within the patient rooms. 

The investigative team hypothesized the presence of biofilm in the sink drains based on a few case reports in published literature, but it was still an unexpected source given the magnitude of the outbreak and the rarity of biofilm as a cause of infection. However, analysis confirmed a genetic match between the environmental samples from the sink drains and patient samples. Indeed, once the facility stopped its sink use and provided temporary hand washing stations, the infections stopped as well. So, just how did the biofilm occur? 

To reduce the risk of transferring COVID-19, the medical center had changed processes to keep activities and waste confined to the room where COVID-19-positive patients were being treated. Like many organizations at the time, staff were disposing of patient fluids and IV/parenteral solutions in sinks intended only for handwashing. 

These nutritive materials created an environment in which the CRE Klebsiella could colonize the sink drains. Over the course of the next nine months, a dense biofilm flourished. When clinical staff went to wash their hands in the sink, water droplets would hit the drain and then splatter onto counters, nearby medical equipment, and supplies, carrying the bacteria with them. And routine cleaning would spread the CRE bacteria from the counter to the other areas of the room, like the patient’s bed. 

Unfortunately, in addition to being antibiotic-resistant, CRE Klebsiella is also thought to be at least partially resistant to some standard disinfectants. A literature review led the environmental investigators to an FDA-approved disinfectant suitable for breaking down biofilms. After application, the team tested again to ensure CRE bacteria were greatly reduced or removed. Maintenance sink drain disinfection and periodic sink drain swab sampling are now ongoing (likely indefinitely), and their effectiveness will be monitored over time. It is important to note that many infection control practices were revised/implemented during this time and that those practices, along with the sink drain disinfection, have been ultimately effective.  

Given the challenging circumstances set by COVID-19, it’s understandable why processes had to be changed during the pandemic. However, this incident is a reminder that every change can bring unintended consequences. Prior to creating a new policy, discussions between clinical, infection prevention, and EVS professionals could prove beneficial in mitigating the risk of introducing unexpected new risks. 

Investigation 2: Out-of-date recommendations lead to novel risk

Several years ago, the CDC warned hospitals of the risk of mycobacterium infections in certain heater-cooler devices used during open heart surgery. As a result, hospitals generally have processes in place for maintaining these devices. So, it was a surprise for one hospital when Burkholderia cepacia infections were ultimately traced back to the heater-cooler devices used in extracorporeal membrane oxygenation for patients in an ICU.

The clinical team was following recommendations for maintaining the equipment, so it was difficult to understand why the water reservoirs within the heater-cooler devices were contaminated. Water was changed out on a regular cadence, tubing was replaced, and equipment was cleaned. Units were refilled using highly filtered water, one of two options the manufacturer had recommended at the time the device was purchased. 

However, it was that last step that proved to be the problem. At some point prior to the start of this hospital’s infections, the manufacturer had changed their recommendations. The updated advice was to use sterile water. With this insight and environmental sampling, it quickly became clear that improperly filtered water was the source of this facility’s contaminants. Once the devices were effectively disinfected, the team ensured only sterile water would be used going forward. 

Through proactive environmental sampling, the hospital has been able to prevent the reintroduction of this contaminant. Moreover, they have learned the critical need to have a process to ensure everyone on the team is up to date on all manufacturer instructions for use. 

Investigation 3: Buildingwide treatments can’t eliminate stubborn bacteria

Legionella risks have been well identified in hospitals, and facilities teams generally have clear processes within their water management plan for mitigating the risk of these dangerous bacteria. That’s why facilities managers were stumped to find typical strategies for managing Legionella didn’t eliminate the problem at one hospital after a cluster of two presumptive healthcare-associated cases were identified—even though the hospital resorted to sometimes disruptive and often expensive options such as shock and low-level chlorination.

While the treatments did lower the overall numbers of pathogens, the risk remained elevated and unacceptable to the public health authority overseeing the mitigation effort. Ultimately, the hospital contacted environmental investigators, with both an industrial hygienist and a professional engineer on the team, to perform a forensic study that could identify why this bacterium proved so difficult to eliminate. 

For the investigators, the real question was about the source of the contamination. In many cases, when a healthcare facility sees evidence of water contamination, it will perform sampling at a system endpoint, such as a sink or shower outlet in a patient room. From that sample, facilities teams might make a characterization about the water throughout the facility. Because this approach doesn’t pinpoint where the problem is occurring, though, facilities must resort to broad treatments that impact the entire building’s water system. By identifying the source of the problem more precisely, it’s possible to target treatment. 

In this case, sampling hot water heaters, hot water piping, cold water piping, and other specific points within the water system led the investigators to a hot water loop contaminated with difficult-to-remove contamination and/or biofilms. Once the source was identified, the problem was mitigated with multiple precisely targeted treatments. Much in the way a physician treats a disease, facilities professionals who get to the root cause of a contamination can treat it far more efficiently and cost-effectively. 

Partnerships support a more proactive approach 

As these case studies indicate, it isn’t enough to follow a proven plan to mitigate infection risks. Instead, it’s far more impactful to have strong communication between the clinicians, infection control practitioners, facilities professionals, and industrial hygienists/indoor environmental professionals, as well as the right experience, so that targeted sampling and treatment can be applied at the first sign of infection. A process-based approach, one that includes regular sampling for acceptable levels of specific contaminants that can indicate the presence of a broader problem, can mitigate the risk of even uncommon contaminants. 

When infection control and facilities professionals work as part of a team, reviewing and reporting clinical data together, professionals are able to take faster action to keep patients safe and healthy.

Bryan Connors, MS, CIH, HEM, directs EH&E’s healthcare practice team, providing guidance and technical support in the areas of environmental health and safety program management, industrial hygiene, hazardous materials management, and regulatory compliance with U.S. Occupational Safety and Health Administration, U.S. Environmental Protection Agency, and Joint Commission requirements.