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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
First Do No Harm: Identifying and Eliminating Health Care Toxics

Marcella Thompson, LEED AP

HDR Inc.

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

First, do no harm.

treating patients in a built environment
Treating Patients in a Built Environment
  • Large & complex modern institution
  • Often a combination of old buildings with newer additions
  • Multifunction infrastructure to support patient care

What kind of environment has healthcare created for healing?

the environmental footprint of a hospital



Healthcare Organization

The Environmental Footprint of a Hospital
  • (def) The impact of an organization in environmental terms
    • Resource use
    • Waste generation
    • Physical environmental changes
the environmental footprint of a hospital5

Facility Operations

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

the environmental footprint of a hospital6
The Environmental Footprint of a Hospital
  • 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
identifying and eliminating health care toxics
Identifying and Eliminating Health Care 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

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

1 | Mercury

fda advisories
FDA Advisories

1 | Mercury

declining threshold of harm










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

hg in hospitals


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

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

1 | Mercury

mmmf award criteria
MMMF Award Criteria


  • 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

mmmf award criteria15
MMMF Award Criteria


  • 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

  • Mercury is viewed as the “gold standard”
  • Multi-discipline effort
  • Cost
  • Not a regulatory requirement

1 | Mercury

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

2 | DEHP

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

2 | DEHP

  • 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

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

2 | DEHP

fda advisory
FDA Advisory


  • 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

fda advisory22
FDA Advisory

TI = FDA determined “Tolerable Intake”

2 | DEHP

fda advisory23
FDA Advisory

2 | DEHP

hospital focus eliminating dehp in the nicu
Hospital Focus: Eliminating DEHP in the NICU

Early Preterm Infants

  • Critically ill patient population
    • IV therapy
    • Parenteral and enteral feedings
    • Ventilation
    • Blood transfusion
  • Long hospital stay
    • Prolonged therapies

2 | DEHP

hospital focus eliminating dehp in the nicu25
Hospital Focus: Eliminating 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

john muir memorial hospital case study
John Muir Memorial Hospital Case Study

Survey found:

  • 31 plastic items
  • Only 5 contain PVC/DEHP and are used in exposure scenarios
  • Others are used for extraction procedures
  • One was eliminated procedurally

Only 4 items need to be replaced!

Extra NICU cost ~$20/patient/day.

2 | DEHP

  • Awareness
  • Takes a Champion in the NICU
  • Federal advisories, but no regulation

2 | DEHP

green cleaning environmentally preferable custodial products
Green Cleaning: Environmentally Preferable Custodial Products






Hospital Occupants

3 | EPP

implementing green cleaning
Implementing Green Cleaning
  • First promote worker safety
  • Use a defensible methodology to identify preferable products
  • Prioritize and implement EPP into contracting language; educate GPOs and suppliers

3 | EPP

chemical exposure

Janitorial data:

  • 54.5 lbs/janitor
  • 6.1 lbs/1000 sq feet

Building maintenance data:

  • 17.7 lbs/year
  • 6.6 lbs/1000 sq feet
Chemical Exposure

3 | EPP

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

chemical exposure31
Chemical Exposure

For every 100 workers:

  • 6 Chemical accidents per year
    • 3 eye injuries
    • 2 skin injuries
    • 1 inhalation/other

3 | EPP

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

chemical exposure32

Metal cleaner

Metal cleaner

Chemical Exposure

Glass cleaners

Toilet bowl cleaner, deodorizers, disinfectants

Wood polish

Disinfectants and General Purpose Cleaners

Hard floor cleaners, strippers, and finishes

Carpet cleaners

3 | EPP

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

defining a preferable chemical product
Defining a Preferable Chemical Product
  • 18 criteria based on:
    • Other EPP Programs
    • Tests with 100+ products
    • Comments from environmental staff, technical experts, and product vendors
  • Lower score is better
  • Failing subtotal scores

3 | EPP

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

health and safety evaluation
Health and Safety Evaluation
  • Failing subtotal score > 200
    • 200 points - Carcinogens
    • 100 points - Neurotoxins
    • 100 points - Eye Irritation
    • 100 points - Skin Irritation
    • 50 points - Ease of Skin Absorption
    • 50 points - Corrosivity
    • 50 points - Flammability

3 | EPP

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

environmental evaluation
Environmental Evaluation
  • Failing subtotal score > 100
    • 100 points – Ozone Depleting
    • 50 points – Endocrine Modifier
    • 100 points – Greenhouse Gases
    • 25 points - Biodegradability
    • 100 points - VOCs
    • 25 points – Added Fragrances
    • 25 points – Added Dyes

3 | EPP

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

other considerations
Other Considerations
  • Failing subtotal score > 35
    • 10 points – Available as Concentrate
    • 15 points – Available as Non-aerosol
    • 10 points – Refill/Return/Recycle
    • 10 points – Recycled Content

3 | EPP

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

information on msds and vendor literature
Information on MSDS and Vendor Literature

3 | EPP

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

focus efforts
Focus Efforts

Step 1: Quantity

Step 2: Widespread use

Step 3: Potential exposure

Step 4: Availability of alternatives

3 | EPP

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

road blocks
Road Blocks
  • Focused on infection control
  • Availability of products (continually improving)
  • Cost
  • Environmental service staff perception

3 | EPP

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

spaulding scheme for medical devices
Spaulding Scheme for Medical Devices
  • Critical

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

  • Semi-Critical

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

  • Non-Critical

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




4 | Minimizing Glutaraldehyde Use

which determines
… which determines
  • Sterilization:

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

  • Disinfection:

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

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

4 | Minimizing Glutaraldehyde Use

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

4 | Minimizing Glutaraldehyde Use

instruments often cleaned with cold process high level disinfectants
Flexible Endoscopy



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

cold liquid high level disinfectant options

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

disadvantages of glutaraldehyde
Disadvantages of Glutaraldehyde
  • Severe irritant - may cause asthma and respiratory sensitization

(although not cancer or reproductive harm)

  • Burning eyes and conjunctivitis
  • Headaches and nausea
  • Low exposure limits
    • 0.2 ppm NIOSH REL
    • 0.05 ppm ACGIH TLV
    • Proposed 0.015 ppm Ceiling Limit in CA

4 | Minimizing Glutaraldehyde Use

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

4 | Minimizing Glutaraldehyde Use

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

4 | Minimizing Glutaraldehyde Use

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

4 | Minimizing Glutaraldehyde Use

bottom line environmental controls
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

cycle times

Glutaraldehyde ($5 per bottle)

  • 20 minutes per cycle

= 24 cycles per 8 hour shift

Cidex OPA ($25 per bottle)

  • 12 minutes per cycle (manual)

= 40 cycles per 8 hour shift

  • 5 minutes per cycle (automated)

= 96 cycles per 8 hour shift

Cycle Times

4 | Minimizing Glutaraldehyde Use

what is sustainable building
What is Sustainable Building?

5 | Sustainable Building

impact of healthcare construction
Impact of Healthcare 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
impact of buildings
Impact of Buildings

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
impact on occupants
Impact on Occupants

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

  • 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
leed credit categories
LEED Credit Categories
  • Sustainable sites
  • Water efficiency
  • Energy and atmosphere
  • Materials and resources
  • Indoor environmental quality
  • Innovation in design

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.

center for health design
Center for Health Design

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.

roadblocks costs of green building turner construction survey
Roadblocks:Costs 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.

Marcella Thompson, LEED AP

(402) 399-1481