The problem was uncovered after a patient tested positive for Legionnaires’ disease, a form of pneumonia. Workers first tested the water supply, as the bacteria thrive in warm water, according to the report. The water supply, however, tested negative for the bacteria. After discovering the patient was only eating ice chips and had aspirated a chip, workers tested the ice machines.
Less than 20 percent of the hospital’s ice machines tested positive for Legionella, but the incident spurred the overhaul and sterilization of 500 ice machines in several UPMC facilities, according to the report. Machines that tested positive were removed, and others were sterilized and had a filter installed that would prevent the bacteria from entering.
UPMC officials notified state and Allegheny County health departments and the Centers for Disease Control and Prevention about the incident. The system plans to share its findings from researching the incident with others in the industry to help other organizations prevent Legionella from growing in their ice machines, according to the report.
“We feel a very strong ethical, organization and patient-driven responsibility to start to share this,” Tami Minnier, UPMC’s chief quality officer, told the Tribune-Review.
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