Legionella linked to inadequate disinfection of water lines

Statement from Mount Carmel:

On Friday, May 31, we notified the public that individuals were diagnosed with Legionnaires’ disease after being at Mount Carmel Grove City. Along with local health officials, we brought in Tim Keane, an internationally known legionella expert, and immediately began steps to protect patients, staff and visitors. Today, measures are in place to ensure that water is safe, and we want to share what we know at this point about the source of bacteria, background on timing and what we are doing.

But first, as an organization working toward high-reliability, we expect more from ourselves, and we hold ourselves accountable. There is nothing more important to us than the safety of our patients and colleagues. Every day we are trusted with people’s lives and we take that responsibility seriously. We are implementing a long-term solution to ensure legionella is effectively controlled and that this doesn’t happen again.

Source of bacteria

After extensive testing throughout the facility, we are confident that we have identified the source of bacteria. Tests received this week from water samples taken May 23 through June 1 showed significant legionella bacteria were in our hot water system at that time. We believe the bacteria are linked to inadequate disinfection prior to Mount Carmel Grove City’s opening.

First awareness and timeline

In the days leading up to a full investigation on May 31, the following took place:

  • We worked with Franklin County Public Health (FCPH) and following CDC guidance, we determined three positive cases for legionella, the earliest being diagnosed May 15 and reported to the health department on May 16.
  • A common source could not be identified during this time due to the individual circumstances of each case, including exposure to other healthcare facilities during the incubation period.
  • Water samples were taken May 23 through June 1, and heightened surveillance for other potential cases identified a fourth case. At that point, a full investigation of an outbreak began on May 31.
  • We quickly implemented water restrictions on May 31 for the safety of our patients as we prepared to hyperchlorinate (disinfected) our entire water system by June 2.
  • We installed temporary water filters known to provide an extremely effective barrier to legionella transmission by June 6.

Actions above and beyond the standard

Completed actions include:

  • Installed a permanent supplemental disinfection system—with 24/7 monitoring and controls—which continuously adds chloramine to the water supply on June 11.
    • Once continuous extensive testing is complete, the temporary filters will be removed.
  • Updated protocol that every patient room (occupied and unoccupied) will be flushed daily.

Actions in process include:

  • Enhancing safety measures.
  • Disinfected and cleaned cooling tower, along with upgrading disinfection controller.

Commitment to leading industry change

We continue to work with the Ohio Department of Health (ODH) and FCPH to resolve legionella at Mount Carmel Grove City. We sincerely appreciate these two teams’ dedication and partnership, and we applaud Dr. Amy Acton’s vision for change.

What has happened at Mount Carmel Grove City has underscored the need for increased regulation and clarity around water management in healthcare settings. We want to be a part of the solution, and we will be when we join Dr. Acton on her newly created legionella taskforce to address these issues. We will also join FCPH to share lessons learned with other healthcare organizations in our community.

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