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

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First do no harm identifying and eliminating health care toxics l.jpg
First Do No Harm: Identifying and Eliminating Health Care Toxics

Marcella Thompson, LEED AP

HDR Inc.

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Mission of Healthcare Toxics

  • Prevention, treatment, and management of illness and the preservation of mental and physical well-being through the services offered by the medical, nursing, and allied health professions.

First, do no harm.

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Treating Patients Toxicsin a Built Environment

  • Large & complex modern institution

  • Often a combination of old buildings with newer additions

  • Multifunction infrastructure to support patient care

What kind of environment has healthcare created for healing?

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Inputs Toxics


Healthcare Organization

The Environmental Footprint of a Hospital

  • (def) The impact of an organization in environmental terms

    • Resource use

    • Waste generation

    • Physical environmental changes

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Facility Operations Toxics

Indirect air emissions

Medical devices

Wastewater discharge

Medical supplies

Medical waste


Solid waste

Pharmaceutical waste

Central processing


The Environmental Footprint of a Hospital

Example: Surgical Procedure

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The Environmental Footprint of a Hospital Toxics

  • Energy

  • Water

  • Medical devices & supplies

  • Electronics, technology

  • Pharmaceuticals

  • Laboratory chemicals

  • Food

  • Administrative supplies

  • Cleaning chemicals

  • … and much more!



  • Emissions

  • Wastewater

  • Solid waste

  • Medical waste

  • Hazardous waste

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Identifying and Eliminating Health Care Toxics Toxics

  • Mercury


  • Green cleaning

  • Sterilants and disinfectants

  • Green Building

    Other environmental hot buttons:

Regulated Medical Waste

Pharmaceutical Waste

Food – Organics and locally grown


Green chemistry

Flame retardants

Multiple chemical sensitivity and IAQ

Recycling and solid waste management

Laboratory waste

Integrated pest management

JCAHO & the Environment

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Mercury Health Concerns Toxics

  • Mercury is a known and ubiquitous hazard

  • Persistent, Bioaccumulative & Toxic

  • CDC: 1 in 12 women of childbearing age risk giving birth to infants with neurological disorders due to mercury exposure in-utero.

1 | Mercury

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FDA Advisories Toxics

1 | Mercury

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100 Toxics









Declining Threshold of Harm

Level associated with

harmful effect

Regulatory standard

(maximum safe exposure or high

end exposure from allowed fish



(micrograms/kg/day Hg)





1 | Mercury

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Obvious Toxics

Less Apparent

  • Thermometers

  • Sphygs

  • Cantor, Miller-Abbott tubes

  • Esophageal bougies

  • Laboratory chemicals

  • Thermostats

  • Fluorescent lamps

  • Batteries

  • Dental amalgams

  • Caustic soda

  • Laundry chemicals-bleach

  • Antibacterial soaps

  • Boiler & air conditioning chemicals

  • Reagents

  • Plastics

Hg in Hospitals

  • Know where it is:

    • Clinical, facility, and laboratory sources

1 | Mercury

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Virtual Hg Elimination Toxics

  • Making MedicineMercury-Free program

    • Sets goals for “virtual” elimination of mercury

    • Provides framework for comprehensive elimination strategies

    • Provides recognition to facilities that achieve these goals

  • 185 hospitals have won the award since 2002

1 | Mercury

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MMMF Award Criteria Toxics


  • Established a facility policy statement

  • Established a mercury management policy

  • Implemented an Environmentally Preferable Purchasing (EPP) policy statement


  • Replaced patient mercury thermometers

  • Replaced all or majority (75%) of sphygmomanometers and have a plan and timeline for total elimination

  • Replaced majority (75%) of clinical devices; inventoried those remaining and have a plan in place to for total elimination

1 | Mercury

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MMMF Award Criteria Toxics


  • Recycle fluorescent lamps

  • Implemented battery collection programs

  • Inventoried and labeled all mercury-containing facility devices and have an elimination plan in place


  • Replaced B5/Zenkers stains

  • Inventoried mercury-containing lab chemicals with plan in place for substitution

  • Inventoried all lab thermometers - replaced at least 75% with total phase-out plan in place

1 | Mercury

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Roadblocks Toxics

  • Mercury is viewed as the “gold standard”

  • Multi-discipline effort

  • Cost

  • Not a regulatory requirement

1 | Mercury

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  • Most widely used plastic in medical products

    • Cost

    • Flexibility

    • Transparency

    • Resistance to breakage

  • The only common plastic that is chlorinated

  • DEHP (di-ethylhexyl phthalate) often used as a plasticizer in medical devices

2 | DEHP

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Impacts of PVC Toxics

  • Dioxins and furans generated as by-products of manufacture of PVC feedstocks

  • Dioxins, furans, HCl formed and released when PVC is burned

    • Municipal waste incinerators

    • Medical waste incinerators

    • Landfill fires

  • Leaching of plasticizers, metals from landfills

  • Difficult to recycle

2 | DEHP

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DEHP Toxics

  • Migrates from PVC when in contact with fluids, air, or heat

  • Lipophilic

    Leaching increases with…

    • Temperature

    • Contact (storage time)

    • Amount of fluid

    • Agitation

    • Lipid content

2 | DEHP

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National Toxicology ToxicsProgram Advisory

  • “… serious concern for the possibility of adverse effects on the developing reproductive tract of male infants exposed to very high levels of DEHP that might be associated with intensive medical procedures such as those used in critically ill infants.”

  • “… concern that, if infants and toddlers are exposed to levels of DEHP substantially higher than adults, adverse effects might occur in the developing male reproductive tract.”

2 | DEHP

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FDA Advisory Toxics


  • Using alternatives to DEHP-containing products for procedures with excessive exposures

  • Reformulation of products to decrease/eliminate DEHP exposures

  • Labeling of DEHP-containing products

2 | DEHP

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FDA Advisory Toxics

TI = FDA determined “Tolerable Intake”

2 | DEHP

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FDA Advisory Toxics

2 | DEHP

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Hospital Focus: ToxicsEliminating DEHP in the NICU

Early Preterm Infants

  • Critically ill patient population

    • IV therapy

    • Parenteral and enteral feedings

    • Ventilation

    • Blood transfusion

  • Long hospital stay

    • Prolonged therapies

2 | DEHP

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Hospital Focus: ToxicsEliminating DEHP in the NICU




  • Exam, surgery

  • Low exposure risk

  • Parallel efforts to eliminate latex gloves because of allergies…

  • IV

  • Nutrition

  • Blood

  • High exposure risk

  • Problems: pre-mixed and blood bags

  • Feeding tubes

  • Ventilators

  • Generally from equipment to patient

  • High exposure risk

2 | DEHP

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John Muir Memorial ToxicsHospital Case Study

Survey found:

  • 31 plastic items

  • Only 5 contain PVC/DEHP and are used in exposure scenarios

  • Others are used for extraction procedures

  • One was eliminated procedurally

    Only 4 items need to be replaced!

    Extra NICU cost ~$20/patient/day.

2 | DEHP

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Roadblocks Toxics

  • Awareness

  • Takes a Champion in the NICU

  • Federal advisories, but no regulation

2 | DEHP

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Green Cleaning: Environmentally Preferable Custodial Products






Hospital Occupants

3 | EPP

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Implementing ProductsGreen Cleaning

  • First promote worker safety

  • Use a defensible methodology to identify preferable products

  • Prioritize and implement EPP into contracting language; educate GPOs and suppliers

3 | EPP

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Janitorial data: Products

  • 54.5 lbs/janitor

  • 6.1 lbs/1000 sq feet

Building maintenance data:

  • 17.7 lbs/year

  • 6.6 lbs/1000 sq feet

Chemical Exposure

3 | EPP

City and County of San Francisco, Environmentally Preferable Purchasing Program Data

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Chemical Exposure Products

For every 100 workers:

  • 6 Chemical accidents per year

    • 3 eye injuries

    • 2 skin injuries

    • 1 inhalation/other

3 | EPP

City and County of San Francisco, Environmentally Preferable Purchasing Program Data

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Metal cleaner Products

Metal cleaner

Chemical Exposure

Glass cleaners

Toilet bowl cleaner, deodorizers, disinfectants

Wood polish

Disinfectants and General Purpose Cleaners

Hard floor cleaners, strippers, and finishes

Carpet cleaners

3 | EPP

City and County of San Francisco, Environmentally Preferable Purchasing Program Data

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Defining a Preferable Chemical Product Products

  • 18 criteria based on:

    • Other EPP Programs

    • Tests with 100+ products

    • Comments from environmental staff, technical experts, and product vendors

  • Lower score is better

  • Failing subtotal scores

3 | EPP

City and County of San Francisco, Environmentally Preferable Purchasing Program Data

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Health and Safety Evaluation Products

  • Failing subtotal score > 200

    • 200 points - Carcinogens

    • 100 points - Neurotoxins

    • 100 points - Eye Irritation

    • 100 points - Skin Irritation

    • 50 points - Ease of Skin Absorption

    • 50 points - Corrosivity

    • 50 points - Flammability

3 | EPP

City and County of San Francisco, Environmentally Preferable Purchasing Program Data

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Environmental Evaluation Products

  • Failing subtotal score > 100

    • 100 points – Ozone Depleting

    • 50 points – Endocrine Modifier

    • 100 points – Greenhouse Gases

    • 25 points - Biodegradability

    • 100 points - VOCs

    • 25 points – Added Fragrances

    • 25 points – Added Dyes

3 | EPP

City and County of San Francisco, Environmentally Preferable Purchasing Program Data

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Other Considerations Products

  • Failing subtotal score > 35

    • 10 points – Available as Concentrate

    • 15 points – Available as Non-aerosol

    • 10 points – Refill/Return/Recycle

    • 10 points – Recycled Content

3 | EPP

City and County of San Francisco, Environmentally Preferable Purchasing Program Data

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Information on MSDS and Vendor Literature Products

3 | EPP

City and County of San Francisco, Environmentally Preferable Purchasing Program Data

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Focus Efforts Products

Step 1: Quantity

Step 2: Widespread use

Step 3: Potential exposure

Step 4: Availability of alternatives

3 | EPP

City and County of San Francisco, Environmentally Preferable Purchasing Program Data

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Road Blocks Products

  • Focused on infection control

  • Availability of products (continually improving)

  • Cost

  • Environmental service staff perception

3 | EPP

City and County of San Francisco, Environmentally Preferable Purchasing Program Data

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Spaulding Scheme for Medical Devices Products

  • Critical

    Enters sterile tissue or vascular system (e.g., surgical instruments, cardiac and urinary catheters, implants)

  • Semi-Critical

    Contacts mucous membranes or non-intact skin (e.g., endoscopes, respiratory therapy and anesthesia equipment, diaphragm rings)

  • Non-Critical

    Contacts intact skin (e.g., bedpans, blood pressure cuffs, crutches)




4 | Minimizing Glutaraldehyde Use

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… which determines Products

  • Sterilization:

    Validated process used to render a product free of all forms of viable microorganisms.

  • Disinfection:

    Destruction of pathogenic and other kinds of microorganisms by thermal or chemical means. Destroys most recognized pathogenic microorganisms, but not necessarily all microbial forms, such as bacterial spores.

1 Rutala, W.A., “Draft Guidelines for Disinfection and Sterilization in Healthcare Facilities,” HICPAC 2b, CDC 02/20/2002

4 | Minimizing Glutaraldehyde Use

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High-level Disinfection & the Environment Products

  • Must maintain strict infection control standards to ensure patient safety while also being mindful of environmental impacts.

    • Based on use and construction of instrument

    • Disposal considerations

    • Chemical requirements

    • Available P2 opportunities.

4 | Minimizing Glutaraldehyde Use

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Flexible Endoscopy Products



Head & Neck Surgery


Rigid Endoscopy

Operating Room

Instruments Often Cleaned with Cold Process High-Level Disinfectants

  • Ultrasound Transducers

    • Obstetrics

    • Radiology

    • Cardiology

    • Urology

  • Miscellaneous

    • Cryo probe tips

    • Diaphragms

4 | Minimizing Glutaraldehyde Use

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Glutaraldehyde Products

Cetylcide-G (3.2%)

Cidex (2.4, 2.5, 3.4%)

MedSci (3%)

Metricide (2.5, 2.6, 3.4%)

Omnicide (2.4, 3.4%)

Procide (2.4%)

Rapidcide (2.5%)

Sporicidin (1.12/1.93% glut/phenol)

Wavicide-01 (2.5%)

Cold Liquid High-Level Disinfectant Options

  • Hydrogen Peroxide

    • Sporox (7.5%)

  • Hydrogen Peroxide/ Peroxyacetic Acid

    • EndoSpor Plus (7.5/0.23%)

    • Peract 20 (1.0/0.08%)

  • ortho-Phthalaldehyde

    • Cidex OPA (0.55%)

  • Peroxyacetic Acid

    • Steris S-20 (35%)

4 | Minimizing Glutaraldehyde Use

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Disadvantages of Glutaraldehyde Products

  • Severe irritant - may cause asthma and respiratory sensitization

    (although not cancer or reproductive harm)

  • Burning eyes and conjunctivitis

  • Headaches and nausea

  • Low exposure limits

    • 0.2 ppm NIOSH REL

    • 0.05 ppm ACGIH TLV

    • Proposed 0.015 ppm Ceiling Limit in CA

4 | Minimizing Glutaraldehyde Use

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Kaiser Woodland Hills Case Study: ProductsOPA vs. Glutaraldehyde

  • Low vapor pressure, therefore minimal inhalation risk

  • Switch can be accomplished relatively quickly compared to installing engineering controls

  • Reduces disinfection time to 12m manual and 5mautomated processing (from 20m. for glut)

  • Allows twice the disinfection cycles before solution failure

4 | Minimizing Glutaraldehyde Use

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OPA Considerations Products

  • Unknown long-term health effects or cross-sensitivity to other aldehydes

  • No validated air sampling method

  • No exposure limits set – so for now, requires same engineering controls as glutaraldehyde

  • Contact with CIDEX® OPA may stain skin or clothing. Solution may also stain surfaces such as walls, floors and countertops.

  • Product more expensive than glutaraldehyde

4 | Minimizing Glutaraldehyde Use

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June 2004 Product Notification Products

  • Possibility of sensitization to CIDEX OPA Solution with repeated exposure.

  • In rare instances CIDEX OPA Solution has been associated with anaphylaxis-like reactions in bladder cancer patients undergoing repeated cystoscopies.

  • CIDEX OPA Solution should not be utilized to process instrumentation for patients with known sensitivity to CIDEX OPA Solution or any of its components.

4 | Minimizing Glutaraldehyde Use

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Isolation of cleaning and disinfection process from clinical procedure areas

Separation of clean and dirty areas

Process flow from dirty to clean, with no cross-over encouraged between the two

Bottom Line: Environmental Controls

  • Engineering controls of vapor-generating activities and equipment

  • Safety equipment (eyewash, shower, spill containment, emergency shut-off)

4 | Minimizing Glutaraldehyde Use

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Glutaraldehyde procedure areas($5 per bottle)

  • 20 minutes per cycle

    = 24 cycles per 8 hour shift

Cidex OPA ($25 per bottle)

  • 12 minutes per cycle (manual)

    = 40 cycles per 8 hour shift

  • 5 minutes per cycle (automated)

    = 96 cycles per 8 hour shift

Cycle Times

4 | Minimizing Glutaraldehyde Use

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What is procedure areasSustainable Building?

5 | Sustainable Building

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Impact of procedure areasHealthcare Construction

  • $17 billion market (McGraw Hill, 2006)

    Generating solid waste…

    • The typical North American construction process generates

    • 2.5 lb. of solid waste per square foot of floor space

    • Construction and demolition of buildings account for 40% of the solid waste in landfills

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Impact of Buildings procedure areas

Wasting Energy ...

  • Buildings account for 30% to 37% of the total energy used and 60% to 68% of electricity used

  • $40 Billion is spent annually in the U.S. to air condition buildings

  • 75% of U.S. electricity comes from fossil fuels

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Impact on Occupants procedure areas

Making people sick and unproductive... 90% of a person’s time is spent indoors, where levels of pollution can be 2 to 5 to 100x worse than outdoors

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LEED procedure areas

  • Self-assessing rating system

  • Evaluation of whole building performance

  • For all building types

  • Evaluates and recognizes performance in accepted green design categories

  • Will be improved continually

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LEED Credit Categories procedure areas

  • Sustainable sites

  • Water efficiency

  • Energy and atmosphere

  • Materials and resources

  • Indoor environmental quality

  • Innovation in design

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LEED Checklist procedure areas

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GGHC procedure areas

The GGHC builds on LEED™ by:

  • addressing the particular structural, usage, and regulatory challenges of healthcare buildings, and

  • emphasizing the environmental and public health issues.

    Unlike LEED™,the GGHC is structured as a self-certifying system.

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Center for Health Design procedure areas

A Catalyst for Change

Through research, education, advocacy and technical assistance, The Center for Health Design supports healthcare and design professionals all over the world in their quest to improve the quality of healthcare through evidence-based building design.

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Metro Health Hospital procedure areasWyoming, Michigan

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Roadblocks: procedure areasCosts of Green BuildingTurner Construction Survey

  • Executives involved in Green buildings on average estimated Green construction costs to be 14% higher;

  • Executives NOT involved with Green buildings estimated construction costs at 20% higher.

  • 80% or more of each group believed that Green buildings repay these perceived higher construction costs through lower operating costs and other benefits.

  • February 2003 U.S. Green Building Council white paper says that LEEDTM Green certification can be achieved with as little as 2% premium.

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Questions? procedure areas

Marcella Thompson, LEED AP

[email protected]

(402) 399-1481