Healthy Hospitals: A Transformation
http://mcs-america.org/January2008pg12345678.htmMCS America News, Volume 3, Issue 1, January 2008.
Health care establishments should be among the healthiest of environments.
People who are ill go to hospitals for treatments, operations, and therapies
with the hopes of getting well. Though hospitals are generally considered
sterile environments, this might not be in the best interests of the
environment or human health. Many hospitals do not use environmentally
preferable purchasing policies, follow environmentally conscious waste
management strategies, attempt to decrease the use of chemical pollutants,
or promote the use of healthy foods, let alone provide leadership in
environmental stewardship.
Individuals with multiple chemical sensitivity (MCS) may find hospitals
hostile environments, not only because of the environment itself, but also
because the staff often dismisses their complaints as trivial, adding
emotional stress on top of medical problems. Products that MCS patients
react to include any quantity of exposures to pesticides, secondhand smoke,
alcohol, fresh paint, scented products, perfumes, candles, fragrances, food
preservatives, flavor enhancers, aerosols, tap water, cosmetics, personal
care products, new carpets, petroleum products, formaldehyde, outdoor
pollutants, newspaper ink, cleaning compounds, printing and office products,
and other synthetically derived chemicals. In a hospital setting,
disinfectants and floor wax are among many common, and often unavoidable,
irritants. The truth remains that many of these chemical pollutants. which
can be found within the hospital setting, impact both staff and patients,
especially those with asthma, immunodeficiency, allergies, and MCS.
A recent article published in the Online Journal of Nursing states that
"while it is commonly understood that the quality of the air we breath and
the water we drink can impact our health, it is often more difficult to
recognize that our choices of the health care products, along with the way
we dispose of them, and the chemicals we spray on our foods or use to clean
and disinfect may actually compromise the environment and consequently our
health" (Sattler & Hall, 2007). Hospitals are in need of standard
guidelines to transform into environmentally healthy and safe places.
In order to create environmentally preferable purchasing policies one must
understand how products impact the environment in three stages: production,
use, and disposal. For example, a product that is effective in the
hospital, but is a persistent organic pollutant after it is disposed of may
not be the best all around choice.
Keep in mind that vast sectors of industry have a high stake in the
purchasing power of hospitals... food, equipment, paper and office products,
batteries, linens, construction products, medicaments, cleaning products,
and more. Each sector of industry has vested interests in the purchasing
power of hospitals across the country. When environmentally preferable
purchasing policies are established, industry will vie for continued
business and may even make vehement objections, downplaying the importance
of environmentally healthier products.
A good example Sattler & Hall (2007) cite is the mercury thermometer
experience, where nurses employed strategic use of their purchasing power to
affect positive change in hospital environments by pressing for the use of
mercury free thermometers in the hospital and offering to exchange mercury
thermometers for mercury-free versions as a public service. In this way,
nurses used their purchasing power to influence industry and now the market
has many mercury-free thermometers.
Greener Choices for the Environment
The following products are cited as environmentally preferable purchasing
requests (Sattler & Hall, 2007):
· Reduced packaging
· Bulk buying to reduce packaging
· Double-sided copiers
· Reusable (versus single-use) products
· Products with recycled content
· Latex-free products
· Mercury-free products
· Polyvinyl chloride-free products
· Diethyhexyl phthalate-free products
· Unbleached paper products
· Use of stainless steel which can be sterilized and reused rather than
disposable plastics which contaminate the environment.
In addition, waste management is encouraged. The "3 R's" are:
· Reduce - less waste through less packaging and single use devices, and
bulk purchasing without packaging, and fewer single-use devices.
· Reuse - eliminate single-use devises whenever possible and select products
that are more durable.
· Recycle - select products that can be recycled.
While this is all really nice, great for the macro environment, and
commendable, it does little to reduce chemical incitants that impact
everyone, including both staff and patients, especially those with asthma,
immunodeficiency's, allergies, and MCS. Chemical pollutants must also be
reduced.
Chemical Pollutants
"Many of the chemicals we once thought useful in providing safe care in
hospitals have been found to be dangerous for patients and health care
workers alike. These include, among others, chemicals called persistent
organic pollutants (POPs), which are some of the most dangerous chemicals
that have been created by man and include pesticides, industrial chemicals,
and chemical by-products. They are sustained in the environment for long
periods of time, hence the descriptive term "persistent." Also included are
compounds found to be asthma triggers, chemicals in the plastic family
called di(2-ethylhexyl) phthalate (DEHP), and pesticides" (Sattler & Hall,
2007). These chemicals are both dangerous and polluting.
Persistent Organic Pollutants (POPs), primarily pesticides, are still in
current use and include insecticides, including (Sattler & Hall, 2007):
· Aldrin and Chloradane for termites
· DDT for mosquitoes
· Heptachlor for mosquitoes and fire ants
· Dieldrin and Endrin for crops
· Toxaphene for ticks and mites
· Hexachlorobenzene as a fungicide
· Poly chlorinated biphenyl (PCBs) for capacitors, transformers, and
hydraulic and heat transfer systems, weatherproofing, carbonless copy paper,
paint, adhesives, and plasticizers in synthetic resins.
These POPs have been linked to reproductive disorders, developmental
disorders, suppression of the immune system, dysfunction of the nervous
system, and cancer. Integrated Pest Management (IPM) is a safer, relatively
new approach to managing pests that involves monitoring, treating only the
affected areas rather than the entire property, and keeping close records.
Hospital Induced Asthma & MCS
According to Sattler & Hall (2007), "given the prevalence of asthma in both
children and adults in the US, the last thing one would want, or expect to
encounter in a hospital setting, would be a chemical associated with causing
asthma or triggering asthma symptoms", yet asthma inciting chemicals are
quite common. Hospital trigger risks include cleaners, disinfectants,
sterilizers, ethylene oxide, formaldehyde, glutaraldehyde, natural rubber
latex gloves, pesticides, and other volatile organic compounds. This is
compounded by fragrancesm such as scented cleaners, fragrance-emitting
devices (air fresheners), and people wearing perfume or scented lotions.
Any one of these items alone could bring on a life threatening breathing
reaction or cause dizziness and fatigue. Combined, they create a
significant health hazard.
But that's not all. Add in phthalates, plastics, tobacco smoke residues on
the clothing of smokers, mold, fungus, pollen, dust, cockroaches,
fluorescent lights, an assortment of pharmaceuticals, and food that many
consider unfit for human consumption. It would seem that a hospital is not
the safest place to be for an individual with asthma or MCS.
Sattler & Hall (2007), explain that "transforming hospitals into
environmentally healthy places necessitates forging and building
relationships among various departments within a facility." It takes a
coordinated effort and the caring concern of all staff members.
Administrators must stand behind the effort and ensure that training of
staff who have an influence in this area is mandatory. Staff should be
encouraged to join committees and give their input. Sattler & Hall (2007)
state that "over time these changes to protect human health may also have a
positive impact on the bottom line of the facility as the facility learns
how to be reimbursed for recyclables, explores free composting services for
food waste, rethinks reusable products, and ultimately reduces the waste
stream." However there is still more.
Additional Challenges for MCS Patients
One thing that was left out of the review by Sattler & Hall (2007) is
patient comfort and safety. Often hospitals can be cold and frightening
places. Patients are not feeling well and may be may be agitated and
concerned about their needs. Patients with MCS in specific often have their
needs overlooked. Carolyn Cooper (2007) presented an excellent review that
was published in the American Journal of Nursing. She explained simple ways
to take care of patients with MCS to avoid unnecessary discomfort and make
for a better working relationship with the patient. Among her tips was to
heed patient concerns. She affirmed that it is never really appropriate not
to heed a patient's concerns. Regardless of etiology, a patient should be
made as comfortable as possible.
In her review, Cooper discusses Mr. Norris, a man with MCS under her care
who she was able to accommodate during his hospital stay through various
measures, including a warning sign on his door, a scent free nurse, a "sniff
test" by Mrs. Norris before entering his room, and a respirator when needed.
Cooper recommends a hospital protocol and staff training to include the
policies quoted below (Cooper, 2007):
General
· Don't use perfume, aftershave, or scented lotion.
· Keep free of the odor of cigarette smoke.
· Wear a long-sleeved cotton surgical gown (and cap if necessary) to mask
odors if you know you smell of a potential irritant and no other caregiver
is available.
· Knock first and wait to be admitted to the patient's room.
Surgery
· When a patient with MCS is scheduled for surgery, notify perioperative
areas well in advance. It is particularly important that the
anesthesiologist confer with the patient before a surgical procedure so that
medication sensitivities can be considered. Perioperative clinicians must
be prepared to carefully reassure patients that safety measures will be
taken on their behalf.
· Schedule the procedure as the first case of the day to minimize exposure
to environmental irritants that will be stirred up during the day.
· A ceramic or porcelain oxygen mask may be indicated to deliver anesthesia.
· Povidone iodine is generally a safe antiseptic solution, but isopropyl
alcohol should be used sparingly.
· Use paper tape for surgical dressings (or assess the patient's reactions
to other adhesives 24 to 48 hours in advance by using patch tests).
· Use only latex-free gloves.
Diet
· Until a dietitian's evaluation has taken place, nurses should allow
patients to provide their own "safe food supplies," when appropriate. Be
particularly watchful for asthmalike symptoms that may progress to
bronchospasm in response to irritants.
· Intolerance for peanuts, soy products, and dairy products is common in
those with MCS.
· Avoid plastic and Styrofoam containers; use glass or ceramic containers.
· Bottled drinking water should be provided with meals.
· Dyes, preservatives, artificial sweeteners, and monosodium glutamate may
not be tolerated.
· Avoid processed or prepackaged foods that contain preservatives.
Medication
· Based on your initial assessment, you may find it necessary to ask the
physician for "as needed" orders for medications the patient usually uses to
alleviate hypersensitivity symptoms, including oxygen or nebulizer
treatments. Other important considerations include the following:
· Ensure that the pharmacist is aware of the patient's specific allergies,
sensitivities, and possible intolerance to preservatives.
· Confer with the pharmacist and physician if you have concerns about
medications. Enforce a "no substitutions" policy for medications ordered in
order to avoid unexpected reactions.
· Some patients may be sensitive to chemicals that leach from plastic IV
bags; glass bottles may be necessary for iv fluid administration in such
cases.
Preparing the Hospital Room
· Though not always possible, a private room is ideal. In the ED, ICU, or
perioperative area, use existing isolation cubicles to protect the patient
from odors that could trigger a reaction.
· A sign on the door will alert staff to the patient's sensitivities (confer
with the patient first to ensure consent and protect privacy).
· The patient's own respirator mask, if needed-or an R95 respirator if your
institution carries them and fit testing can be performed-should be
available for the patient to wear when being transported within the clinical
setting. (The R95 mask contains a carbon filter that provides both odor and
organic-vapor filtration. Other masks do not filter odors.)
· The soap dispenser should contain unscented soap only. If unscented soap
is not available, empty the dispenser and place a bar of Ivory brand or
another brand of unscented soap in the room.
· Place a new sharps container in the patient's room (the old container may
contain odor-producing trash along with sharps).
· Remove latex glove boxes and replace with latex- and powder-free gloves
until the patient's sensitivities can be assessed.
· If necessary, use a negative pressure machine and a high-efficiency
particulate air filter, or a reverse isolation room to avoid exposure from
air that enters from the hallway. (A rolled towel placed underneath the door
can be used as a temporary measure.)
· The room should be free of carpeting and cloth draperies (gasses may be
released from the synthetic materials).
· The room should not have been recently painted or wallpapered. There
should be no floor wax removal, floor waxing, or pesticide use near the
patient's room for the duration of the stay.
· Allow patients to bring linens from home. Otherwise, you may request a
sterilized linen pack from your facility's housekeeping department if the
patient cannot tolerate lingering traces of detergent on sheets.
· Inform the housekeeping staff that only fragrance-free disinfectants may
be used when cleaning the patient's room; that means no bleach, ammonia, or
aerosols may be used. MCS patient advocates have suggested using a moist
cotton cloth and baking soda to clean surfaces if unscented products are not
available, but you must collaborate with the infection control and
housekeeping departments to determine an appropriate course of action.
Choosing Equipment and Supplies
· Avoid fragrances and deodorizers. (Be aware that "hypoallergenic" doesn't
necessarily mean fragrance free.)
· Don't bring standard admission packs with plastic basins and
patient-hygiene items into the patient room until the patient's
sensitivities are known.
· Latex-free products are often indicated.
· The patient might bring her or his own oxygen tubing from home and choose
to use it instead of new tubing from a sealed package. (The odors released
from new plastic materials may irritate.)
· Patients may request that a metal "butterfly" needle be used for iv
therapy instead of a plastic cannula.
· Have paper tape conveniently available-other adhesive tapes may not be
tolerated.
· Don't use pens or markers with strong-smelling ink in the patient's
vicinity.
Health care establishments should be among the healthiest of environments.
With a little caring, concern, and thought, they can be.
- Lourdes Salvador
References
Cooper, C. Multiple Chemical Sensitivity in the Clinical Setting: Although
the cause and diagnosis of this condition remain controversial, the
patient's concerns should be heeded.
Sattler, B., Hall, K. Healthy Choices: Transforming Our Hospitals into
Environmentally Healthy and Safe Places. OJIN: The Online Journal of Issues
in Nursing. May 31, 2007;12(2)(3).
About the Author
Lourdes Salvador volunteers as a writer and social advocate for the
recognition of multiple chemical sensitivity (MCS). As a former human
services professional, she was a passionate advocate for the homeless and
worked with her local governor to provide services to the homeless through a
new approach she created to end homelessness. That passion soon turned to
advocacy and activism for people with MCS and the medical professionals who
treat them. She co-founded MCS Awareness in 2005 and went on to found MCS
America in 2006. She serves as a partner for Environmental Education Week,
a partner for the Collaborative on Health and the Environment (CHE), and a
supporter for the American Cancer Society: Campaign for Smokefree Air. She
is an active writer for both the American Chronicle and NewsTarget.
Copyrighted © 2008 MCS America
