Guidance for Healthcare Water System Repair and Recovery Following a Boil Water Alert or Disruption of Water Supply

What to know

  • An Emergency Water Supply Plan (EWSP) details steps healthcare facilities must take to prepare for, respond to, and recover from water supply interruptions. This ensures that essential operations can continue smoothly even during a disruption.
  • An EWSP ensures that essential functions can continue during a total or partial water supply disruption.

Overview

The Joint Commission and the Centers for Medicare and Medicaid Services require all hospitals to have plans addressing facility response for recovery from both internal and external disasters. These plans are required to address:

  1. General emergency preparedness.
  2. Staffing.
  3. Regional planning among area hospitals.
  4. Emergency supply of potable water.
  5. Infection control and medical service's needs.
  6. Climate control.
  7. Remediation.

Healthcare facilities should create an EWSP to handle any interruptions in their water supply. Water supply interruptions can result from natural disasters, community water system failures, construction damage, or even acts of terrorism. Since water supplies can fail, it's crucial to understand and address the impact on patient safety, quality of care, and facility operations.

During a boil water alert

  • When performing hand hygiene for surgery (e.g., surgical scrub).1
  • Emergency surgical procedures.
  • Patient-care equipment (e.g., ventilators, nebulizers, heater-cooler units, etc.) if electrical power is available.12

  • Alert patients, families, staff, and visitors not to consume water from drinking fountains, ice, or drinks made from municipal tap water during the advisory unless first disinfected. Disinfect water by bringing it to a rolling boil for over 1 minute or use bottled water).1
  • Do not use ice for drinks or other procedures.1

  • Do not use tap water. Consider using either boiled, disinfected, or bottled sterile water.
  • Restrict burn patients and those with open sores or wounds from whirlpool treatments and hydrotherapy for debridement. Only use these treatments if the water is filtered or treated (i.e., boiled, disinfected).

  • Use tap water for patients with healthy immune systems during advisories without evidence of contamination.
  • Use bottled or boiled water for infants, young children and anyone with a weakened immune system, wounds, or abrasions.
  • For advisories with evidence of contamination (microbial/chemical), do not use tap water for bath or shower.

  • Use sterile water as normal for ventilators.2
  • Use bottled, sterile water for isolettes or incubators (also refer to manufacturer’s instructions for use).
  • Use sterile or distilled bottled water for Continuous Positive Airway Pressure (CPAP) machines.
  • Check the manufacturer's instructions for the type of water to use. They often recommend sterile, distilled, or demineralized bottled water for humidifiers.

  • Water for device reprocessing and sterilization should meet the AAMI recommended standards; see Table 1.
  • If water treatment is in place, sterile processing can continue. Pretreatment may be warranted (e.g., methods like reverse osmosis, reverse osmosis with deionization polishing, and filtration to remove microbes and endotoxin).
  • If no additional water treatment is available, suspend operations until the water system is fixed and safe drinking water is restored. Alternatively, consider installing point-of-use water treatment to meet equipment requirements.13
Table 1. Categories and recommended levels of water quality for medical device reprocessing
 Type of Water – Water Use  Utility Water – Flushing   Utility Water – Washing or Rinsing  Critical Water – Final Rinse, Steam
 Hardness  <150 mg/L  <150 mg/L  <1 mg/L
Conductivity  <500 µS/cm  <500 µS/cm  <10 µS/cm
pH  6 - 9  6 - 9  5 - 7
Total Organic Carbon (TOC)  Not applicable  Not applicable  <1 mg/L
Chlorides  <250 mg/L   <250 mg/L  <1 mg/L
Bacteria1  Not applicable  <10 CFU/mL  <10 CFU/mL
Endotoxin2  Not applicable  <20 EU/mL  <10 EU/mL

1 Water should be drinking water quality; rinse and final rinse (for devices that are high-level disinfected) and water for sterilization should contain total cell counts <10 CFU/mL.

2 Units of measure for endotoxin in endotoxin units or EU/mL. There is no limit for endotoxin in utility/drinking water; however devices and reprocessed instruments should be nonpyrogenic, which is why rinse and final rinse, and steam have limits.

  • Perform enhanced clinical surveillance for healthcare-associated infections caused by waterborne pathogens.
  • Use both syndromic surveillance and microbiology laboratory data.
  • If healthcare-associated waterborne infections occur, investigate to identify the source and potential transmission routes.

Remediation of water distribution systems

The water management team should meet to review the situation and define goals. They should then implement a plan to return the water system to normal operation. This plan should follow the steps outlined in their water management program.

  • If the boil water alert is for an extended period and microbiological contamination is suspected, consider a more aggressive remediation. Consider consulting the State Health Department and Drinking Water Administrator about implementing short-term supplemental treatment.
  • After the boil water alert has been lifted, flush all fixtures (e.g., faucets, drinking fountains) and equipment, then restart them. Continue flushing faucets and fixtures until you detect chlorine.
    • Flush for more than 5 minutes until you detect residual disinfectant.
    • Discard ice from ice machines, then clean and sanitize them according to the manufacturers' instructions.
    • If you do not detect chlorine at point of use after flushing, implement supplemental disinfection. This will subject the institution to drinking water regulations, as it is now considered a small public water system.
  • Remove point-of-use filters and flush outlets for several minutes before installing new filters (e.g., ice-machines, sinks and showers).
  • Run water softeners through a regeneration cycle.
  • Drain, disinfect, flush, and refill water storage tanks if needed.
  • Change pre-treatment filters, backwash carbon tanks, regenerate softener, and clean and disinfect RO membranes, disinfect dialysis distribution loops.
  • You might need to decontaminate the hot water system after a long service disruption or a cross-connection with sewer lines.
    • Decontaminate the system when the building has the fewest occupants to reduce possible exposure to waterborne pathogens. This is best done during nights and weekends.[1, 4]
    • If using chlorination, add enough chlorine to achieve a free chlorine residual of over 2 mg/L (ppm) throughout the system. Preferably, do this overnight.[4] Flush each outlet until chlorine odor is detected and maintain the elevated chlorine concentration in the system for >2 hours (but <24 hours).
    • Use a very thorough flushing of the water system instead of chlorination if a highly chlorine-resistant microorganism (e.g., Cryptosporidium spp.) is suspected as the water contaminant.
  • Check the steam system if you use clean steam for autoclaves in sterile supply.
    • Check water quality used for steam generation.
    • Consult the manufacturer for instructions on how to bring the system back online after a contamination event.

Setting-specific considerations

Hemodialysis facilities need substantial amounts of water to treat their patients. Maintaining clear communication with their water provider is crucial for the program. Following disasters, dialysis programs can consult CDC guidance on:

  • Continuation of treatment during boil water advisories.
  • Safe use of tanker delivered water.
  • Technical considerations when bringing dialysis systems back online following a disaster.
Keep Reading: Water Use in Dialysis

Dental clinics also use water in the treatment of patients. In short:

  • Do not deliver potentially contaminated water to the patient through the dental unit water lines (DUWL).
  • It is acceptable to use the dental units for patient treatment if they are isolated from the municipal system by an FDA-cleared water treatment device or reservoir.
  • Have patients rinse with bottled or distilled water until authorities cancel the boil water advisory.

Learn more by referencing Best Practices for Dental Unit Water Quality.

Environmental monitoring

  • Consider periodic testing of disinfectant residual at point of use sites as determined by your water management program.
  • Consider using heterotrophic plate count (< 500 CFU/mL) to measure water quality.
  • For special types of water (some examples include water used in compounding pharmacy, for dialysis and clinical laboratory reagent water) follow appropriate guidelines [e.g., CLSI, AAMI, CMS participation of coverage (see references)].
  • After system remediation, review and reemploy the facilities water management plan.[5]
Keep Reading: Considerations for Reducing Risk: Water in Healthcare Facilities

Background

Excerpted from the Guidelines for Environmental Infection Control in Healthcare Facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC), Emergency Water Supply Planning Guide for Hospitals and Healthcare Facilities and standards published by the Association for the Advancement of Medical Instrumentation (AAMI), United States Pharmaocopeia (USP), and manufacturers' instructions.

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Content Source:
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)
  1. Sehulster LM, Chinn RYW, Arduino MJ, Carpenter J, Donlan R, Ashford D, Besser R, Fields B, McNeil MM, Whitney C, Wong S, Juranek D, Cleveland J. Guidelines for environmental infection control in health-care facilities. Recommendations from CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Chicago IL; American Society for Healthcare Engineering/American Hospital Association; 2004. [Last Update February 15, 2017; available from https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines.pdf
  2. CDC. Guidelines for preventing healthcare—associated pneumonia, 2003. MMWR 2004;53(RR06):1-36. (https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm)
  3. Rutala WA, Weber DJ, HICPAC. Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) (https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html)