Evidence Based Practice in Health Service Management

Introduction to Preventing Legionnaires’ Disease

Legionnaires’ is a disease triggered by bacteria called as Legionella, which grow in water systems and utility such as water tanks, cooling towers, and AC units. If the detection of these bacteria found in hospitals and hence hospital staff and patients could become vulnerable to breathing in airborne haze that contains LD bacteria, propagation of Legionnaires’ problem reported. This bacterial infection ultimately results in increasing cases of pneumonia in the hospital (Cunha, Burillo & Bouza, 2016). This kind of pneumonia drives serious changes in affected person’s body and may cause death. Therefore, administration is required to develop or adopt a well-established policy or protocol to reduce the threat of such disease in the workplace. The objective of this report is to evaluate the evidence for facility board to determine their role in controlling the danger of legionnaires’ disease (LD) within the hospital. The facility management board is accountable to present the ways for prevention control and locate water safety guideline to protect the people from LD in the premises.

The framework of the study includes evidenced literature review, essential problem analysis, reasons for improvement, key stakeholders, resistive and assistive forces, decision-making process, selected rationales and strategies and stakeholder impacts, clinical practise and management of health services. The study finds that music therapy has beneficial effects on the health of the patient and can improve the quality of life further. Further addressed suggestions include hospital management, preparation of personnel and an incentive for patients.

Issue to Be Investigated

Facility management should identify and consider the potential sources, obtain competent evidence-based data and tools, then assist the hospital in mitigating the risk factor for LD. "The PICOT format can be used to set a question as" I what ways can facility management reduce the risk of legionnaires disease for hospital individuals? the PICOT elements can be separated as follows:

"P = people in hospital, I = disease of legionnaires, C = without and with facility management, O = hazard reduction and T = not applicable."

Background and Literature Review

It is stated by International Facility Management association (2019) that facility management is an occupation which incorporates several disciplines to safeguard comfort, functionality, efficiency and safety in the workplace by assimilating place, people, procedure and technology together. This board is responsible for the duty to provide and uphold the efficacies hardware to be in safe and good condition for operation (International Facility Management Association, 2019).

Bacteria named Legionella Pneumophila is responsible for the occurrence of legionnaires’ disease. The disease was identified after a severe pneumonia outbreak reported in a convention center of USA in 1976 (CHP, 2018). It comes from potting mix or water. It can also be found in natural aquatic surroundings globally. Moreover, artificial water circulations create a suitable environment for Legionella to grow (WHO, 2018). The utmost mutual way of bacterial transmission is inhalation of polluted aerosols. Cooling water towers, air conditioners, hot and cold water systems, refrigerators, and humidifiers are the origin of aerosols which linked with communication of Legionella. EMSD (2016) illustrated that LD patients shows symptoms of headache, fever, muscle pain, malaise, breathlessness and cough. These consequences may sometimes results in failure of respiratory system. It has an incubation cycle of 2 to 10 days. Presently, no vaccine is available for this disease; therefore, prevention is the only way to avoid the risk factors of the disease. Hence, prevention should be the mutual goal for all hospitals of such infectious diseases (Capelletti & Moraes, 2016). The hospital administration should process mutually with facility management team and infection control norm to handle this challenge to offer a safe and healthy atmosphere. The following figure displays the sharp increment on LD reported from 1994 to 2015.

Aquatic pathogens can be prejudiced to a health care competence water circulation system from multiple sources, like raw water reservoirs or catch basin or by leakage in artificial circulation system. Despite of chlorine disinfection process and water treatment, the water bodies still accumulated with small concentration of several microorganisms. Then these microorganisms travelled into the plumbing system, they can tempt the expansion of biofilms, consist of both the extracellular and matrix the cells created by the cells. Biofilms can be found in potable water supply piping, hot water tanks, water cooling tower, sink as well as shower domes. When the situation (optimum temperature for bacteria propagation of is around 20ºC-45ºC, and predominantly in the sort of 35ºC - 43ºC. The explosion ceases below 20° and above 46°C (EMSD, 2016)) are suitable for biofilm mature, a thick biofilm coating can be formed in few days.

Leoni et al. (2015) studied, the application of the risk management program occasioned legionella to be 100% eliminated from 53 dental unit waterlines section. The articles determine that the risk management program offers positive result on controlling and preventing legionella (Leoni et al., 2015).

The constituents of the risk management plans are somewhat similar, the general steps of the plan are:

  1. Risk assessment,
  2. Environmental Surveillance,
  3. Sample Collection,
  4. Bacteriological Analysis
  5. Corrective Measures.

The authors also emphasis on the education to healthcare and workers technical staff and considered it as a source of success. A good communication and reporting channel are additional factors in implementing the plan. Finally, evaluation of the plan and audit plan are the operative way for concluding the loop of the delinquent.

Leoni et al. (2015) mainly emphasis on dental waterline pollution and hence, several researchers stated the limitation on the reading that there are other potential environmental sources of legionella such as ACs, cooling towers, which were not observed by Leoni. Quinn et al. (2015) studied the outbreak of Legionella which was caused by cooling tower at Long-term Care Facility in 2013. In this outbreak total 39 cases of LD were identified and 6 of them were died because of severe pneumonia infection. The sample taken from cooling tower displayed positive result for Legionella pneumophila serogroup 1. Hence he concluded that guidelines for automated water systems should be addressed to control such incidents.

Reasons for The Change

As discussed in the above literatures, there is a great association between prevention and control of legionella and the risk management plan. Leoni et al. (2015) and Quinn et al. (2015) specified the necessity of presenting “a risk management proposal that delivers defensive measures, the observing of the microbiological adulteration of the water and, if necessary provide the ways for decontamination and treatments. Exner et al. (2005) also illustrated the vital importance of risk management policies to control and prevent healthcare related infections. New control measures and prevention strategies accompanied through facility remodeling, reconstruction and advanced planning. Filtration and disinfection have occasioned a noteworthy reduction of waterborne contagions. Leoni et al. (2015) also highlighted that risk management plan and environmental investigation are useful for evaluating the effectiveness of preventive actions. This plan can also act as a guide to select nominal controls out of corrective plans. EMSD and WHO code of practices are resolution to apprehend the risk management preparation by facility management which is the utmost operative way to control and prevent the hazard of legionella infections. The consequences are inspiring for the facility management to advance their legionella risk management plan to control and prevent the effect of legionella in hospital atmosphere.

Evidence Sources

The evidence related to Legionella and its consequences was sourced from Government Units such as WHO (World Health Organization), Hospital Authority, Mechanical and Electrical Services Department, Department of Health, and Centre for Health Protection (Electrical and Mechanical Services Department, 2016). These sources are consistent to reinforce this paper. The connected readings were sourced from EBSCO, Elsevier, DOAJ, PubMed Central, and University Library. These sources are highly reliable and well-known; therefore, the information and data are accurate and precise which is respectable for evidence-based sources.

Tools Used for Appraisal

In terms of selecting quality articles as secondary documents for the study, suitable appraisal and evaluation tools were recycled. The CASP (Critical Appraisal Skills Programs) and the JBI (Joanna Briggs Institute) case regulator checklists were fermented and utilized as a comprehensive and widely used tool for the evaluation. After using the tools to critique the quality all the reviewed articles, the results showed that these articles are classified from moderate to high quality.

Selected Solution and Rational for Decision

Recommended Solution

To conclude the articles’ recommendations, Table 1 shows facility and Administrative solution aspects are essential to control and prevent the risk of legionella (Lindmair-Snell & Reading, 2019).

Administrative Aspects

Facility Aspects

· Education and enhance staff awareness about consequences of infection

· Perform Risk Assessment

· Setup water safety plans / risk management plans

·

· Surroundings surveillance

· Remove and reduce existing pipelines dead legs

· Collection of water sample

· Use of regular flushes for rarely used pipelines

· Routine replacement of shower heads

Table 1. Recommended Solutions to prevent and control the risk of legionella

Rationale for The Decision

From research, the authors claimed that workers must be trained to understand good practices. It is recognized that education would be necessary to convey new evidence-based practice to all people interested in the hospital association and to whom the pathogens have not been well documented so far. Leoni et al. (2015) confidently clarified that a risk assessment that included reviewing the historical background of environmental conditions, facilities and types of patients under treatment would help hospital managers in understanding the harshness and importance of the risk, so that a risk ranking plan can be established to challenge each factor. The facility elements tend to reduce the microorganism's rate of growth and advancement of the harmful biofilm. The risk of transmission will be minimized if pathogens do not find an acceptable environment to develop. The efficient practices to manage and prevent the growth of legionella in the hospital set are water sampling and environmental monitoring (Hoffmann, Bennett, & Del Mar, 2013). It can therefore be concluded that these proposed solutions are evidence-based and effective in reducing the in-hospital risk of legionella.

Implementation and Evaluation

By identifying specific priorities, targets and the task force, the risk of legionella reduction is established inclusively. Support for the Head Courts and the equipment involved is required to change and introduce the new programs. By delivering training and education initiatives, management is responsible for inspiring and encouraging workers to implement new practices (Bédard et al., 2015). Responsibilities should be clearly organized and specified for each employee. Professional consultants must use the Water Protection Plan and the Risk Management Plan. Efficient methods of water sampling and environmental surveillance should be developed and implemented in conjunction with risk management strategies (Water Supplies Department, 2017). For the workers to follow and provide succinct details for the activities, this would be useful. In order to present new plans and conduct regular monitoring tasks within the hospital, facility management should play the role of coordinating with health care teams. When introducing new policies, the areas undergoing organizational modifications are illustrated in the following table 2.

Design and Structure Operations and Technology People

Job Design for the task force

Equipment for environmental surveillance

and Water sampling

Hospital Management

Human resource as

additional works involved

Test Process and

Sequences

Facility Manager

Technical Staff

Reporting system in case of any cases found

Information System support for analysis the

data

Laboratory technical staff

Culture develop – educate staff and enhance their awareness of the risk

Control system to observe designed to minimize the effects of variables other than the existing

independent variable

Health Care Workers

Emergency / Contingency plan workflow and responsible persons

charts

Risk Assessment and Water Safety Plan

 

Table 2. Areas of organizational change when implementing the recommended solutions.

Defensive steps must be measured on the basis of the results obtained and the switch trial must be compared. In order to deal with Legionella, continuous observation, both environmental and epidemiological, has also applied to the management and use of the scheme and is important for identifying the most suitable solutions to manage pollution. As a result, before introducing the new reform, the reporting framework and assessment system should be well shaped. The cost of the application and correctness of water sampling, by assessing the efficiency of the tactics, closes the loop of the question stated at the beginning of this paper.

Stakeholders and Their Roles

Several stakeholders are liable during the implementation of change process and they are stated below:

Stakeholders

 

Roles

Patients

 

The consumers of hospital. They act as a victims too if subjected to poor facilities in the hospital.

Staff

 

Employers of hospital. They may also be the victims of outbreak occurred.

 Facility Management Department (FMD)

 

Provide professional understanding of:

· Fulfill risk assessment

· Setup a strategy for water protection

· Track construction work that complies with the norms.

· To comply with the norms, liaise with other agencies.

· Regular inspection and control of hospital water systems.

· Plan and suggest enhancement work to fix the water systems.

· Evaluating the success of rectification that works.

Nursing Departments

 

· Build a system to search shower areas that are underused.

· The report is available in the case of LD.

· Co-work with FMD on enhancement work

Infection Control Team

Laboratory

Hospital Services Management

· Co-work with FMD to develop a strategy for water protection.

· Provide professional guidance about how LD can be avoided.

· Increase employee knowledge of LD.

Working as an assistant for environmental monitoring and study of water sampling.

ž Provide financial and manpower supports on rectify works.

ž Responsible for the workplace safety to patients and staff in hospital.

ž Oversee the facility management

and water safety plans.

Driving Forces

The model of Lewin's force field analysis ( Figure 1) is a major influence on the theory of change management developed in 1951 by Lewin. There are two forces in this model: pushing forces for progress and limiting forces. This model will help the identification of driving and restraining forces when the current strategy of minimising the risks of Legionella infection is implemented by facility management (Swanson & Creed, 2014).

The driving force behind this new policy is to confirm the wellbeing of employees and patients, as the hospital association is responsible for providing its employees and users with a safe environment for care. In addition, the basic need for hospital to function is to follow international standards and WHO standards in the current healthcare world, so these two powers will be in the uppermost ranks. The best scores for the restraining forces will be the additional expense of job resolution. Though, when comparing staff safety and patient and picture, it could be stable by the hospital executive. The result shows that the driving forces have a higher effect than the controlling forces by prioritizing and listing all forces from the sides (table 3), so improvement is possible and worth doing. However, restraining powers are often important to be dealt with by hospital administrators.

Outcomes Desired

The overall aim is to reduce the risk of legionella occurring in the hospital by introducing the new policy. There are several key desire outcomes that executives have to define in order to achieve the goal. Firstly, to identify the hazards and possible hazards of risk areas, a risk assessment summary table should be prepared. Prioritization of the risks is expected. Second, the precautions (preventive measures) that need to be taken to reduce the risk of legionella development in the water system should be established. Third, in order to track the efficacy of a preventive measure, a well-functioning monitoring manual should be created. For regular checking, a simple checklist should be prepared. The Water Sample Monitoring Guideline is a method to ensure compliance with the WHO standard for water quality in hospital areas. If there are unusual conditions or operations that could affect the quality of water, environmental monitoring may help to take careful care of it. Third-party companies may be audited. To fix the issue of the new policy, the audit report is more objective. Good communication is another vital component of the new strategy, as soon as non-compliant water quality test results are identified, an effective reporting flow and system is ready for reporting and follow-up by employees (Reynolds & Sexton, 2017). Chart 1 displays the Hong Kong Water Supplies Department's development and execution of the Water Safety Strategy. It is a clear example of the introduction of the new strategy by facility management. In addition, a contingency plan in the event of an outbreak is also necessary. The planned rectification works, such as disinfection and isolation of the affected area(s), should also be discussed in the new policy.

Impacts

On practice

One of the hospital's priorities is to reduce the risk of legionella production in contemporary hospital environments. It will show best practise to the stakeholders and the regulatory organization through the implementation of the new policy. Accreditation and the reputation of the hospital can be maintained.

Stakeholders

On patients

Good facility management contributes to providing patients with an efficient and secure environment. It is undoubtedly an advantage for patients and their families. When renovation work is required, disruption must occur. However, during the rectification works, it can be reduced by administration practices such as close ward for each affected area that is one-off (Bick et al., 2010).

Workers

They will benefit from job in a multicultural environment without thinking about Legionella, just like patients. Legionella’s understanding will be increased, as they are also water supply consumers. To avoid the formation of biofilm, the pipeline, they have to cultivate a habit of flushing less used waterline periodically.

Team of Facilities Management

Obviously, since they have the responsibility to collaborate with other departments and set up the risk evaluation and water protection plan, as well as routine environmental monitoring, the workload of facility management would increase sharply. However, they should track the workplace on a daily basis and checklist, by setting the necessary procedures for the workers, it is more effective and reliable.

Leadership

Though the new strategy requires additional personnel and expenditure, hospital management still feels comfort in moving to reform. It is the responsibility of hospital management to provide patients and staff with a secure atmosphere. The improved performance of outcomes provides management trust that the hospital achieves the international norm of evidence-based practice through the implementation of this strategy. In addition, hospital management can provide a swift and accurate response in the event of Legionella Disease by establishing prevention measures and effective action plans such as disinfection or isolation.

Recommendations for Using Evidence-Based Practice (EBP) to Further Change

The evidence-based practise allows the manager to resolve the differences between the current situation and the reviews or guidance of knowledgeable colleagues. It will encourage the manager to recognise the concerns and assist him in identifying and implementing an organisation's improvement plan(s). Such activity, which can ensure the consistency of knowledge and recommendations, is confirmed and validated by evidence and expert statements. In addition, it can direct us to predict the results by following the pre-set query.

By using EBP, the quality of patient care can be enhanced and organisations and patients can benefit from the savings. The EBP is ready to be embraced by government and well-known organizations as it offers proof of increasing productivity and efficacy, as well as reducing inconsistency compared to old practise (Keib, Cailor, Kiersma, & Chen, 2017). Such papers are well-governed by institutions or colleges, and are now generally recognised by national and international health organisations. The persuasive capacity, therefore, is substantial. Change is not a simple move, but it can demonstrate the importance and efficacy of the opposition and persuade the stakeholders by using evidence-based practise.

Conclusion on Preventing Legionnaires’ Disease

It can be inferred from the studies of both papers that an effective risk management plan / water protection plan offers positive help to prevent and monitor the growth of legionella in hospitals. These steps help the hospital build a global perspective to tackle the issue of Legionella disease from the start of risk assessment to define risk areas, prioritize risk rankings, define preventive measures, develop water sampling and environmental surveillance procedures, disinfection actions, and finally audit and review the plan. Facility management may be the pioneer in collaborating with other practitioners, such as microbiologists, members of the infection control system, etc. In order to protect the workplace for all individuals in the hospital, facility management thus plays an important role based on evidence-based practice.

The facility management could seek more advice on dealing with the cooling water tower to limit the studies. Air-cool oil-free chiller will be a choice in today's technology for the hospital to get rid of cooling water tower when the hospital decides to replace the chiller plant in the future. Further studies are needed, however, on cooling performance, energy saving and reliability.

References for Preventing Legionnaires’ Disease

Bédard, E., Fey, S., Charron, D., Lalancette, C., Cantin, P., Dolcé, P., ... & Prévost, M. (2015). Temperature diagnostic to identify high risk areas and optimize Legionella pneumophila surveillance in hot water distribution systems. Water research71, 244-256.

Bick, D., & Graham, I. D. (Eds.). (2010). Evaluating the impact of implementing evidence-based practice (Vol. 1). John Wiley & Sons.

Capelletti, R. V., & Moraes, Â. M. (2016). Waterborne microorganisms and biofilms related to hospital infections: strategies for prevention and control in healthcare facilities. Journal of Water and Health14(1), 52-67.

Centre for Health Protection (CHP) (2018). Legionnaires' disease. Retrieved from https://www.chp.gov.hk/en/healthtopics/content/24/2117.html

Cunha, B. A., Burillo, A., & Bouza, E. (2016). Legionnaires' disease. The Lancet387(10016), 376-385.

Electrical and Mechanical Services Department (2016). Code of Practice for Prevention of Legionnaires' Disease (2016 Edition). Retrieved from https://www.emsd.gov.hk/en/supporting_government_initiatives/legionnaires_disease/publications/codes_of_practice/

Hoffmann, T., Bennett, S., & Del Mar, C. (2013). Evidence-based practice across the health professions-e-book. Elsevier Health Sciences.

International Facility Management Association (IFMA) (2019). What is Facility Management? Retrieved from https://www.ifma.org/about/what-is-facility-management

Keib, C. N., Cailor, S. M., Kiersma, M. E., & Chen, A. M. (2017). Changes in nursing students' perceptions of research and evidence-based practice after completing a research course. Nurse Education Today54, 37-43.

Leoni, E., Dallolio, L., Stagni, F., Sanna, T., D'Alessandro, G., & Piana, G. (2015). Impact of a risk management plan on Legionella contamination of dental unit water. International journal of environmental research and public health12(3), 2344-2358.

Lindmair-Snell, J., & Reading, L. (2019). Utilizing a System Water Management Program to Mitigate Legionella Risk. American Journal of Infection Control47(6), S37-S38.

Quinn, C., Demirjian, A., Watkins, L. F., Tomczyk, S., Lucas, C., Brown, E., ... & Brewer, S. (2015). Legionnaires’ disease outbreak at a long-term care facility caused by a cooling tower using an automated disinfection system—Ohio, 2013. Journal of environmental health78(5), 8-13.

Reynolds, K., & Sexton, J. (2017). Legionellosis Prevention and Response Training for Environmental Health Professionals. American Journal of Infection Control45(6), S60-S61.

Swanson, D. J., & Creed, A. S. (2014). Sharpening the focus of force field analysis. Journal of change management14(1), 28-47.

Water Supplies Department (2017). Guidelines for Drinking Water Safety Plans for Buildings in Hong Kong. Retrieved from https://www.wsd.gov.hk/filemanager/en/content_1734/WSPBHK_main_text_e.pdf

World Health Organisation (WHO) (2018) : Legionellosis. Retrieved 6th March 2019 from https://www.who.int/news-room/fact-sheets/detail/legionellosis

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