environmental health in the health care setting · environmental health in the health care setting...

ANF-EHHC

Environmental Health in the Health Care

Setting

Look for ANA Independent Study Modules available on ANA’s NursingWorld web page at www.NursingWorld.org/ce.

University of Maryland School of NursingEnvironmental Health Education Center

■ Volume 34, No. 2 • March/April 2002 ■

Support for this continuing education module was provided by the United States Environmental Protection Agency, Office of Children’s Health Protection

to the American Nurses Foundation

Author: Barbara Sattler, DrPH, RN

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March/April 2002 ■ The American Nurse ■ www.NursingWorld.org

Introduction

As nurses, we have chosen a health-pro-moting and healing profession and haveelected to care for individuals, their fam-

ilies, and whole communities. We incorporatethe risks posed by our patients’ and their com-munities’ environments into our nursing assess-ments, develop strategies to reduce risks andprevent disease, and advocate for their well-being. We often focus on the most vulnerablepopulations—the very young, the very old andfrail, the sick. We would never intentionallyplace our charges in harm’s way, and yet sever-al of the elements of our current health caredelivery system are indeed placing our mostvulnerable populations at risk.

Annually, 2.4 million tons of hospital wasteare generated in the United States (Rutula,1992). Contrary to popular belief, non-haz-ardous medical waste makes up nearly three-fourths of the waste generated in a hospital.

In many hospitals, all waste is thrown into“red bags,” which are subsequently incinerated,either on- or off-site. This indiscriminant pro-cess of medical waste incineration is making adreadful contribution of toxic chemicals to our

environment, resulting in health risks to us all.This health care process contradicts our profes-sional calling as healers and protectors ofhealth. Fortunately, there are many actions thatwe, as nurses, can take to stem the tides of thisunfortunate development.

The profligate use of “red-bagging” was inpart a result of the concerns that developed inthe beginning stages of our awareness aboutHIV/AIDS. Out of early ignorance regardingHIV/AIDS transmission, and in an effort toreduce the handling of any and all hospital-related waste, all waste was thrown directly intoa red bag and treated as though it was highlyinfectious. Although our understanding aboutHIV/AIDS transmission has progressed signifi-cantly, our misdirected “red-bagging” practicescontinue. The vast majority of hospital waste isthe same type of waste that would be found in ahousehold or hotel.

The content of our red bags includes paper,plastics, and heavy metals (especially mercury-containing products), as well as constructiondebris, pharmaceuticals, and potentially infec-tious waste. Only a very small amount of hospi-tal waste cannot be recycled or sent to amunicipal landfill. However, in many hospitals,

all of the waste is sent to an incinerator, eitheron- or off-site. The process of incinerating hos-pital waste creates pollution, with two particu-larly worrisome pollutants—dioxin andmercury. Dioxin, a known carcinogen, poses ahost of health problems as it is bioaccumulatedin the environment and eventually consumed bypeople. Mercury has already sufficiently accu-mulated in our waters that it has made some fishdangerous to eat in even modest quantities. Thehealth effects of dioxin and mercury will be fur-ther explored in this module, as will the effectsof DEHP (di(2-ethylhexyl)phthalate), a chemi-cal that is used in many of the plastic productsfound in health care.

It is important to note how we begin tounderstand the relationship between environ-mental chemical exposures and their potentialfor harm. There are several ways in which wehave historically made such discoveries:

• When humans present signs and symp-toms that can be connected to a specificchemical exposure. This has most com-monly occurred when workers have beenoccupationally exposed. In suchinstances, the temporal and geographicrelationships to the exposures and healtheffects have helped to identify healthhazards.

• When large, accidental releases of chemi-cals have befallen a community and con-taminated its air or water and this hasresulted in health effects. When this hasoccurred, we have learned about thechemicals’ toxicity to humans, as well asto other species in the environment.

• In rare instances, when human environ-mental (and occupational) epidemiologi-cal studies have been performed andshown associations. Through such stud-ies, we have learned about the toxiceffects of chemicals.

However, the most common way in whichthe relationships between chemical exposuresand health risks are posited is when toxicolo-gists study the effects of chemicals on animalsand we then estimate what the effects might beon humans. This estimation process is called“extrapolation.” There have been over 100,000man-made chemical compounds developed andintroduced into our environment since WWII;we are most often reliant on the data that is cre-ated in animal studies to warn us about their

Environmental Health in the Health Care Setting

AbstractThe health care industry is a major contributor to environmental pollu-tion. Through the processes of waste disposal, including incineration,the health care industry is one of the largest contributors to environ-mental dioxin and mercury. Mercury contamination of our waterwayshas created the conditions by which a significant number of fish aresufficiently mercury-laden so as to pose a human health threat. Addi-tionally, there are products and processes within the hospital that cre-ate health risks for the patients and health care staff. There are anumber of positive actions that nurses can take to address the healththreats posed by these exposures. These actions include: purchasingenvironmentally preferable products, implementing pollution preven-tion actions within the health care setting, and learning more aboutenvironmental health.

Objectives1) Describe the major environmental health threats posed by the

health care sector.2) Identify three chemicals that may affect children’s environmental

health associated with the health care sector.3) Explain the nurse’s role in taking action to improve the environ-

mental health risks in the health care sector.4) Specify three resources that can provide more guidance in improv-

ing environmental health in the health sector.5) Discuss the goals of the ANA Resolution on Pollution Prevention. 6) Describe two products/processes that are employed in hospitals

which create health risks.7) List three health effects associated with incineration.8) Name three indicators of children’s health that may be related to

environmental health risks.

Extracted from a table in the California Business Waste Reduction Program.See: http://www.ciwmb.ca.gov/bizwaste/factsheets/hospital.htm.

potential toxicity to humans. For many of thesechemicals, no toxicity data is available.

Astute observers of nature, such as RachelCarson, the biologist and author of SilentSpring, have helped us to understand that thebirds, reptiles, fish, and rodents in nature cansometimes be the harbingers of warning regard-ing hazardous chemicals. In 1962, Carson alert-ed the world to the harmful effects of pesticideson wildlife reproduction. It was through Car-son’s specific observations regarding the use ofDDT (a pesticide) and its associated negativeeffects in nature that its toxicity to humans andothers was brought to light, resulting in its banfrom use in the United States. In this studymodule, you will learn about DEHP, a chemicalfound in many of the plastics that we use inhealth care—a chemical about which we shouldbe heeding new warnings, including concernsabout male reproduction.

With thousands upon thousands of chemicalcompounds now creating a chemical soup in ourair and water (and in our bodies, in our breastmilk), it is increasingly difficult to prove specifichypotheses regarding the relationship of exposureto a singular chemical and disease outcomes inhumans. It has been suggested that we adopt a“precautionary approach” when animal researchand other indicators demonstrate a possible toxicrelationship between a chemical and healtheffect. (See box on “Wingspread Statement onthe Precautionary Principle.”) This “precaution-ary approach” calls for action to reduce potential-ly toxic exposure to humans in light of data orother indicators, rather than delaying until more“conclusive” studies are performed.

When there is evidence for serious,widespread, and irreversible harm, residual sci-entific uncertainties should not be used to delayprecautionary actions. Actions should includereduction and/or elimination of exposures, aswell as continued scientific investigation. As

nurses who are trained in disease prevention, wecan appreciate and should advocate for a pre-cautionary approach when it may preventinjuries or illnesses.

There is a substantial body of compelling sci-entific evidence regarding human health threatsassociated with mercury and dioxin, two majorpollutants emitted by the health care industry. Itis recommended by the ANA that action betaken in response to this knowledge. This inde-pendent study module concurrently providesinformation regarding critical environmentalindicators in health care and presents actionsthat nurses can take, individually and collective-ly, to turn the tides on several critical environ-mental health conditions. Additional resourceswill be presented throughout the module toguide the reader to sources for further explo-ration and more explicit direction.

Nurses can play a key role in affecting occu-pational and environmental health choices in thehealth care sector. An explanation of preferredpractices will be offered regarding health carepurchasing, waste management, and waste dis-posal choices. National and international initia-tives to reduce pollution in the health careindustry will be described including the Ameri-can Nurses Association’s efforts, the Environ-mental Protection Agency’s efforts with theAmerican Hospital Association, and the nationaland international efforts of the Health CareWithout Harm Campaign.

This independent study module will alsoexplore some of the unintentional, yet oftenavoidable, environmental health risks posed bythe health care industry. It will also exploresome of the specific health risks to our children,elucidating some current trends in environmen-tally-related exposures and diseases outcomes.Human health effects associated with selectchemicals will be outlined, with a focus on mer-cury, DEHP, and dioxin.

Children’s EnvironmentalHealthWe are slowly becoming increasingly sophisti-cated in our knowledge regarding the healtheffects associated with exposures to hazardouschemicals. Years ago, we had fairly blunt indi-cators such as whether or not a chemical expo-sure could cause an acute effect or perhapswhether or not it might cause cancer. Generallyspeaking this knowledge was limited to healtheffects in adult males. However, in the last cou-ple of decades, many more scientists have beenexpanding their exploration to evaluate the rela-tionship between exposures in women, includ-ing pregnant women, and to humans during allof their stages of development, includingembryonic and fetal development, early child-hood, and adolescence. We have learned thattoxic chemicals can have different effectsdepending on the timing of exposure. Fetusesand children have particular vulnerabilities totoxic chemicals.

During fetal development, there are periodsof exquisite sensitivity to the effects of toxicchemicals. At such times even extraordinarilysmall exposures can prevent or change a processthat may permanently affect normal develop-ment. The fetal brain undergoes rapid structuraland functional changes during late pregnancyand in the neonatal period. Developmental toxi-cants such as lead, mercury, and pesticides (allfound in hospitals and their waste streams) candirectly interfere with the processes required fornormal brain development.

Children are more vulnerable to many of thetoxic chemicals that comprise our air and waterpollution. Because children eat more, drinkmore, and breathe more per body weight thando adults, they receive higher doses of the con-taminants that are found in our food, water, andair. They are also generally less efficient atmetabolizing toxic chemicals, and therefore theresidence time of the toxic chemicals in theirbodies is longer. Children’s neurological sys-tems continue to mature for a long time afterbirth, and their reproductive systems go throughdramatic changes during certain stages of devel-opment, thus creating added vulnerabilities tothese systems. Research on the differentialimpact that most environmental pollutants haveon children is still quite sparse. In this studymodule, dioxins, mercury, and DEHP have beenchosen for elaboration because the scientificevidence indicates a clear differential effect onour children’s health.

A number of indicators reveal that problemsin child development are on an upward trend.In the United States, 17% of our children sufferfrom one or more developmental disabilities(Boyle, 1994). Learning disabilities alone mayaffect 5-10% of children in public schools(American Psychiatric Association, 1994). Inthe United States, 1.5 million children are tak-ing Ritalin, 1% of all children are mentallyretarded, and the increase in the prevalence ofautism is up 200% in the last two decades.Over a 12-year period, childhood bone cancershave increased 40% in boys and 33% in girls,and childhood brain cancer has increased 24%in boys and 19% in girls. Since 1960, the inci-dence of undescended testes and hypospadiashas doubled (ANA publication—”Sample Pre-sentation” in the Pollution Prevention Kit).Although chemical pollutants certainly do notcontribute to the whole of this trend, the scien-

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Wingspread Statement on the Precautionary PrincipleIn 1998, an international group of health and public health professionals, scientists, governmentofficials, lawyers, grass-roots activists, and labor activists met at a conference center called“Wingspread” in Wisconsin to define the “precautionary principle.” The group issued the fol-lowing consensus statement:

“The release and use of toxic substances, the exploitation of resources, and physical alter-ations of the environment have had substantial unintended consequences affecting humanhealth and the environment. Some of these concerns are high rates of learning deficiencies,asthma, cancer, birth defects and species extinctions, along with global climate change, strato-spheric ozone depletion and worldwide contamination with toxic substances and nuclear mate-rials.

“We believe existing environmental regulations and other decisions, particularly those basedon risk assessment, have failed to protect adequately human health and the environment—thelarger system of which humans are but a part.

“We believe there is compelling evidence that damage to humans and the worldwide envi-ronment is of such magnitude and seriousness that new principles for conducting human activi-ties are necessary.

“While we realize that human activities may involve hazards, people must proceed morecarefully than has been the case in recent history. Corporations, government entities, organiza-tions, communities, scientists and other individuals must adopt a precautionary approach to allhuman endeavors.

“Therefore, it is necessary to implement the Precautionary Principle: When an activity raisesthreats of harm to human health or the environment, precautionary measures should be takeneven if some cause and effect relationships are not fully established scientifically. In this con-text the proponent of an activity, rather than the public, should bear the burden of proof.

“The process of applying the Precautionary Principle must be open, informed and democrat-ic and must include potentially affected parties. It must also involve an examination of the fullrange of alternatives, including no action.” [End of statement.]

(See: http://www.gdrc.or g/u-gov/precaution-3.html.)

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tific evidence that they make a contribution isstrong.

Dioxin and mercury are pollutants from thehealth care industry, and pesticides are routinelyused in most hospitals. Primates exposed todioxin as fetuses show evidence of learning dis-abilities. Likewise in a tragic incident of mer-cury exposure to pregnant women in Japan,children were born severely mentally retardedand with impaired gaits and visual disturbances.A recent five-year study of pesticide exposuressuggests that combinations of commonly usedagricultural chemicals, in levels typically foundin ground water, can significantly influenceimmune and endocrine systems, as well as neu-rological function, in laboratory animals (Schet-tler et al., 2000).

Of the top 20 pollutants reported to the EPA,through the Toxic Release Inventory in 1997,nearly three-quarters are known or suspectedneurotoxicants (Schettler et al., 2000). Medi-cal waste incinerators contribute to this list ofenvironmental neurotoxicants when they releasemercury, lead, cadmium, and dioxin.

Of the tens of thousands of man-made chem-icals that are in commerce today, the EPA hasonly been able to complete toxicity testing on asmall number of them. Right now the EPA isworking with industry to test some 2,000 of thehighest production volume chemicals. To makethings even more complicated, risks from multi-ple chemical exposures are rarely consideredwhen research is designed or regulations draft-ed. Such an omission ignores the reality thatchildren (as well as adults) are exposed to manytoxic chemicals, often concurrently.

(A rare regulatory exception to this rule isthe case of regulations for pesticides that areused on food. This exception was created bythe 1996 Food Quality Protection Act, in whichCongress acknowledged that children eat morethan one type of food that may contain pesti-cides, thus creating the risk of more than onepesticide exposure at any given time. Addition-ally, children tend to eat much more fruit anddrink more fruit juices than adults, thus furtherincreasing their exposure to pesticide residues.For more information on the Food Quality Pro-tection Act, see: www.epa.gov/opppsps1/fqpa.)

Children have unique vulnerabilities to mostchemicals and specifically to the three chemi-cals emphasized in this study module: mercury,DEHP, and dioxin.

Environmental Health Risksin the Health Care Setting

Mercury

Mercury is an element that has many uses andwhich becomes a toxic pollutant in a variety ofways. Methylmercury, the form mercury oftentakes in the environment, is toxic to human ner-vous systems and immune systems and createsa risk for hypertension and renal damage. Ani-mal studies, including non-human primates,have found reproductive problems includingdecreased conception rates, early fetal loss, andstillbirths (Burbacher et al., 1988). Based onhuman exposures, there is suggestive evidenceof a negative effect on human fertility (NationalResearch Council, 2000). The largest contribu-tors of mercury in our environment are thecoal-fired power plants (in which naturally-occurring mercury is found in coal and released

into the atmosphere when the coal is burned)and municipal and medical waste incinerators(when mercury-containing products areburned). Mercury contamination in the healthcare industry comes from the incineration ofsome of the products listed in the box below.

Mercury may exist in a number of differentchemical forms but usually is released into theenvironment as a metal or an inorganic com-pound. When it is dispersed into the atmo-sphere, it can travel widely to all reaches of theearth, and when it lands on a body of water, itis converted by bacteria into methylmercury,an organic form that is highly toxic. Organicmercury is the most dangerous form of mer-cury because, like many environmental toxi-cants, it crosses into the brain and into thefetus so easily.

Mercury contamination of our waterways isnow so severe that over 40 states have issuedhealth advisories warning pregnant women orwomen of reproductive age to avoid or limitfish consumption. To find out about the specif-

ic fish advisories in your community, seewww.epa.gov/ost/fish. A drop of mercury assmall as 1/70 of a teaspoon can contaminate a25-acre lake to the point that the fish will beunsafe to eat (Thompson and Erickson, 1999).Alarmingly, ten states have issued advisoriesfor every lake and river within their state’s bor-ders.

According to the EPA, over 1 millionwomen in the United States of childbearing ageeat sufficient amounts of mercury-contaminatedfish to risk damaging brain development intheir children (NRC, 2000). The NationalAcademy of Science report on methylmercurystates that “over 60,000 newborns annuallymight be at risk for adverse neurodevelopmen-tal effects from in utero exposure to MeHg[methylmercury]” based on consumption ofmercury-contaminated fish (NRC, 2000).

Nurses need to understand the implicationsthat the fish advisories have for their patientsand communities and the contribution that thehealth sector has in creating this health risk.

Mercury-Containing ProductsEquipment Use

Batteries Hearing AidsMercuric Oxide Pacemakers

Defibrillators Fetal Monitors Hofler Monitor Pagers Picker Caliber Spirometer Alarm Telemetry Transmitter Temperature Alarm Blood Analyzer

Thermometers Temperature Measurement

Sphygmomanometers Blood Pressure

Barometers Weather Conditions

Esophageal Dilators Hg is used as weight at the bottom of the tubes.Cantor Tubes Miller Abbot Tubes Feeding Tubes

Electrical Instruments Laboratory Ovens (including Microwave Ovens) Nursing Incubators Room Temperature Controllers Refrigerators Relays Switches (no-noise switch used in patient rooms)

Lamps Fluorescent Lamps Metal Halide Lamps High Pressure Sodium Lamps Ultraviolet Lamps Cathode Ray tubes

Analytical Instruments using mercury Sequential Multiple Analyzer (SMAC)chloride as reagent AU 2000

Electron Microscope Mercury used as vibration damper.

(For this chart and more information on mercury use in health care, including a helpful virtual tour of the hospital for sources of mercury,

see: www.epa.gov/seahome/mercury/src/outmerc.htm.)

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Methylmercury bioaccumulates in the foodchain, magnifying in dose as it goes up the foodchain to larger and larger species. Humans typi-cally eat fish that are high on the aquatic foodchain, resulting in high mercury contamination.“There are extensive data on the effects ofMeHg [methylmercury] on the development ofthe brain (neurodevelopmental effects) inhumans and animals” (NRC, 2000). Throughtwo tragic environmental exposures in humanpopulations, we have first-hand knowledge ofboth the acute and chronic effects of methyl-mercury poisoning.

In the 1950s, in Japan, Minamata Bay wasseverely contaminated with mercury from anindustrial plant. Although the women in thearea showed no symptoms, the children born tothe women developed a heartrending array ofdevelopmental symptoms including mentalretardation, disturbances of gait, speech, suck-ing and swallowing, and abnormal reflexes(Harada, 1978). In another instance, in Iraq inthe 1970s, where bread was baked with grainthat had been sprayed with organic mercury as apesticide to treat fungus, acute symptomsincluded visual disturbances, with blindness inseveral instances. The effect on children bornto poisoned mothers was psychomotor retarda-tion with delays in walking and increased inci-dence of seizures (Amin-Zaki, 1976).

When there is a mercury spill in a hospitalroom, the indoor air can become contaminated.“If mercury is inhaled, as much as 80% of the

FDA’s Fish Advisory

CONSUMER ADVISORY Center for Food Safety and Applied Nutrition, U.S. Food and Drug Administration March 2001

AN IMPORTANT MESSAGE FOR PREGNANT WOMEN AND WOMEN OF CHILDBEARING AGE WHO MAY BECOME PREGNANT

ABOUT THE RISKS OF MERCURY IN FISH

Seafood can be an important part of a balanced diet for pregnant women. It is a good sourceof high quality protein and other nutrients and is low in fat.

However, some fish contain high levels of a form of mercury called methylmercury that canharm an unborn child’s developing nervous system if eaten regularly. By being informed aboutmethylmercury and knowing the kinds of fish that are safe to eat, you can prevent any harm toyour unborn child and still enjoy the health benefits of eating seafood.

HOW DOES MERCURY GET INTO FISH?

Mercury occurs naturally in the environment and it can also be released into the air throughindustrial pollution. Mercury falls from the air and can get into surface water, accumulating instreams and oceans. Bacteria in the water cause chemical changes that transform mercury intomethylmercury that can be toxic. Fish absorb methylmercury from water as they feed on aquat-ic organisms.

HOW CAN I AVOID LEVELS OF MERCURY THAT COULD HARM MY UNBORNCHILD?

Nearly all fish contain trace amounts of methylmercury which are not harmful to humans.However, long-lived, larger fish that feed on other fish accumulate the highest levels ofmethylmercury and pose the greatest risk to people who eat them regularly. You can protectyour unborn child by not eating these large fish that can contain high levels of methylmercury:Shark, Swordfish, King mackerel and Tilefish.

While it is true that the primary danger from methylmercury in fish is to the developing ner-vous system of the unborn child, it is prudent for nursing mothers and young children not to eatthese fish as well.

IS IT ALL RIGHT TO EAT OTHER FISH?

Yes. As long as you select a variety of other kinds of fish while you are pregnant or maybecome pregnant, you can safely enjoy eating them as part of a healthful diet. You can safelyeat 12 ounces per week of cooked fish . A typical serving size of fish is from 3 to 6 ounces. Ofcourse, if your serving sizes are smaller, you can eat fish more frequently. You can chooseshellfish, canned fish, smaller ocean fish or farm-raised fish—just pick a variety of differentspecies.

WHAT IF I EAT MORE THAN 12 OUNCES OF FISH A WEEK?

There is no harm in eating more than 12 ounces of fish in one week as long as you don’t doit on a regular basis. One week’s consumption does not change the level of methylmercury inthe body much at all. If you eat a lot of fish one week, you can cut back the next week or twoand be just fine. Just make sure you average 12 ounces of fish a week.

Some kinds of fish are known to have much lower than average levels of methylmercury andcan be safely eaten more frequently and in larger amounts. Contact your federal, state, or localhealth department or other appropriate food safety authority for specific consumption recom-mendations about fish caught or sold in your local area.

WHAT ABOUT THE FISH CAUGHT BY MY FAMILY OR FRIENDS IN FRESHWATER LAKES AND STREAMS? ARE THEY SAFE TO EAT?

There can be a risk of contamination from mercury in fresh waters from either natural orindustrial causes that would make the fish unsafe for you or your family to eat. The Environ-mental Protection Agency provides current advice on fish consumption from fresh water lakesand streams. Also check with your state or local health department to see if there are specialadvisories on fish caught from waters in your local area.

For information about the risks of Mercury in Seafood, call toll-free 1 (888) SAFEFOODU. S. Food and Drug Administration

Center for Food Safety and Applied NutritionFood Information Line 24 hours a dayOr Visit FDA’s Food Safety Website

www.cfsan.fda.gov

FURTHER INFORMATION IS ALSO AVAILABLE: Environmental Protection Agencywww.epa.gov/ost/fish

EPA’s Fish AdvisoryUnited States Environmental

Protection AgencyOffice of Water

4301EPA-823-F-01-004

January 2001

National Advice on Mercury inFish Caught by Family and

Friends: For Women Who ArePregnant or May Become

Pregnant, Nursing Mothers,and Young Children

Summary

EPA is issuing a national advisory con-cerning risks associated with mercury infreshwater fish caught by friends and fami-ly. The groups most vulnerable to theeffects of mercury pollution include:women who are pregnant or may becomepregnant, nursing mothers, and youngchildren. To protect against the risks ofmercury in fish caught in freshwaters, EPAis recommending that these groups limitfish consumption to one meal per week foradults (6 ounces of cooked fish, 8 ouncesuncooked fish) and one meal per week foryoung children (2 ounces cooked fish or 3ounces uncooked fish).

(To get more information on EPA’s fishadvisory program, visit EPA’s fish adviso-

ry Web site at www.epa.gov/ost/fish/or contact Jeff Bigler at 202-260-1305;

e-mail: [email protected].)

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inhaled mercury may be absorbed into the bloodstream, thus creating the following:

• Short-term exposures can cause poison-ing, pneumonitis, bronchitis, and bron-chiolitis.

• Repeated exposure to relatively low toxiclevels can cause muscle tremor, irritabili-ty, personality changes, and gingivitis.

• Nerve damage from mercury may start asa simple loss of sensitivity in hands andfeet, difficulty in walking, or slurredspeech.

• Mercury has also been known to affectthe development of prenatal life andinfants.” (Shaner, 1997)

When a mercury thermometer breaks, it isdifficult and very expensive to clean up proper-ly. If mercury spills from a thermometer and isnot cleaned up, it will all eventually evaporate,potentially reaching dangerous levels in indoorair. A single broken fever thermometer contain-ing 0.5 to 1.5 grams of mercury is enough tocreate a health risk when it evaporates into asmall, poorly ventilated room (“How to Planand Hold a Mercury Thermometer Exchange,”Health Care Without Harm, 1999). Mercuryclean-ups can be extremely expensive. If a car-pet is affected, it must be removed, disposed ofas hazardous waste, and a new carpet laid, cre-ating clean-up costs in the thousands of dollars.

Given the highly accurate, non-mercury ther-mometer choices that are on the market, allhealth care institutions should be selecting non-mercury alternatives. Several hospitals havemade great strides in mercury reduction,becoming virtually mercury-free in all of theirmedical equipment.

Actions

• Hold a mercury thermometer exchange• Provide annual mercury training/spill/label-

ing program• End the purchase of new mercury-contain-

ing equipment and implement a mercury-free purchasing policy for vendors thatincludes reagents and other background

uses of mercury• Create a replacement plan and budget for

elimination of mercury-containing equipment• Collect all wastes from processes involving

the fixative B5 and designate a team to inves-tigate the use of mercury-free alternatives

• Set up a fluorescent bulb (and other mercurycontaining bulb) recycling program

• Establish a battery collection program• Develop a waste trap cleaning/replacement

plan• Implement a labeling and replacement plan

for other mercury-containing devices(mechanical equipment).

(For more specific direction on accomplishingthese objectives, see: http://www.noharm.org/library/docs/SHEA_Proceedings_Mercury_Elimination_White_Pap.pdf.)

In several cities around the country, nursesand others have organized mercury thermometerexchanges in their communities. In Washing-ton, DC, the DC Hospital Association alongwith the local Health Care Without Harm Cam-paign and the City Health Department, support-ed by the city firehouses, did a city-widemercury thermometer exchange whereby peoplebrought their mercury thermometers to localfirehouses and were given mercury-free ther-mometers. Health Care Without Harm has creat-ed a very helpful guide to implementing anexchange—see www.noharm.org to downloadthe pamphlet “How to Plan and Hold a MercuryThermometer Exchange.” A communityexchange program, in combination with elimi-nation of all mercury-containing medical equip-ment, can make a significant impact on reducingmercury contamination in our rivers and lakes,which will translate to healthy people.

DEHPThe chemical compound DEHP, Di(2-ethyl-hexyl)phthalate, is contained in many of thecommon plastic products found in health caresettings. It is in a category of toxic chemicalsknown as pthalates, which are commonly addedto polyvinyl chloride (PVC) plastic to make theplastic product flexible and strong. It allows theotherwise stiff PVC to be molded into a varietyof products such as IV tubing, IV bags, andfeeding tubes. By weight, DEHP comprise 20-40% of the PVC products on average. There isnew evidence regarding the human toxicityassociated with exposure to DEHP that shouldhelp to inform our product selection in thehealth care setting.

“DEHP does not bind with plastic, so it canleak out of PVC medical products during medi-cal procedures, or when PVC objects such astoys are chewed. Everyone is exposed to DEHPthrough off-gassing from vinyl products in thehome and workplace, as well as from industrialemissions. However, some infants and especial-ly pre-term neonates are receiving, in somecases, megadoses of DEHP. Neonatal nursesshould know what they can do to protect theirtiny patients from the potentially harmful effectof DEHP. The multiple and relatively highexposures that may occur in neonatal intensivecare units (NICUs) are significant. Many ofthese babies are exposed during blood and otherintravenous infusions, respiratory therapy,enteral feedings and extra corporeal membraneoxygenation (ECMO)” (quote from AnnMelamed in The American Nurse, December2000, online at www.nursingworld.org/tan/novdec00/pollutio.htm).

The National Toxicology Program’s ExpertPanel who reviewed DEHP studies only lookedat reproductive and developmental effects.Based on animal studies, there are concerns thatthere may also be effects on the liver, kidneys,and lungs, as well as effects on heart rate andblood pressure. (See insert “Relevant AnimalStudies” for review of animal study results.)Nonetheless, the Expert Panel noted the follow-ing:

Saint Mary’s Duluth ClinicSaint Mary’s Duluth Clinic in Minnesota isa small hospital that has made large reduc-tions in its mercury use. The clinic insti-tuted a mercury-free purchasing programin 1991 after participating in an education-al seminar on the link between mercuryuse and pollution in Minnesota’s lakes andstreams. Saint Mary’s stopped purchasingmercury thermometers and blood pressureunits in the first year of their program andhas since nearly eliminated mercury batter-ies, rubber cantor tubes, and mercury fixa-tives. In addition, the clinic has started anaggressive fluorescent light recycling pro-gram and has stopped sending mercurythermometers home with patients (this isnow Minnesota law).

(Case Study from Protecting by Degrees:What Hospitals Can Do To Reduce Mer-cury Pollution by Environmental WorkingGroup, 1999)

Don’t send mercurythermometers home with new moms!In a recent study, Carpi and Chen foundthat 10% of the homes they evaluated hadindoor air levels of mercury exceeding theEPA’s reference concentration (300ng/m3)due to historic accidents with mercury-containing devices. Exposure to mercuryvia indoor air is seen as second only to fishconsumption as a source of mercury in thegeneral population (Carpi & Chen, 2001).

FDA Safety Assessment ofDEHP from PVC MedicalDevices“The FDA/CDRH has examined this[DEHP] issue and has concluded that chil-dren undergoing certain medical proce-dures may represent a population atincreased risk for the effects of DEHP.

“This decision is supported by three find-ings:

1. Children undergoing some medicalprocedures receive a greater dose ofDEHP, on a mg/kg basis, thanadults do,

2. Pharmacokinetic differencesbetween children and adults mayresult in greater absorption ofDEHP, greater conversion of DEHPto MEHP (the toxic metabolite ofDEHP), and reduced excretion ofMEHP in children compared toadults, and

3. Children may be more pharmacody-namically sensitive to the adverseeffects of DEHP than adults are.”

FDA web site, see: http://www.fda.gov/cdrh/ost/dehp-pvc.pdf.

This conclusion is consistent with thatreached by the expert panel convened bythe Center for the Evaluation of Risks toHuman Reproduction of the National Tox-icology Program.

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So how does the chemical DEHP create arisk to humans when it is in PVC medicaldevices? When it is in PVC, it is not actuallybound chemically. It can therefore escape thePVC product under certain conditions such aswhen the product is heated, or when the medicaldevice contacts fluids—such as the fluids thatwould be in an IV or blood bag. DEHPmigrates into a variety of fluids including blood,plasma, and total parenteral and enteral nutri-

tion solutions. During medical interventionsthat require long-term IV interaction such ashemodialysis or ECMO, DEHP exposure is sig-nificantly enhanced. Pediatric exposures are ofthe greatest concern. Sick newborns andinfants face the greatest risk of exposure frommedical interventions and may also be the mostvulnerable to the toxic effects of DEHP becauseof their stage in human development.

During critical stages of development, pre-term babies, and neonates may be exposed toDEHP, a reproductive and developmental toxi-cant. This occurs because of the ubiquitouspresence of DEHP in their environment. Themultiple and rela-tively high expo-sures that can occurin the NICU arepotentially at or inexcess of levelsknown to causeadverse healtheffects in relevantanimal studies.

“Since DEHPreleases to vinylproducts are noteasily controlled,prevention shouldbe the primary man-agement option”(Rossi, 2000). Toensure that ourpatients are notexposed to DEHP,we will have todemand DEHP-freehealth care prod-ucts, particularly inthose settings whereour smallest andmost vulnerablepatients are cared

for. Using PVC-free products virtually assuresthat the product will be DEHP-free because theother plastics rarely add DEHP. “In addition,PVC-free products avoid the lifecycle hazardsof vinyl, including the use of a known carcino-gen to manufacture vinyl (vinyl chloridemonomer) and the downstream formation ofdioxin when vinyl is burned in a medical wasteincinerator” (Rossi, 2000; Thornton et al., 1996;Wagner and Green, 1993).

PVC is the most widely used plastic in medi-cal products. It accounted for 27% of all plasticused in durable and disposable medical productsin the United States in 1996 (Schettler et al.,

2000). Approximately 445 million pounds ofPVC were consumed in the manufacture ofintravenous (IV) and blood bags, tubing, exami-nation gloves, medical trays, catheters, and test-ing and diagnostic equipment in 1996. Tubing,IV and blood bags, and gloves are the primaryend-uses for PVC in disposable medical prod-ucts. Both patients’ health and safety, as well asthe public’s health, are of concern regardingPVC.

In January 2002, the Health Canada ExpertAdvisory Panel recommended that health careproviders not use DEHP-containing devices inthe treatment of pregnant women, breastfeedingmothers, infants, males before puberty, andpatients undergoing cardiac bypass, hemodialy-sis, or heart transplant surgery. They recom-mended the alternative measures be introduced“as quickly as possible.”

Actions

Elimination of DEHP exposure can occur whenDEHP-free products are selected.

The Sustainable Hospitals Program at the Uni-versity of Massachusetts, Lowell, can be aninvaluable resource to assist you in selectingalternatives. They have been researching andevaluating hospital products and have created alist of DEHP-free alternatives for a vast array ofproducts. They provide the product type and themanufacturer information, including phone num-

Relevant Animal Studies Regarding DEHP Exposures and Toxic EffectsAnimal Species Target Organ Effect

Rat Testes Disorganization of seminiferous tubule structurein male offspring, sertoli cell vacuolation, atrophyof seminiferous tubules, loss of spermatogenesis,testicular and epididymal atrophy, testicular agen-esis, hemorrhagic testes, and hypospadias

Rat Ovaries Suppressed or delayed ovulation, suppressedestradiol production, polycystic ovaries

Human neonate Lungs Respiratory distress, pathological changes resem-bling hyaline membrane disease

Rat Heart Decreased heart rate and blood pressure

Rat Kidneys Reduction in creatinine clearance, cystic changes

Mouse Fetus/embryo Fetal death, exencephaly, open neural tubes,reduced pup size

Monkey Liver Abnormalities in histology, reduced liver function

Table adapted from Table 1.Toxicity of DEHP to Various Organ Systems, p. 3, in NeonatalExposure to DEHP and Opportunities for Prevention, Mark Rossi, 2000. To download theentire report with full scientific references, see: http://www.noharm.org/library/docs/Neona-tal_Exposure_to_DEHP_di-2-ethylhexyl-phth.pdf

DEHP Health Risks byPopulationCritically Ill Infants:“The available reproductive and develop-mental toxicity data and the limited butsuggestive human exposure data indicatethat exposures of intensively-treatedinfants/children can approach toxic dosesin rodents, which causes the Panel seriousconcern that exposure may adverselyaffect male reproductive tract develop-ment” (page 101).

Healthy Infants and Toddlers:“If healthy human infant/toddler exposuresis several-fold higher than adults, the Panelhas concern that exposure may adverselyaffect the male reproductive tract develop-ment” (page 101).

Pregnant and Lactating Women:“(T)he Panel has concern that ambient oralDEHP exposures to pregnant or lactatingwomen may adversely affect the develop-ment of their offspring” (page 102).

(Source Document: U.S. Department ofHealth and Human Services, 2000.)

DEHP-Plasticized PVC Products in the NICUFeeding-Related Products Intravenous ProductsBreast milk delivery tube IV bagsEnteral feeding bags IV tubingLipid extension tubes Red blood cell bagsNG tubes Tubing for breast pumps Sources of Dermal Exposure

Exam glovesRespiratory Therapy Products Patient ID braceletsET tubes and trach tubes Humidifier (sterile water bags, tubing) Other Potential PVC ProductsOxygen masks and tubing Drainage tubes and bagsResuscitators, O2 reservoir bags Isolette portal coversSuction tubing Mattress coversVentilator tubing Flooring and wall covering

Ostomy and neuro shunt bagsUmbilical vessel catheters

[Sources: Sustainable Hospital Project, 2000, “Alternative Products,”see: http://www.uml.edu/centers/LCSP/hospitals/ (Lowell: SustainableHospitals Project, U.Mass., Lowell); and Tickner et al.., 1999, The Useof Di-2-Ethylhexyl Phthalate in PVC Medical Devices: Exposure Toxici-ty, and Alternatives (Lowell: Lowell Center for Sustainable Production,UMass Lowell.)]

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bers and Web sites. See its Web site: www.sus-tainablehospitals.org for product informationregarding DEHP (as well as mercury-free choic-es, latex alternatives, safer needle devices, andother extremely useful information).

Dioxins

Dioxins are a family of highly toxic chemicalsthat are in our environment—in our air, water,soil, and food supply, as well as in our bodies.Dioxins are not intentionally produced, butrather are by-products of combustion and indus-trial processes, including the manufacture ofchlorinated chemicals, the bleaching of paperproducts, and the incineration of waste (munici-pal, hazardous, and hospital waste). Dioxins areone of a grouping of toxic pollutants that arepersistent in our environment, as well as in thehuman body. Once they get into the environ-ment and into our bodies, they do not quicklybiodegrade into something less toxic, and theyhave extremely slow natural paths for removalor excretion. They are believed to have a half-life of seven to twelve years in the human body(Wolfe et al., 1995).

Dioxin bioaccumulates in such a manner thatit biomagnifies up the food chain. Contaminationin the food chain begins with dioxin particles inwater or soil and then proceeds up the food chainthrough fish and livestock, ultimately reachinghuman tissues through the food we eat. Itbecomes increasingly concentrated in living tis-sues as it moves up the food chain (Oris, 2000).

Approximately 90% of human exposure todioxin comes from food, specifically in the formof beef, fish, and dairy products. According tothe EPA, beef and dairy products remain amongthe leading sources of dioxin exposure to adults.In 1998, Consumer Reports assayed the dioxincontent in a dozen brands of baby food jars ofmeat. They projected that “a baby who ate onejar—just 2.5 ounces—of an average meat-basedbaby food on a given day would consumearound 100 times the EPA’s daily limit of diox-ins. No brand was significantly more contami-nated than another” (Consumer Reports, 1998).When dioxin is consumed by humans, it isstored in the fatty tissue—it is lipophilic.Human babies who are breastfed can receive10% of their lifetime exposure to dioxin fromtheir mother’s fat-laden milk. As nurses, weshould continue to advocate that women breastfeed, as we concurrently advocate for policiesand practices that will decrease the dioxin levelsin our environment.

Studies of humans occupationally exposedhave shown dioxins to be associated with cancerof the lung, thyroid gland, hematopoietic sys-tem, and liver, as well as connective and soft

tissue sarcoma (Thornton et al., 1996). Accord-ing to the EPA draft report on dioxin’s healtheffects, the levels of dioxin-like compoundsfound in the general population may cause alifetime cancer risk as high as one in 1,000.This is 1,000 times higher than the generally“acceptable” risk of one in a million. For themost recent EPA statements on dioxin, see thedraft reassessment report, http:/cfpub.epa.gov/ncea/cfm/dioxreass.cfm?ActType=default.

In addition to dioxin’s carcinogenicity status,it is also a known endocrine disruptor, a chemi-cal that mimics or otherwise disrupts normalhormone activity. Endocrine disruption canoccur at extremely small doses of exposure.Theo Colborn, in her 1996 book Our StolenFuture, describes the amassing research onendocrine-disrupting chemicals in our air andwater and their effects in nature and on humanhealth. While early discussions of endocrine-disrupting chemicals focused on estrogeniceffect of environmental contaminants, morerecent research extends concerns to anti-estro-gens, androgens, or anti-androgens, as well asthyroid hormone, cortisone, and others(McLachlan, 1985). Animal studies confirm awide range of reproductive and developmentaleffects of dioxin in different species, someoccurring at very low exposure levels. Theyinclude changes in hormone levels, fertility,sexual behavior, litter size, ability to carry preg-nancy to term, birth defects, learning disabili-ties, and endometriosis. A potential connectionexisting between exposure to dioxin andendometriosis is based on primate studieswherein dioxin exposure increased the inci-dence and severity of endometrosis in monkeysand in rodent populations (Birnbaum and Cum-mings, 2002).

“Human studies designed to examine repro-ductive or developmental effect of dioxin expo-sure have produced mixed results. The studiesare often limited by inadequate exposure infor-mation, incomplete recognition of health out-comes, or low power to detect rare events, andthey virtually always lack an unexposed controlpopulation. Nevertheless, there is now suffi-cient evidence to conclude that dioxin is proba-bly a cause of some birth defects. There is alsoevidence that testosterone levels are depressedin occupationally-exposed workers, and thyroidhormone is depressed in infants exposed atambient levels through breast feeding.” (Schet-tler et al, 2000)

The EPA has been in a multidecade-longprocess to assess (and reassess) the health risksof dioxin. The discussions and debates are oftenas influenced by economics and politics as theyare by science. Dioxin is one of the 12 chemi-cals covered by the United Nation’s Stockholm

Convention on Persistent Organic Pollutants(POPs), which the United States signed in May,2001. This Convention calls for the reductionof industrial dioxin releases, including thosefrom medical waste incinerators.

Actions

In the health care industry, dioxin is primarily aproduct of waste incineration. Therefore, theprime action is to discontinue the incineration ofhospital waste and choose non-incinerationalternatives.

During the manufacture of (PVC) plastics,dioxins are created, as they are when incinerat-ed. Therefore limiting the use of plastics is rec-ommended:

• Eliminate plastic utensils and replacethem with stainless steel.

• Eliminate plastic covered “chux” andreplace them with washable, cotton pads.

• Request that products have only essentialpackaging, thereby reducing redundantplastic packaging.

The Hospitals for a Healthy Environment,Health Care Without Harm, and SustainableHospital’s Web sites all have excellent guidancefor reducing PVC use in hospitals, with valuableinformation on the alternatives. They also pro-vide comprehensive guidance on waste reduc-tion. See: http://www.h2e-online.org/,www.noharm.org, and www.sustainablehospi-tals.org, respectively.

Incineration

Incineration, the process of burning waste, is anage-old practice for waste management. How-ever, the process of burning modern-day waste,particularly medical waste, presents us with newand extensive environmental health risksbecause of the makeup of the waste stream.Incineration creates toxic air pollution and toxicash. The air pollutants can affect both the localcommunities and can travel the jet stream topollute distant lands and people. The ash maybe placed in a landfill, creating the potential forthe pollutants to leach into our ground water.Some of the pollutants persist in the environ-ment, accumulating in the environment and inour bodies. The incineration of regulated medi-cal and general hospital waste results in air andwater emissions of dioxin, mercury, other toxicmetals, particulates, and sulfur dioxide (John-ston and Erickson, 2000).

During the combustion process of incinera-tion, new chemical compounds can be created.It is during this process that dangerous dioxinsare unintentionally created. Dioxins, which arechlorine compounds, are created during com-bustion in the presence of chlorinated wastesuch as bleached white paper and polyvinylchloride plastic. The EPA has identified medicalwaste incineration as the third largest source ofdioxin air emissions and as the contributor ofabout 10% of the mercury from human activity(US EPA, 1997).

Plastics comprise roughly 15—30% of themedical waste stream, roughly twice as much asis found in municipal waste streams. Polyvinylchloride plastic (PVC) is approximately 50%chlorine by weight. Paper and cardboard com-prise 45—50%, food waste 10%, glass 7%,wood 3%, metals 10%, and other materialsapproximately 10% (Shaner, 1993).

Human Cancer Classification of Dioxin by AgencyEnvironmental Protection Agency Dioxin (2378-TCDD and related

compounds) are known carcinogens

National Toxicology Program of the NIH Dioxin (2378-TCDD) is a known carcinogen(http://ntp-server.niehs.nih.gov/)

International Agency for Research on Dioxin is a known carcinogenCancer (IARC)

National Institute of Occupational Safety Dioxin is a probable carcinogenand Health

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Actions

Careful waste segregation provides an opportu-nity to select the most environmentally safe dis-posal for each category of waste. Nurses canplay a pivotal role in the process of identifyingopportunities for improving waste segregation,including decisions about products for reuse,recycling, and the safest methods of disposal.

Stephanie Davis ([email protected]), a waste management specialist,has created a ten-item set of guidelines for sys-tematically reducing regulated medical waste;available in Going Green: A Resource Kit forPollution Prevention in Health Care:www.noharm.org.

There are a variety of alternatives to inciner-ation for the treatment of waste. Although eachof them has its own pros and cons, none createsthe same level of environmentally unhealthyconsequences as incineration. The alternativesinclude autoclave/steam sterilization,microwave, and chemical disinfection. Whenany of these methods are chosen, the treatedwaste is then placed in a landfill. An extensiveand technical discussion on alternatives to incin-eration can be found in the report, “Non-Incin-eration Medical Waste Treatment Technologies:A Resource for Hospital Administrators, Facili-ties Managers, Health Care Professionals, Envi-ronmental Advocates, and CommunityMembers” (2001) found on the Web site:http://www.noharm.org/library/docs/Non-Incin-eration_Medical_Waste_Treatment_Techn.pdf

Hazardous Products andProcesses in Health CareIt is possible to eliminate or significantly reducehazardous exposures to workers in the healthcare setting (or any other work setting) byemploying the Industrial Hygiene Hierarchy ofControls. This hierarchy provides a frameworkfor categorizing methods of health and safetymeasures. They are listed in the order of theireffectiveness:

1. Elimination of hazardous materials anddangerous activities (needleless IV sys-tems, no lifting)

2. Substitution of less hazardous materials(substitute oxidizing chemicals such asparacetic acid for glutaraldehyde, nitrilegloves for latex or vinyl gloves)

3. Engineering Controls , the use oftechnical means to isolate or removehazards (safer needle devices, liftingdevices)

4. Administrative Controls, policies thatlimit worker exposures to hazards (appro-priate allocation of resources to prioritizehealth and safety, rotation of staff to min-

imize exposure time in areas where theymay be exposed)

5. Personal Protective Equipment (PPE),barriers and filters between the worker andexposure (gloves, respirators, gowns, etc.)

Another important tenet in worker protectionis appropriate employee training and educationabout potential hazards and safe work practices.When workers have a good understanding ofwhy they should employ certain safety precau-tions or processes, they are more likely to com-ply.

For more information on the Industrial Hygiene Hierarchy of Controls andoccupational safety and health, see the federalOccupational Safety and Health AdministrationWeb site: www.osha.gov.

Cleaning and DisinfectantProducts

Health care institutions pride themselves in theexceptional attention they pay to cleanliness.However, many industrial strength cleaners anddisinfectants present health risks to employeesand patients during application and afterwards.They may contribute to poor indoor air quality,trigger asthma events, cause skin and mucousmembrane irritation, and even cause neurologi-cal effects. The most frequently reported haz-ardous exposures in health care were latex, poorindoor air quality, and toxic cleaning products(MA DPH SENSOR, 2000). (For more infor-mation on latex exposure, see: www.nursing-world.org or www.niosh.gov.) By carefullychoosing environmentally healthier and safercleaning chemicals, cleaning methods, andcleaning equipment, health risks can be reduced.More than 70,000 chemicals are registered withthe EPA for use in cleaning products, includinga number that are suspected hormone disruptorsand carcinogens (Green Birthdays, 2001).

Disinfectants and Sterilants

Disinfectants and sterilants used in hospitals,such as quaternary ammonium compounds, phe-nols, bleach, and ethylene oxide are registeredwith the EPA as pesticides. These toxic chemi-cals are used for routine cleaning on every sur-face in the hospital environment, as well as forsterilizing equipment. Ethylene oxide, a coldsterilizing agent, is a carcinogen and a reproduc-tive toxin that can cause miscarriage (Danielson,1998). There is currently an Occupational Safetyand Health Standard for ethylene oxide becauseof its health risks. There is a web-based factsheet on ethylene oxide that describes six alterna-tives to ethylene oxide sterilization, includingsteam and ozonation processes. For moredetailed information, see: http://es.epa.gov/tech-

info/facts/ca-htm/oxide-fs.html.Glutaraldehyde is a potent skin irritant and

sensitizer known to trigger asthma (Nethercott,1988; Di Stefano et al., 1999). Effective andless hazardous alternatives to glutaraldehyde areavailable. The Sustainable Hospitals Programlists a number of acceptable alternatives on itsWeb site: www.sustainablehospitals.org. TheOccupational Safety and Health Administrationis currently developing an occupational expo-sure standard for glutaraldehyde because of thehealth risks that it can pose. (Some brand namesfor glutaraldehyde are: Cidex, Aldesen, Hospex,and Sonacide.)

Floor Care Products

Many floor care products used in hospitals,including wax strippers, contain known haz-ardous substances. Chemicals included in theseproducts include diethylene glycol ethyl ether,aliphatic petroleum distillates and nonyl-phenolethoxylate, ethanolamine (a known sensitizer),butoxyethannol, and sodium hydroxide (lye).(HCWH, 2001) Available at: www.noharm.org.See Going Green). A number of health effectsare associated with this constellation of floorchemicals including: respiratory, eye and skinirritation; nausea; headache; difficulty in concen-trating; and asthma events. Industrial strengthcleaners often require diluting before use andjanitorial staff, whose first language may not beEnglish or who have literacy problems, mayhave difficulty in following written directions fordiluting. Problems with acute exposures tocleaning problems can occur if full strength solu-tions are used. Pour-and-wipe applicationsdecrease the types of airborne exposures thatmay occur when spray bottles, aerosol cans, ormechanical devices are used for dissemination ofthe product. Adequate ventilation, well-trainedcleaning staff who understand the correct dilut-ing ratios and methods, and choosing the leasttoxic chemicals can significantly reduce the risksof health effects and injuries.

There are several municipal initiatives toreduce the use of toxic cleaning products bypublic workers, including the Sustainable CityProgram of Santa Monica, California. In aneffort to purchase less harmful products, theprogram evaluated cleaners for their environ-

In addition to dioxins and mercury, many other hazardous pollutants have been identifiedin medical waste incineration emissions, including:Arsenic Ammonia BenzeneBromodichloromethane Cadmium Carbon tetrachlorideChromium Chlorodibromomethane ChloroformCumene 1,2-dibromethane DichloromethaneDichloroethane Ethyl benzene LeadMesitylene Nickel Particulate matterNaphthalene Tetrachloroethane TolueneTrichloroethane Vinyl chloride Xylene

Resources for CleaningProducts• Report on cleaning chemicals and solu-

tions—email: [email protected]• List of environmentally-preferable

cleaning products—mail: MA Opera-tional Services Division, One AshburtonPlace, Rm. 1017, Boston, MA 02108

• Quick reference and worksheets fromthe Janitorial Pollution Prevention Pro-ject—Web site: www.westp2net.org/Janitorial /jp4.html

• The American Society for TestingMaterials has a standard for the selec-tion of environmentally-preferablecleaning agents and processes: “GuideD6361-98 Standard Guide for SelectingCleaning Agents and Processes,” seewww.astm.org

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mental and health effects. As a result, theyreduced the use of hazardous products, savedmoney, and reduced worker complaints. In gen-eral, less toxic alternatives should not contain:ammonia, chlorine, phosphates, alkylphenolethoxylates, volatile organic compounds(VOCs), propellants, or petroleum solvents.Additional considerations should be to avoidcaustic or corrosive products (very low or highpH), unnecessary fragrances (which may affectpeople with asthma or chemical sensitivity), andunnecessary packaging (which will merely con-tribute to the waste stream).

Pesticides

Pesticides are chemicals that are formulated tokill or prevent reproduction in a variety of pestssuch as insects, rodents, weeds, and microbes.All pesticides are required to be registered bythe EPA. In New York State, in 1995, theAttorney General surveyed hospitals in the stateand found all but three of them used pesticides.The science regarding health effects and pesti-cide exposures is creating mounting evidencethat we must proceed with much caution whentrying to control pests.

Integrated Pest Management (IPM) is a phi-losophy and system of managing pests that pro-vides a framework for removing life supportsystems for pests (food, water, and nestingspace) along with least hazardous methods suchas traps and sticky tapes before moving on tochemical solutions. If chemical solutions arerequired, then the selection of the least toxicchoices come first. This staged system of pestcontrol can significantly reduce an institution’sreliance on hazardous pesticide applications,thus removing the associated health risks to theworkers in the institution, the patients and theirfamilies, and the environment generally. Thereare a number of excellent IPM resources. See:http://www.epa.gov/pesticides/ipm/#fact ,www.oag.state.ny.us/environment/environment.htm, www.crisny.org/not-for-profit/nycap/nycap.htm, and www.behondpesticides.org.

The 10 teaching and research hospitals asso-ciated with Harvard University have been prac-ticing Integrated Pest Management for about 15

years. They use sticky traps, vacuums, caulk-ing, silica gel, and other typical IPM methods.As necessary, they use boric acid and pyrethrumformulations that are generally applied as crackand crevice treatments. They use no rodenti-cides, no pesticide sprays, mists, or fogs, and no“preventative” pesticide applications (NewYork City Health Care Without Harm Coalition,2000).

Environmentally-PreferablePurchasing

Through the careful selection and purchase ofless toxic products, our work as health careproviders becomes more internally consistent.We can indicate an additional level of caring forour employees, patients, and community mem-bers by taking the time to understand the prod-ucts that we choose to have in the health caresetting. By understanding how the products aremade, including the occupational and environ-mental health risks posed by their productionprocesses, as well as the impacts of their finaldisposal, we begin to understand the full “lifecycle” of the products we select and all of theirpotential impacts. Environmentally preferablepurchasing (EPP) is the act of purchasing prod-ucts/services whose environmental impacts havebeen considered and found to be less damagingto the environment and human health whencompared to competing products/services(Health Care Without Harm, available online:www.noharm.org). Environmentally preferablepurchasing can be implemented in clinics andschool health suites as well as hospitals.

Obviously, implementing an EPP program ina hospital is a complex endeavor. A teamapproach will facilitate change. Many hospitalsare members of Group Purchasing Organiza-

tions—organizations established to make bulkpurchases for several hospitals or hospital sys-tems. The GPOs interface directly with vendorsto purchase many hospital products. Therefore,an EPP team should include all those who helpto make purchasing decisions, including theGPOs. Nurses should be represented on thisteam and, if one does not exist, nurses can takeleadership in helping to create a team. Goalsshould be established for the institution such asthe phase-out of mercury-containing products orreducing the packaging waste by purchasingproducts with less “packaging.” A “How-toGuide” for Environmentally Preferable Purchas-ing can be found at the Health Care WithoutHarm Web site, www.noharm.org under the“Going Green: A Resource Kit for PollutionPrevention in Health Care.”

Almost half of U.S. hospital waste is officepaper and cardboard, and most of the paperproducts have been bleached with chlorine dur-ing the paper production process. By moving tothe purchase of chlorine-free paper, a number ofhealthier and safer impacts will be experienced.During the production of bleached paper, anumber of pollutants are released into the envi-ronment, including dioxin. An average papermill that uses chlorine will use around 35,000—45,000 gallons of water per ton of pulp, whereasa chlorine-free pulp mill will use 2,500—3,000gallons per ton of pulp. The non-chlorine pro-cess results in the use of less water and energyand produces less pollution. Nurses should beadvocating that chlorine-free paper be used inall of their workplaces. For more informationon chlorine-free paper product selection, seeWeb site: www.chlorinefreeproducts.org.

Because so much of hospital waste is paperproducts, it is essential to recycle the paper afteruse. Hospitals can realize a huge reduction intheir waste stream and waste-related costs byrecycling paper.

Actions

Follow the Ten Actions to Promote Environ-mentally Preferable Purchasing (EPP).

Ten Actions to Promote Environ-mentally Preferable Purchasing(EPP)

What is Environmentally Preferable Pur-chasing? EPP is the act of purchasingproducts and services whose environmen-

Human Health EffectsAssociated With PesticidesAcute Effects

Irritation of eyes, nose, throat and skinNausea, vomiting, and diarrheaCoughing, wheezing, and asthma eventsHeadaches, dizziness, and loss of

consciousness

Chronic EffectsCancerReproductive and developmental

dysfunctionEndocrine disruptionImmunological and neurological

dysfunctionRespiratory diseaseBehavioral impairmentSkin conditions

(Physicians for Social Responsibility, 2000)

Integrated PestManagement Actions• Careful Monitoring—Clearly define

the type of pest, the level of infestation,the area infested, and the pathways ofentry and dispersal. Well-placed andcarefully observed sticky traps can alsohelp locate pests’ points of entry andhiding places.

• Sanitation and Maintenance—Remove the sources of food and water;without these sources, pests will die orsimply go elsewhere. Good housekeep-ing and timely repairs work wonders.

• Physical barriers—Screen, caulking,door sweeps, and similar devices caneliminate pest access to the hospitalinterior, to specific areas within the hos-pital, or to waste containers outside.

• Mechanical controls—Traps can catchand kill rodents. Flying insects can becontrolled with properly placed “bugzappers.”

• Insect sex attractants or hormonesused in baits and traps can interfere withbreeding, arrest development, or simplyenhance the effectiveness of a trap.

(New York State Health Care WithoutHarm Coalition, 2000)

The SustainableHospital Project—

www.Sustainablehospitals.org

The Sustainable Hospital Project at theUniversity of Massachusetts—Lowell hasa web-based clearinghouse for selectingproducts and work practices that eliminateor reduce occupational and environmentalhazards, maintain quality patient care, andcontain costs. Information about latex-freemedical gloves, safer needle devices, alter-natives to PVC products, batteries, andmercury-free products can be found at itssite.

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tal impacts have been considered andfound to be less damaging to the environ-ment and human health when compared tocompeting products and services. EPP is aculture that must be fostered at all levels,including development of government andhealth care industry policies. However,there are many everyday actions that canpromote and reinforce EPP. Here are ten:

1. Print a copy of the Hospitals for aHealthy Environment (H2E) “EPP HowTo Guide,” read it, and pass it on or postit. Make it required reading for people inyour department. This guide was writtenby the EPP Work Group of Hospitals for aHealthy Environment and is availableonline at: www.geocities.com/EPP_How_To_Guide

2. Understand why the purchasing stage isimportant.

• Procurement of most products andservices goes through the Purchas-ing Department.

• Money changes hands here, offeringthe greatest leverage on vendors.

• The closer to the source a problem iscorrected, the less costly it is (dol-lars, adverse publicity, technicalcomplexity.)

3. Incorporate environmental language inyour requests for proposals (RFPs) andpurchasing contracts.

4. Continually ask your vendors andGroup Purchasing Organizations for prod-ucts that are environmentally preferable.

5. Implement modest, measurable goalsfor EPP, then monitor progress. Forexample, buy only non-mercury ther-mometers, sphygmomanometers, andesophageal dilators.

6. Visit the Sustainable Hospitals Website, www.uml.edu/centers/LCSP/hospitals,for a list of alternative health care prod-ucts and practices. Contact the SHP Clear-inghouse for additional information andprinted resources: phone: 978-934-3386and e-mail: [email protected]

7. Subscribe to an EPP Newsletter. Askfor an electronic copy, rather than paper.A terrific EPP newsletter is published bythe Massachusetts Office of TechnicalAssistance. Read it online atwww.state.ma.us/ota/otapubs.htm#eppnet

8. Build a network of resources that pro-vide good ideas and allow you to identifybest practices. Visit the Web site:www.ciwmb.ca.gov/BizWaste/Fact-sheets/Hospital.htm for starters.

9. Ask hospital personnel how everydayactivities can be tuned to be more envi-ronmentally sound. Work with vendors toincorporate employees’ suggestions. Witha little prompting, an abundance of goodideas will come forth. For example, whenevaluating copy machines, place a premi-um on ones that are strong on two-sidedcopying.

10. Broadcast your successes. For exam-ple, use the hospital newsletter to promoteEPP achievements. (“Environmentally Preferable PurchasingHow To Guide,” Hospitals for a HealthyEnvironment (an AHA/EPA Partnership),online at www.h2e-online.org)

Batteries

Batteries come in all sizes and shapes and areproduced for many uses. Additionally, theyoften contain toxic chemicals that should neverbe incinerated. In hospitals, batteries powerpagers, IV pumps, fetal monitors, flashlights,and a variety of diagnostic scopes. Some batter-ies contain mercury, some lead, some cadmium,and some lithium. Whenever possible, recharge-able batteries should be employed. When this isnot possible, a careful battery round-up shouldbe implemented to capture and recycle or appro-priately dispose of the batteries. For more guid-ance, see “Battery Round-ups—Get Charged!”on the Health Care Without Harm web site:www.noharm.org in the Going Green: AResource Kit for Pollution Prevention in HealthCare.

Actions

Use rechargeable batteries whenever possible.On the Sustainable Hospital Program’s Web sitea list of rechargeable batteries is presented.See: www.sustainablehospitals.org.

If rechargeable batteries are not possible, col-lect and recycle used batteries. Make it easy forthose who use batteries to do this. For example,place the recycling container where the new bat-teries are stored so that recycling can be accom-plished concurrently with replacement.

Pollution PreventionThere are several important tenets to pollutionprevention:

• Use the least amount of “stuff” to beginwith;

• Select the least toxic product and pro-cesses;

• Choose products that can be reused ver-sus disposable;

• Recycle products when reuse is not possi-ble;

• Carefully segregate waste to optimizeyour reuse, recycling, and disposal choic-es;

• Opt for the most environmentally sounddisposal practices; and

• Avoid incineration.

Waste Minimization in HealthCare Settings

Managing health care related waste in an envi-ronmentally sound way can also be a cost-sav-ing management strategy. When Beth IsraelMedical Centers, in New York, implemented anaggressive waste minimization strategy in 1996,to reduce both the volume and toxicity of theirwaste, their resulting program saved the hospital$600,000, a savings that has subsequently beenrealized annually. Here are the steps outlinedby the Health Care Without Harm Campaign forwaste minimization, segregation, and recycling

in hospitals in their Going Green resource kit: • Establish a “Green Team” made up of

nurses, administrators, housekeepingstaff, and others who are responsible forwaste handling and occupational andenvironmental health and safety.

• Conduct a “waste audit” by examiningwhat comes into the hospital and what(and how it) leaves. Observe red bagwaste, solid waste, food waste, laboratorychemicals, and chemotherapeutic andpathological waste. (Typically, about85% of the waste will be noninfectiousand similar to the waste one would findin a hotel or even an office building. Theremaining 15% is classified as “regulat-ed” or “potentially infectious” and mustbe handled in a special manner.)

• Use the results of the audit to identifywasteful practices and develop a wastemanagement strategy that incorporateswaste reduction, reuse, and recyclingmeasures. Segregating the waste at thepoint of generation, before treatment ordisposal, is critical.

• Educate all hospital staff about the safeand appropriate segregation of waste forrecycling, reuse, and disposal. Card-board, glass, office paper, cans, newspa-pers, magazines, and certain plastics arecommonly recycled. (See inset for listingof recyclables.) Place signage at thepoint of waste disposal (trash cans,garbage bins, recycling containers, bat-tery capturing receptacles) to reinforcethe directions for proper segregation anddisposal.

• Combine waste management strategieswith sound purchasing practices toselect reusable versus disposable prod-ucts, as well as less hazardous productsand products with less packaging.

The Nightingale Institute for Health and theEnvironment (www.nihe.org) lists several addi-tional recommendations for managing medicalwaste: (1) Stay focused on reduction; (2) Ensureworker health and safety—provide appropriatepersonal protective equipment, as necessary; (3)Utilize safe medical waste treatment and dispos-al technologies; and (4) Ensure safe handling,storage, and disposal of hazardous materials, inaccordance with environmental regulations(Shaner and McCray, [online] available:www.nihe.org/elevreng.html).

“Environmentally smart materials manage-ment prevents problems down the road, such asmercury spills, grown waste disposal costs,dioxin creation, public relations problems fromhealth care’s environmental impact, etc. Thethree R’s of environmental responsibility—reduce, reuse, recycle—all involve opportuni-ties to prevent waste and eliminate toxicmaterials through materials management choic-es. When a hospital opts for disposable prod-ucts in place of reusable ones, it increases thevolume of waste dumped in landfills. When ahospital chooses mercury thermometers insteadof digital, it increases mercury pollution at land-fills and incinerators. Conversely, when Materi-als Managers evaluate the entire life of theproduct they are considering buying, they canreduce the negative environmental impact of theproducts.

“When hospitals choose to buy aneroid sphyg-momanometers instead of mercury blood pres-sure gauges, they protect hospital staff, patients,

36


the community and the environment. Theseenvironmentally-friendly decisions are also fre-quently cost-effective, as well. The cost of ananeroid blood pressure gauge can be less expen-sive than a sphygmomanometer containing mer-cury. Materials managers can take actions thatreduce waste volume and toxicity throughout thefacility. Their efforts are often easier to manageand can have a greater impact than end-of-the-pipe waste management” (New York City HealthCare Without Harm Coalition, 2000).

Reuse Success Stories

• At Boston’s New England Medical Center,sharps containers are sent to a company inNew York to be sterilized and then shippedback for reuse.

• New York’s Beth Israel Medical Center hasswitched from disposable to reusable foodservice plates, silverware, trays, examinationgowns, and bed underpads. (Contact personat EPA for more detailed information onsuch pollution prevention strategies: RussClark (202) 564-8856.)

• One hospital saved over $100,000 a year byreturning to reusable scrubs in the OR.

• Mattresses are now available with built-inegg crate foam pads rather than having toprovide disposable ones for each patient.

(Maryland Public Interest Group, 2000)

Nursing Leadership andAdvocacyWe are living in a time of incredible possibilities.We are also living in a time of troubling contra-

dictions. So many of our essential practices—energy production, food production, transporta-tion, and even the provision of healthservices—are not sustainable, not compatiblewith a healthy environment and thereby healthypeople. Nurses, as the foot soldiers and generalsin the defense of our public’s health, have thepotential to lead our patients and communities.We can educate and guide our policy-makers,including elected officials, to a new way of see-ing the relation between our life’s choices (bothindividual and societal) and their impact onhealth. Nurses are trusted and credible sources ofinformation and education regarding environ-mental health issues.

The good news is that there are a great manypeople in a wide range of organizations workingon environmental health concerns related to thehealth care sector: from nursing professionalassociations, other nonprofit organizations, thefederal government and academic institutions, tobroad-based coalitions.

The ANA continues to advocate for and teachabout environmentally safer and healthier hospi-tals in their joint venture with the EPA and theAmerican Hospital Association (AHA) in the for-mation of the “Hospitals for a Healthy Environ-ment” (H2E). H2E was born out of a landmarkagreement between the EPA and AHA in 1998 toeliminate mercury from the health care waste

stream and reduce total volume of waste by onethird by 2005 and by half by 2010. An additionalgoal is to minimize the production of persistent,bioaccumulative, and toxic pollutants.

Many other organizations, including nursingsubspecialty organizations, are taking active rolesin encouraging expansion of nurses’ roles inenvironmental health. The ANA has passed sev-eral environmental health-related resolutions,including a call for nurses to actively engage inpollution prevention. The American College ofNurse Midwives has assisted in the creation of abooklet entitled “Green Birthdays,” in which theydescribe the environmental health risks to preg-nant women and newborns in hospitals andbirthing facilities. It also guides midwives in thecreation of environmentally healthier birthingplaces. In this way, nurses can provide the nec-essary leadership to encourage primary preven-tion of environmentally-related illnesses, whichis a prescription for primary prevention.

In 1994, the American Public Health Associ-ation (APHA) called for a timed phase-out ofthe production and use of materials that lead tothe creation and release of persistent toxic sub-stances, including chlorinated organic chemi-cals—a source of building blocks for dioxin. In1996, APHA further recognized the relationshipbetween medical waste incineration and dioxinformation and called for steps to minimize diox-

Recyclables in HealthCare SettingsBatteries: White office paper

Ni-Cad Mixed office paperLead Acid Corrugated cardboardAlkaline BoxboardMercury oxide Junk MailLithium NewspaperZinc air MagazinesDry cell BooksOthers Steel cans

SilverAluminum Toner cartridgesGlass XyleneFluorescent lights FormalinOverhead transparency film

Plastics #1 PETE, #2 HDPE, #3 PVC, #4LPDE, #5 PP, #6 PS, #7 mixed

H2E OverviewThe primary goal of the H2E effort is to educatehealth care professionals about pollution preven-tion opportunities in hospitals and healthcaresystems. Through activities, such as the devel-opment of best practices, model plans for totalwaste management, resource directories, andcase studies, the project hopes to provide hospi-tals and healthcare systems with enhanced toolsfor minimizing the volumes of waste generatedand the use of persistent, bioaccumulative, andtoxic chemicals. Such reductions are beneficialto the environment and health of our communi-ties. Furthermore, improved waste managementpractices will reduce the waste disposal costsincurred by the health care industry.

To achieve the program’s goals, the Ameri-can Hospital Association and the US Environ-mental Protection Agency signed a landmarkagreement to advance pollution preventionefforts in our nation’s hospitals. The Memoran-dum of Understanding (MOU), which is thecornerstone of the H2E initiative, calls for:

• Virtually eliminating mercury-contain-ing waste from hospitals’ waste streamsby 2005

• Reducing the overall volume of waste(both regulated and non-regulated waste)by 33 percent by 2005 and by 50 percentby 2010

• Identifying hazardous substances forpollution prevention and waste reductionopportunities, including hazardouschemicals and persistent, bioaccumula-tive, and toxic pollutants

AHA and EPA entered into the MOU toequip AHA members and other health care pro-fessionals with the tools and information neces-sary to achieve the goals outlined above. Suchreductions are not only beneficial to the envi-ronment, but will also help hospitals minimizewaste disposal costs, and realize cost savings.

Program SponsorsH2E is a joint project of the AHA, the US

EPA, Health Care Without Harm, and theANA. In addition, various state and localresources have also joined the effort to helphospitals achieve the goals outlined in H2E.

How Can I Participate in H2E?If your organization is a health care facility,

you can join the H2E effort through the H2EPartners for Change program — www.h2e-online/program/partners.htm. Tools to guidepollution prevention activities include:

• Model plans for reduction of solid,infectious, and chemical waste—thegoals of H2E

• Model plan for mercury elimination • Model practice tool for minimizing the

volumes of waste generated and the pro-duction of persistent, bioaccumulative,and toxic pollutants

• Resource directories • Case studies

If your organization is not a health care facil-ity, but you would like to help, consider joiningthe H2E Champion Program, www.h2e-online.org/programs/champions.htm. Champi-ons encourage their members and customers tojoin the H2E program and attain the goals out-lined above. It’s a great way to help your mem-bers/customers reduce costs, while becomingbetter environmental stewards. H2E will alsorecognize top champions through its award pro-gram.

Where Can I Get Help?A set of resources have been collected

exclusively for the H2E program. See:www.h2e-online.org/tools/index

Last Updated: December 18, 2001 URL: http://www.h2e-online.org/about/

overview.htm

Use Reusable Alternativesto these DisposableProductsBedpans and urinals Cover gownsResuscitation bags Diapers Thermal blankets OR gowns and packsSuture removal sets Underpads Washcloths Laser printer cartridges

37


in generation and release. Members recognizedthe need for a fundamental re-examination ofmaterials and purchasing policies with the intentof reducing the use of hazardous products andkeeping them out of the waste stream as much aspossible without compromising patient care.

In 1997, the American Nurses AssociationHouse of Delegates passed a resolution for the“Reduction of Health Care Production of ToxicPollution.” In summary, the resolution called forthe ANA to:

• Support the definition of regulated medi-cal waste as developed by the Associationof Operating Room Nurses (in their defini-tion, “regulated medical waste” includespathological waste, human blood, bloodproducts, and body fluids plus four addi-tional categories of waste—sharps, cul-tures and stocks of infectious wastes,animal waste, and selected isolationwaste);

• Promote alternatives to products madefrom PVC; to support mercury-free healthcare delivery and facilities;

• Support non-incineration methods of med-ical waste disposal;

• Lobby for medical waste incinerator diox-in emissions to be less than 0.1 nanogramTEQ/dscm; and

• Educate nurses and other health care per-sonnel about these issues.

Background documents for the resolution, acopy of the resolution, and many exceptionalresources for nurses are provided in the ANAPollution Prevention Kit that can be obtainedthrough the ANA. (Available online: www.nurs-ingworld.org/DLWA/OSH.) The kit includes twovideos, one on mercury and one on PVC. It isimportant to note that the ANA resolution waspassed before the nursing community was madeaware of the issues involving DEHP; thereforethere is no language regarding this new andemerging issue.

In recent years, Physicians for Social Respon-sibility, an international Nobel Peace Prize win-ning organization, has expanded its work toencompass environmental health. (See:www.psr.org.) Its national office in Washington,DC, monitors activities on Capitol Hill that relateto environmental health and provides training andeducation programs on such issues as drinkingwater quality and antibiotic use in agriculture.Their web site provides several important full-textworks such as In Harm’s Way, a book on chil-dren’s health effects associated with persistentpollutants in our environment, including mercuryand dioxin. They have an excellent new web sitefeature that allows the interested viewer to followCongressional and regulatory efforts on environ-mental health. See: www.envirohealthaction.org.

Another set of potential partners for nursesinterested in environmental health is the commu-nity of academics, government employees, andactivists who are working on “sustainability,” theart and science of living in a manner that is bothfriendly to the environment and healthy for all.Some of the campaigns that have evolved in thesustainability movement include: Smart Growth,“Reduce, Re-use, and Recycle” activities, andGreen Buildings. Alliances with the sustainabili-ty community will help to build another practicaland multidisciplined approach to creating an envi-ronmentally sustainable future. They share muchcommon ground with the nursing profession.

Health Care Without Harm is the prime advo-cacy “organization” working with and in the

health care industry to become environmentallyhealthy. Health Care Without Harm expandedinternationally and now boasts hundreds of mem-ber organizations, with the ANA as one of theirfirst and most important ones. Many nursing sub-specialty organizations such as the Association ofOperating Room Nurses and the American Col-lege of Nurse Midwives are also members.Health Care Without Harm is a democraticallyrun campaign that has the following mission:

To transform the health care industry so it isno longer a source of environmental harm byeliminating pollution in health care practiceswithout compromising safety or care.

All nurses are welcome to join the “NursingGroup” of Health Care Without Harm. On amonthly conference call, the group discussesnurses’ roles in promoting and implementing themission of the Health Care Without Harm Cam-paign. Susan Wilburn, senior occupationalhealth and safety specialist at the ANA and Dr.Barbara Sattler, Director of the EnvironmentalHealth Education Center at the University ofMaryland School of Nursing, co-coordinate theNurses Work Group. The Health Care WithoutHarm web site provides invaluable informationabout the campaign, as well as contact informa-tion for getting involved—see www.noharm.org.

SummaryIn summary, the last page of “Green Birthdays,”the Health Care Without Harm and AmericanCollege of Nurse Midwives publication forenvironmentally healthy and safe birthingplaces, provides an excellent synopsis of theactions promoted in this independent studymodule. It recommends: • Reusable cutlery and dishware• Reusable linens and diapers• Reusable, mercury-free batteries• Supplies with minimum packaging in

reusable tubs• Recycling bins for paper, plastic, and cans• A red bag or other regulated waste container

that will be disposed of without incineration• Mercury-free thermometers and sphygmo-

manometers• Mercury-free lighting or low mercury fluo-

rescents that are recycled• Mercury fixatives and cleaning products• Integrated pest management instead of pesti-

cides• Cleaning products that are the least toxic

alternatives• PVC-free IV bags, tubing, wristbands, mat-

tress covers, shower curtains, upholstery, andbinders

• Low VOC, PVC wall coverings and flooring• Design that maximizes use of natural lighting• Mercury-free thermostats and switches• Rooms that are well ventilated• Adequate staffing levels• Needleless IV sets and other devices to pre-

vent needlesticks• Gloves that do not contain latex or vinyl• A no-lift or team-lift policy• A set of policies, practices, and educational

programs that insure greener birth days forfuture generations

(Full text for “Green Birthdays” can be found atwww.noharm.org/Green_Birthdays.pdf. Thecomplete booklet can be ordered from HealthCare Without Harm.)

Acting together, with each nurse takingjust one step, we can create a powerful collec-tive force to reduce the pollution created bythe health care industry and thereby keepourselves, our families, our patients, and ourcommunities healthier.

ReferencesAmerican Psychiatric Association. (1994). Diagnos-tic and statistical manual of mental disorders, FourthEdition.

Amin-Zaki, L. (1976). Perinatal methylmercury poi-soning in Iraq. Am. J. Dis. Child. 130:1070—1076.

Birnbaum, L.S. and Cummings, A.M. (2002). Diox-ins and endometriosis: a plausible hypothesis. Envi-ronmental Health Perspectives 110(1): 15—21.

Boyle, C.A. (1994). Prevalence and health impact ofdevelopmental disabilities in U.S. children. Pedi-atrics 93(3): 399—403.

Burbacher , T.M., Hohamed, M.K., and Mollett, N.K.(1988). Mercury effects on reproduction and off-spring size at birth. Reproductive Toxicology1(4):267—278.

Carpi, A. and Chen, Y.F. (Nov. 1, 2001). Environ-mental Science Technology 35(21): 4170—4173.

Carson, R. (1962). Silent Spring . New York:Houghton Mifflin Company.

Colborn, T., J.P. Meyers, and Dumanoski, D. (1996).Our Stolen Future: Are We Threatening Our Fertili-ty, Intelligence, and Survival? A Scientific DetectiveStory.

Consumer Reports (June, 1998). Your HEALTH:Hormone mimics: They’re in our food: Should weworry?

Danielson, N. (1998). Ethylene Oxide Use in Hospi-tals: A Manual for Health Care Personnel, 3rd Edi-tion. Chicago: American Society of Healthcare Cen-tral Service Professionals of the American HospitalAssociation.

Di Stefano, F., Siriruttanapruk, S., McCoach, J., andSerwood Burge, P. (1999). Glutaraldehyde: An occu-pational hazard in the hospital setting. Allergy 54:1105—1109.

Environmental Working Group. (1999). Protectingby Degrees: What Hospitals Can Do to Reduce Mer-cury Pollution.

Green Birthdays. (2001). Health Care Without Harmand the American College of Nurse Midwives. Avail-able online: www.noharm.org.

Harada, H. (1978). Congenital Minamata disease:Intrauterine methylemercury poisoning. Teratology18: 285—288.

Health Care Without Harm. (2001). Going Green: AResource Kit for Pollution Prevention in HealthCare. Available online: www.noharm.org.

Health Care Without Harm. (1999). How to Plan andHold a Mercury Thermometer Exchange.

Johnston, L. and Erickson, K. (2000). PreventablePoisons: A Prescription for Reducing Medical Wastein Maryland. Maryland Public Interest ResearchGroup.

MA DPH SENSOR Occupational Lung Disease Bul-letin. (2000).

Maryland Public Interest Group. (2000). PreventablePoisons.

McLachlan, J.A. (1985). Estrogens in the Environ-ment. Elsevier Science Publishing Co. Inc.

Melamed, A. (2000). Nurses attack hidden dangers ofhealth care. The American Nurse 32(6): 17. Availableonline: www.nursingworld.org/tan/novdec00/pollu-tio.htm.

National Research Council (NRC, 2000), NationalAcademy of Science. Toxicological Effects ofMethylmercury. National Academy Press.

(continued on next page)

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Resources

Books and Other Publications

• Look for new Environmental Health and Nursing byB. Sattler and J. Lipscomb, with invited authors,published by Springer Publications (to be out in Fall2002). See: http://www.springerpub.com/

• In Harm’s Way: Toxic Threats to Child Develop-ment. Ted Schettler, Jill Stein, Fay Reich, MariaValenti. Greater Boston Physicians for SocialResponsibility. See web site: www.gbpsr.org

• “An Ounce of Prevention: Waste ReductionStrategies for Health Care Facilities and Guide-book for Hospital Waste Reduction Planning andProgram Implementation” — (800) AHA-2626

• “Preventable Poisons: A Prescription for Reduc-ing Medical Waste in Massachusetts” — (617)292-4821

• “The Case Against Mercury: RX for PollutionPrevention”— (703) 548-5478

• “Guides to Pollution Prevention: Selected Hospi-tal Waste Streams”—Publication # EPA/635/7-90/009

• “Protecting by Degrees: What hospitals can do toreduce mercury pollution,” Environmental Work-ing Group, available on the web: www.ewg.org

Videos

• “The Health Care Industry’s Impact on the Envi-ronment: Strategies for Global Change” — Website: http://uvmce.ubm.edu:443/profprog.htm orcall (800) 639-3188 or (802) 656-2088

• “First Do No Harm” and “Mercury and theHealthcare Profession,” both available as part ofthe ANA Pollution Prevention Kit (product #9911; available from American Nurses Publish-ing: www.nursesbooks.org)

• “Moving Toward a Pollution PreventionApproach in the Healthcare Setting,” produced bythe University of Vermont (a new video is dueout on managing health care’s waste from theUniversity of Vermont)

Organizations• American Nurses Association — www.nursing-

world.org • Children’s Environmental Health Network —

www.cehn.org• Environmental Health and Nursing, University of

Maryland School of Nursing —www.enviRN.umaryland.edu

• Environmental Protection Agency —www.epa.gov

• Health Care Without Harm — www.noharm.org• Food and Drug Administration (for information

on DEHP and medical devices) —http://www.fda.gov/

• Hospitals for a Healthy Environment (H2E) —http://www.h2e-online.org

• Nightingale Institute for Environment and Health— www.nihe.org

• National Institute of Health (NIH) Mad as a Hat-ter — Mercury Elimination Program —http://www.nih.gov/od/ors/ds/nomercury

• National Toxicology Program, NIH — http://ntp-server.niehs.nih.gov/

• Physicians for Social Responsibility —www.psr.org

• Sustainable Hospitals / Lowell Center for Sustain-able Production — www.sustainablehospitals.org

• Vermont Agency of Natural Resources for Mer-cury Information ——www.anr.state.vt.us/dec/ead/ mercury/merc.htm

References (cont.)National Toxicology Program (NTP, 2000)—SourceDocument: NTP_CERHR Expert Panel Report onDi(2-ethylhexyl)phthalate, National Toxicology Pro-gram, U.S. Department of Health and Human Ser-vices, Center for the Evaluation of Risks to HumanReproduction, October, 2000.

Nethercott, J.R. (1988). Occupational contact der-matitis due to glutaraldehyde in health care workers.18: 193—196.

New York City Health Care Without Harm Coalition.(2000). Environmentally Safe Hospitals: ReducingWaste and Saving Money—A Resource Guide forNew York City Hospital Materials and Waste Man-agers.

Oris, P. (2000). Persistent Organic Pollutants (POPs)and Human Health. World Federation of PublicHealth Associations’ Persistent Organic PollutantsProject.

Physicians for Social Responsibility. (2000). Pesti-cides and Human Health: A Resource Guide forHealth Care Professionals.

Rossi, M. (2000). Toxicity of DEHP to VariousOrgan Systems. Neonatal Exposure to DEHP andOpportunities for Prevention.

Rutula, W.A. (1992). Medical waste. Infection andHospital Epidemiology 13(1): 38—48.

Schettler, T., Solomon, G., and Valenti, M. (1999).Generations at Risk: Reproductive Health and theEnvironment. MIT Press. (Can also be ordered onlineat http://www.igc.org/psr/pubs.htm.)

Schettler, T., Stein, J., Reich, F., and Valenti, M.(2000). In Harm’s Way: Toxic Threats to Child Devel-opment. Greater Boston Physicians for Social Respon-sibility. (Can be ordered online athttp://www.igc.org/psr/pubs.htm.)

Shaner, H. and McCray, [On-line]. Eleven Recom-mendations for Improving Medical Waste Manage-ment. Available online: www.nihe.org/elevreng.html.

Shaner, H. (1993). An Ounce of Prevention. Ameri-can Society for Healthcare Environmental Services ofthe American Hospital Association.

Shaner, H. (1997). Becoming a Mercury Free Facili-ty: A Priority To Be Achieved By The Year 2000.Professional Development series (Catalog #197103,American Society for Healthcare Environmental Ser-vices of the American Hospital Association).

Thompson, L. and Erickson, K. Preventable Poi-sons: A Prescription for Reducing Medical WastePollution in Maryland.

Thornton, J., McCally, M. and Orris, P. (1996). Hos-pital and plastics. Public Health Reports 11: 298—313.

Tickner, J. et al. (1999). The Use of Di-2-EthylhexylPhthalate in PVC Medical Devices: Exposure Toxic-ity, and Alternatives. Lowell Center for SustainableProduction, University of Massachusetts Lowell.Available online as a Lowell Center ResearchReport: http://www.uml.edu/centers/LCSP/.)

U.S. Department of Health and Human Services(2000). Center for the Evaluation of Risks to HumanReproduction. NTP_CERHR Expert Panel Report onDi(2-ethylhexyl)phthalate, National Toxicology Pro-gram.

US EPA (1997). Office of Air. Inventory of Sourcesof Dioxin in the United States, Mercury Study Reportto Congress, Volume I: Executive Summary .EA/600/P-98/002Aa. December, 1997.

Wagner, J. and Green, A. (1993). Correlation of chlo-rinated organic compound emissions from incinera-tion with chlorinated organic input. Chemosphere26: 2039—2054.

Wolfe, W.H., Michalek, J.E. and Miner, J.C. (1995).Paternal serum dioxin and reproductive outcomesamong veterans of Operation Ranch Hand. Epidemi-ology 6: 17—22.

Web Sites Cited in the StudyModule United States Environmental Protection Agency(EPA)• Office of Pesticide Programs, Food Quality Pro-

tection ACT(FQPA) of 1996—www.epa.gov/opppsps1/fqpa

• EPA, United States Environmental ProtectionAgency—www.epa.gov/seahome/mercury/Src/outmerc.htm

• EPA, mercury www.epa.gov/seahome/mercury/svc/ title.htm

• National Fish and Wildlife Contamination Pro-gram—www.epa.gov/ost/fish

• Integrated Pest Management (IPM) in Schools—www.epa.gov/pesticides/ipm/#fact

Nursing World• Nurses Attack Hidden Dangers of Health Care—

www.nursingworld.org/tan/novdec001/pollutio.htm• Workplace Issues, Occupational Safety and

Health—www.nursingworld.org/DLWA/OSH• Children’s Environmental Health—www.nursing-

world.org/mods/mod250/CESAVERS.htm• Pollution Prevention in Health Care—www. nurs-

ingworld.org/rnnoharm/

Heath Care Without Harm• Mercury Elimination— www.noharm.org/library/

docs/SHEA_proceedings_Mercury_Elimina-tion_White_Pap.pdf

• Neonatal Exposure to DEHP and Opportunitiesfor Prevention in Europe www.noharm.org/library/docs/ Neonatal_Exposure_to_DEHP-di-2-2ethylhexyl-phth.pdf

Hospitals for a Healthy Environment• H2E Programs: Become a Partner—www.h2e-

online.org/program/partners.htm• H2E Champion for Change Program—www.h2e-

online/program/champions.htm• Tools and Resources—www.h2e-online.org/

tools/index

Other Federal Agency andNGO Resources• Center for Food Safety and Applied Nutrition—

www.cfsan.fda.gov• Food and Drug Administration (FDA)—

www.fda.gov• National Institutes of Health (NIH) (mercury-free

campaign)—www.nih.gov/od/ors/ds/nomercury• Sustainable Hospitals four ways to find alterna-

tive products—www.sustainablehospitals.org/cgi-bin/DB_Index.cgi

• P2West, Western Regional Pollution PreventionNetwork for janitorial products pollution preven-tion project—www.westp2net.org/Janitorial/jp4.htm

• Office of New York’s Attorney General EliotSpitzer for Environment Protection Bureau—www.oag.state.ny.us/environment/environment.html

• The Capital Region Information Service of NewYork for New York coalition for alternatives topesticides—www.crisny.org/not-for-profit/nycap-nycap.htm

• Chlorine Free Products Association—www.chlo-rinefreeproducts.org

• Commonwealth of Massachusetts for health careenvironmentally preferable purchasing (EPP) net-work information exchange bulletin—www.state.ma.us/ ota/otapubs.htm#eppnet

• The Nightingale Institute for Health and the Envi-ronment—www.nihe.org

• Physicians for Social Responsibility (PSR)—www.psr.org

• Envirohealthaction—www.envirohealthaction.org

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1) Approximately how much hospital waste isgenerated annually?a. A half million tonsb. A million tonsc. Two million tonsd. Over two million tons

2) Nurses can have an influence on wastemanagement but first they must under-stand the makeup of hospital waste. Thelargest single component in hospital wasteis:a. Food wasteb. Plasticsc. Paperd. Infectious waste

3) The most commonly used plastic in thehealth care industry is:a. Polystyreneb. Polyvinyl chloridec. Styrofoamd. Polypropylene

4) The most common source of informationregarding human health effects associatedwith environmental chemical exposures isfrom:a. Occupational exposures to hazardous

chemicalsb. Animal-modeled toxicological studiesc. Accidental releases of hazardous

chemicalsd. Pharmacological studies

5) What form of mercury pollution presentsthe greatest risk to human health?a. Methylmercuryb. Mercury oxidesc. Elemental mercuryd. Inorganic mercury

6) Mercury contamination is a serious threatto children and pregnant women in whichof the following foods?a. Red meatb. Breast milkc. Fishd. Dairy products

7) DEHP (di(2-ethylhexyl)phthalate) compris-es what percent of PVC plastic?a. <5%b. 10%c. 20—40%d. >50%

8) Dioxin is an unintentional product of com-bustion when chlorinated compounds areincinerated. Dioxin is:a. Biodegraded in the environment when

exposed to sunlight.b. A product that has several useful func-

tions.c. A family of chemicals that is toxic and

bioaccumulative.d. Believed to have a half-life of 50 years

in the human body.

9) What percent of human exposure to dioxincomes from food?a. 1%b. 10%c. 90%d. 100%

10) The Industrial Hygiene Hierarchy of Con-trols is a:a. Framework for categorizing methods

of health and safety measures.b. Model for understanding the effective-

ness of disinfectants. c. Rule for selecting sterilants in health

care settings and schools.d. New Occupational Safety and Health

Regulation for cleaning products.

11) Two chemicals used for disinfection andsterilization that pose significant healththreats are:a. Alcohol and gluteraldehydeb. Gluteraldehyde and ethylene oxidec. Ethylene oxide and PVCd. DEHP and PVC

12) Integrated Pest Management (IPM) callsfor the: a. Use of several chemical solutions in

combating insect infestationsb. Employment of several disciplines

when using pesticidesc. Banning of chemical pesticides used in

hospitals and schoolsd. Combination of traps, physical barri-

ers, and chemical agents, as necessary

13) The 1997 ANA “Reduction of Health CareProduction of Toxic Pollution” Resolutioncalls for all of the following, except:a. Promotion of alternatives to products

made from PVCb. Support for mercury-free health care

delivery and facilitiesc. Support for non-incineration methods

of medical waste disposald. Support for the reduction of DEHP use

14) Nurses are playing a key role in improvingenvironmental health risks in the healthcare sector. Which of the following orga-nizations has the ANA partnered with toform Hospitals for a Healthy Environment(H2E)?a. American Hospital Association, Health

Care Without Harm, and OSHAb. Health Care Without Harm, OSHA, and

EPAc. American Hospital Association, EPA,

and Health Care Without Harmd. EPA, OSHA, and Health Care Without

Harm

15) There are several pollutants emitted duringthe process of incineration that posehealth risks. Dioxin is one of the pollu-tants and is known to be associated with:a. Visual impairmentb. Endocrine dysfunctionc. Osteoporosisd. Scleroderma

Environmental Health in the Health Care Setting

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

POST-TEST ANSWER SHEETDirections: Please circle the correctanswer. Answers on back of page.

INSTRUCTIONSRead the article and complete the POST-TEST ANSWER SHEET below. Check your answers and grade your-self using the FEEDBACK SECTION on the next page. Each answer is worth 6.66 points. If you receive a gradebelow 75 percent, please re-read the article and retake the test until you successfully score 75 percent or bet-ter. Complete the EVALUATION OF THE INDEPENDENT STUDY MODULE and the CE PROGRAM REGISTRA-TION (on the back).

This exam can also be taken online at www.NursingWorld.org/CE to obtain your ANA continuing educationcontact hours certificate.

Environmental Health in theHealth Care Setting1. D is correct. An estimated 2.4 million tons of waste is created annu-

ally by the health care industry.2. C is correct. Paper comprises about 50% of health care waste.3. B is correct. Polyvinyl chloride is the most common form of plastics

used in the health care industry.4. B is correct. The vast majority of our knowledge regarding the toxici-

ty of chemicals comes from animal and in vitro studies. We thenextrapolate the information to estimate human health risk.

5. A is correct. Methylmercury, the organic form of mercury created inthe environment poses the greatest risk to human health.

6. C is correct. Due to the mercury contamination in our water (bothfresh and ocean) fish have become sufficiently contaminated to posea serious health threat.

7. C is correct. DEHP is a significant portion of most PVC plastic: 20—40%

8. C is correct. Dioxin is a family of toxic chemicals that bioaccumulatein the environment.

9. C is correct. Approximately 90% of human exposure to dioxincomes from food, specifically in the form of beef, fish, and dairyproducts.

10. A is correct. The hierarchy provides a framework for categorizingmethods of health and safety measures.

11. B is correct. Ethylene oxide, a cold sterilizing agent, is a carcinogenand a reproductive toxin that can cause miscarriage; glutaradehyde isa potent skin irritant and sensitizer known to trigger asthma.

12. D is correct. Integrated pest management is a philosophy and sys-tem of managing pests that provides a framework for removing lifesupport systems for pests (food, water, and nesting space) alongwith least hazardous methods such as traps and sticky tapes beforemoving on to chemical solutions.

13. D is correct. DEHP concerns are not raised in the 1997 ANA resolu-tion. It is important to note that the ANA resolution was passedbefore the nursing community was made aware of the issues involv-ing DEHP, therefore there is no language regarding this new andemerging issue.

14. C is correct. H2E was born out of a landmark agreement between theEPA and AHA in 1998 to eliminate mercury from the health carewaste stream and reduce total volume of waste by one third by 2005and by half by 2010. The two newest sponsors of H2E are now theAmerican Nurses Association and the Health Care Without Harmcampaign.

15. B is correct. Endocrine dysfunction is one of the health effects asso-ciated with dioxin exposure. Dioxin exposure is also linked to neuro,immune, and behavioral dysfunction; cancer; altered glucose toler-ance; and endometriosis.

If you have a question about the incorrect answers or want a copy of the incorrect rationales, please call (800) 274-4262, ext. 7233.

40

Send the completed POST-TEST ANSWER SHEET, EVALUATION OFTHE INDEPENDENT STUDY MODULE, CE PROGRAM REGISTRA-TION and your check ($14 CMA members/$19 non-CMA members)by the deadline of December 31, 2003, to:

ANA/ANF Independent Study ProgramsAmerican Nurses Foundation

P.O. Box 90294Baltimore, MD 21279-0294

Fees are non-refundable. NY and CA residents must add sales tax.Your ANA Nursing CE Contact Hours Certificate will be mailed to you within 8 weeks.

CE PROGRAM REGISTRATION Checks should be made payable to ANA. Fees are non-refundable. NY and CA residents must add sales tax.

1. Name and Credentials: __________________________________________________Home Address: ________________________________________________________City, State, Zip: ________________________________________________________

2. Professional Role Title: __________________________________________________3. Specialty Area of Practice: ________________________________________________4. Institution/Employer: ____________________________________________________5. Business Phone: ___________________________ Fax: ________________________

Home Phone: _____________________________ 6. Social Security Number: __________________________________________________7. Are you a member of an ANA constituent member association (CMA)? __yes __no

If yes, which state? ________________________________________________________8. State of RN License: _____________ RN License #: __________________________9. State in which you are currently practicing: __________________________________10. Today’s Date: __________________________________________________________

The American Nurses Association is an accredited provider of continuing education in nursing by the American Nurses Credentialing Center’sCommission on Accreditation. Provider approved by the California Board of Registered Nursing Provider #CEP6178.

CONTINUING EDUCATION PROGRAMAMERICAN NURSES ASSOCIATION

Evaluation of the Continuing Education Independent Study:“Environmental Health in the Health Care Setting”

Author: Barbara Sattler, DrPH, RNPublished in TAN issue: March/April 2002

Program Code LD: 20204028 / Contact Hours: 3.3Processing Fee: $14 CMA members/$19 non-CMA members

Inquiries or Comments: If you have any questions about this or any otherANA/ANF Independent Study Module, please call our toll-free number (800) 274-4262 and ask for extension 7233. For questions related to other ANA continuingeducation activities, please contact RoAnne Dahlen-Hartfield, DNSc, RN, byasking for extension 7106. Duplicate Nursing Continuing Education Certificatesare available. All requests for duplicate certificates must be made in writing andinclude a check for $5 per certificate made payable to ANA. This and other ANA/ANF Independent Study Modules may be reprinted in their entiretyfor purposes of distribution to nurses for continuing education submission. All otherrights reserved.

Comments welcome! What other topics would you like to see developed into an independent study module? Please attach additional pages.

Look for ANA Independent Study Modules available on ANA’s NursingWorldweb page at www.NursingWorld.org/ce. Watch for new CE topics in future edi-tions of The American Nurse.

This continuing education is supported by Cooperative Agreement X-82812701-0 U.S. Environmental Protection Agency (EPA).

EVALUATION OF THE INDEPENDENT STUDY MODULEDirections: Please circle the appropriate number, which indicates your rating of each statement. Ratings range from 1=low/poor to 5=high/excellent.

Low or Poor High or Excellent Not Applicable ..............1. To what extent have you achieved each objective of this independent study?

Objective 1: Describe the major environmental health threats posed by the health care sector. 1 2 3 4 5 N/AObjective 2: Identify three chemicals that may affect children’s environmental health 1 2 3 4 5 N/A

associated with the health care sector.Objective 3. Explain the nurse’s role in taking action to improve the environmental health 1 2 3 4 5 N/A

risks in the health care sector.Objective 4. Specify three resources that can provide more guidance in improving 1 2 3 4 5 N/A

environmental health in the health sector.Objective 5. Discuss the goals of the American Nurses Association’s Resolution on Pollution 1 2 3 4 5 N/A

Prevention.Objective 6. Describe two products/processes that are employed in hospitals which create 1 2 3 4 5 N/A

health risks.Objective 7. List three health effects associated with incineration. 1 2 3 4 5 N/AObjective 8. Name three indicators of children’s health that may be related to environmental 1 2 3 4 5 N/A

health risks.

2. To what extent did the content relate to the study objective? 1 2 3 4 5 N/A

3. To what extent was the teaching method and aids appropriate and used effectively? 1 2 3 4 5 N/A

To what extent do you feel this independent study module will be:

4. Essential to your area of nursing practice. 1 2 3 4 5 N/A

5. Useful to your area of nursing practice. 1 2 3 4 5 N/A

6. Total amount of time in minutes it took you to enter on line www.nursingworld.org/ce and register for one of the free independent study modules: __________________

7. Total amount of time in minutes it took you to complete this independent study module, “Environmental Health in the Health Care Setting”: ________________________


environmental health in the health care setting · environmental health in the health care setting...

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