Although the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) wasn't around in the 1800s, environment of care (EC) in hospitals has been an issue ever since Florence Nightingale first made her observations on cleanliness and health outcomes.
Just like Nightingale determined that cleanliness could improve patient outcomes, hospitals are now showing that pollution prevention programs can help improve JCAHO EC outcomes and reduce overall costs as well.
Some possibilities
How can ES managers develop pollution prevention strategies into JCAHO performance improvement initiatives? The following are some possibilities:
* "Green" cleaners. One improvement initiative reinforcing the JCAHO's mandate that "the organization plans for a safe environment" could be the use of safe cleaning chemicals.
Many traditional cleaners have negative health effects. Some can be immediate, like headaches, eye and nose irritation and respiratory problems. Evaluate cleaners that are less harmful to people and the environment.
For instance, when Rosario Simone, ES manager at Greenwich (Conn.) Hospital, learned that one of his sister hospitals instituted green cleaning in its pediatrics department because of concerns over the effects of traditional chemicals on newborns, he saw an opportunity to decrease the environmental harm from cleaners at his facility too.
"We want the cleaners to be safe for people using them daily and for the people exposed--patients, visitors and staff," explains Simone. "Nurses in a couple of units reported sensitivity to chemicals like shampoos and strippers. They'd smell the chemical and react with a respiratory problem."
After inventorying all the chemicals used in all cleaning chores, Simone identified their ingredients and cross-referenced those in toxicology texts.
The hospital took about nine months to investigate alternatives.
Simone looked into the vendors, reviewed their literature and
checked into their claims. Many of the products met the specifications
of a Washington, D.C.-based nonprofit group called "Green
Seal," whose Web site is at www.greenseal.
org.
The hospital also tested them internally for efficacy. The nurses who previously experienced side effects were also involved in selecting the green cleaners. Of course, the new cleaners were also presented for approval to the infection control committee.
In selecting alternatives, managers should remember that different levels of cleanliness are needed for different activities, and to use the lowest level that meets their needs. For instance, Greenwich Hospital did not change the germicide for infection control. It will still be used in ORs and where the likelihood of microbes is high. The new cleaners are for general purpose uses, such as certain furniture, lounges, conference rooms and offices.
The hospital did a product-by-product cost comparison, and the green cleaners priced out similar to the traditional cleaners, Simone adds.
* Eliminating phenols. When looking at disinfectants, another way to plan for a safe environment may be by considering a move away from phenols.
Phenols are toxic and highly corrosive. Overexposure can cause headaches, and sinus and respiratory problems. They are not recommended for nurseries, because their fumes are noxious and babies cannot metabolize them. They are also hard to dispose of in an environmentally sound manner.
Health facilities are moving toward safer chemicals by switching from phenolic disinfectants to using Hepatitis B quaternary ammonium compounds (HB quats), which have demonstrated efficacy against Hepatitis B and human immunodeficiency virus. They meet the U.S. Occupational Safety & Health Administration's Bloodborne Pathogen Standard for cleaning blood spills.
For instance, Ridgeview Medical Center, Waconia, Minn., switched from using phenols to using HB quats, says Laurie Salden, guest services manager.
There was concern that the products wouldn't work. But, she says, they work well and are much easier on the environment, which fits with Ridgeview's mission to become sustainable to improve community health.
Quats are less toxic than phenols. But they contain chlorine. Chlorine-based compounds, such as DDT, chlorofluorocarbons and dioxins, have been problematic for the environment and possibly human health. Better alternatives may be developed, possibly using hydrogen peroxide. Of course, it is essential that ES managers receive approval from their hospitals' infection control professionals for any contemplated changes in disinfection products.
* Concentrates. Switching from ready-to-use cleaners to hyperconcentrates can help achieve the JCAHO's mandate that the organization plans for employee safety by reducing the chance of spills and splashing, as well as decreasing the volume of solid waste that is created.
Because hyperconcentrates use a closed-handling system, pouring is eliminated, making product mixing and transfer safer. Systems no longer require staff to change out dispensing tips.
For example, St. Joseph's Medical Center in Brainerd, Minn., uses a twist-and-fill concentrate system. Kim Henson, director of housekeeping, says she couldn't stand having all those extra chemicals around and she finds that the dispensing system decreases the amount of chemical used and is safer. St Joseph's also finds that one or two products now do the job of many different cleaners they had been using.
"You basically don't get spills," says Henson. "I looked at the change as JCAHO standards for employee safety."
Ridgeview Medical Center also uses hyperconcentrates. "At first, staff didn't like losing their ready-to-use cleaners," says Salden. "Once I started focusing on their safety, the new system started gaining their acceptance."
Even though the ES staff has to dispense the cleaner, the system saves them time because they spend less time getting their supplies.
"The service closets are small, so we used to keep the chemicals close to the [ES] department. Now, the concentrates are stored right in the service closets," Salden says.
A one-quart container of concentrate disinfectant replaces 180-gallon containers of HB quat, which frees up storage space, and cuts down on the volume of waste. The smaller cartridges are put on a shelf, also making it easier to track inventory.
"We've reduced the volume of container waste from aerosol cans, spray bottles and gallon jugs," Salden adds.
* Solid waste. Hospitals produce an average 6,600 tons of waste a day. Reducing waste improves the organization's environment by improving cleanliness in the facility and also improves safety conditions for environmental services staff by reducing the waste moved from site to site.
Environmental services staff members are all over a facility and they know what people are tossing. When environmental services staff pay attention to trends inside the dumpster and the roll-offs from each floor, the observations can be turned into suggestions for how other departments could be making better tossing and purchasing decisions. In addition to improving the environment, such programs also provide financial benefits.
For example, Kaiser Permanente in Portland, Ore., has decreased solid waste by 45 percent in the past four years, reducing everything from paper and cardboard to "e-waste" like computer disks and microfiche. "Last year we avoided $67,000 in waste disposal costs," says Mike Walter, strategic sourcing manager.
The cost of garbage and debris in health care is tremendous, agrees Joe Carroll, facilities engineer at Covenant Health Care in Saginaw, Mich. Carroll tells contractors and vendors that they can't leave their waste behind after a project or a delivery.
Instead of sending paper documents to an outside source for shredding and recycling, Ridgeview now shreds all of its paper internally. A local farmer picks up the shredded material to use as animal bedding. Since August 2002, 51,530 pounds of paper have become animal bedding, saving the medical center $7,000 in waste handling charges.
* Infectious waste. Keeping volumes of infectious waste--red bag, biohazardous or regulated medical waste--as low as possible reduces risks from spills and from handling large volumes of a potentially hazardous waste stream, again contributing to safety.
Economically, infectious waste costs five times as much to manage as solid waste. Keeping solid waste out of the red bag can cut disposal costs.
When three health care organizations in Burlington, Vt., merged, they standardized waste management programs. One of the hospitals reduced regulated medical waste by 76 percent within 90 days by adopting another site's guidelines and definitions for regulated medical waste.
In another instance, staff members working with isolation patients at Ridgeview Medical Center were throwing linens away in the red bags. "They needed to know that all linens are washed for infection control," says Salden. "With 1,000 people on the campus and new staff all the time, education is important."
Ridgeview also educated people on what is infectious waste, and has placed postings at collection points instructing them on proper and improper items for collection.
* Suction canisters. One study found that 25 percent of infectious waste at hospitals is suction canister waste. Environmental services staff is at risk of exposure to the infectious waste when carrying the containers and dealing with spills.
At Mary Greeley Medical Center in Ames, Iowa, canisters were a big infection control issue, as well as a cost and time issue, according to Jan Robinson, clinical supervisor. When suction canisters at the medical center were full, nurses would change them out, and there was always the possibility of splashing.
Additionally, canister systems are expensive to maintain. The medical center was spending about $850 a month just in canister supplies. The waste had to be put in hazard containers that were expensive to dispose of.
Robinson learned about suction drain system technology and brought it to the medical center's product improvement committee. Suction drain systems are canister-free and empty directly into the sanitary sewer.
By installing the canister-free system, Mary Greeley Medical Center has eliminated potential exposures to infectious materials and the expense of handling canisters and disposing of the infectious waste.
Making change
Environmental services has a great impact on the hospital's environment of care, and it can have an even greater impact by using pollution prevention strategies.
The hospital's environment of care team is the best place to get direction on how to look at performance improvement initiatives, especially when the director of ES sits on the team, says Laura Brannen, program coordinator for Hospitals for a Healthy Environment (H2E), a Washington D.C.-based voluntary environmental program founded through a memorandum of understanding between the U.S. Environmental Protection Agency and the American Hospital Association.
Attaching environmental initiatives to Environment of Care standards creates an opportunity to advance a pollution prevention and safety project. And that's the first step toward accomplishing it.
Debra McKinley is communications manager and Catherine Zimmer is health care specialist for the Minnesota Technical Assistance Program, University of Minnesota, Minneapolis. McKinley can be reached at mckin013@umn.edu and Zimmer can be reached at zimme053@umn.edu.
This article first appeared in the March 2004 issue of HFM.
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