Pollution Prevention for Nurses: Minimizing the Adverse Environmental Impact of Health Care Delivery
by Hollie Shaner MSA, RN
Each day, as we venture off to care for people in the world, we create pollution. Most of us create it unconsciously. Whether it is pollution from our cars as we drive to work, or pollution we generate in the health care delivery setting, we do have an impact. US hospitals alone, are responsible for over 6600 tons of waste per day, 1% of all the waste generated in America. As we enter an era of changing health care delivery systems, nurses can do a lot to reduce pollution in the workplace. The purpose of this article is to inform nurses about some of the things they can do to promote pollution prevention practices in health care settings. Pollution Prevention practices protect the health of the environment. Protection of the environment is the most fundamental form of primary prevention of disease and illness. The small steps we take, as clinicians, will make a big difference.
Medical waste incinerators are currently at the top of the list of contributors of dioxin to the environment. The technology designed to protect the public against a potential biological threat is now the source of tremendous chemical pollution. Much of what is burned in incinerators are wastes from nurses providing health care services. The 1996 July/August issue of Public Health Reports contains an article by Drs. Mike McCally, Peter Orris, Joe Thornton and Mr. Jack Weinberg of Greenpeace, entitled "Dioxin Prevention and Medical Waste Incinerators." The American Public Health Association has taken on the ethical issue of "iatrogenic pollution", pollution generated from health care delivery. It is ironic that the very institutions which are characterized as promoting health and healing are at the top of the list of polluters that create dioxin. This is contrary to the "first, do no harm" ethic. In their article, Dr. McCally and his colleagues issue a "wake up call" to practitioners by noting the need to pay close attention to waste management to ensure that wastes are not mismanaged, creating an exposure threat to the community.
Dioxin is the name given to a group of persistent, very toxic chemicals. The most toxic form of dioxin is 2,3,7,8-tetrachlorodibenzo-p-dioxin or TCDD. TCDD was the toxic contaminant found in Agent Orange and at Times Beach, Missouri. A number of chemicals have toxicity similar to TCDD - but are less potent - and are called "dioxin-like." Of the 75 possible chlorinated dibenzo -dioxins, seven have TCDD-liki, toxicity.
The health effects of dioxin are known from studying laboratory animals. Some effects have also been observed in accidentally exposed people. Dioxin is a potent cancer-causing agent. Dioxin causes reproductive and developmental effects in animals at very low doses. Dioxin exposure damages the immune systems, leading to the increased susceptibility to infectious disease. It can also disrupt the proper function of hormones which are chemical messengers that the body uses for growth and regulation.
Garbage and medical waste incinerators are the largest sources of dioxin identified by the EPA. PVC (polyvinyl chloride) plastic is a major source of chlorine in these wastes. Besides being emitted into the air, dioxins end up in the bottom ash and the fly ash captured by pollution control equipment in incinerators. Other combustion sources of dioxin include cement kilns, hazardous waste incinerators, metal smelters, wood burning and vehicles running on leaded gasoline.
Most hospitals in Vermont, no longer have on-site medical waste incinerators. (There is only one hospital based incinerator operating in the state). Safety Medical Systems, a commercial medical waste company in Colchester, Vermont, operates a medical waste incinerator and an autoclave. Autoclave treatment, or steam sterilization, is a viable technology for medical waste (except for pathology waste and certain EPA listed pharmaceuticals) and it has not been associated with dioxin formation at this time.
Mercury Reduction
Nurses play a key role in reducing pollution by practicing waste segregation in their workplaces. Specifically, nurses can ensure that mercury wastes are collected separately and managed as a hazardous material. Even better, nurses can advocate for Mercury Free Workplaces. Initiate a plan to eliminate mercury from your workplace to provide a healthier environment for everyone, and decrease liability for the facility. Keeping mercury in the workplace requires training in mercury spill management, supplies and disposal plans to discard it when necessary. Proper clean up of even a small mercury spill (such as a broken thermometer) requires special training and special disposal. Under no circumstances should mercury be discarded down the drain, in a needle box or sharps container or in the trash.
Mercury has been identified as a neurotoxin. Mercury products are frequently found in health care settings. For years, nurses have used mercury thermometers, blood pressure monitoring devices, mercury containing Miller-Abbott tubes, cantor tubes and other products routinely. As more is understood about mercury, it behooves nurses to consider reducing their personal exposure to it. For example, exposures can occur when a thermometer breaks or a mercury containing solvent spills. If mercury vapor is inhaled, as much as 80% of the inhaled mercury may be absorbed into the bloodstream. Short-term exposures can cause poisoning, pneumonitis-, bronchitis, and bronchiolitis. Repeated exposure to relatively low toxic levels can cause muscle tremor, irritability, personality changes and gingivitis. Nerve damage from mercury may start as a simple loss of sensitivity in hands and feet, difficulty in walking or slurred speech. Mercury has also been known to affect the development of prenatal life and infants.
Mercury is a naturally occurring element found in rocks, soil, water, the air and living organisms. Mercury conducts electricity, measures temperature and pressure, and works as a biocide and an industrial catalyst. Mercury can readily change from a solid to a liquid to a gas.
The degree of risk varies depending on how much mercury one is exposed to and how often.
Practicing pollution prevention for mercury would include phasing out the use of mercury based technologies in the workplace. Start first with mercury items in carpeted areas, or mobile mercury products (more likely to tip over and break). Replace with non-mercury products such as digital thermometers, aneroid blood pressure monitoring devices or digital monitoring devices.
Battery Waste Management
Initiate battery recovery programs in the workplace, to ensure that batteries are not discarded in the trash, down the drain, or in needle boxes or sharps containers. Batteries are used everywhere in health care. Every beeper, pump, flashlight, and many of our diagnostic devices are battery powered or have battery back-up. There are many types of batteries with different geometries and chemical composition, some more toxic than others. Some types of batteries include: alkaline, lead acid, nickel cadmium, mercury, lithium, dry cell and zinc air. Do not discard batteries in sharps containers or needle boxes. Some types of batteries can be recycled. Others need to be disposed of as a hazardous waste. Collect batteries separately from other wastes. Contact your local solid waste authority and see if they can provide assistance with the proper disposal of batteries.
Fluorescent Tubes
Health care facilities frequently have fluorescent lighting fixtures. Each fluorescent tube has as much mercury as 400 or more batteries. Work with your facility to ensure that fluorescent tubes are recovered for recycling or disposed of as a hazardous waste. Fluorescent tubes need to be stored carefully and kept intact prior to disposal.
Biohazardous Waste: Toxicity Reduction
Red bags and needle disposal boxes used to collect infectious or biohazardous waste can be a source of cadmium, a heavy metal, when incinerated. Check to be sure that red bags and sharps containers used in the workplace are cadmium-free. Some companies use cadmium as a colorant/pigment enhancer in the manufacture of these products. Cadmium emissions from medical waste incinerators creates a pollution problem.
Biohazardous Waste: Toxicity Reduction
Reduce the amount of biohazardous waste in the workplace by carefully segregating wastes. Check biohazardous waste container placement. Be sure containers are not located in places where they are likely to be filled with non-infectious, non-biohazardous wastes. Items such as paper towels, product supply packaging, and other solid wastes should be discarded as trash, and not as biohazardous waste.
Find out where the biohazardous waste (red bags and needle boxes) are disposed of Are they being incinerated or autoclaved? Are they placed in the dumpster in the parking lot? There are many treatment technologies available for this type of waste, such as incineration, autoclaves, microwaving, and electro-thermal deactivation to name a few. Avoid incineration except for wastes which can only be treated by that technology.
Disposal of Pharmaceutical Waste
Minimize pharmaceutical waste by only accepting quantities of medication samples from drug representatives that will be consumed. Encourage drug reps to "take back" expired or unused samples. If that strategy is not successful, discard the actual pharmaceutical product in a needle box or sharps container. Do not flush medications down the toilet, especially hormonal medications such as replacement therapy and birth control pills, or narcotics.
Purchasing for Pollution Prevention
Get involved in the process of acquiring products used in health care. Develop an environmental criteria for products being purchased. Evaluate the type of packaging that products come in: is it excessive, are the components recyclable? For example, seek out rechargeable batteries where appropriate. Specify cadmium-free red bags and needle boxes. Purchase battery operated thermometers and digital or aneroid blood pressure monitoring devices instead of mercury based products. Choose reusable cloth gowns and drapes when possible. Minimize the use of chlorinated plastics (They have been associated with creating dioxin when incinerated.).
When purchasing waste disposal services for your organization, seek companies that offer alternatives to incineration whenever possible and appropriate. Specify autoclaving or an alternate technology. This is especially important for disposal of wastes containing PVC (polyvinyl chloride), items such as IV bags, IV tubing, and blood bags.
It is well within the realm of nursing practice to take steps to protect the environment. Florence Nightingale emphasized the role of clean air and clean water in the promotion of human health. Practicing pollution prevention in the workplace gives nurses the opportunity to contribute to a healthier environment and honor the wisdom of the founder of our profession.
For more information on strategies to reduce pollution and waste in health care settings refer to:
Hollie Shaner, RN, M.S.A., President and co-founder of CGH Environmental Strategies, Inc. in Burlington, Vermont, is a nationally known consultant on waste reduction efforts in the health care industry and a member of Vermont State Nurses Association.