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Environmental Accountability in Perioperative Settings
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Environmental Accountabilitv in Perioperative Settings J
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or many years, a critical factor in caring for the sick and injured was control of the environment. Control of temperature, fresh air, cleanliness, good food and water, and clean rooms and bedding were the basis of good nursing care. In 1860, Florence Nightingale wrote
In watching diseases, both in private houses and in public hospitals, the thing which strikes the experienced observer most forcibly is this, that the symptoms or the sufferings generally considered to be inevitable and incident to the disease are very often not symptoms of the disease at all, but of something quite dflerent-f the want offlesh air: or of light, or of warmth, or of quiet, or of cleanliness, or of punctualiv and care in the administration of diet, of each or of all of these.‘
than environment and community factors.z What role do nurses play in promoting cleaner, healthier environments for patients, staff members, and communities today? How does the health care industry affect the environment, and what steps can nurses take to promote the very foundation of nursing care (eg, control and promotion of a healthy environment)? At a groundbreaking conference in 2000 titled Setting Healthcare k Environmental Agenda, Michael Lemer, PhD, founder of the health and environmental research institute Commonweal, said,
As nursing developed into a profession, nurses continued to control environmental factors as much as possible, but as hospitals assumed greater control over the direction of health care, nurses focused more on individual patients and immediate needs rather
The question is whether healthcare professionals can begin to recognize the environmental consequences of our operations and set our own house in ordex This is no trivial question. Thefact that it plays out with little issues, like eliminating mercury thermometers and medical waste incineration,and all the technical aspects of transforming one of the greatest industrial centers in the world. Thefact that itplays out in that detail shouldn t blind us to what it is that we’re actually doing. . . in this concrete work. . . setting in order the house of healthcare.’
A B S T R A C T Global environmental problems are connected to patient care issues. The amount and toxicity of medical waste have increased in recent decades. Certain medical products contribute significantly to pollution and contamination of the food chain with persistent, bioaccumulative toxins, including mercury and dioxins. Perioperative nurses need to understand how best to segregate waste and take advantage of opportunities for reuse and recycling. There are many ways nurses can contribute to pollution prevention in health care, some of which are detailed in this article. AORN J 77 (June 2003) 1 1 571168. A N N MELAMED. RN
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This issue encompasses both ecology (ie, the science of preservation of natural resources) and environmental health (ie, the study of health outcomes that may be associated with exposure to environmental hazard^).^ Every nurse today is aware of the problems of global warming; contamination of air, soil, and water; loss of habitat; and species extinctions. These are ecological issues. Every nurse surely understands the effects of
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contaminated air, water, and soil on the food chain, water supply, and human health and reproduction. Nurses can be the link between the science of ecology and the art and science of environmental health. During the past 30 years, the health care industry has undergone tremendous changes in the types of products it uses and its waste practices. Not only has the industry embraced disposable products, many of them plastic, but it also has redefined infectious versus noninfectious waste. Waste disposal methods have come under continued and increasing attack for human health and environmental reasons. Perioperative nurses are leaders in examining these complex issues and finding solutions. This article examines some of the history of pollution prevention and environmental movements in health care and nursing, explains basic concepts about the hospital waste stream, and examines some of the toxic products used in health care settings and by-products of health care waste. It also provides concrete examples for nursing actions that promote environmental leadership at all levels and discusses two organizational efforts at “greening” the health care industry-Hospitals for a Healthy Environment (H2E) and the Health Care Without Harm (HCWH) coalition, of which AORN is a member organization. Through collaboration with HCWH and the H2E project, there are many opportunities for AORN members and chapters to continue to take the lead in identifying the scope and direction of environmentally preferable and healthier practices in the health care industry. MEDICAL WASTE, AORN, AND THE ENVIRONMENT
Historically, there was little guidance for dealing with medical waste separately from other waste because most hospitals had on-site incinerators and incinerated everything. In addition, the quantities of waste were much smaller, and there were fewer plastic items. The increasing rise of bloodborne disease, such as HIV and hepatitis B virus, in the early 1980s along with concurrent televised scenes of medical waste washing up on US beaches resulted in a movement to regulate medical waste and protect the public and health care and waste workers from bloodborne infections. Universal precautions standards, which were introduced in 1987, and the Medical Waste Tracking Act, which was signed into law in 1988,’ set in motion a movement to treat most medical waste, even clean hospital waste, as infectious. This resulted in increased amounts of waste being identified as “red
bag” (ie, infectious) waste, including the now ubiquitous polyvinyl chloride (PVC) plastics and other disposable items. Most of this waste was incinerated. As the waste problem in hospitals grew, many nurses sought to raise awareness of the problem and call for environmental accountability in the health care industry. At the AORN Congress in 1990, a resolution that called for perioperative nurses to consider the effects of medical practice on the environment was introduced, and it was approved by AORN’s Board of Directors in November 1990.6 The “Statement on the protection of the environment” encouraged AORN members to participate in research and education and look for effective ways to reduce the environmental impact of surgical waste.’ In 199I , responding to confusion about medical waste definitions, the AORN Subcommittee on Environmental Issues produced a “Report on infectious and noninfectious surgical waste disposal and its relation to the overall waste problem.”*After the universal precautions standard was enacted, there was continued confusion about infectious waste and what items should be disposed of in red bags. The definition of infectious waste needed clarification. AORN subsequently developed a position statement, “Regulated medical waste definition and treatment: A collaborative document” (Table 1): This AORN position statement has been the basis for defining regulated medical (ie, infectious) waste and helping state regulators and health care facilities sort out the complex treatment and disposal issues and regulation of medical waste. AORN leaders helped clarify the issue of medical and infectious waste; however, Jeannie Botsford, RN, MS, CNOR, past President of AORN and a leader in the development of the position statement said, The need still existsfor education and behavior changes at the sites where regulated medical waste is generated. Health care personnel also need a better understanding of which items should and should not be designated as infectious waste to reduce the volume and cost of disposal.“ This still is true today in most health care settings. According to the US Environmental Protection Agency (EPA), medical waste incineration historically has been one of the two largest sources of dioxins in the environment. Although dioxins emissions from
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Table 1 this source have been reduced significantly during the past decade, medical waste incineration continues to be a source of dioxins pollution.” Medical waste incineration also is a leading contributor to anthropogenic mercury in the environment, as well as a number of other serious pollutants. This knowledge has generated even more interest in the medical waste problem and the search for solutions. In 1997, the EPA issued its final standards and guidelines on medical waste incinerators called the “Model state regulations for medical waste incinerators.” The rules established limits on emissions of pollutants from medical waste incinerators, including dioxins, hrans, lead, mercury, cadmium, particulates, sulhr dioxide, hydrogen chloride, nitrogen oxides, carbon monoxide, and ash emissions. The rules also established requirements for waste management plans and training medical waste incinerator operators, as well as testing and monitoring emissions from medical waste incinerators.” Subsequently, many medical waste incinerators were unable to comply with the new regulation and have shut down. This is good news for the environment and for public health. SElTING THE STANDARD FOR ENVIRONMENTAL ACCOUNTABILITY
Nursing leadership in the area of health care pollution prevention continued with the 1997 American Nurses Association (ANA) house of delegates report on the “Reduction of health care production of toxic pollution.” This report has six key components. Adopt the definition of regulated medical waste as developed by AORN in 1992. Support and lobby for dioxins emission standards for medical waste incinerators to be at least as rigorous as those for hazardous waste incinerators. Promote the use of alternatives to PVC plastic products. Commit to mercury-free health care facilities and delivery by the year 2000. Promote use of nonincineration methods of disposal for all health care wastes that can be disposed of safely in other ways. Educate RNs and other health care personnel about the issues discussed in recommendations one to five? The ANA continues to advocate for environmental health issues, which it identifies as a key component of the core issue of health and safety.I4 In the same year, AORN’s “Recommended practices for environmental responsibility” was
DEFINITION OF REGULATED MEDICAL (I€, INFECTIOUS) WASTE’
Sharps, used and unused Cultures and stocks of infectious wastes Animal waste Selected isolation waste Pathological waste Human blood, blood products, and body fluids NOTE 1. “Regulated medical waste definition and treatment A collaborative document,’ in Stundafds, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2000) 146-147.
approved.” It provides a template for other nursing specialty organizations to use in developing best practices for environmental responsibility. Perioperative nurses should follow these recommended practices because they are useful guides for promoting environmentally responsible nursing practice (Table 2). In 2001, ANA became a partner in the H2E collaboration with the EPA, the American Hospital Association (AHA), and HCWH. In the same year, a work group within HCWH was developed for nurses working to promote pollution prevention in health care around the country. AORN and ANA both identify nursing education about health care waste and disposal, including education about environmentally preferable products, as within the scope of nursing responsibility and practice. PURCHASING
Waste issues begin with the purchase of materials because everything that comes into a hospital eventually goes out as waste. It is critical to look at product purchasing at every level of the health care facility. A new way to look at purchasing is that everything purchased by a department or facility is a resource, and resource conservation begins with each purchase. Environmentally preferable purchasing considers products by using a life cycle analysis in which the impact of a product from factory to disposal and even length of time in a landfill are taken into account. For nurses and other health care professionals, it also is important to include an analysis of the health and safety aspects of a product. For example, is there a product that can be steam sterilized safely
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Table 2
2. Surgical supplies should be opened only when there is a reasonable certainty they will be used during the procedure.
purchasing reusable, durable goods; or using reusable containers for goods rather than wasteful packaging. Examples of reusable containers are reusable metal instrument sterilizing trays or reusable tote cartons for products rather than cardboard boxes. By changing simple things, employee handling time and exposures are reduced, as are the costs of waste treatment, hauling, and disposal.I6
3. Single use and reusable products should be selected
HEALTH CARE WASTE STREAM
RECOMMENDED PRACTICES FOR ENVIRONMENTAL RESPONSIBILITY’
1 . Personnel should actively promote and participate in resource conservation.
and used with consideration for the environment during the entire lifetime of the products. 4. An efficient segregation program for infectious and noninfectiouswaste should be developed and implemented according to AORNs ‘Recommended practices for environmental cleaning in the surgical practice setting” and AORNs position statement ‘Regulated medical waste definition and treatment: A collaborative document.’
5. Blood, body fluids, disinfectant solutions, and other hazardous materials should be disposed of in accordance with local, state, and federal recommendations and with concern for the environment. 6. Recycling programs should be an integral part of health care facilities’ policies and procedures. 7. Sterilization of items in health care facilities should be accomplished with steam sterilization as the method of choice.
8. Policies and procedures regarding environmental protection should be written in accordance with local, state, and federal regulations; reviewed periodically; and be readily available within the perioperative practice setting. NOTE 1. ‘Recommended practices for environmental responsibility,’ in Sbndufds, Recommended Pfucfim, and Guidelines (Denver: AORN, Inc, 2003) 265-269.
The amount of waste generated per hospital patient has more than doubled since 1955 and now is estimated to be 4 billion lbs of waste per year.” To do a better job of reducing waste, it is necessary to understand the complex waste stream from a hospital. Hospital waste is defined as all solid waste generated from a facility, including cafeteria, office, and construction waste (Table 3). The majority of waste (ie, 80% to 85%) is noninfectious and much of this, such as paper, cardboard, metal, glass, food waste, and some plastics, can and should be recycled. Medical waste is a smaller percentage, about 10% to 15% of waste, not all of which is infectious. Hazardous waste is an even smaller percentage and includes waste from chemotherapeutics, mercury, and other toxic metals. Radioactive waste is a small, highly regulated part of the health care waste stream that will not be addressed in this article. Medical waste is waste generated as a result of patient care, treatment, or diagnosis.18 Infectious waste is a smaller component of medical waste that has the capacity to transmit infectious disease. All medical waste does not need to be disposed of in a red bag, although frequently it is. For example, after a nurse inserts a catheter into a patient, parts of the insertion kit are contaminated with body fluid (ie, urine). These parts are medical waste but are not considered infectious and should be disposed of with the regular trash. REDUCE, REUSE, RECYCLE
“Reducing the amount of red bags generated is rather than requiring ethylene oxide sterilization? A the first step in any hospital waste management prolife cycle analysis includes considering the environ- gram.”” According to H2E, one of the most commental and health effects from ethylene oxide on hos- pelling reasons to reduce red bag waste is to reduce pital workers, the hospital environment, and the envi- costs for facilities. Reduction of this waste stream may ronment as a whole. prove so rewarding that it will provide incentive, and Basic concepts of waste reduction include reduc- sometimes even pay, for further waste reduction proing waste as much as possible (ie. source reduction) grams. Average red bag disposal costs are at least five and recycling or reusing. Source reduction refers to times greater than those of regular trash disposal.*’ Another reason to reduce the infectious waste purchasing and includes buying just enough items; 1160 AORN JOURNAL
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Table 3 ANALYSIS OF A HOSPITAL WASTE STREAM
MedicaI waste Hazardous waste (eg, chemicals, mercury, batteries) Solid waste (eg, trash similar to household garbage) Recyclables (eg, paper, cardboard) Construction and demolition debris-important on the US West Coast because of earthquake retrofitting of hospitals
stream is that it may help a facility make a better selection in medical waste treatment choices. With reduced amounts of infectious waste, it may prove cost effective, for example, to send the waste to a treatment center off-site rather than installing a waste treatment autoclave. By reducing infectious waste, a facility also may be able to reduce the number of times per week a hauler has to come. The most important thing to remember is to reduce the volume of this waste stream by better waste sorting and segregation. A medical waste audit is a good first step in this process. Help with conducting a medical waste audit can be found on H2E’s web site at http://www.H2E-online.org. Ongoing education is important so that staff members have the skills and training to “know where to throw.” Have an annual waste training requirement as part of health and safety training, or put up a wall display with signs and information about waste issues (Figure 1 ). Other important suggestions include having extra recycling containers handy with smaller, covered red bag waste containers wherever possible. In the OR, have only kick buckets or, for bloody procedures, just one red bag open at a time along with the kick buckets. Regular staff member training is essential to prevent bloody or contaminated items from being thrown into recycling or solid waste containers. SEGREGATION OF WASTE
Better waste management begins with segregation at the source of generation. Resource recovery and recycling can be done only when there is a segregation program for separating infectious from noninfectious waste. Segregation at the point of use is the best way to accomplish this because it prevents contamination of the materials to be recycled, maximizing the potential for recycling and reusing valuable components of the waste stream, such as paper, linens, metals, and some plastics. Perioperative nurses can
Figure 1 Red bag waste poster. The information on this poster is specific to California and may not be applicable to all states. (Photograph courtesy of California Integrated Waste Management Board, Sacramento, Calif)
take the initiative to set up areas to collect clean packaging, blue wrap, plastics, and paper. They will have to work with environmental services to ensure that, after it leaves the OR, recycled material truly goes to recycling vendors and not eventually into the trash. Reuse of durable goods is preferable wherever possible. For example, there are many companies that provide real linens and stainless steel basins for custom packs. This is preferable to disposables wherever feasible. Many hospitals now are recycling paper, cardboard, and plastics, including blue wrap, a pure polypropylene textile. The perioperative nurses at Dominican Hospital in Santa Cruz, Calif, with leadership from ecology coordinator Mary Ellen Leciejewski, OP, established a recycling system with a janitorial supplier to haul their blue wrap and other plastics to a collection site (Figure 2). At the San Francisco Veterans’ Administration Hospital, perioperative nurses began a system of recycling
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Table 4 RECYCIABLES C O M M O N IN PERlOPERATlVE SETTINGS'
High density polyethylene (eg, milk jugs, dialysis solutions, food stuffs, cleaning solutions) Polypropylene (eg, sterile irrigation fluid bottles, blue wrap) Polystyrene (eg, food service, supply packaging) Aluminum and metal cans
Figure 2 A perioperative nurse recycles polypropylene blue wrap. (Photograph courtesy of Dominican Hospital, Santa Cruz, Cali9
Glass Paper NOTE 1. H G Shaner, C L Bisson, G McRae, An Ounce of Prevention: Waste Reduction Strategies for Healfh Care Fuci/ities(Chicago: American Society for Healthcare Environmental Services of the American Hospital Association, 1993) 31 .
paper and cardboard. This is not difficult to institute, and because many communities have mandates to reduce the waste going to landfills, there may be community support (ie, financial, technical) for beginning some projects at a facility. The waste manager or health and safety officer should know about government-sponsored or community help and incentives, but he or she may need nurses' help and support to get a program started. Information is available on the H2E and HCWH (ie. http://www.noharm.org) web sites. Common recyclables are presented in Table 4. Any perioperative unit can begin recycling. Resourceful perioperative team members can work with their environmental services department to set up areas for collection with regular pick up times. Teamwork is essential; it is one of the reasons that both H2E and HCWH recommend that a green team be established at a facility. The benefits of better waste management include reduction of environmental effects from health care; improved employee and patient safety; protection of confidentiality; decreased operating costs; and contribution to licensure and accreditation requirements, including Joint Commission on Accreditation of Healthcare Organizations Environment of Care Standards.2' Another benefit to perioperative nurses is their
involvement in the greater health care culture and increased visibility of their wealth of knowledge and skills. The connection between care of an individual patient and a healthy environment is essential for nurses to emphasize when making changes. A healthy environment is a nursing and patient care issue. INFECTIOUS WASTE TREATMENT
Infectious waste must be treated before disposal in a municipal landfill. Treatment can be accomplished on- or off-site. Treatment modalities include three basic processes: heat (ie, sterilizing, microwaving, incineration, pyrolysis), chemical treatment (ie. hypochlorite, chlorine dioxide), and radiation treatment. Medical waste incineration creates many toxic by-products, is a serious contributor to pollution, and has been identified by the EPA as a leading source of dioxins and anthropogenic mercury in the environment.22Some states still require incineration of certain portions of the infectious waste stream (eg, pathology waste, including body In general, however, incineration of waste is an outdated technology and one that the health care industry must stop using because even the most advanced incinerators continue to produce and release dioxins and other serious, persistent pollutants. Dioxins. Dioxins are a group of chemicals that are toxic by-products of industrial processes. They enter the air as waste from combustion. Some of the
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major sources of dioxins in the environment are the manufacture of chlorinated chemicals; bleaching of paper products; and incineration of medical, municipal, and hazardous Dioxins are a known human carcinogen. Other health effects associated with dioxins include changes in hormone systems, alterations in fetal development, infertility, endometriosis, immune suppression, and chloracne. Every person ever tested has a body burden of dioxins. It is a persistent and bioaccumulative toxin with a half-life in decades. Bioaccumulation refers to the tendency of a pollutant to magnify as it moves up the food chain. Humans get their major exposure to dioxins through fatty food, especially animal products, because dioxins, like many other toxins, are lipophilic. A nursing infant receives some of its highest lifetime doses of dioxins when nursing.” Although authorities agree that breast-feeding still is the preferable feeding method for infants because of the many other benefits, all nurses should know that keeping these serious toxins out of infants’ milk supply is a global patient care issue. Alternatives to medical waste incineration are preferable because the toxic byproducts emitted from incinerators are transported into the global environment and enter the food chain everywhere. Alternatives to incineration. Many incinerators have closed down because of their inability to comply with stricter regulations. Alternative treatment technologies are developing rapidly, but at present, they must be approved state by state. In any waste treatment technology, segregation is a key issue. Hazardous wastes must be segregated and disposed of according to state hazardous waste regulations, or the air, land, and water will become contaminated. Careful segregation at the source of generation is essential, regardless of the waste stream or its ultimate disposal. Many hospitals and health care systems use autoclaves to treat most types of infectious waste to render them suitable for a sanitary landfill. Waste treatment autoclaves work in much the same way as they do in a perioperative setting, and there are prevacuum and gravity displacement types. After the waste is loaded into the chamber, the prevacuum autoclave, which is more efficient but often more costly,” vacuums out the air so that high pressure and temperature are achieved faster. Gravity displacement works on the principle that steam, being lighter than air in the autoclave, will displace the air down-
ward and allow the steam and heat to reach optimum temperature and pressure. After treatment, the waste is rendered noninfectious and can be sent to a sanitary landfill. Many autoclave technology systems also shred or compact the waste before it is sent to a landfill.27 Figure 3 shows a hospital medical waste autoclave. Smaller models serve individual hospitals. The types of waste that can be treated in a autoclave include cultures and stocks, sharps, materials contaminated with blood and limited amounts offluids, isolation and sueeiy wastes, laboratory waste (excluding chemical waste), and soft wastes (gauze, bandages, drapes, gowns, bedding etc.ji-om patient care).” Very large items and items that would resist penetration of steam (eg. animal carcasses) are not good prospects for autoclaves. Another type of heat treatment for medical waste is a microwave. This technology works on the same principle as an autoclave, using steam for the heating of the material. The waste is sprayed with water to create steam, but the source of heat is microwave energy, much like that of microwave ovens used in homes. These systems often shred the waste and are ideal for cases in which a landfill requires nonrecognition of the waste as medical waste. There are commercial and hospital-size microwaves available on the market. Figure 4 shows a hospital microwave with shredded waste inside. Chemicals have been used for disinfection and sterilization in the perioperative environment for decades.” As a treatment for medical waste, the major difficulty with chemical treatments is ensuring that the chemical contacts the waste in adequate concentrations and for sufficient time to disinfect it. The types of waste that can be treated chemically include cultures and stocks; sharps; liquid human and animal wastes, including blood and body fluids; surgical and isolation wastes; laboratory waste; and soft wastes (eg, gauze bandages, bedding).)O Chlorine- and nonchlorine-based treatment methods are the major types of chemical treatment. Chlorinebased chemicals generally are less desirable because of their significant environmental effects.”
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Mercury is a heavy metal, and whether it contaminates a landfill and leaches into the water table or enters the hydrologic cycle via airborne particles released from an incinerator, it eventually finds its way into streams and lakes. In a lake or streambed, it is transformed by bacteria into its organic form, methylmercury, and it enters the food chain via microorganisms and then fish and other water animals. Similar to many other pollutants, mercury biomagnifies up the food chain so Figure 3 0 Hospital medical waste autoclave. (Photograph courtesy of the larger and older a fish, the Sun-I-Pak, Inc, Tracy, Calif) greater the potential for contamination with mercury. Mercury is a potent neurotoxin; therefore, pregnant women, women of childbearing age, and infants and small children are at the greatest risk for health effects from mercury. Recently, a US Food and Drug Administration (FDA) panel recommended that pregnant women and children limit consumption of canned tuna due to mercury contamination.-” Some sources of mercury in health care are thermometers, sphygmomanometers, bougies, cantor tubes, batteries, and fluorescent lights. In perioperative and Figure 4 Hospital medical waste microwave. gastroenterology settings, nurses can lobby to replace mercury-containing bougies and other intestinHAZARDOUS WASTES al tubes, sphygmomanometers, and batteries. The A waste audit is an important way to identify best way to-convince managers to eliminate mercury hazardous waste and be certain that it is being prop- products is to emphasize the cost of a hazardous erly segregated and disposed of. Nothing containing waste clean up from a spill. At a recent medical waste hazardous wastes, such as certain neoplastic agents, seminar, it was reported that which themselves are largely carcinogenic, or heavy metals, should go into sharps containers or red bags. it often costs around $5,000 .for one broken sphygmomanometer clean up, and a facility Proper segregation will prevent accidental release could buy 30 or 40 nonmercury ones for into the environment. Mercury, a toxic by-product from the health care that cost. One local hospital recently industry, is a frequent contaminant in medical waste. spent $10,054 dollars to clean up a spilled The EPA estimates that mercury disposed of impropsphygmomanometez34 erly in medical waste and incinerated contributes 10% of the anthropogenic mercury in the en~ironment.~’ When there are no mercury products in a facility, 1164 AORN JOURNAL
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there is no need to have a spill kit; train personnel in how to deal with a spill; risk potential exposure to staff members, patients, and the environment; or risk regulatory citation.
make educated choices about products and prevent patients’ exposure to undesirable effects from DEHP during medical treatment. HEALTH CARE WITHOUT HARM
DIETHYLHEXYL PHTHALATE
Although it is not yet common medical terminology, every nurse and physician using plastic medical products should know about diethylhexyl phthalate (DEHP), a plasticizer that is added to PVC plastic medical products to make the plastic soft and flexible. Polyvinyl chloride plastic normally is hard and brittle, so most uses require the addition of plasticizers and stabilizers. A problem arises, however, because DEHP is not chemically bound to the plastic, so it leaches out. Leaching is facilitated by exposure to heat; agitation; and especially to lipid-containing fluids, such as blood products, feeding products, and certain chemotherapeutic agents.35 Approximately 25% of all plastic medical products are PVC plastic, and many of them are critical items that leach DEHP. Diethylhexyl phthalate is a reproductive and developmental toxicant in laboratory animals. Male neonates receiving intensive medical treatments are at the highest risk for effects from DEHP exposures. According to a July 12, 2002, FDA advisory, procedures that have been identified as posing the highest risk of exposure to DEHP include exchange transfusion in neonates, extracorporeal circulation membrane oxygenation (ECMO) in neonates, total parenteral nutrition in neonates (ie, with lipids in PVC bag), multiple procedures in sick neonates (ie, high cumulative exposure), hemodialysis in peripubertal males, hemodialysis in pregnant or lactating women, enteral nutrition in neonates and adults, heart transplantation or coronary artery bypass graft surgery (ie, aggregate dose), massive infusion of blood into trauma patients, and transfusion in adults undergoing ECM0.36 Perioperative nurses need to be aware that medical exposure of critically ill infants to DEHP can exceed general population exposures by several orders of magnitude.” Perioperative nurses care for many patients undergoing high risk procedures in the perioperative setting. Diethylhexyl phthalate contamination is a patient care issue. Nurses must advocate for better products and product labeling so they can
The irony that medical waste incineration is a major source of dioxins and anthropogenic mercury in the environment resulted in the founding, in 1996, of HCWH, the campaign for environmentally responsible health care. At the time, many hospitals still had on-site, unregulated incinerators, which they used to burn all their waste. The mission of HCWH is to “transform the health care industry worldwide, without compromising patient safety or care, so that it is ecologically sustainable and no longer a source of harm to public health and the environment”(Tab1e 5).’* Health Care Without Harm now has 380 member organizations in 40 countries. AORN joined
Table 5 GOALS O F HEALTH CARE WITHOUT HARM
1. To work with a wide range of constituenciesfor an ecologically sustainable health care system
2. To promote policies, practices, and laws that eliminate incineration of medical waste, minimize the amount and toxicity of all waste generated, and promote the use of safer materials and treatment practices 3. To phase out use of polyvinyl chloride (PVC) plastics and persistent toxic chemicals in health care and to build momentum for a broader PVC phase-out campaign 4. To phase out use of mercury in all aspects of the health care industry
5. To develop health-based standards for medical waste management and to recognize and implement the public’s right to know about chemical use in the health core industry 6. To develop just siting and transportation guidelines that conform to the principles of environmental justice: No communities should be poisoned by medical waste treatment and disposal
7. To develop an effective collaboration and communication structure among campaign allies (Reprinted from “Mission and goals, hftp://lvww.noham .o@aboutUdmissionGoals, with permission from Health Care Without Ham, Washington, Dc.)
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HCWH as a member organization in 2000.39 Nurses' work group. Within HCWH, a nurses' work group meets monthly via conference call. These nurses have an annual work plan that currently focuses on training other nurses as environmental leaders and advocates. Perioperative nurses are well positioned to be leaders in reducing the health and environmental effects of the health care industry. Perioperative nurses work closely with medical product manufacturers and vendors and so are able to influence purchasing. If every perioperative nurse called one vendor and insisted on environmental accountability for a product, the market probably would respond more quickly. Perioperative nurses work closely with waste managers to ensure proper handling of waste and proper clean up in their facilities, so they are in a unique position to lobby for responsible waste disposal and recycling. Perioperative nurses are identified leaders in infection control and reprocessing and can facilitate healthier, less toxic, methods for disinfection and sterilization. Health Care Without Harm is an organization through which perioperative nurses can begin to establish ties with the greater environmental world that seeks to change the way health care does business.
homes, and 140 other types of facilitie~.~' Partners are health care facilities that have pledged to meet the goals of the H2E memorandum of understanding. Involvement in H2E provides a perfect opportunity for perioperative nurses to help identify strategies and set goals for eliminating mercury, reducing waste amounts and toxicity, and developing purchasing guidelines and policies in their facilities. Nurses can work to institutionalize environmental programs by emphasizing that a cleaner, healthier environment is primary prevention and a nursing practice issue. An exciting place for nurse involvement in the H2E program is pollution prevention policy at the state level. Several states have developed programs to mirror the national H2E program. State nurses associations, state hospital associations, state departments of health, state equivalents of the EPA, and local member groups of HCWH are meeting to collaborate on hospital pollution prevention in their states. Nurses must be at the table when statewide health care pollution prevention initiatives are being developed. No one is better qualified to advocate and promote environmental health in the health care industry than a nurse.
HOSPITALS FOR A HEALTHY ENVIRONMENT MEMORANDUM OF UNDERSTANDING
AORN CHAPTERS AND MEMBERS
In 1998, the EPA and the AHA signed a memorandum of understanding to advance pollution prevention work in the health care industry. This voluntary agreement to reduce mercury waste and the total volume and toxicity of waste from the health care industry resulted in the H2E partnership, which now includes the ANA and HCWH. The goals of the memorandum of understanding are to virtually eliminate mercury-containing waste from the health care industry waste stream by the year 2005; reduce the total volume of all waste, including both regulated and nonregulated waste, generated by the health care industry, with an annual goal of achieving a 33% reduction in all hospitals by 2005 and a 50% reduction by 2010;4"and help hospitals reduce or eliminate persistent, bioaccumulative toxics, such as mercury, pesticides, and other chemicals and heavy metals. Hospitals for a Healthy Environment is another avenue that perioperative nurses can explore. As of Feb 17, 2003, the H2E program had 398 partners representing 425 hospitals, 755 clinics, 28 nursing
There are many ways that AORN chapters can promote a healthier, less polluting health care industry. Chapters can work with state nurses associations to promote state level H2E projects. By partnering with state departments of environmental quality and public health and state hospital associations, nurses can be extremely influential in promoting environmentally healthy facilities. Chapters can encourage nursing participation by providing continuing education contact hours for pollution prevention conferences. AORN of San Francisco & Marin sponsored continuing education contact hours for nurses attending a hospital pollution prevention conference in fall, 2001, in Oakland, Calif. Chapters can form an environmental health committee. Chapters also may be interested in sending a nurse to HCWH training so he or she can become a nursing expert on environmental issues at the state, city, or facility level. Everyone is responsible for public and environmental health. Other ways perioperative nurses can be involved in this work include educating citizens and communities about environmental health issues, advocating for social and economic equity
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(ie, environmental justice) so that certain communities are not dumping grounds for hazardous substances, supporting and encouraging legislation for environmental protection, serving on boards of state and specialty nursing and nonprofit environmental health organizations,4? volunteering to be on or start a health and safety committee or green team at their facility, and getting involved in initiatives like HCWH and H2E. Health Care Without Harm can provide connection with other nurses around the country who are working on pollution prevention in health care; connection with environmental groups around the country and world that will help nurses find information about local environmental issues, as well as community resources; 9 information about medical and health care waste issues and tools for making changes at a facility; and mini-grant funding for pollution prevention training for health professionals. Support available from H2E includes help getting chapters involved in pollution prevenNOTES 1. F Nightingale, Notes on Nursing: What It Is.and What It IS Not (New York: Dover Publications, 1969) 8. 2. A M Pope, M A Snyder, L H Mood, eds, Nursing, Health and the Environment: Strengthening the Relationship to Improve the Public h Health (Washington, DC: National Academies Press, 1995) 2-4. Also
available from http://books.nap .edu/books/030905298X/htmVindex.
html. 3. M Lemer, Setting Healthcare k Environmental Agenda, Papers and Proceedingsfim the October 16, 2000 Conference (Falls Church,Va: Health Care Without Harm, 2000) 66. 4. Pope, Snyder, Mood, Nursing, Health and the Environment: Strengthening the Relationship to Improve the Publick Health, 4. 5. W A Rutala, C G Mayhall,
tion initiatives at the state nursing association level, connection with the state hospital association and the state nurses association for collaborative work toward the goals of H2E (ie, mercury and waste reduction, reducing toxicity of hospital waste), connection with the regional EPA and state departments of environment, and technical and possibly financial help for pollution prevention projects. Nurses, especially perioperative nurses, can be the nexus between health care and environmental health both in health care settings and in the outside world. According to Susan Wilburn, RN, BSN, MPH, senior occupational health and safety specialist at the ANA, “The environment of care for patients is the same as the environment of work for nurses, and both can impact the environment at large.” For nurses to advocate for environmental health is not only a nursing practice issue, it is primary prevention. Nurses can have a measurable, sustained impact on the environment of care and, thus, on the environment and public health. A Ann Melamed, RN,MA, is the environmental health specialistfor the American Nurses Association, Washington, DC.
“Medical waste,” Infection Control and Hospital Epidemiology 13 (January 1992) 38-48. 6. “Forum discussion, House of Delegates action,” AORN Journal 5 1 (May 1990) 1241- 1252; “Board creates Project 2000, adopts statement on the environment, proposes dues increase,” (Board Report) AORN Journal 53 (February 1991) 232-235. 7. “Statement on protection of the environment,” in Standad, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2000) 153; J Botsford, “Environ-
mental issues are still a concern to perioperative nursesBoth globally and locally,” (President’s Message) AORN Journal 66 (September 1997) 384. 8. C Spry et al, “A report on
infectious and noninfectious surgical waste disposal and its relation to the overall waste problem,” AORN Journal 53 (April 1991) 905-916. 1167 AORN JOURNAL
9. “Regulated medical waste definition and treatment: A collaborative document,” in Standad, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2000) 145-148. 10. Botsford, “Environmental issues are still a concem to perioper-
ative nurses-Both globally and locally,” 385. 11. “Dioxin: Summary of Major EPA Control Efforts,” US Environmental Protection Agency, http://www.epa.gov/ncedpdfddioxin /factsheets/dioxin-regs.pdf(accessed 2 May 2003). 12. Health Care Without Harm, “Model state regulations for medical waste incinerators,” in Pollution Prevention Kit for Nurses
(Washington, DC: American Nurses Association, 1998). 13. American Nurses Association house of delegates, Reduction of Health Care Production of Toxic
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Pollution (Washington, DC: American Nurses Association, Inc: 1997). 14. “Core issues,’’ American Nurses Association, http://nursing world.org/ana2000/coreflyr.htm (accessed 18 March 2003). 15. “Recommended practices for environmental responsibility,” in Standards. Recommended Practices, and Guidelines (Denver: AORN, Inc, 2003) 265-269. 16. “Section I: Talking about waste,” Hospitals for a Healthy Environment, http://www. h2e-online .org/pubs/wrguide/setion1.pdf (accessed 18 March 2003). 17. K Gerwig, “Waste management & healthcare,” in Setting Healthcare S Environmental Agenda: Papers and Proceedingshm the October 16, 2000 Conference (Falls Church, Va: Health Care Without Harm, 2000) 67. 18. H Shaner, G McRae, “Eleven recommendations for improving medical waste management,” The Nightingale Institute for Health & the Environment, http://www.nihe .org/elevreng.html(accessed 18 March 2003). 19. “Section VII-More about regulated medical waste,” Hospitals for a Healthy Environment, http:// www.h2e-online.org/pubs/wrguide lsection7.pdf (accessed 18 March 2003). 20. Ibid. 2 I . K Gerwig, “Waste management & healthcare,” 68. 22. “Dioxins and kans,’’ US Environmental Protection Agency, http://www.epa.gov/pbtldioxins. htm (accessed 18 March 2003). 23. J Emmanuel, Non-incineration Medical Waste Treatment Technologies (Washington, DC: Health Care Without Harm, 2001) 13. 24. “Dioxins and furans.” 25. M Rossi, T Schettler, “PVC & healthcare,” Setting Healthcare 5 Environmental Agenda: Papers and Proceedings Ji.omthe October 16, 2000 Conference (Falls Church, Va:
Health Care Without Harm, 2000) 30; America 5 Choice: Children 5 Health or Corporate ProJt, The American People k Dioxin Report, Technical Support Document, November 1999, Center for Health, Environment and Justice, http://www .chej.org/report.htInl#Chapter%204 (accessed 4 April 2003). 26. Emmanuel, Non-incineration Medical Wmte Treatment Technologies, 24. 27. Ibid, 23-24. 28. Ibid, 24. 29. Ibid, 61. 30. Ibid, 61. 31. Ibid, 63. 32. “Mercury,”US Environmental Protection Agency, http://www.epa .gov/mercury/information.htm#factsheets (accessed 18 March 2003). 33. FDA Panel Utges US Government to Warn Pregnant Women, Young Children About Mercury Exposure RisksJi.omTuna, (news release, Montpelier, Vt: Mercury Policy Project, July 26, 2002) http://www.mercurypolicy
Reproduction, http://cerhr.niehs.nih .gov/news/index.html (accessed 18 March 2003). 38. ‘‘Mission and goals,” Health Care Without Harm, http://www.no
harm.org/aboutUdmissionGoals
(accessed 30 April 2003). 39. A Melamed, “AORN joins effort to eliminate pollution in health care,” Congress News, 24 April 2002,s. 40. L Robinson, letter to William Saunders, US Environmental Protection Agency, Washington, DC, 24 July 2001, Hospitals for a Healthy Environment, http://www.h2e-online .org/pubdletter.pdf(accessed 18 March 2003). 41. “Current partners,” Hospitals for a Healthy Environment, http:// www.h2e-online.org/programs /partner/p-mbr.cfin (accessed 2 1 March 2003). 42. J Washington, G K Paramino, P G Butterfield, Environmental Health: A Nursing Opportuni@ (Atlanta: Centers for Disease Control and Prevention, Public Health .org/new/documents/FDArelease072 Training Network, Aug 10,2000) Videotape. 602.pdf (accessed 18 March 2003). 34. “Reducing mercury in hospiRESOURCES tals and biomedical facilities: A ANA Pollution Prevention Kit for MIRT seminar, May 23,2001,” Nurses, American Nurses Publishing, Medical Industry Waste Prevention http://www.nursingworld.org/mno Round Table, http://dnr.metrokc.gov harm. /swd/bizprog/wasteqre/MIRTsem8 Hospitals for a Healthier Environ.htm (accessed 18 March 2003). ment, http://w.h2e-online.org. 35. AMelamed, C Temullo-Retta, The Nightingale Institute for “Plastic chemicals are a threat to Health and the Environment, http:// neonates,” Central Lines: The N A ” www.nihe.org. Pages 17 (December 2001/January Nurses Welcome Kit, Health Care 2002) 31-33. Without Harm, http://www.noharm 36. “Public health notification: .org/index.cfin/tools/nurseswelcome. PVC devices containing the plasti“Red bag (biohazard) waste,” cizer DEW,” (July 12,2002) US California Integrated Waste ManageFood and Drug Adminisixation, http://www. fda.gov/cdrhlsafety/dehp ment Board, http://www.ciwmb.ca .gov/BizWaste/Posters/RedBag.htm. .pdf (accessed 18 March 2003). Sattler, B. Environmental Health 37. ‘“TP-CERHR expert panel report on di (2-ethyhexyl) phthalate, in the Health Care Setting, American October 2000,” National Toxicology Nurses Association, http://nursing world.org/moddmod37O/cehchll Program, US Department of Health .htm. and Human Services, Center for the Education of Risks to Human
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Environmental Accountabilitv in Perioperative Settings J
F
or many years, a critical factor in caring for the sick and injured was control of the environment. Control of temperature, fresh air, cleanliness, good food and water, and clean rooms and bedding were the basis of good nursing care. In 1860, Florence Nightingale wrote
In watching diseases, both in private houses and in public hospitals, the thing which strikes the experienced observer most forcibly is this, that the symptoms or the sufferings generally considered to be inevitable and incident to the disease are very often not symptoms of the disease at all, but of something quite dflerent-f the want offlesh air: or of light, or of warmth, or of quiet, or of cleanliness, or of punctualiv and care in the administration of diet, of each or of all of these.‘
than environment and community factors.z What role do nurses play in promoting cleaner, healthier environments for patients, staff members, and communities today? How does the health care industry affect the environment, and what steps can nurses take to promote the very foundation of nursing care (eg, control and promotion of a healthy environment)? At a groundbreaking conference in 2000 titled Setting Healthcare k Environmental Agenda, Michael Lemer, PhD, founder of the health and environmental research institute Commonweal, said,
As nursing developed into a profession, nurses continued to control environmental factors as much as possible, but as hospitals assumed greater control over the direction of health care, nurses focused more on individual patients and immediate needs rather
The question is whether healthcare professionals can begin to recognize the environmental consequences of our operations and set our own house in ordex This is no trivial question. Thefact that it plays out with little issues, like eliminating mercury thermometers and medical waste incineration,and all the technical aspects of transforming one of the greatest industrial centers in the world. Thefact that itplays out in that detail shouldn t blind us to what it is that we’re actually doing. . . in this concrete work. . . setting in order the house of healthcare.’
A B S T R A C T Global environmental problems are connected to patient care issues. The amount and toxicity of medical waste have increased in recent decades. Certain medical products contribute significantly to pollution and contamination of the food chain with persistent, bioaccumulative toxins, including mercury and dioxins. Perioperative nurses need to understand how best to segregate waste and take advantage of opportunities for reuse and recycling. There are many ways nurses can contribute to pollution prevention in health care, some of which are detailed in this article. AORN J 77 (June 2003) 1 1 571168. A N N MELAMED. RN
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This issue encompasses both ecology (ie, the science of preservation of natural resources) and environmental health (ie, the study of health outcomes that may be associated with exposure to environmental hazard^).^ Every nurse today is aware of the problems of global warming; contamination of air, soil, and water; loss of habitat; and species extinctions. These are ecological issues. Every nurse surely understands the effects of
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contaminated air, water, and soil on the food chain, water supply, and human health and reproduction. Nurses can be the link between the science of ecology and the art and science of environmental health. During the past 30 years, the health care industry has undergone tremendous changes in the types of products it uses and its waste practices. Not only has the industry embraced disposable products, many of them plastic, but it also has redefined infectious versus noninfectious waste. Waste disposal methods have come under continued and increasing attack for human health and environmental reasons. Perioperative nurses are leaders in examining these complex issues and finding solutions. This article examines some of the history of pollution prevention and environmental movements in health care and nursing, explains basic concepts about the hospital waste stream, and examines some of the toxic products used in health care settings and by-products of health care waste. It also provides concrete examples for nursing actions that promote environmental leadership at all levels and discusses two organizational efforts at “greening” the health care industry-Hospitals for a Healthy Environment (H2E) and the Health Care Without Harm (HCWH) coalition, of which AORN is a member organization. Through collaboration with HCWH and the H2E project, there are many opportunities for AORN members and chapters to continue to take the lead in identifying the scope and direction of environmentally preferable and healthier practices in the health care industry. MEDICAL WASTE, AORN, AND THE ENVIRONMENT
Historically, there was little guidance for dealing with medical waste separately from other waste because most hospitals had on-site incinerators and incinerated everything. In addition, the quantities of waste were much smaller, and there were fewer plastic items. The increasing rise of bloodborne disease, such as HIV and hepatitis B virus, in the early 1980s along with concurrent televised scenes of medical waste washing up on US beaches resulted in a movement to regulate medical waste and protect the public and health care and waste workers from bloodborne infections. Universal precautions standards, which were introduced in 1987, and the Medical Waste Tracking Act, which was signed into law in 1988,’ set in motion a movement to treat most medical waste, even clean hospital waste, as infectious. This resulted in increased amounts of waste being identified as “red
bag” (ie, infectious) waste, including the now ubiquitous polyvinyl chloride (PVC) plastics and other disposable items. Most of this waste was incinerated. As the waste problem in hospitals grew, many nurses sought to raise awareness of the problem and call for environmental accountability in the health care industry. At the AORN Congress in 1990, a resolution that called for perioperative nurses to consider the effects of medical practice on the environment was introduced, and it was approved by AORN’s Board of Directors in November 1990.6 The “Statement on the protection of the environment” encouraged AORN members to participate in research and education and look for effective ways to reduce the environmental impact of surgical waste.’ In 199I , responding to confusion about medical waste definitions, the AORN Subcommittee on Environmental Issues produced a “Report on infectious and noninfectious surgical waste disposal and its relation to the overall waste problem.”*After the universal precautions standard was enacted, there was continued confusion about infectious waste and what items should be disposed of in red bags. The definition of infectious waste needed clarification. AORN subsequently developed a position statement, “Regulated medical waste definition and treatment: A collaborative document” (Table 1): This AORN position statement has been the basis for defining regulated medical (ie, infectious) waste and helping state regulators and health care facilities sort out the complex treatment and disposal issues and regulation of medical waste. AORN leaders helped clarify the issue of medical and infectious waste; however, Jeannie Botsford, RN, MS, CNOR, past President of AORN and a leader in the development of the position statement said, The need still existsfor education and behavior changes at the sites where regulated medical waste is generated. Health care personnel also need a better understanding of which items should and should not be designated as infectious waste to reduce the volume and cost of disposal.“ This still is true today in most health care settings. According to the US Environmental Protection Agency (EPA), medical waste incineration historically has been one of the two largest sources of dioxins in the environment. Although dioxins emissions from
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Table 1 this source have been reduced significantly during the past decade, medical waste incineration continues to be a source of dioxins pollution.” Medical waste incineration also is a leading contributor to anthropogenic mercury in the environment, as well as a number of other serious pollutants. This knowledge has generated even more interest in the medical waste problem and the search for solutions. In 1997, the EPA issued its final standards and guidelines on medical waste incinerators called the “Model state regulations for medical waste incinerators.” The rules established limits on emissions of pollutants from medical waste incinerators, including dioxins, hrans, lead, mercury, cadmium, particulates, sulhr dioxide, hydrogen chloride, nitrogen oxides, carbon monoxide, and ash emissions. The rules also established requirements for waste management plans and training medical waste incinerator operators, as well as testing and monitoring emissions from medical waste incinerators.” Subsequently, many medical waste incinerators were unable to comply with the new regulation and have shut down. This is good news for the environment and for public health. SElTING THE STANDARD FOR ENVIRONMENTAL ACCOUNTABILITY
Nursing leadership in the area of health care pollution prevention continued with the 1997 American Nurses Association (ANA) house of delegates report on the “Reduction of health care production of toxic pollution.” This report has six key components. Adopt the definition of regulated medical waste as developed by AORN in 1992. Support and lobby for dioxins emission standards for medical waste incinerators to be at least as rigorous as those for hazardous waste incinerators. Promote the use of alternatives to PVC plastic products. Commit to mercury-free health care facilities and delivery by the year 2000. Promote use of nonincineration methods of disposal for all health care wastes that can be disposed of safely in other ways. Educate RNs and other health care personnel about the issues discussed in recommendations one to five? The ANA continues to advocate for environmental health issues, which it identifies as a key component of the core issue of health and safety.I4 In the same year, AORN’s “Recommended practices for environmental responsibility” was
DEFINITION OF REGULATED MEDICAL (I€, INFECTIOUS) WASTE’
Sharps, used and unused Cultures and stocks of infectious wastes Animal waste Selected isolation waste Pathological waste Human blood, blood products, and body fluids NOTE 1. “Regulated medical waste definition and treatment A collaborative document,’ in Stundafds, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2000) 146-147.
approved.” It provides a template for other nursing specialty organizations to use in developing best practices for environmental responsibility. Perioperative nurses should follow these recommended practices because they are useful guides for promoting environmentally responsible nursing practice (Table 2). In 2001, ANA became a partner in the H2E collaboration with the EPA, the American Hospital Association (AHA), and HCWH. In the same year, a work group within HCWH was developed for nurses working to promote pollution prevention in health care around the country. AORN and ANA both identify nursing education about health care waste and disposal, including education about environmentally preferable products, as within the scope of nursing responsibility and practice. PURCHASING
Waste issues begin with the purchase of materials because everything that comes into a hospital eventually goes out as waste. It is critical to look at product purchasing at every level of the health care facility. A new way to look at purchasing is that everything purchased by a department or facility is a resource, and resource conservation begins with each purchase. Environmentally preferable purchasing considers products by using a life cycle analysis in which the impact of a product from factory to disposal and even length of time in a landfill are taken into account. For nurses and other health care professionals, it also is important to include an analysis of the health and safety aspects of a product. For example, is there a product that can be steam sterilized safely
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Table 2
2. Surgical supplies should be opened only when there is a reasonable certainty they will be used during the procedure.
purchasing reusable, durable goods; or using reusable containers for goods rather than wasteful packaging. Examples of reusable containers are reusable metal instrument sterilizing trays or reusable tote cartons for products rather than cardboard boxes. By changing simple things, employee handling time and exposures are reduced, as are the costs of waste treatment, hauling, and disposal.I6
3. Single use and reusable products should be selected
HEALTH CARE WASTE STREAM
RECOMMENDED PRACTICES FOR ENVIRONMENTAL RESPONSIBILITY’
1 . Personnel should actively promote and participate in resource conservation.
and used with consideration for the environment during the entire lifetime of the products. 4. An efficient segregation program for infectious and noninfectiouswaste should be developed and implemented according to AORNs ‘Recommended practices for environmental cleaning in the surgical practice setting” and AORNs position statement ‘Regulated medical waste definition and treatment: A collaborative document.’
5. Blood, body fluids, disinfectant solutions, and other hazardous materials should be disposed of in accordance with local, state, and federal recommendations and with concern for the environment. 6. Recycling programs should be an integral part of health care facilities’ policies and procedures. 7. Sterilization of items in health care facilities should be accomplished with steam sterilization as the method of choice.
8. Policies and procedures regarding environmental protection should be written in accordance with local, state, and federal regulations; reviewed periodically; and be readily available within the perioperative practice setting. NOTE 1. ‘Recommended practices for environmental responsibility,’ in Sbndufds, Recommended Pfucfim, and Guidelines (Denver: AORN, Inc, 2003) 265-269.
The amount of waste generated per hospital patient has more than doubled since 1955 and now is estimated to be 4 billion lbs of waste per year.” To do a better job of reducing waste, it is necessary to understand the complex waste stream from a hospital. Hospital waste is defined as all solid waste generated from a facility, including cafeteria, office, and construction waste (Table 3). The majority of waste (ie, 80% to 85%) is noninfectious and much of this, such as paper, cardboard, metal, glass, food waste, and some plastics, can and should be recycled. Medical waste is a smaller percentage, about 10% to 15% of waste, not all of which is infectious. Hazardous waste is an even smaller percentage and includes waste from chemotherapeutics, mercury, and other toxic metals. Radioactive waste is a small, highly regulated part of the health care waste stream that will not be addressed in this article. Medical waste is waste generated as a result of patient care, treatment, or diagnosis.18 Infectious waste is a smaller component of medical waste that has the capacity to transmit infectious disease. All medical waste does not need to be disposed of in a red bag, although frequently it is. For example, after a nurse inserts a catheter into a patient, parts of the insertion kit are contaminated with body fluid (ie, urine). These parts are medical waste but are not considered infectious and should be disposed of with the regular trash. REDUCE, REUSE, RECYCLE
“Reducing the amount of red bags generated is rather than requiring ethylene oxide sterilization? A the first step in any hospital waste management prolife cycle analysis includes considering the environ- gram.”” According to H2E, one of the most commental and health effects from ethylene oxide on hos- pelling reasons to reduce red bag waste is to reduce pital workers, the hospital environment, and the envi- costs for facilities. Reduction of this waste stream may ronment as a whole. prove so rewarding that it will provide incentive, and Basic concepts of waste reduction include reduc- sometimes even pay, for further waste reduction proing waste as much as possible (ie. source reduction) grams. Average red bag disposal costs are at least five and recycling or reusing. Source reduction refers to times greater than those of regular trash disposal.*’ Another reason to reduce the infectious waste purchasing and includes buying just enough items; 1160 AORN JOURNAL
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Table 3 ANALYSIS OF A HOSPITAL WASTE STREAM
MedicaI waste Hazardous waste (eg, chemicals, mercury, batteries) Solid waste (eg, trash similar to household garbage) Recyclables (eg, paper, cardboard) Construction and demolition debris-important on the US West Coast because of earthquake retrofitting of hospitals
stream is that it may help a facility make a better selection in medical waste treatment choices. With reduced amounts of infectious waste, it may prove cost effective, for example, to send the waste to a treatment center off-site rather than installing a waste treatment autoclave. By reducing infectious waste, a facility also may be able to reduce the number of times per week a hauler has to come. The most important thing to remember is to reduce the volume of this waste stream by better waste sorting and segregation. A medical waste audit is a good first step in this process. Help with conducting a medical waste audit can be found on H2E’s web site at http://www.H2E-online.org. Ongoing education is important so that staff members have the skills and training to “know where to throw.” Have an annual waste training requirement as part of health and safety training, or put up a wall display with signs and information about waste issues (Figure 1 ). Other important suggestions include having extra recycling containers handy with smaller, covered red bag waste containers wherever possible. In the OR, have only kick buckets or, for bloody procedures, just one red bag open at a time along with the kick buckets. Regular staff member training is essential to prevent bloody or contaminated items from being thrown into recycling or solid waste containers. SEGREGATION OF WASTE
Better waste management begins with segregation at the source of generation. Resource recovery and recycling can be done only when there is a segregation program for separating infectious from noninfectious waste. Segregation at the point of use is the best way to accomplish this because it prevents contamination of the materials to be recycled, maximizing the potential for recycling and reusing valuable components of the waste stream, such as paper, linens, metals, and some plastics. Perioperative nurses can
Figure 1 Red bag waste poster. The information on this poster is specific to California and may not be applicable to all states. (Photograph courtesy of California Integrated Waste Management Board, Sacramento, Calif)
take the initiative to set up areas to collect clean packaging, blue wrap, plastics, and paper. They will have to work with environmental services to ensure that, after it leaves the OR, recycled material truly goes to recycling vendors and not eventually into the trash. Reuse of durable goods is preferable wherever possible. For example, there are many companies that provide real linens and stainless steel basins for custom packs. This is preferable to disposables wherever feasible. Many hospitals now are recycling paper, cardboard, and plastics, including blue wrap, a pure polypropylene textile. The perioperative nurses at Dominican Hospital in Santa Cruz, Calif, with leadership from ecology coordinator Mary Ellen Leciejewski, OP, established a recycling system with a janitorial supplier to haul their blue wrap and other plastics to a collection site (Figure 2). At the San Francisco Veterans’ Administration Hospital, perioperative nurses began a system of recycling
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Table 4 RECYCIABLES C O M M O N IN PERlOPERATlVE SETTINGS'
High density polyethylene (eg, milk jugs, dialysis solutions, food stuffs, cleaning solutions) Polypropylene (eg, sterile irrigation fluid bottles, blue wrap) Polystyrene (eg, food service, supply packaging) Aluminum and metal cans
Figure 2 A perioperative nurse recycles polypropylene blue wrap. (Photograph courtesy of Dominican Hospital, Santa Cruz, Cali9
Glass Paper NOTE 1. H G Shaner, C L Bisson, G McRae, An Ounce of Prevention: Waste Reduction Strategies for Healfh Care Fuci/ities(Chicago: American Society for Healthcare Environmental Services of the American Hospital Association, 1993) 31 .
paper and cardboard. This is not difficult to institute, and because many communities have mandates to reduce the waste going to landfills, there may be community support (ie, financial, technical) for beginning some projects at a facility. The waste manager or health and safety officer should know about government-sponsored or community help and incentives, but he or she may need nurses' help and support to get a program started. Information is available on the H2E and HCWH (ie. http://www.noharm.org) web sites. Common recyclables are presented in Table 4. Any perioperative unit can begin recycling. Resourceful perioperative team members can work with their environmental services department to set up areas for collection with regular pick up times. Teamwork is essential; it is one of the reasons that both H2E and HCWH recommend that a green team be established at a facility. The benefits of better waste management include reduction of environmental effects from health care; improved employee and patient safety; protection of confidentiality; decreased operating costs; and contribution to licensure and accreditation requirements, including Joint Commission on Accreditation of Healthcare Organizations Environment of Care Standards.2' Another benefit to perioperative nurses is their
involvement in the greater health care culture and increased visibility of their wealth of knowledge and skills. The connection between care of an individual patient and a healthy environment is essential for nurses to emphasize when making changes. A healthy environment is a nursing and patient care issue. INFECTIOUS WASTE TREATMENT
Infectious waste must be treated before disposal in a municipal landfill. Treatment can be accomplished on- or off-site. Treatment modalities include three basic processes: heat (ie, sterilizing, microwaving, incineration, pyrolysis), chemical treatment (ie. hypochlorite, chlorine dioxide), and radiation treatment. Medical waste incineration creates many toxic by-products, is a serious contributor to pollution, and has been identified by the EPA as a leading source of dioxins and anthropogenic mercury in the environment.22Some states still require incineration of certain portions of the infectious waste stream (eg, pathology waste, including body In general, however, incineration of waste is an outdated technology and one that the health care industry must stop using because even the most advanced incinerators continue to produce and release dioxins and other serious, persistent pollutants. Dioxins. Dioxins are a group of chemicals that are toxic by-products of industrial processes. They enter the air as waste from combustion. Some of the
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major sources of dioxins in the environment are the manufacture of chlorinated chemicals; bleaching of paper products; and incineration of medical, municipal, and hazardous Dioxins are a known human carcinogen. Other health effects associated with dioxins include changes in hormone systems, alterations in fetal development, infertility, endometriosis, immune suppression, and chloracne. Every person ever tested has a body burden of dioxins. It is a persistent and bioaccumulative toxin with a half-life in decades. Bioaccumulation refers to the tendency of a pollutant to magnify as it moves up the food chain. Humans get their major exposure to dioxins through fatty food, especially animal products, because dioxins, like many other toxins, are lipophilic. A nursing infant receives some of its highest lifetime doses of dioxins when nursing.” Although authorities agree that breast-feeding still is the preferable feeding method for infants because of the many other benefits, all nurses should know that keeping these serious toxins out of infants’ milk supply is a global patient care issue. Alternatives to medical waste incineration are preferable because the toxic byproducts emitted from incinerators are transported into the global environment and enter the food chain everywhere. Alternatives to incineration. Many incinerators have closed down because of their inability to comply with stricter regulations. Alternative treatment technologies are developing rapidly, but at present, they must be approved state by state. In any waste treatment technology, segregation is a key issue. Hazardous wastes must be segregated and disposed of according to state hazardous waste regulations, or the air, land, and water will become contaminated. Careful segregation at the source of generation is essential, regardless of the waste stream or its ultimate disposal. Many hospitals and health care systems use autoclaves to treat most types of infectious waste to render them suitable for a sanitary landfill. Waste treatment autoclaves work in much the same way as they do in a perioperative setting, and there are prevacuum and gravity displacement types. After the waste is loaded into the chamber, the prevacuum autoclave, which is more efficient but often more costly,” vacuums out the air so that high pressure and temperature are achieved faster. Gravity displacement works on the principle that steam, being lighter than air in the autoclave, will displace the air down-
ward and allow the steam and heat to reach optimum temperature and pressure. After treatment, the waste is rendered noninfectious and can be sent to a sanitary landfill. Many autoclave technology systems also shred or compact the waste before it is sent to a landfill.27 Figure 3 shows a hospital medical waste autoclave. Smaller models serve individual hospitals. The types of waste that can be treated in a autoclave include cultures and stocks, sharps, materials contaminated with blood and limited amounts offluids, isolation and sueeiy wastes, laboratory waste (excluding chemical waste), and soft wastes (gauze, bandages, drapes, gowns, bedding etc.ji-om patient care).” Very large items and items that would resist penetration of steam (eg. animal carcasses) are not good prospects for autoclaves. Another type of heat treatment for medical waste is a microwave. This technology works on the same principle as an autoclave, using steam for the heating of the material. The waste is sprayed with water to create steam, but the source of heat is microwave energy, much like that of microwave ovens used in homes. These systems often shred the waste and are ideal for cases in which a landfill requires nonrecognition of the waste as medical waste. There are commercial and hospital-size microwaves available on the market. Figure 4 shows a hospital microwave with shredded waste inside. Chemicals have been used for disinfection and sterilization in the perioperative environment for decades.” As a treatment for medical waste, the major difficulty with chemical treatments is ensuring that the chemical contacts the waste in adequate concentrations and for sufficient time to disinfect it. The types of waste that can be treated chemically include cultures and stocks; sharps; liquid human and animal wastes, including blood and body fluids; surgical and isolation wastes; laboratory waste; and soft wastes (eg, gauze bandages, bedding).)O Chlorine- and nonchlorine-based treatment methods are the major types of chemical treatment. Chlorinebased chemicals generally are less desirable because of their significant environmental effects.”
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Mercury is a heavy metal, and whether it contaminates a landfill and leaches into the water table or enters the hydrologic cycle via airborne particles released from an incinerator, it eventually finds its way into streams and lakes. In a lake or streambed, it is transformed by bacteria into its organic form, methylmercury, and it enters the food chain via microorganisms and then fish and other water animals. Similar to many other pollutants, mercury biomagnifies up the food chain so Figure 3 0 Hospital medical waste autoclave. (Photograph courtesy of the larger and older a fish, the Sun-I-Pak, Inc, Tracy, Calif) greater the potential for contamination with mercury. Mercury is a potent neurotoxin; therefore, pregnant women, women of childbearing age, and infants and small children are at the greatest risk for health effects from mercury. Recently, a US Food and Drug Administration (FDA) panel recommended that pregnant women and children limit consumption of canned tuna due to mercury contamination.-” Some sources of mercury in health care are thermometers, sphygmomanometers, bougies, cantor tubes, batteries, and fluorescent lights. In perioperative and Figure 4 Hospital medical waste microwave. gastroenterology settings, nurses can lobby to replace mercury-containing bougies and other intestinHAZARDOUS WASTES al tubes, sphygmomanometers, and batteries. The A waste audit is an important way to identify best way to-convince managers to eliminate mercury hazardous waste and be certain that it is being prop- products is to emphasize the cost of a hazardous erly segregated and disposed of. Nothing containing waste clean up from a spill. At a recent medical waste hazardous wastes, such as certain neoplastic agents, seminar, it was reported that which themselves are largely carcinogenic, or heavy metals, should go into sharps containers or red bags. it often costs around $5,000 .for one broken sphygmomanometer clean up, and a facility Proper segregation will prevent accidental release could buy 30 or 40 nonmercury ones for into the environment. Mercury, a toxic by-product from the health care that cost. One local hospital recently industry, is a frequent contaminant in medical waste. spent $10,054 dollars to clean up a spilled The EPA estimates that mercury disposed of impropsphygmomanometez34 erly in medical waste and incinerated contributes 10% of the anthropogenic mercury in the en~ironment.~’ When there are no mercury products in a facility, 1164 AORN JOURNAL
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there is no need to have a spill kit; train personnel in how to deal with a spill; risk potential exposure to staff members, patients, and the environment; or risk regulatory citation.
make educated choices about products and prevent patients’ exposure to undesirable effects from DEHP during medical treatment. HEALTH CARE WITHOUT HARM
DIETHYLHEXYL PHTHALATE
Although it is not yet common medical terminology, every nurse and physician using plastic medical products should know about diethylhexyl phthalate (DEHP), a plasticizer that is added to PVC plastic medical products to make the plastic soft and flexible. Polyvinyl chloride plastic normally is hard and brittle, so most uses require the addition of plasticizers and stabilizers. A problem arises, however, because DEHP is not chemically bound to the plastic, so it leaches out. Leaching is facilitated by exposure to heat; agitation; and especially to lipid-containing fluids, such as blood products, feeding products, and certain chemotherapeutic agents.35 Approximately 25% of all plastic medical products are PVC plastic, and many of them are critical items that leach DEHP. Diethylhexyl phthalate is a reproductive and developmental toxicant in laboratory animals. Male neonates receiving intensive medical treatments are at the highest risk for effects from DEHP exposures. According to a July 12, 2002, FDA advisory, procedures that have been identified as posing the highest risk of exposure to DEHP include exchange transfusion in neonates, extracorporeal circulation membrane oxygenation (ECMO) in neonates, total parenteral nutrition in neonates (ie, with lipids in PVC bag), multiple procedures in sick neonates (ie, high cumulative exposure), hemodialysis in peripubertal males, hemodialysis in pregnant or lactating women, enteral nutrition in neonates and adults, heart transplantation or coronary artery bypass graft surgery (ie, aggregate dose), massive infusion of blood into trauma patients, and transfusion in adults undergoing ECM0.36 Perioperative nurses need to be aware that medical exposure of critically ill infants to DEHP can exceed general population exposures by several orders of magnitude.” Perioperative nurses care for many patients undergoing high risk procedures in the perioperative setting. Diethylhexyl phthalate contamination is a patient care issue. Nurses must advocate for better products and product labeling so they can
The irony that medical waste incineration is a major source of dioxins and anthropogenic mercury in the environment resulted in the founding, in 1996, of HCWH, the campaign for environmentally responsible health care. At the time, many hospitals still had on-site, unregulated incinerators, which they used to burn all their waste. The mission of HCWH is to “transform the health care industry worldwide, without compromising patient safety or care, so that it is ecologically sustainable and no longer a source of harm to public health and the environment”(Tab1e 5).’* Health Care Without Harm now has 380 member organizations in 40 countries. AORN joined
Table 5 GOALS O F HEALTH CARE WITHOUT HARM
1. To work with a wide range of constituenciesfor an ecologically sustainable health care system
2. To promote policies, practices, and laws that eliminate incineration of medical waste, minimize the amount and toxicity of all waste generated, and promote the use of safer materials and treatment practices 3. To phase out use of polyvinyl chloride (PVC) plastics and persistent toxic chemicals in health care and to build momentum for a broader PVC phase-out campaign 4. To phase out use of mercury in all aspects of the health care industry
5. To develop health-based standards for medical waste management and to recognize and implement the public’s right to know about chemical use in the health core industry 6. To develop just siting and transportation guidelines that conform to the principles of environmental justice: No communities should be poisoned by medical waste treatment and disposal
7. To develop an effective collaboration and communication structure among campaign allies (Reprinted from “Mission and goals, hftp://lvww.noham .o@aboutUdmissionGoals, with permission from Health Care Without Ham, Washington, Dc.)
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HCWH as a member organization in 2000.39 Nurses' work group. Within HCWH, a nurses' work group meets monthly via conference call. These nurses have an annual work plan that currently focuses on training other nurses as environmental leaders and advocates. Perioperative nurses are well positioned to be leaders in reducing the health and environmental effects of the health care industry. Perioperative nurses work closely with medical product manufacturers and vendors and so are able to influence purchasing. If every perioperative nurse called one vendor and insisted on environmental accountability for a product, the market probably would respond more quickly. Perioperative nurses work closely with waste managers to ensure proper handling of waste and proper clean up in their facilities, so they are in a unique position to lobby for responsible waste disposal and recycling. Perioperative nurses are identified leaders in infection control and reprocessing and can facilitate healthier, less toxic, methods for disinfection and sterilization. Health Care Without Harm is an organization through which perioperative nurses can begin to establish ties with the greater environmental world that seeks to change the way health care does business.
homes, and 140 other types of facilitie~.~' Partners are health care facilities that have pledged to meet the goals of the H2E memorandum of understanding. Involvement in H2E provides a perfect opportunity for perioperative nurses to help identify strategies and set goals for eliminating mercury, reducing waste amounts and toxicity, and developing purchasing guidelines and policies in their facilities. Nurses can work to institutionalize environmental programs by emphasizing that a cleaner, healthier environment is primary prevention and a nursing practice issue. An exciting place for nurse involvement in the H2E program is pollution prevention policy at the state level. Several states have developed programs to mirror the national H2E program. State nurses associations, state hospital associations, state departments of health, state equivalents of the EPA, and local member groups of HCWH are meeting to collaborate on hospital pollution prevention in their states. Nurses must be at the table when statewide health care pollution prevention initiatives are being developed. No one is better qualified to advocate and promote environmental health in the health care industry than a nurse.
HOSPITALS FOR A HEALTHY ENVIRONMENT MEMORANDUM OF UNDERSTANDING
AORN CHAPTERS AND MEMBERS
In 1998, the EPA and the AHA signed a memorandum of understanding to advance pollution prevention work in the health care industry. This voluntary agreement to reduce mercury waste and the total volume and toxicity of waste from the health care industry resulted in the H2E partnership, which now includes the ANA and HCWH. The goals of the memorandum of understanding are to virtually eliminate mercury-containing waste from the health care industry waste stream by the year 2005; reduce the total volume of all waste, including both regulated and nonregulated waste, generated by the health care industry, with an annual goal of achieving a 33% reduction in all hospitals by 2005 and a 50% reduction by 2010;4"and help hospitals reduce or eliminate persistent, bioaccumulative toxics, such as mercury, pesticides, and other chemicals and heavy metals. Hospitals for a Healthy Environment is another avenue that perioperative nurses can explore. As of Feb 17, 2003, the H2E program had 398 partners representing 425 hospitals, 755 clinics, 28 nursing
There are many ways that AORN chapters can promote a healthier, less polluting health care industry. Chapters can work with state nurses associations to promote state level H2E projects. By partnering with state departments of environmental quality and public health and state hospital associations, nurses can be extremely influential in promoting environmentally healthy facilities. Chapters can encourage nursing participation by providing continuing education contact hours for pollution prevention conferences. AORN of San Francisco & Marin sponsored continuing education contact hours for nurses attending a hospital pollution prevention conference in fall, 2001, in Oakland, Calif. Chapters can form an environmental health committee. Chapters also may be interested in sending a nurse to HCWH training so he or she can become a nursing expert on environmental issues at the state, city, or facility level. Everyone is responsible for public and environmental health. Other ways perioperative nurses can be involved in this work include educating citizens and communities about environmental health issues, advocating for social and economic equity
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(ie, environmental justice) so that certain communities are not dumping grounds for hazardous substances, supporting and encouraging legislation for environmental protection, serving on boards of state and specialty nursing and nonprofit environmental health organizations,4? volunteering to be on or start a health and safety committee or green team at their facility, and getting involved in initiatives like HCWH and H2E. Health Care Without Harm can provide connection with other nurses around the country who are working on pollution prevention in health care; connection with environmental groups around the country and world that will help nurses find information about local environmental issues, as well as community resources; 9 information about medical and health care waste issues and tools for making changes at a facility; and mini-grant funding for pollution prevention training for health professionals. Support available from H2E includes help getting chapters involved in pollution prevenNOTES 1. F Nightingale, Notes on Nursing: What It Is.and What It IS Not (New York: Dover Publications, 1969) 8. 2. A M Pope, M A Snyder, L H Mood, eds, Nursing, Health and the Environment: Strengthening the Relationship to Improve the Public h Health (Washington, DC: National Academies Press, 1995) 2-4. Also
available from http://books.nap .edu/books/030905298X/htmVindex.
html. 3. M Lemer, Setting Healthcare k Environmental Agenda, Papers and Proceedingsfim the October 16, 2000 Conference (Falls Church,Va: Health Care Without Harm, 2000) 66. 4. Pope, Snyder, Mood, Nursing, Health and the Environment: Strengthening the Relationship to Improve the Publick Health, 4. 5. W A Rutala, C G Mayhall,
tion initiatives at the state nursing association level, connection with the state hospital association and the state nurses association for collaborative work toward the goals of H2E (ie, mercury and waste reduction, reducing toxicity of hospital waste), connection with the regional EPA and state departments of environment, and technical and possibly financial help for pollution prevention projects. Nurses, especially perioperative nurses, can be the nexus between health care and environmental health both in health care settings and in the outside world. According to Susan Wilburn, RN, BSN, MPH, senior occupational health and safety specialist at the ANA, “The environment of care for patients is the same as the environment of work for nurses, and both can impact the environment at large.” For nurses to advocate for environmental health is not only a nursing practice issue, it is primary prevention. Nurses can have a measurable, sustained impact on the environment of care and, thus, on the environment and public health. A Ann Melamed, RN,MA, is the environmental health specialistfor the American Nurses Association, Washington, DC.
“Medical waste,” Infection Control and Hospital Epidemiology 13 (January 1992) 38-48. 6. “Forum discussion, House of Delegates action,” AORN Journal 5 1 (May 1990) 1241- 1252; “Board creates Project 2000, adopts statement on the environment, proposes dues increase,” (Board Report) AORN Journal 53 (February 1991) 232-235. 7. “Statement on protection of the environment,” in Standad, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2000) 153; J Botsford, “Environ-
mental issues are still a concern to perioperative nursesBoth globally and locally,” (President’s Message) AORN Journal 66 (September 1997) 384. 8. C Spry et al, “A report on
infectious and noninfectious surgical waste disposal and its relation to the overall waste problem,” AORN Journal 53 (April 1991) 905-916. 1167 AORN JOURNAL
9. “Regulated medical waste definition and treatment: A collaborative document,” in Standad, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2000) 145-148. 10. Botsford, “Environmental issues are still a concem to perioper-
ative nurses-Both globally and locally,” 385. 11. “Dioxin: Summary of Major EPA Control Efforts,” US Environmental Protection Agency, http://www.epa.gov/ncedpdfddioxin /factsheets/dioxin-regs.pdf(accessed 2 May 2003). 12. Health Care Without Harm, “Model state regulations for medical waste incinerators,” in Pollution Prevention Kit for Nurses
(Washington, DC: American Nurses Association, 1998). 13. American Nurses Association house of delegates, Reduction of Health Care Production of Toxic
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Pollution (Washington, DC: American Nurses Association, Inc: 1997). 14. “Core issues,’’ American Nurses Association, http://nursing world.org/ana2000/coreflyr.htm (accessed 18 March 2003). 15. “Recommended practices for environmental responsibility,” in Standards. Recommended Practices, and Guidelines (Denver: AORN, Inc, 2003) 265-269. 16. “Section I: Talking about waste,” Hospitals for a Healthy Environment, http://www. h2e-online .org/pubs/wrguide/setion1.pdf (accessed 18 March 2003). 17. K Gerwig, “Waste management & healthcare,” in Setting Healthcare S Environmental Agenda: Papers and Proceedingshm the October 16, 2000 Conference (Falls Church, Va: Health Care Without Harm, 2000) 67. 18. H Shaner, G McRae, “Eleven recommendations for improving medical waste management,” The Nightingale Institute for Health & the Environment, http://www.nihe .org/elevreng.html(accessed 18 March 2003). 19. “Section VII-More about regulated medical waste,” Hospitals for a Healthy Environment, http:// www.h2e-online.org/pubs/wrguide lsection7.pdf (accessed 18 March 2003). 20. Ibid. 2 I . K Gerwig, “Waste management & healthcare,” 68. 22. “Dioxins and kans,’’ US Environmental Protection Agency, http://www.epa.gov/pbtldioxins. htm (accessed 18 March 2003). 23. J Emmanuel, Non-incineration Medical Waste Treatment Technologies (Washington, DC: Health Care Without Harm, 2001) 13. 24. “Dioxins and furans.” 25. M Rossi, T Schettler, “PVC & healthcare,” Setting Healthcare 5 Environmental Agenda: Papers and Proceedings Ji.omthe October 16, 2000 Conference (Falls Church, Va:
Health Care Without Harm, 2000) 30; America 5 Choice: Children 5 Health or Corporate ProJt, The American People k Dioxin Report, Technical Support Document, November 1999, Center for Health, Environment and Justice, http://www .chej.org/report.htInl#Chapter%204 (accessed 4 April 2003). 26. Emmanuel, Non-incineration Medical Wmte Treatment Technologies, 24. 27. Ibid, 23-24. 28. Ibid, 24. 29. Ibid, 61. 30. Ibid, 61. 31. Ibid, 63. 32. “Mercury,”US Environmental Protection Agency, http://www.epa .gov/mercury/information.htm#factsheets (accessed 18 March 2003). 33. FDA Panel Utges US Government to Warn Pregnant Women, Young Children About Mercury Exposure RisksJi.omTuna, (news release, Montpelier, Vt: Mercury Policy Project, July 26, 2002) http://www.mercurypolicy
Reproduction, http://cerhr.niehs.nih .gov/news/index.html (accessed 18 March 2003). 38. ‘‘Mission and goals,” Health Care Without Harm, http://www.no
harm.org/aboutUdmissionGoals
(accessed 30 April 2003). 39. A Melamed, “AORN joins effort to eliminate pollution in health care,” Congress News, 24 April 2002,s. 40. L Robinson, letter to William Saunders, US Environmental Protection Agency, Washington, DC, 24 July 2001, Hospitals for a Healthy Environment, http://www.h2e-online .org/pubdletter.pdf(accessed 18 March 2003). 41. “Current partners,” Hospitals for a Healthy Environment, http:// www.h2e-online.org/programs /partner/p-mbr.cfin (accessed 2 1 March 2003). 42. J Washington, G K Paramino, P G Butterfield, Environmental Health: A Nursing Opportuni@ (Atlanta: Centers for Disease Control and Prevention, Public Health .org/new/documents/FDArelease072 Training Network, Aug 10,2000) Videotape. 602.pdf (accessed 18 March 2003). 34. “Reducing mercury in hospiRESOURCES tals and biomedical facilities: A ANA Pollution Prevention Kit for MIRT seminar, May 23,2001,” Nurses, American Nurses Publishing, Medical Industry Waste Prevention http://www.nursingworld.org/mno Round Table, http://dnr.metrokc.gov harm. /swd/bizprog/wasteqre/MIRTsem8 Hospitals for a Healthier Environ.htm (accessed 18 March 2003). ment, http://w.h2e-online.org. 35. AMelamed, C Temullo-Retta, The Nightingale Institute for “Plastic chemicals are a threat to Health and the Environment, http:// neonates,” Central Lines: The N A ” www.nihe.org. Pages 17 (December 2001/January Nurses Welcome Kit, Health Care 2002) 31-33. Without Harm, http://www.noharm 36. “Public health notification: .org/index.cfin/tools/nurseswelcome. PVC devices containing the plasti“Red bag (biohazard) waste,” cizer DEW,” (July 12,2002) US California Integrated Waste ManageFood and Drug Adminisixation, http://www. fda.gov/cdrhlsafety/dehp ment Board, http://www.ciwmb.ca .gov/BizWaste/Posters/RedBag.htm. .pdf (accessed 18 March 2003). Sattler, B. Environmental Health 37. ‘“TP-CERHR expert panel report on di (2-ethyhexyl) phthalate, in the Health Care Setting, American October 2000,” National Toxicology Nurses Association, http://nursing world.org/moddmod37O/cehchll Program, US Department of Health .htm. and Human Services, Center for the Education of Risks to Human
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