Legionnaire’s was bred in hot water system

The Legionnaires’ disease outbreak at Mount Carmel Grove City hospital came from the hospital’s hot water system and likely was the result of inadequate disinfection, the health system’s parent firm said Thursday.

At least 16 patients at the hospital have been diagnosed with Legionnaires’ disease. One patient, 75-year-old Deanna “Dee” Rezes, of Grove City, died June 2. On Tuesday, one of the patients filed a lawsuit against the hospital system.

The Legionnaires’ outbreak was announced May 31, just over a month after the seven-floor, $361 million hospital opened. Patients who contracted the severe form of pneumonia were exposed sometime between April 27 and May 31, said Dr. Tammy Lundstrom, chief medical officer for Trinity Health, Mount Carmel’s Michiganbased parent company. The patients who were affected were not all being treated on the same patient floors.

Water-use restrictions were put in place that prevented patients from showering and forced them to drink only bottled water. Those restrictions were lifted late last week after more than 2,000 temporary water filters were installed at the 210-bed hospital. The hospital’s water system also was flushed and

over-chlorinated.

Mount Carmel’s longterm plan to prevent further Legionella issues is now in place and includes extensive testing and a secondary water treatment system that constantly adds a small dose of disinfectant into the water.

The supplemental disinfection system was installed Tuesday, said Tim Keane, a Legionella expert and consultant for Mount Carmel. The temporary water filters will be removed after additional testing.

Portions of Mount Carmel’s water system were disinfected in February and other areas were disinfected in April. The areas that were disinfected in February weren’t done again before the hospital opened, Keane said.

The hospital’s opening had been delayed on multiple occasions.

Keane noted that the federal Centers for Medicare and Medicaid Services requires healthcare facilities to have

plans to diminish the risk of Legionella bacteria but doesn’t require testing.

“If you don’t test for Legionella, you don’t know,” he said.

Keane said there were other issues beyond the effectiveness of the disinfection that could have played a role in the Legionnaires’ outbreak.

When asked what they were and if it had anything to do with how the facility was constructed, Keane said it was being investigated and he wouldn’t comment on possible conclusions.

“We’re not saying anybody didn’t do their job in disinfection,” he said. “What we’re saying is there were multiple issues associated with the bacteria growth. The disinfection procedure didn’t resolve those issues.”

The first case of Legionnaires’ disease linked to the hospital was reported to Mount Carmel on May 15, Lundstrom said. Within a week, there were three possible cases associated

with Mount Carmel Grove City.

Because those who got sick weren’t in the hospital during the entire two-week period in which the disease develops, Lundstrom said they were considered “possible cases.” The hospital alerted Franklin County Public Health, and “then as these things evolved, we determined we had an outbreak occurring with the facility,” she said.

As for whether Mount Carmel should have made a declaration of an outbreak before May 31, at which point there were seven confirmed cases, Lundstrom said the health system followed the guidelines in place for investigating individual cases. It also relied on the health department to make that decision, she said.

“It’s not uncommon to see sporadic cases that have nothing to do with being in a health care facility,” Lundstrom said.

Legionella bacteria is naturally found in water, but it can become troublesome

when it spreads into building water systems and shower stalls, faucets, drinking fountains and ice machines. The problem arises when someone breathes in airborne water droplets that contain the bacteria. Franklin County had the highest number of Legionella bacteria cases in Ohio in 2018.

The most recent Legionnaires’ case was confirmed Monday, Lundstrom said, but the number may still rise because of the disease’s roughly two-week incubation period. The hospital system expects the likelihood of additional cases to arise to be diminished on Saturday, she said.

Officials stressed that the Grove City’s hospital water is safe now and that the additional safety measures implemented there will be extended to the rest of the health system’s facilities.

“We feel this is a tragedy,” Lundstrom said.