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First Do No Harm: Identifying and Eliminating Health Care Toxics

First Do No Harm: Identifying and Eliminating Health Care Toxics

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First Do No Harm: Identifying and Eliminating Health Care Toxics

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  1. First Do No Harm: Identifying and Eliminating Health Care Toxics Marcella Thompson, LEED AP HDR Inc.

  2. Mission of Healthcare • Prevention, treatment, and management of illness and the preservation of mental and physical well-being through the services offered by the medical, nursing, and allied health professions. First, do no harm.

  3. Treating Patients in a Built Environment • Large & complex modern institution • Often a combination of old buildings with newer additions • Multifunction infrastructure to support patient care What kind of environment has healthcare created for healing?

  4. Inputs Outputs Healthcare Organization The Environmental Footprint of a Hospital • (def) The impact of an organization in environmental terms • Resource use • Waste generation • Physical environmental changes

  5. Facility Operations Indirect air emissions Medical devices Wastewater discharge Medical supplies Medical waste Pharmaceuticals Solid waste Pharmaceutical waste Central processing Cleaning/disinfection The Environmental Footprint of a Hospital Example: Surgical Procedure

  6. The Environmental Footprint of a Hospital • Energy • Water • Medical devices & supplies • Electronics, technology • Pharmaceuticals • Laboratory chemicals • Food • Administrative supplies • Cleaning chemicals • … and much more! Inputs Outputs • Emissions • Wastewater • Solid waste • Medical waste • Hazardous waste

  7. Identifying Environmental Concerns in Healthcare

  8. Identifying and Eliminating Health Care Toxics • Mercury • DEHP/PVC • Green cleaning • Sterilants and disinfectants • Green Building Other environmental hot buttons: Regulated Medical Waste Pharmaceutical Waste Food – Organics and locally grown E-waste Green chemistry Flame retardants Multiple chemical sensitivity and IAQ Recycling and solid waste management Laboratory waste Integrated pest management JCAHO & the Environment

  9. Mercury Health Concerns • Mercury is a known and ubiquitous hazard • Persistent, Bioaccumulative & Toxic • CDC: 1 in 12 women of childbearing age risk giving birth to infants with neurological disorders due to mercury exposure in-utero. 1 | Mercury

  10. FDA Advisories 1 | Mercury

  11. 100 10 1 0.1 0.01 1970 1980 1990 2000 Declining Threshold of Harm Level associated with harmful effect Regulatory standard (maximum safe exposure or high end exposure from allowed fish contamination) DAILY INTAKE (micrograms/kg/day Hg) FDA WHO ATSDR EPA 1 | Mercury

  12. Obvious Less Apparent • Thermometers • Sphygs • Cantor, Miller-Abbott tubes • Esophageal bougies • Laboratory chemicals • Thermostats • Fluorescent lamps • Batteries • Dental amalgams • Caustic soda • Laundry chemicals-bleach • Antibacterial soaps • Boiler & air conditioning chemicals • Reagents • Plastics Hg in Hospitals • Know where it is: • Clinical, facility, and laboratory sources 1 | Mercury

  13. Virtual Hg Elimination • Making MedicineMercury-Free program • Sets goals for “virtual” elimination of mercury • Provides framework for comprehensive elimination strategies • Provides recognition to facilities that achieve these goals • 185 hospitals have won the award since 2002 1 | Mercury

  14. MMMF Award Criteria Policies • Established a facility policy statement • Established a mercury management policy • Implemented an Environmentally Preferable Purchasing (EPP) policy statement Clinical • Replaced patient mercury thermometers • Replaced all or majority (75%) of sphygmomanometers and have a plan and timeline for total elimination • Replaced majority (75%) of clinical devices; inventoried those remaining and have a plan in place to for total elimination 1 | Mercury

  15. MMMF Award Criteria Facility • Recycle fluorescent lamps • Implemented battery collection programs • Inventoried and labeled all mercury-containing facility devices and have an elimination plan in place Laboratory • Replaced B5/Zenkers stains • Inventoried mercury-containing lab chemicals with plan in place for substitution • Inventoried all lab thermometers - replaced at least 75% with total phase-out plan in place 1 | Mercury

  16. Roadblocks • Mercury is viewed as the “gold standard” • Multi-discipline effort • Cost • Not a regulatory requirement 1 | Mercury

  17. PVC/DEHP • Most widely used plastic in medical products • Cost • Flexibility • Transparency • Resistance to breakage • The only common plastic that is chlorinated • DEHP (di-ethylhexyl phthalate) often used as a plasticizer in medical devices 2 | DEHP

  18. Impacts of PVC • Dioxins and furans generated as by-products of manufacture of PVC feedstocks • Dioxins, furans, HCl formed and released when PVC is burned • Municipal waste incinerators • Medical waste incinerators • Landfill fires • Leaching of plasticizers, metals from landfills • Difficult to recycle 2 | DEHP

  19. DEHP • Migrates from PVC when in contact with fluids, air, or heat • Lipophilic Leaching increases with… • Temperature • Contact (storage time) • Amount of fluid • Agitation • Lipid content 2 | DEHP

  20. National Toxicology Program Advisory • “… serious concern for the possibility of adverse effects on the developing reproductive tract of male infants exposed to very high levels of DEHP that might be associated with intensive medical procedures such as those used in critically ill infants.” • “… concern that, if infants and toddlers are exposed to levels of DEHP substantially higher than adults, adverse effects might occur in the developing male reproductive tract.” 2 | DEHP

  21. FDA Advisory Recommends: • Using alternatives to DEHP-containing products for procedures with excessive exposures • Reformulation of products to decrease/eliminate DEHP exposures • Labeling of DEHP-containing products 2 | DEHP

  22. FDA Advisory TI = FDA determined “Tolerable Intake” 2 | DEHP

  23. FDA Advisory 2 | DEHP

  24. Hospital Focus: Eliminating DEHP in the NICU Early Preterm Infants • Critically ill patient population • IV therapy • Parenteral and enteral feedings • Ventilation • Blood transfusion • Long hospital stay • Prolonged therapies 2 | DEHP

  25. Hospital Focus: Eliminating DEHP in the NICU Gloves Bags Tubing • Exam, surgery • Low exposure risk • Parallel efforts to eliminate latex gloves because of allergies… • IV • Nutrition • Blood • High exposure risk • Problems: pre-mixed and blood bags • Feeding tubes • Ventilators • Generally from equipment to patient • High exposure risk 2 | DEHP

  26. John Muir Memorial Hospital Case Study Survey found: • 31 plastic items • Only 5 contain PVC/DEHP and are used in exposure scenarios • Others are used for extraction procedures • One was eliminated procedurally Only 4 items need to be replaced! Extra NICU cost ~$20/patient/day. 2 | DEHP

  27. Roadblocks • Awareness • Takes a Champion in the NICU • Federal advisories, but no regulation 2 | DEHP

  28. Green Cleaning: Environmentally Preferable Custodial Products Environment Chemical Products Custodial Staff Hospital Occupants 3 | EPP

  29. Implementing Green Cleaning • First promote worker safety • Use a defensible methodology to identify preferable products • Prioritize and implement EPP into contracting language; educate GPOs and suppliers 3 | EPP

  30. Janitorial data: • 54.5 lbs/janitor • 6.1 lbs/1000 sq feet Building maintenance data: • 17.7 lbs/year • 6.6 lbs/1000 sq feet Chemical Exposure 3 | EPP City and County of San Francisco, Environmentally Preferable Purchasing Program Data

  31. Chemical Exposure For every 100 workers: • 6 Chemical accidents per year • 3 eye injuries • 2 skin injuries • 1 inhalation/other 3 | EPP City and County of San Francisco, Environmentally Preferable Purchasing Program Data

  32. Metal cleaner Metal cleaner Chemical Exposure Glass cleaners Toilet bowl cleaner, deodorizers, disinfectants Wood polish Disinfectants and General Purpose Cleaners Hard floor cleaners, strippers, and finishes Carpet cleaners 3 | EPP City and County of San Francisco, Environmentally Preferable Purchasing Program Data

  33. Defining a Preferable Chemical Product • 18 criteria based on: • Other EPP Programs • Tests with 100+ products • Comments from environmental staff, technical experts, and product vendors • Lower score is better • Failing subtotal scores 3 | EPP City and County of San Francisco, Environmentally Preferable Purchasing Program Data

  34. Health and Safety Evaluation • Failing subtotal score > 200 • 200 points - Carcinogens • 100 points - Neurotoxins • 100 points - Eye Irritation • 100 points - Skin Irritation • 50 points - Ease of Skin Absorption • 50 points - Corrosivity • 50 points - Flammability 3 | EPP City and County of San Francisco, Environmentally Preferable Purchasing Program Data

  35. Environmental Evaluation • Failing subtotal score > 100 • 100 points – Ozone Depleting • 50 points – Endocrine Modifier • 100 points – Greenhouse Gases • 25 points - Biodegradability • 100 points - VOCs • 25 points – Added Fragrances • 25 points – Added Dyes 3 | EPP City and County of San Francisco, Environmentally Preferable Purchasing Program Data

  36. Other Considerations • Failing subtotal score > 35 • 10 points – Available as Concentrate • 15 points – Available as Non-aerosol • 10 points – Refill/Return/Recycle • 10 points – Recycled Content 3 | EPP City and County of San Francisco, Environmentally Preferable Purchasing Program Data

  37. Information on MSDS and Vendor Literature 3 | EPP City and County of San Francisco, Environmentally Preferable Purchasing Program Data

  38. Focus Efforts Step 1: Quantity Step 2: Widespread use Step 3: Potential exposure Step 4: Availability of alternatives 3 | EPP City and County of San Francisco, Environmentally Preferable Purchasing Program Data

  39. Road Blocks • Focused on infection control • Availability of products (continually improving) • Cost • Environmental service staff perception 3 | EPP City and County of San Francisco, Environmentally Preferable Purchasing Program Data

  40. Spaulding Scheme for Medical Devices • Critical Enters sterile tissue or vascular system (e.g., surgical instruments, cardiac and urinary catheters, implants) • Semi-Critical Contacts mucous membranes or non-intact skin (e.g., endoscopes, respiratory therapy and anesthesia equipment, diaphragm rings) • Non-Critical Contacts intact skin (e.g., bedpans, blood pressure cuffs, crutches) STERILIZATION HIGH LEVELDISINFECTION DISINFECTION 4 | Minimizing Glutaraldehyde Use

  41. … which determines • Sterilization: Validated process used to render a product free of all forms of viable microorganisms. • Disinfection: Destruction of pathogenic and other kinds of microorganisms by thermal or chemical means. Destroys most recognized pathogenic microorganisms, but not necessarily all microbial forms, such as bacterial spores. 1 Rutala, W.A., “Draft Guidelines for Disinfection and Sterilization in Healthcare Facilities,” HICPAC 2b, CDC 02/20/2002 4 | Minimizing Glutaraldehyde Use

  42. High-level Disinfection & the Environment • Must maintain strict infection control standards to ensure patient safety while also being mindful of environmental impacts. • Based on use and construction of instrument • Disposal considerations • Chemical requirements • Available P2 opportunities. 4 | Minimizing Glutaraldehyde Use

  43. Flexible Endoscopy Gastroenterology Gynecology Head & Neck Surgery Urology Rigid Endoscopy Operating Room Instruments Often Cleaned with Cold Process High-Level Disinfectants • Ultrasound Transducers • Obstetrics • Radiology • Cardiology • Urology • Miscellaneous • Cryo probe tips • Diaphragms 4 | Minimizing Glutaraldehyde Use

  44. Glutaraldehyde Cetylcide-G (3.2%) Cidex (2.4, 2.5, 3.4%) MedSci (3%) Metricide (2.5, 2.6, 3.4%) Omnicide (2.4, 3.4%) Procide (2.4%) Rapidcide (2.5%) Sporicidin (1.12/1.93% glut/phenol) Wavicide-01 (2.5%) Cold Liquid High-Level Disinfectant Options • Hydrogen Peroxide • Sporox (7.5%) • Hydrogen Peroxide/ Peroxyacetic Acid • EndoSpor Plus (7.5/0.23%) • Peract 20 (1.0/0.08%) • ortho-Phthalaldehyde • Cidex OPA (0.55%) • Peroxyacetic Acid • Steris S-20 (35%) 4 | Minimizing Glutaraldehyde Use

  45. Disadvantages of Glutaraldehyde • Severe irritant - may cause asthma and respiratory sensitization (although not cancer or reproductive harm) • Burning eyes and conjunctivitis • Headaches and nausea • Low exposure limits • 0.2 ppm NIOSH REL • 0.05 ppm ACGIH TLV • Proposed 0.015 ppm Ceiling Limit in CA 4 | Minimizing Glutaraldehyde Use

  46. Kaiser Woodland Hills Case Study:OPA vs. Glutaraldehyde • Low vapor pressure, therefore minimal inhalation risk • Switch can be accomplished relatively quickly compared to installing engineering controls • Reduces disinfection time to 12m manual and 5mautomated processing (from 20m. for glut) • Allows twice the disinfection cycles before solution failure 4 | Minimizing Glutaraldehyde Use

  47. OPA Considerations • Unknown long-term health effects or cross-sensitivity to other aldehydes • No validated air sampling method • No exposure limits set – so for now, requires same engineering controls as glutaraldehyde • Contact with CIDEX® OPA may stain skin or clothing. Solution may also stain surfaces such as walls, floors and countertops. • Product more expensive than glutaraldehyde 4 | Minimizing Glutaraldehyde Use

  48. June 2004 Product Notification • Possibility of sensitization to CIDEX OPA Solution with repeated exposure. • In rare instances CIDEX OPA Solution has been associated with anaphylaxis-like reactions in bladder cancer patients undergoing repeated cystoscopies. • CIDEX OPA Solution should not be utilized to process instrumentation for patients with known sensitivity to CIDEX OPA Solution or any of its components. 4 | Minimizing Glutaraldehyde Use

  49. Isolation of cleaning and disinfection process from clinical procedure areas Separation of clean and dirty areas Process flow from dirty to clean, with no cross-over encouraged between the two Bottom Line: Environmental Controls • Engineering controls of vapor-generating activities and equipment • Safety equipment (eyewash, shower, spill containment, emergency shut-off) 4 | Minimizing Glutaraldehyde Use

  50. Glutaraldehyde ($5 per bottle) • 20 minutes per cycle = 24 cycles per 8 hour shift Cidex OPA ($25 per bottle) • 12 minutes per cycle (manual) = 40 cycles per 8 hour shift • 5 minutes per cycle (automated) = 96 cycles per 8 hour shift Cycle Times 4 | Minimizing Glutaraldehyde Use