Hidden dangers

At the risk of sounding alarmist, your facility’s bath tubs and accessories such as lifts are likely going to make your residents sick — some experts say very sick.

Unless, of course, you’re taking the right precautions

The biggest problem is, well, people. Not to be indelicate, but bath and shower water are a veritable concoction of harmful bacteria and germs like E. coli and Methicillin-resistant Staphylococcus aureus (MRSA), which find their way onto fixture surfaces and pipes through residents’ orifices, mucous membranes and open wounds such as pressure sores.

Left behind, those infectious bacteria, viruses, yeasts, molds and other pathogens are disasters in waiting, as at least one major vendor notes on its website. Residents can readily self-infect during showering or bathing when water puts the bacteria on their bodies in motion. They can enter through bodily openings and also via inhaled water vapor.

So what’s a provider to do?

Giving rise to disease

One of the biggest threats is water left stagnant in small pools near drains or inside the traps of pipes. It is now seen as the biggest vulnerability leading to deadly outbreaks of Legionellosis, 20 species of which make humans sick, according to Debbie Green, a microbiologist and water utility executive. The disease is contracted when germ-ridden aerosolized droplets or mists are breathed in.

The Legionellosis bug is incredibly hardy. Freezing won’t kill it. Its major food source is other bacteria, but it can survive and multiply in standing water on a diet of rust. It’s quite lethal — about 10% of the people it infects eventually die. Men are three times more likely to contract it simply because their lungs are bigger.

Since 2000, Legionella cases in the country have spiked 286%, according to the Centers for Disease Control and Prevention. One of its many cruel ironies: Legionella cases in healthcare are increasing in part because more and more workers are using gels and alcohol rubs to wash their hands instead of soap and water, which leaves vast amounts of sink water to remain untouched long enough for the bug to thrive, Green says.

Close to a quarter of Legionella outbreaks each year happen inside long-term care facilities, making it a particularly grave threat to the immunocompromised elderly, says Matt Jante, product manager, bathing and lifts, for Direct Supply. Mark Godfrey, vice president of business development for the Apollo Corp., agrees, noting such residents are highly vulnerable to respiratory and urinary tract infections during showering and bathing.

So-called “Legionnaires’ disease” may be grabbing the headlines, but there’s another painful disease operators should take note of, says Gina Pugliese, RN, MS, FSHEA, an epidemiologist and vice president emeritus of the Premier Safety Institute.®

“One of the infection risks in the elderly in long-term care facilities related to bathing and bathing equipment is infectious gastroenteritis, which is transmitted through feces or vomit and can spread quickly from person to person, contaminated surfaces (including bathing equipment), as well as clothing and food,” Pugliese says. “In particular, person-to-person spread of Shigella spp. and C. difficile diarrhea is common because of shared bathrooms and bathing equipment, as well as rehabilitation equipment.”

Gastroenteritis is highly infectious, and its bacterial and viral forms are a major cause of diarrhea outbreaks in long-term care, she adds. High rates of incontinence only increase infection rates.

Vulnerabilities galor

It’s difficult to say what proportion of the 3 million serious nursing home infections each year originate in bathrooms.

“One of the challenges with infection control in nursing homes is that, compared to hospitals, there is less definitive research on specific infection control measures” in long-term care facility populations, says Pugliese.

Compounding matters is apathy, or simple negligence regarding surveillance.

“Because Legionnaires’ disease is often not diagnosed, the actual number of cases is likely to be underreported,” adds James Marx, Ph.D., RN, CIC, an infection prevention consultant and contributing author of a forthcoming book, “Infection Prevention Guide to Long-term Care,” from the Association for Professionals in Infection Control and Epidemiology.

Another key vulnerability for nursing homes comes from a lack of proper education and training on infection control basics, according to Deborah Patterson Burdsall, Ph.D., RN-BC, CIC, FAPIC, who serves as faculty for APIC’s “EPI® 101 for Long-term Care” course and is an author for APIC’s book “Infection Prevention Guide to Long-term Care.”

False complacency

Moreover, long-term care housekeepers and cleaning staff can easily be lulled into thinking tubs that have been unused for a day are germ-free.

Pugliese observes, for example, that because C. difficile is shed in feces, bathing tubs can actually act as a “reservoir” for spores, which can live for long periods of time on surfaces.

Of course, vulnerabilities in a facility’s infrastructure and equipment can be underestimated. In fact, the air itself is an often overlooked vulnerable area in nursing homes, according to infection control experts.

In its precautions regarding the disease, the CDC notes that healthcare resident shower and bathing facilities may pose a risk of legionella exposure only if the water is aerosolized, typically from showerheads and hot tubs with water jets. It grows best between 77°F and 108°F.

“While it is possible to contract Legionnaires’ at home, large buildings with complex systems are the most fertile breeding ground,” notes Kari Harbaugh, senior product consultant for Direct Supply. “Knowing that any standing water from hot tubs to air conditioners can harbor the disease should inform cleaning procedures.”

Best practices

According to Medicare participation requirements, facilities must now establish and maintain an infection prevention and control program for identifying, investigating, reporting, preventing and controlling infections and communicable diseases for residents, families, the public and staff.

This includes having systems and procedures in place for surveillance and early detection, and to demonstrate how they’re managing potential infections.

In June 2017, the Centers for Medicare & Medicaid Services singled out skilled nursing facilities when it issued a memorandum requiring them to reduce Legionella risk in their water systems. The major thrust of CMS’ action was to require they develop and implement a water management plan to identify and mitigate risks.

While CMS made no recommendations for routine water testing in the absence of Legionella disease cases, Marx advises every facility to establish a water management plan and, as mandated by the Requirements of Participation for Medicare and Medicaid inclusion, engage the facility infection preventionist to take a key role.

“The infection surveillance program should be looking for cases of Legionnaires’ disease in residents and those who are admitted in the hospital for pneumonia,” Marx says.

He adds that the CDC currently recommends that facilities conduct a risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system.


• Regularly clean and disinfect: Pugliese advises facilities to establish “written procedures for daily cleaning and disinfection of tubs and bathing equipment and lifting equipment, as well as cleaning and low-level disinfection between patients.”

Procedures also should specify who is responsible for this cleaning and disinfection, and provide a means to monitor direct care personnel to ensure they are properly cleaning and disinfecting tubs, shower stalls, faucets, shower heads, lifts and other equipment before using them on the next resident.

• Follow manufacturers’ recommendations: It’s easy to overlook. As Marx notes, common disinfectants are accelerated hydrogen peroxide, hypochlorite and quaternary ammonium, and some chemicals may not be compatible with tub and equipment surfaces.

• Periodically flush: Some say it’s a “no-brainer,” but it’s easy to forget — especially bathing systems that might not be used frequently — unless it becomes established routine. Keep the reservoir fill tub open to allow it to drain into the tub during the flush, and flush using both hot and cold water lines.

• Conduct infectious disease assessments: This can literally stop a potential outbreak in its tracks if residents with known infectious diseases are handled carefully. For example, patients with diarrhea should be evaluated for possible infectious enterogastritis so that appropriate barrier precautions can be implemented.

• Use proper cleaning chemicals: Tiffany Rayback, vice president of operations for MasterCare Patient Equipment, advises facilities to use “hospital-grade” disinfectants and cleaners on tubs.

• Consider disposables when practical: Doing so greatly reduces the spread of germs to other surfaces and people. Pugliese says disposables are highly advised in areas that have multiple-patient-use bottles in tub dispensing systems (for body soap, hair shampoo or other personal care). She cautions against refilling or topping any disposable bottles. Discard them.