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Implementation of Legionella Prevention Policy in Health Care Facilities

The United States Veterans Health Administration Experience

Ambrose, Meredith MHA; Kralovic, Stephen M. MD, MPH; Roselle, Gary A. MD; Kowalskyj, Oleh MSCE; Rizzo, Vincent Jr PE; Wainwright, Don L. BArch, MBA, FACHE; Gamage, Shantini D. PhD, MPH

Journal of Public Health Management and Practice: April 05, 2019 - Volume Publish Ahead of Print - Issue - p
doi: 10.1097/PHH.0000000000000986
Practice Full Report: PDF Only

Context: The Veterans Health Administration requires implementation of Legionella prevention policy in potable water systems at Department of Veterans Affairs (VA) medical facilities across the United States and territories.

Program: The Veterans Health Administration Central Office program offices with expertise in engineering and clinical aspects of Legionella prevention policy have provided joint, structured on-site assistance to VA medical facilities for consultation on policy implementation. Site visits included review of facility documentation and data, discussions with staff, touring of buildings, and development of recommendations.

Implementation: Information obtained from on-site consultative assistance provided to VA medical facilities from December 2012 through January 2018 was reviewed to identify engineering and clinical challenges and lessons from implementation of Legionella prevention policy in VA health care buildings. Fifteen consultative site visits were conducted during this period regarding implementation of Legionella prevention and validation of effectiveness.

Evaluation: It was found that implementation of Legionella prevention policy in potable water systems was complex and practices varied for each building. Common implementation challenges included capability of applying engineering controls, water stagnation, and assessment of health care association of Legionella cases. Process challenges included routine verification of actions, methods for assessing environmental validation data, and documentation of requirements. It was found that consistent and data-driven implementation of policy is crucial for an effective program.

Discussion: Guidance and standards documents in the community for Legionella prevention in building water systems are often general in nature, but implementation requires specific decisions and routine assessments and modifications to optimize outcomes. This real-world review of challenges and lessons from a large health care system with a detailed primary Legionella prevention policy informs future development of guidance and policy, both within and external to VA, and can provide insight to other health care facilities planning to implement practices for water safety.

National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Department of Veterans Affairs, Washington, District of Columbia (Ms Ambrose and Drs Kralovic, Roselle, and Gamage); Cincinnati VA Medical Center, Cincinnati, Ohio (Drs Kralovic and Roselle); Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio (Drs Kralovic, Roselle, and Gamage); and Office of Capital Asset Management Engineering and Support, Office of the Deputy Under Secretary for Health for Operations and Management, Veterans Health Administration, Department of Veterans Affairs, Washington, District of Columbia (Messrs Kowalskyj, Rizzo, and Wainwright).

Correspondence: Shantini D. Gamage, PhD, MPH, National Infectious Diseases Service, Department of Veterans Affairs, 205 W 4th St, Ste 1020, Cincinnati, OH 45202 (

The authors thank the staff at VA medical facilities for the work being done to implement Legionella prevention policy, and especially acknowledge those staff who were involved with the consultative site visits reported here.

The information and opinions in this manuscript are the authors' own views and do not necessarily represent the official position of the US Department of Veterans Affairs.

All 7 authors participated in some or all of the site visits reported in this manuscript, and these site visits were the primary source for the information and outcomes reported. All authors contributed to the development of the manuscript.

The authors declare no conflicts of interest.

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