Guidance for Reopening Healthcare Facilities After Water and Wind Damage

Evaluate facilities damaged by wind, rain, flooding, or loss of electricity and ventilation to determine the extent of damage and if in-house resources can manage the clean-up safely. The extent of the damage will determine the requirements for personal protective equipment and clean-up methods (Table). If the building remains unoccupied during the process, containment of the remediation area(s) may not be needed.

Facilities with extensive water damage (i.e., >32 sq ft in a given space) would benefit from using professional remediation firms for assessment and recovery.

The facility's Manager and Risk Manager or engineering personnel must first evaluate the building(s) to ensure structural safety and sufficient electrical power for clean-up. Ensure there is stable electrical power, the potable water system is back online, and natural gas supply is restored. Furthermore, the facility's risk management or engineering personnel must evaluate the building(s) for fire safety and protection.

Major remediation activities

• Restore a working sewage system.
• Extract standing water and sewage.
• Restore a potable water system.
• Install appropriate containment for bioaerosols if some portion of the building is occupied.
• Ventilate the work area (e.g., open windows where possible). Devise a process for removal of damaged materials from the work area.
• Remove heavily contaminated and/or damaged items and building materials, especially porous materials. Some building materials, such as insulation, may not be directly assessable, so use moisture detection equipment.
• Physically clean non-porous materials to remove surface contamination.
• Apply biocide/disinfectant to surfaces if needed.
• Dry and reassess remaining structural materials for residual moisture.
• Repair and renovate the structure and replace damaged items.
• Restore electrical power and backup generators.
• Thoroughly clean and dry salvageable porous items (e.g., curtains, draperies, linens) if possible.
• Evaluate equipment, medical support infrastructure (e.g., medical gases, steam, compressed air), furniture, records and documents, and supplies for damage.
• Clean and disinfect surfaces in patient-care areas.

Resources

• U.S. Navy Environmental Health Center: Guide to the Navy Industrial Hygiene Field Operations Manual, Chapter 13: Indoor Environmental Quality
• WHO/PAHO: Principles of Disaster Mitigation in Health Facilities
• U.S. Army Public Health Command: Indoor Air Quality and Mold
• Mold Clean Up Guidelines and Recommendations
  • Dampness and Mold Assessment

Prior to any remediation effort getting underway, it is important to reestablish working electrical, sewage, and water systems.

Major remediation activities

• Determine the integrity of the electrical system (e.g., wiring, insulation, generators). Make repairs to ensure remediation workers have adequate lighting and power for equipment as needed.
• A working sewage system is necessary for effective extraction of standing water. Evaluate the potable water distribution system and make repairs as needed. "Boil water" advisories will most likely be in effect during this time. Consult with municipal water system officials to stay informed about water treatment issues as the community restores essential services.
• Evaluate and repair fire safety systems within the building if needed. Consult local fire safety marshals if you cannot fully restore fire safety before starting remediation work.

Resources

• Guidance for Healthcare Water System Repair and Recovery Following a Boil Water Alert or Disruption of Water Supply
• Guideline for Environmental Infection Control in Healthcare Facilities
• EPA: Emergency Disinfection of Drinking Water
• WHO: Drinking Water Quality
• Safe Use of "Tanker" Water for Dialysis
• Emergency Water Supply Planning Guide for Hospitals and Healthcare Facilities

Evaluate the heating, ventilation, and air conditioning (HVAC) system to determine the extent of damage and contamination. Professional consultation is helpful in deciding if the system needs to be replaced or if repairs and cleaning are sufficient.

If repairs are done on an existing system, inspect motorized components (e.g., fans, blowers) for water damage. Remove dirt and debris from ductwork, disinfect surfaces with EPA registered disinfectants, and replace filters and insulation.

You must clean and disinfect HVAC system components, including ductwork that may not have been submerged, to remove bacteria and mold that can disperse when the system is in use.

Major remediation activities

• Isolate the HVAC remediation work from cleaned areas of the facility by using barriers, negative pressurization, and venting exhaust air to the outside.
• Workers should use respiratory protection for their skin, eyes, and hearing.
• Determine if asbestos is present in the HVAC system before undertaking remediation.
• Remove and replace water-damaged insulation in or around the HVAC system.
• Clean and disinfect surfaces within the HVAC system or, if not possible, discard and replace with new components.
• Remove the HVAC system fan for thorough service and cleaning and replace it into the system after testing.

Major remediation activities

• Replace the damaged structural materials, clean the existing materials, and dry the area.
• Assess structural materials for residual moisture using moisture detection devices (e.g., moisture meters, borescopes).
  • Any structural material that cannot be thoroughly dried out within 48-72 hours and a moisture content <20% should be removed and replaced.
  • Porous materials and items need to be discarded if they have been submerged, are difficult to clean, cannot completely dry out within 48-72 hours and a moisture content <20%, or if odors remain.12
  • Clean hard, non-porous surfaces and items with detergent and water then dry.
• During removal, contain these items with plastic bags or sheeting to minimize dispersion of mold spores.

Clean, disinfect and recertify salvageable items per manufacturer's instructions. Two of the first services hospitals should restore are the central sterile supply area and laundry.

Check regional disaster planning initiatives for standing agreements among area hospitals to see if the documents address temporary cleaning and reprocessing support of instruments, devices, and supplies. Hospitals not impacted by disaster damage can help by offering their central sterile supply services and/or laundry while affected hospitals work to restore their reprocessing capacity.

Major remediation activities

• Assess the instrument washing equipment and laundry equipment to see if these items can be restored to function.
  • Check with the manufacturer of these pieces of equipment for additional guidance.
• Reestablish the hospital’s source of steam and validate its quality. Evaluate steam autoclaves for safe operation and test with chemical and biological monitors.
• To determine which patient-care equipment and medical devices to discard, assess each product's current condition and potential safety risks.
  • Contact manufacturers for appropriate damage assessment for their equipment or instruments and specific cleaning and disinfection methods.
• Contact the original manufacturer regarding instructions for cleaning and drying the equipment or shipment back to the manufacturer for refurbishing.
  • Do not connect wet electronic equipment to electricity.
  • Water can adversely affect electronics, and moisture trapped inside a piece of equipment may trigger the development of rust.

Resources

• FDA: Emergency Situations, Medical Devices, and Tips for Healthcare Providers
• ANSI/AAMI ST79:2017(R2023): Comprehensive guide to steam sterilization in healthcare facilities
• Guideline for Environmental Infection Control in Healthcare Facilities

Assess all supplies, including furniture, to determine if you should discard them. Evaluate whether you can adequately launder or disinfect them to prevent mold growth, or if the manufacturer or healthcare facility can reprocess and repackage them.

Major remediation activities

• Linens and curtains may be salvageable by removing gross soil and laundering in hot water and hot air drying. If discoloration from water damage remains visible after cleaning, it may be prudent to discard the item.
• Discard upholstered furniture, drapery, and mattresses if they have been under water or have mold growth or odor.
• Non-porous (e.g., plastic, or stainless steel) furniture may be salvageable if cleanable.
• Discard furniture made with particle board.
• Inspect packaged supplies (e.g., prepackaged bandages packaged in paper and sterile supplies packaged in paper-peel packs) for tears, dampness, visible moisture, mold growth, or signs of having been wet (such as water stains or discoloration) and discarded if present.
• Re-sterilize sterile supplies with compromised packaging. Keep items in undamaged, intact waterproof packaging.
• Contact manufacturers of affected supplies to determine if in-house reprocessing of these items is appropriate and feasible. If not, the manufacturer should provide the facility with instructions to return the items for reprocessing.
• Protect essential paper files and records with plastic wrap and photocopies. You can freeze and dry documents. Contact professional conservators for assistance.

The FDA is the federal resource for information regarding drugs and biological products.

After a flooding event, take special care to ensure safe food preparation and service.

Major remediation activities

• Identify and throw away food that may not be safe to eat.
• Assess food preparation equipment for damage and replace or repair as appropriate.
• Evaluate the integrity of natural gas lines.
• Verify that potable water lines to refrigerators and washing equipment are flushed once potable water service is restored.
• Stabilize the cooling capacity of freezers and refrigerators before adding food items.
• Clean and sanitize food-contact surfaces.
• Refer to state and local government resources for food service certifications, as regulations differ from state to state.

Some dental devices and equipment may pose safety concerns to patients and personnel if not properly assessed for damage, contamination, and made safe for use. Such devices and equipment include dental units (including waterlines, valves, and connections), waterline treatment systems, steam autoclaves, and air compressors. The degree and type of water and wind damage will vary by dental practice. Evaluate specific equipment on a case-by-case basis.

Major remediation activities

• Dental healthcare personnel should contact the device or equipment manufacturer for guidance on damage assessment, cleaning, and disinfection.
  • Equipment and devices that have been totally submerged in water are probably unsalvageable due to electrical damage and subsequent corrosion and should be disposed of.
  • If the manufacturer cannot immediately provide this information, the dental practice should refrain from using the item until further guidance ensures its safety.

All dialysis units require purified, dialysis-quality water. Loss of potable water or loss of power to a water treatment system can result in the potential contamination of water.

Resources

• Reopening Dialysis Clinics after Restoration of Power and Water
• Guidance for Healthcare Water System Repair and Recovery Following a Boil Water Alert or Disruption of Water Supply
• Infection Control for Peritoneal Dialysis (PD) Patients After a Disaster
• End Stage Renal Disease (ESRD) emergency preparedness resources

Extensive damage to a healthcare facility can disrupt laboratory services if utilities like power, lighting, natural gas, steam, and water utilities are unavailable.

Healthcare facilities should have contingency plans in place to arrange for relocation of essential laboratory services to other facilities. Essential laboratory services may include blood gases and co-oximetry, electrolytes, hepatic and basic metabolic profiles, and hemograms and coagulation studies. Lab services (e.g., microbiological testing, serology, and toxicological testing) should be sent to a referral laboratory until a safe working environment can be reestablished in the healthcare facility.

The laboratory is heavily dependent on utilities support.

Major remediation activities

• Assess the electrical system status and determine if emergency power is available for essential equipment and containment systems.
• Determine if high temperatures and humidity damaged the equipment.
• Reestablish stable electrical power.
• Check lab equipment, refrigerators, and freezers for damage, and consult manufacturers for guidance on evaluating, disassembly, cleaning, drying, repairing, and refurbishing.
• Restore adequate lighting and ventilation.
• Replace damaged or contaminated reagents and supplies.
• If the laboratory has a steam autoclave, verify the steam quality, and perform any repairs to the autoclave prior to validation testing using mechanical and biological indicators.
• Clean and disinfect or sterilize reusable items.
• Restore refrigeration to labs and morgues.
• Clean, disinfect, and arrange for the recertification of biological safety cabinets.
• Clean all working surfaces with detergent and water and disinfect as appropriate.

Contact radiological equipment manufacturers for appropriate damage assessment and specific cleaning and disinfection methods. Water can adversely affect electronics, and moisture trapped inside a piece of equipment may trigger the development of rust. Do not connect wet electronic equipment to electricity.

Major remediation activities

• Contact the original manufacturer regarding instructions for cleaning and drying the equipment or shipment back to the manufacturer for refurbishing.
  • Clean, disinfect, and recertify salvageable items according to manufacturer's instructions.
• FDA Offers Tips about Medical Devices and Natural Disasters

Measures for damaged radiological equipment or radioisotopes spills have occurred

• Perform inspections and decontamination using radiological control personnel with a valid Nuclear Regulatory Commission or State license.
• Monitor for radioactivity.
• Shield the contaminated area.
• Equip personnel entering the contaminated area with radiological monitors and personal protective equipment as recommended by OSHA and the Nuclear Regulatory Commission.
• Properly dispose of radioactive waste using approved packaging.

The healthcare facility's epidemiologist, infection control personnel, and laboratory director should agree on a period of enhanced review of clinical microbiology reports to determine whether patients who are receiving care in the reopened facility are acquiring infections attributed to Aspergillis species or other fungi, nontuberculous mycobacteria, Legionella, or other waterborne microorganisms above expected levels (i.e., rates similar to those identified before water damage occurred).

If the need for active investigation is identified, environmental microbial sampling may be indicated to determine if:

• The water in the facility's water distribution system meets the microbial quality of the Safe Drinking Water Act; and/or
• Mold remediation efforts were effective in reducing microbial contamination in the affected areas of the hospital.

Regulations regarding healthcare facility certification and licensing differ from state to state. Refer to specific state and local government resources for more information.