INTRODUCTION: WHAT DOES THE INTENSIVE CARE UNIT HAVE TO DO WITH THE NATURAL ENVIRONMENT?
There is a growing body of evidence that degradation of the natural environment causes harm to human health. Human health depends on clean air, clean water, freedom from poison, availability of nutritious food, and a stable climate. When these basic necessities are compromised, human health suffers.1
The focus of nursing is on health and healing. As described by their profession, nurses aim to create and support situations that support healing for their patients and their communities. One of nurses' most crucial roles is that of patient advocate, striving to protect a vulnerable patient or family member from harm. Although nurses work to create health, they are inadvertently causing harm, as the American health care sector is responsible for a significant amount of pollution, which puts us, our patients, and our communities at risk. The US health care system is responsible for 8% of annual greenhouse gas production by the United States.2 US hospitals create more than 6000 tons of waste per day, an average of 33 lb for every patient each day.3,4 Hospitals also use a large amount of toxic chemicals in everyday products and processes.
Health care and nursing practice, with resource- and energy-intensive processes, contribute to environmental harm through pollution and resource depletion. These negative impacts contribute to illness or poor health. When ill, people seek health care for treatment, which then further contributes to environmental harm, and so on. Through this process in US health care, a harming circle is created, as illustrated by the Figure.
In US acute care practice sites, the intensive care unit (ICU) is one of the most resource-intense environments. Replete with energy-intensive equipment, significant waste production, and multiple toxic chemicals, ICUs contribute to environmental harm. However, as noted previously, this is not the intent of nurses, neither professionally nor personally. Nurses would prefer to practice within their professional standards of practice, including Standard 16, stating: “The registered nurse practices in an environmentally safe and healthy manner.”5 What does that mean in the ICU? Can ICU nurses follow the lead of their operating room colleagues, who have addressed waste reduction and energy management in their professional position statements? This article explores opportunities to reduce factors in ICUs that contribute to environmental harm. It is hoped that it invites conversation and creative solutions, as ICU nurses strive to give the best care possible while causing the least amount of harm.
In the United States, more than 4 million patients are admitted to ICUs every year.6 The patients admitted to the ICU are the most critically ill, and while they account for only 5% to 10% of all patients in the hospital, the charges associated with their stays in the ICU account for 20% to 35% of hospital costs.6(p3) These costs are due to the complexity of these illnesses, greater use of interventions, and close monitoring necessitated by ICU patients. This atmosphere of high cost, high stress, and a highly vulnerable patient population provides an excellent opportunity to evaluate this area of the hospital, through the lens of hospital sustainability and environmental stewardship, for ways to decrease costs, improve patient outcomes, and increase satisfaction among patients, staff, and visitors.
There are a number of areas that can be evaluated within the ICU. In this article, these are broken these down into 4 main topics: energy use, waste, toxic chemicals, and the healing environment. Within each of these areas, there are multiple opportunities for nurses to become change agents on their units.
A nurse who has spent time in an ICU can close his or her eyes and imagine all the lights, monitors, pumps, computers, and other equipment that seem to line the walls. Fossil fuel–based energy use causes significant impacts on human health. First, the pollution created when fossil fuels are burned to generate energy cause health problems. Mercury, acid gases, and other pollutants are formed and enter the atmosphere. Mercury is a potent neurotoxin, contributing to health impacts and risk for fetuses and children. Acid gases contribute to respiratory disease, including asthma, bronchitis, and chronic obstructive pulmonary disease. Particulates contribute to heart and lung disease.7 Second, burning of fossil fuels releases greenhouse gases, which contribute to global climate change.8 Climate change is a serious threat to human health from heat-related illness, lung and heart disease, infectious disease, displacement, and more.9
Thus, when ICU nurses can reduce the amount of energy used, they are reducing risks to human health. There are a number of solutions to decrease energy use, as well as provide dollar savings to the health care facility through decreased energy costs.
Energy Star–rated equipment
Direct care nurses may not feel they have a lot of input into purchasing decisions about equipment choices. However, at the same time, nurses are responsible for nursing practice decisions and outcomes. Therefore, with every decision that impacts nursing practice, a nurse should be involved in the decision at some point. This could be as a member of the purchasing committee or as giving input as a nurse who will be using the equipment.
Nurses can request and advocate for energy efficiency in patient monitors, intrave-nous (IV) pumps, intra-aortic balloon pumps, temporary pacemakers, and other energy-intensive equipment. If energy-efficient equipment is not available, nurses can ask vendors to develop it. The Environmental Protection Agency's Energy Star rating is a great start for decision-making support to choose energy-efficient equipment and utilities.10
Newer hospital buildings may have digitally controlled heating and cooling systems. These will be set for optimal temperatures and air exchanges. Older buildings may not. In this case, nurses can contribute to energy savings by optimizing temperature settings according to the facilities management staff. Hospital facilities personnel have a challenging job to keep a building comfortable, hygienic, and energy efficient. Some areas of the hospital need to be kept cool (data centers, operating rooms, catheterization laboratories), whereas others need to be heated. Facilities staff may be heating one space while cooling the next, or cooling and then reheating the next. Nurses can reduce energy waste by working with facilities staff to provide optimal heat settings, which is often at 70°F year-round. Check with your facility's staff to learn what is most efficient in your area, maintaining stable room temperatures, using other means to heat and cool fluctuating patient temperatures.
After HVAC (heating, ventilation, and air-conditioning), lighting is typically the most energy-intensive factor in a hospital. Many hospitals are changing from incandescent lighting to fluorescent, and now to LED (light emitting diodes), since both labor and energy dollars are saved. Many hospitals are using more occupancy sensors for lighting so that lights are not left on when not needed. Occupancy sensors are very effective for closets, restrooms, offices, and other non–acute care spaces. They are not safe (nor are they allowed by regulation) in patient care or medication preparation areas. Thus, nurses can save energy by being aware of excess lighting and turning it off manually. If occupancy sensors are not in place in your facility, consider requesting them.
Computer systems in hospitals may be on around the clock. However, computer systems use a significant amount of energy if not on a planned hibernation cycle of a power management system.11 It is important to work with the Information Technology (IT) department to optimize energy savings while providing critical readiness of computers. Some hospitals use computer power management software. Others use centralized hibernation, controlling energy use from the IT department. Others set individual computers to hibernate when left alone. Others may do nothing to control computer energy use. Depending on the situation in a given hospital, nurses can impact energy use. If no power management program is in place, request it for the health of the community. If the IT department asks that computers themselves are left on, it is still possible to turn off the monitors when not in use.
Televisions in patient rooms present similar issues. Are they left on night and day to provide soft light, background noise, or distraction? Consider whether it is truly needed, and if not, turn off the TV. Especially any time a patient is discharged or a room is unoccupied, ensure that the television is off.
Sunlight coming into rooms can add wanted heat in the winter or unwanted heat in the summer. Nurses can develop a system for optimizing the use of blinds to help control room temperature. Closing blinds on the sunny side of buildings on summer days can help prevent overheating (and the need for more air-conditioning). Opening blinds on winter days can add heat to the room, decreasing the need for power plant–generated heat.
Much electrical equipment uses energy when plugged in even when the equipment is turned off. Hospital beds, IV pumps, code carts, and more may be among them. It is important to check with the Biomedical Engineering department, but it may be possible to prevent this vampire power loss (power spent on plugged in equipment even when fully charged). It may be possible to leave beds, pumps, and other equipment unplugged when not in use.
Rechargeable batteries have not typically been as convenient as disposable batteries, used for pagers, Vocera, temporary pacemakers, and so on. However, as their efficiency improves, it may be worth switching from disposable alkaline batteries to rechargeable reusable batteries for these purposes.
Hospitals are constantly remodeling, updating, or rebuilding. It is important to have nurses on building teams to address issues such as infection control, injury prevention, and process efficiency. Nurses can also contribute meaningfully on the health and safety of products and on the energy efficiency of buildings and equipment (Box 1).
As described earlier, hospitals create 33 lb of waste per patient-day. The largest creator of waste is thought to be the operating rooms, and ICUs may be second. In one of the few published evaluations of waste in the ICU, a 10-bed ICU at a 320-bed hospital produced 5% of the total hospital waste.12 Intensive care unit nurses know how much comes out of every room each day. Including landfill waste, infectious waste, hazardous waste, pharmaceutical waste, and recycling waste, the volumes are large. There are many opportunities to reduce waste in an ICU. Waste reduction, besides being environmentally friendly, may also achieve cost savings for the health care facility.
Recycling opportunities vary across the nation, depending on what markets exist for specific materials. Nurses can be key recyclers, helping to start, support, or expand a recycling program. Nurses can help organize recycling processes in the ICU and can help identify new products to recycle.
Case study 1: Nurses identify recycling opportunities
At Providence St. Patrick Hospital in Missoula, Montana, plastic recycling was limited to #1 and #2 plastic bottles. Two ICU nurses noticed that the IV bag dustcovers were made of #2 plastic and asked the recycling vendor if they could be recycled. After finding a buyer for that plastic, they said yes. Intensive care unit nurses set up collection bins for the dustcovers, which quickly spread to the rest of the hospital. When single-stream recycling became possible, and #1 to #7 rigid plastics were acceptable, this nonrigid #2 stream was continued. This spread to other hospitals and surgery centers in town. The ICU nurses had established a new recycling opportunity.
While recycling is important, reducing the use of resources in the first place is the most effective way to reduce waste. Many procedures in the ICU begin with premade kits. Intravenous start kits, catheter insertion kits, central line insertion kits, are a few examples. After each use, frequently there are items discarded that have not been used. It is possible to collect these items for later use or to give to medical missions, veterinarians, or others. It is also possible to reformulate the kits so that less is discarded. This not only takes effort but also typically saves the hospital money. When the kits are premade by the vendor, this can be a slow process. However, through nursing practice councils or purchasing committees, a more efficient kit can be designed and used.
Specialized waste treatment is both expensive and energy-intensive. Infectious waste is typically autoclaved. Hazardous and pharmaceutical waste is incinerated. Proper segregation of waste at the bedside can save energy and money. Intensive care unit nurses can lead this charge, establishing clear instructions and convenient processes. Metrics can be used to measure progress and savings. It is important to work closely with environmental services and facilities staff.
There are often many opportunities for reuse of tubs, trays, or other containers. These can be collected and given away or used in the ICU. The ubiquitous blue wrap may be reused at home or school. Some nurses have arranged for it to be given to animal shelters or to house painters or artists. It is a versatile water-impermeable fabric that can only be used once in a sterilization process but can be reused many times for other purposes. It is helpful if a collection area can be established and kept tidy in a busy ICU.
Understand cost of waste
Nurses are often unaware of the costs of energy and waste. When more aware, it is easier to make decisions aligned with efficiency. Facilities staff may be willing to share information with nursing staff on how much is spent each month and how waste segregation impacts the bottom line. They will often have a price per pound of various waste streams, such as that shown in Table 1.
After decades of disposable products, including isolation gowns, there is some movement toward reusable cloth gowns. They are often cost-effective and more comfortable, and they reduce waste. The infection control officer can work with direct care nurses to establish a system to trial or use reusable isolation gowns. They can typically be laundered 75 times or more without losing fluid impermeability. This means that 1 reusable gown replaces 75 disposable gowns.
Single-use device reprocessing
Many products are designed as single-use products. Yet, ICU nurses know that they often have much more life in them. The Food and Drug Administration has approved a list of single-use devices for reprocessing.13 This means that they are collected from practice sites, including operating rooms, ICUs, and other areas. The vendor cleans, inspects, repairs, resterilizes, repackages, and sells back to the institution at significant cost savings. Items may be reprocessed once or several times, depending on the product. Common items reprocessed in an ICU include oximetry probes, disposable blood pressure cuffs, and sequential compression device sleeves. Nurses can help establish and support this option, maximizing reuse and reducing waste.
Case study 2: Reducing waste through reprocessing
Many devices that are labeled as single use can actually be reprocessed by a third party reprocessing company and used again. Hospitals that implement reprocessing programs can reduce waste costs and decrease costs for the reprocessed devices, all without decreasing the effectiveness of the device or negatively impacting patient care. In 2011, Anne Arundel Medical Center began implementing a program to reprocess their single-use pulse oximetry devices. According to Sandy Fox, MSN, CCRN, RN-BC, Clinical Director Critical Care, the success of the program has been achieved through nurse engagement right from the start of the program, having adequate staff training on why this was being implemented, and placing containers for the used devices in a space that made staff less likely to forget to recycle the device upon patient discharge. Over the past year, the medical center has saved $349 305 by reprocessing their pulse oximetry devices.
Rethink contact isolation
Standard precautions for patients in contact isolation include disposable plastic gowns. See previous description for the potential use of reusable gowns. Another common practice is to discard any item that was in a contact isolation room to eliminate the possibility of transmitting infectious material from supplies to the next patient in that room. Some antibiotic-resistant bacteria die on surfaces within days or weeks. However, some bacteria develop spores (Clostridium difficile, for example). These spores can survive essentially forever, and it is considered unsafe to place equipment exposed to spores back in circulation for use.
Intensive care unit nurses can establish plans to reduce prestocking of all patient rooms so that only the equipment needed for the next shift is included. Nurses can avoid bringing any equipment and linen (see p. 7) into rooms until just before use. If leftover equipment has been exposed, nurses can work with infection control staff to establish safe guidelines for handling unused equipment. Depending on the organism, it could be stored for a period so no organisms remain, or it could be given to veterinarians or schools if they agree to take it for use.
Researchers are exploring the effectiveness of decolonizing all ICU admissions as a way to reduce the transmission of organisms. Decolonizing involves a series of baths with chlorhexidine and a nasal application of mupirocin.14 This would reduce the need for isolation, saving resources that isolation precautions require, thus reducing the amount of waste created.
Reduce linen waste
Washing hospital linen takes energy, water, and chemicals. Typically, any linen that enters a patient room requires washing even if it was not used by the patient. Nurses can decrease the amount of linen waste by planning ahead, using only what is needed, and checking to see what is already in the room before getting more. Nurses can also advocate for reusable pillows. Single-use pillows are a significant expense throughout their lifecycle when costs for purchase and disposal are considered.
The electronic health record should in theory reduce the amount of paper used, yet nurses know that is not always the case. There are many opportunities to reduce paper waste in the ICU. Nurses can request that laboratory orders or reports are not automatically printed. Nurses can ensure that printers are set to print double-sided as a default. Staff can track paper usage based on the number of reams purchased, setting goals for reduction over time. Meetings can be electronic, using slides and projectors for agenda, notes, and handouts.
Many hospitals have adopted a system providing meals on demand, when patients are ready to eat. In the ICU, nurses are often decision makers about meals and servings. They can order only what the patient is likely to eat, knowing that more can be ordered if needed. Likewise, staff can reduce unneeded food for employees to reduce waste and poor nutrition.
Exposures to toxic chemicals in the ICU can occur from a number of sources—such as air, dust, products, and food. By evaluating the types of products being used and exposure sources, nurses can advocate for an environment that is healthier for patients and staff. The following includes ways that nurses can engage to reduce exposure to potentially toxic chemicals, as well as several chemicals of concern in the ICU.
Environmentally preferable purchasing
A crucial way that nurses can reduce the number of toxic chemicals being introduced onto the unit is to become a member of the purchasing committee. By engaging in environmentally preferable purchasing, a purchasing approach that evaluates goods and services for their effects on human health and the environment, this committee can evaluate goods across the lifecycle from production to disposal, avoiding products that have the potential to harm human health and the environment. Kaiser Permanente has been a leader in environmentally preferable purchasing and has developed a Sustainability Scorecard for Medical Products, which they use to guide their purchasing decisions.15
Di-2-ethylhexyl phthalate (DEHP) is a chemical additive found in a number of products including flooring, food packaging, auto upholstery, and shower curtains. It is used throughout health care in products such as IV bags and tubing, nasogastric tubes, urinary catheters, and blood administration sets. DEHP is a plasticizer added to polyvinyl chloride to make it flexible. This flexible property is attained because DEHP does not tightly bond with polyvinyl chloride, and this creates a situation in which the DEHP can easily leach out of the product and into patients during procedures such as medication administration, blood transfusions, total parenteral nutrition, and dialysis.16
Data on DEHP, predominantly from animal studies, show developmental and reproductive effects with DEHP exposure. Male infants appear to be especially susceptible, and for infants undergoing multiple medical procedures, such as in the neonatal ICU, parenteral exposure to DEHP “can exceed general population exposure by several orders of magnitude.”16,17 Other populations that may be more vulnerable to the health impacts of DEHP exposure include pregnant women, peripubertal males, and infants younger than 1 year.18 Patients undergoing certain medical procedures such as all patients receiving enteral nutrition, adults undergoing cardiopulmonary bypass, adults and infants undergoing extracorporeal membrane oxygenation therapy, and pregnant or nursing mothers undergoing dialysis may also be exposed to unsafe levels of DEHP.
Many of the devices that typically contain DEHP are now available in DEHP-free versions. Nurses who care for high-risk populations, especially in the neonatal ICU and pediatric ICUs and those caring for pregnant or lactating women can advocate for DEHP alternatives to be used on their units. A number of tools have been developed that can assist in performing a unit audit and provide examples of alternatives.19 Because of the high demand from a growing number of health care facilities, the cost for many DEHP-free products is comparable with those containing DEHP.
Disinfection and proper cleaning are essential to infection control in the ICU. Intensive care unit patients are vulnerable to developing hospital-acquired infections (HAIs), due to the severity of illness, a high number of invasive procedures, and more frequent interactions with hospital staff. Hospital-acquired infections are associated with significant morbidity and mortality as well as increased health care costs. In the United States, 4.5% of hospitalized patients develop an HAI.20 This results in an estimated 100 000 deaths per year and $35 billion to $45 billion in additional health care costs and are associated with increased length of stay and readmission rates.20–22(p163)
To battle many of the organisms common in ICUs and responsible for HAIs, such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, or C difficile, many hospitals use strong disinfectant cleaners that, while effective, may pose health risks to staff and patients. For example, bleach-based cleaners are linked to respiratory and eye irritation among environmental services staff as well as nursing staff.23 In a survey of more than 1500 nurses on chemical exposures in health care, those nurses with the highest exposure to housekeeping and disinfecting chemicals (more than once a week) had 50% higher rates of asthma than those with lower exposures.24 Considering that respiratory failure is the most common cause of ICU admission, for the respiratory health of staff and visitors, hospitals are now looking at ways to disinfect without causing harm to patients and staff.6(p3)
Case study 3: Making the switch to peroxide based wipes—persistence pays off
In 2009, the University of Maryland Medical Center began investigating switching from CavaCide wipes to a peroxide-based wipe for use on durable medical equipment that stayed on the unit and was cleaned by nurses or other unit staff, such as IV poles and glucometers. The plan to switch was initiated because of long dwell times required by CavaCide for complete disinfection and reports of eye and respiratory irritation by staff. Peroxide-based wipes are nonirritating to skin, eyes, and respiratory system and have a significantly decreased dwell time needed for disinfection. Many stakeholders, including safety officers, infection control, nursing, and purchasing, were involved in the process. Unfortunately, they do not kill C difficile, so the hospital switched to bleach wipes instead. Soon after switching to the bleach wipes, staff began to complain of respiratory irritation with use and an unexpected outcome began to surface, the bleach wipes were creating a film on plastic surfaces, such as IV pumps, rendering the digital readings unreadable. Because of the reactions, the hospital decided to switch to the peroxide wipes and use bleach wipes only for patients with C difficile infection. While it was not a straight road to changing to a less-toxic product, through trial and error, this hospital was able to make the switch to a product that is safer for staff and patients while preserving infection control.
A new technology that is being embraced by ICUs and other high-infection/high-risk areas is the use of UV light technology to reduce infection and HAI rates. The UV lights break the molecular bonds in the organisms' DNA, rendering them incapable of reproduction. These devices are used following the standard room cleaning after patient discharge. The UV light devices are set according to the types of organisms found in the room and automatically calculate the length of time needed for the light to disinfect the room. Staff cannot be in the room during use due to the potential for eye damage from the light. A 2010 study found that bacteria on room surfaces reduced by 99.9% after 15 minutes of use and 99.8% of C difficile spores within 50 minutes.25 Hospitals that have begun using UV lights have noted that staff training is key and that staff needs to be prepared for the increased room turn over time that occurs with UV light infection control.
Triclosan is a synthetic chemical used in products for its antibacterial and antifungal properties.26 It is found in both household products and those used in health care, including antibacterial soaps, sutures, deodorant, toothpaste, and cosmetics. Since triclosan is an antibacterial agent, it is important to note that using triclosan has no impact on transmitting cold or influenza viruses.
Triclosan is a possible endocrine-disrupting chemical and in animal studies has been shown to interfere with thyroid hormone production and also been found to impact growth of breast cancer cells.27,28 In biomonitoring studies performed as part of the National Health and Nutrition Survey conducted by the Centers for Disease Control and Prevention, more than 75% of the US population has triclosan in their bodies.29
Most antibacterial soaps in the home and hospital contain triclosan. However, studies have shown that plain soap and water work just as well at reducing bacterial counts on hands.30 See case study 4 for an example of how one hospital was able to discontinue the use of soaps containing triclosan without compromising infection control.
Case study 4: Choosing safer hand soaps
Triclosan is commonly used as an antimicrobial agent found in hand soaps. In hospitals, nurses and other clinical staff are exposed to chemicals in hand soaps multiple times per day. A handful of hospitals have been successful eliminating or reducing the use of triclosan, reducing harm for staff, patients, and visitors.
Nursing staff at Providence St. Patrick Hospital led the way to find a safer alternative. After reviewing the literature, talking with experts from other hospitals, and talking with infection control medical and nursing staff, the decision was made to eliminate triclosan use in hand soaps. This was a 2-stage process. First, antimicrobial soap was placed only in high-touch areas, including patient rooms and nurses' stations. Plain soap was placed in public areas, all restrooms (including staff restrooms), and office areas. This reduced exposure significantly, as staff are required to wash with soap and water after using the restroom and can use alcohol cleaners much of the rest of the time. Second, triclosan was replaced with a soap using chloroxylenol. Chloroxylenol is not perfect but has less associated risk than triclosan.
A side benefit is that this 2 pronged approach also saved money. The chloroxylenol product was more expensive than the triclosan-containing product; however, by introducing plain soap in much of the hospital, overall costs were reduced.
Fragrances are found in numerous products throughout health care, including cleaning supplies, personal care products, and air fresheners. Many fragrances are considered respiratory irritants. Organizations such as the American Academy of Allergy and Immunology and the National Asthma Education and Prevention Program of the National Institutes of Health's Heart, Lung, and Blood Institute have provided guidance that asthmatic patients should avoid fragrances.22(p60) Fragrance-free items should be included in environmentally preferable purchasing plans. Hospitals may also consider becoming fragrance free, asking staff, visitors, and patients to refrain from using scented personal care products and perfumes while in the facility. It is important to note that fragrance free does not mean a product is toxic chemical free. Some products will include chemicals to mask the smell of an ingredient, and while not considered a fragrance, it may be an allergen or respiratory irritant. Staff and visitors should also be made aware when switching to nonscented cleaning products that the same high level of cleaning is still occurring but the fragrance they associate with cleaning will no longer be apparent.
Personal care products
Personal care products used in the hospital are similar or the same as those used in the home. The laws governing chemicals used in personal care products allow almost any ingredient to be used in these products, so many of them may contain chemicals linked to a number of health impacts: formaldehyde—skin irritation and a known human carcinogen; parabens—skin irritation, possible endocrine disruption, and reproductive toxicity; perfumes or fragrance—allergy and respiratory irritation; and polyethylene gylcol/Ceteareth/polyethylene compounds—usually contaminated with 1,4-dioxane, which is a probable human carcinogen.23,30–33(p176) When making personal care product purchasing decision, nurses can advocate for unscented products. They can also evaluate the ingredients on a Web site such as the Skin Deep Cosmetics Database and choose products made from safer ingredients (Table 2).34
The ICU, where you find the most vulnerable, critically ill patients in the hospital, can actually be among the areas least conducive to healing. It is a fast-paced, noisy environment that may increase the stress for the patient and family and decrease their ability to heal. Besides increasing the health and well-being of patients and visitors, a healing environment may increase staff satisfaction and improve retention and commitment to the job.
The ICU is a very noisy environment with alarms, beepers, overhead pagers, and staff conversations. The typical ICU has average sound levels of 55 to 70 dB(A), with pagers and alarms recorded at 84 and 79 dB(A), respectively, with peak sound levels in the ICU from 100 to 120 dB(A).40 These are significantly higher than the levels recommended by the US Environmental Protection Agency, which recommends hospital sound levels should not exceed 30 dB(A), with peaks no higher than 40 dB(A).41 To put these sounds in context, a vacuum cleaner sound is 70 dB(A) and a lawn mower is 90 dB(A).
Noise in the ICU environment has been shown to cause sleep disturbances, and there is a positive correlation between ICU delirium related to sleep deprivation and ICU sound levels.42 Noise also triggers the human stress response, which can result in delayed wound healing, hypertension, increased heart rate, and ischemic heart disease.43 Nurses working in the ICU may also be negatively impacted by the noisy environment. While nurses may not identify noise in the ICU as an issue for staff, the effects of noise may result in increased stress, increased irritability, and decreased patient safety due to delayed response to alarms in a noisy environment.43(p330)
There are a number of ways nurses can be change agents to reduce the noise in the ICU. Alarms can be set on the basis of patient needs, not to the default, so that unnecessary alarms do not sound. Staff conversations have been found to be one of the largest contributors to hospital noise. Nurses can become aware of conversational levels and put in place practices that will decrease conversational noise, such as closing patient doors during change of shift and giving report in conference or staff room instead of the nurses' station. Nurses can promote a quiet hour once a day where lights are dimmed, visitors are asked to leave, no nonemergent procedures are performed, and no deliveries are made to the unit. They can also advocate for vibrating pagers or personal hand-held devices for nurses instead of overhead paging. If a new unit is being constructed or renovations made to an existing unit, sound-dampening ceiling tiles, sound-absorbing wall coverings, and soft floors can also reduce noise on the unit.
Besides noise from alarms and monitors, many of these devices can also cause visual disturbances with flashing numbers and lights. The ICU rooms may not have natural light and the lighting in the room may be jarring, bright overhead lights. Natural light should be used as much as possible, as patients exposed to more natural sunlight have been shown to use less pain medication, report decreased stress, and have improved sleep quantity and quality.44 If the ICU windows can look out onto a healing garden or a natural environment, studies have shown that patients able to view the trees or other garden scenes from their windows use fewer pain medicines, heal more quickly, and have decreased stress.45,46 Ceiling-mounted fluorescent lights should be avoided, and if possible, dimmable, multidirectional lights should be used instead. If the screens on alarms and monitors can be dimmed or turned off while staff are not actively using them, this can also help decrease stress and visual disturbances for the patient. Painting rooms with soothing colors can also decrease stress and improve rest.
Respite spaces for family and staff
Depending on the design of the ICU rooms, there may not be comfortable places for family and friends, when they are in the room visiting the patient. Providing comfortable places for the family and friends to recharge may increase their ability to cope with the stress and anxiety of having a critically ill loved one in the ICU, helping integrate the family into the care of the patient. These respite spaces may include a lounge with comfortable seating and soothing colors on the walls. If a television is placed in the room, it is preferable to have individual speakers, with on and off switches, placed next to seats so that disturbances to others in the room and the ICU in general are kept to a minimum. An area with a refrigerator/freezer and a microwave can provide respite for family and other visitors. Both family and staff may benefit from a meditation area that can be used for “meditation, reflection, and spiritual contemplation. Special attention should be paid to designing restorative space for multiple cultures and faiths, so that all users feel welcome and comfortable.”44(p1595)
Just as food nourishes the body, it also nourishes the soul, and high-quality, nutritious foods can both increase appetites and aid in healing. Choosing sustainably grown foods, preferably from local sources, can reduce waste, improve conditions for farmers and animals and decrease the use of fossil fuels that are used to transport foods thousands of miles and may improve nutritional quality.47
More than 70% of antibiotics used in the United States are utilized as a feed additive for meat production.48 These antibiotics are not used to treat illness but are being added for nontherapeutic uses such growth promotion. Scientific consensus among experts, such as the National Academy of Science and the World Health Organization, highlights that this use of these antibiotics is contributing to rising rates of antibiotic-resistant bacteria and that nontherapeutic use of antibiotics in meat production should be curtailed.49 By procuring meat produced only without antibiotics, hospitals can help drive the industry to turn away from using antibiotics for growth promotion.
The Healthy Food in Health Care Initiative can help health care institutions evaluate the food available for patients, staff, and visitors and provide a “menu” of options for addressing this issue.50 This includes meat purchasing, purchasing from local farms, organic produce, free trade coffee, and creating an on-site farmers market. Health care makes up 17.6% of the US gross domestic product, and when hospitals make changes to their food procurement guidelines and specifications, these changes can positively impact other industries.51 While nurses may not feel they have control over the food purchasing decisions for their institution, they can reach out to dietary services with their concerns. By changing to healthier food for patients and staff, hospitals can model good eating behavior that will have positive impacts long after a patient is discharged.
Engaging staff in the effort to reduce the environmental impacts of ICU care offers many opportunities for education and idea generation. To a busy nurse in an adrenalin-filled ICU, reducing waste or saving energy may not be top of mind. To other nurses, who work hard to reduce waste, recycle, save energy, and water at home, it can be a frustrating experience to come to work and recognize the amount of resource use inherent in their daily work. Learning more about the links between resource use and health can help provide guidance and support for changing the way we practice.
Creating and supporting group activities can also help build interest and commitment to approach care processes from the perspective of reducing environmental impacts. A few ideas are listed as follows (Box 2).
Many hospitals have committees that address issues of environmental sustainability such as recycling, commuting, Earth Week celebrations, and education. Nurses often lead these efforts and always serve as prized members of the team. A unit-based green team can provide the education, awareness, and reminders that are needed for a sustained effort.
Some employers provide incentives to commuters who get to work in some way other than a single occupancy vehicle. Commuting can be healthier if walking or biking. Some hospitals now provide monetary incentives to employees who bike or walk to work. Nurses may also save money if carpooling or taking public transportation. Any single occupancy vehicle trip not taken saves fuel and the pollution it causes.
Professional Practice Councils or Unit-based Councils can address the American Nurses Association's Standard of Practice 16, which states: “The RN practices in a safe and healthy manner.”5 They can explore sustainability issues with staff to educate, gain support, and create engagement for advancing projects.
Nurses may be interested in volunteering for a river cleanup or Earth Week activities. Helping to organize projects can provide fun social interactions while contributing work that is meaningful. Some hospitals have created healing gardens, or productive gardens growing food for neighborhoods. Nurses may be asked to speak at colleges or high schools to discuss the complexities of environmental sustainability in an ICU setting. Intensive care unit nurses may have opportunities to provide education for other staff members.
There are several national nursing groups that provide information and support for environmental sustainability in nursing practice. The Alliance of Nurses for Healthy Environments is a robust group that offers webinars, phone meetings, and resources.52 They focus on practice, education, advocacy, and research. The American Nurses Association provides materials on climate change and health, environmental health, hazardous chemicals, and environmental policy issues.53 See Box 3 for resources.
Many opportunities exist to get involved to work toward a healthier natural environment, which, in turn, supports human health. State nurses associations, professional organizations, and environmental advocacy groups are all possibilities. The nurse is a valued team member.
Practicing in an environmentally safe and healthy manner protects patients, nurses, and our communities. While working toward environmentally safe and healthy ICUs is a complex endeavor, there are many small steps nurses can take, such as those outlined in this article. By focusing on reducing energy use, reducing waste, and handling waste responsibly, as well as by reducing use of and exposure to toxic chemicals, nurses can create safer and more sustainable work environments for both nurses and critically ill patients.
1. Corvalan C, Hales S, McMichael AJ. Ecosystems and Human Well-being. Geneva, Switzerland: World Health Organization; 2005 .
3. Hall AG. Green health care and nursing practice. AAACN Viewpoint. 2010; 32:(2):4–6.
5. American Nurses Association. Code of Ethics for Nurses With Interpretive Statements. Silver Spring, MD: American Nurses Association; 2010 .
6. Joint Commission Resources. Improving Care in the ICU. Oakbrook Terrace, IL: Joint Commission on the Accreditation of Healthcare Organizations; 2004; 3–16.
8. McFarlane GJ. Climate change—the greatest public health threat of our time: seeing the wood, not just the trees. Perspect Public Health. 2010; 130:(1):21–26.
9. Farquhar D. Climate change and public health. NCSL Legisbrief. 2010; 18:(27):1–2.
12. McGain F, Story D, Hendel S. An audit of intensive care unit recyclable waste. Anaesthesia. 2009; 64:1299–1302. doi:10.1111/j.1365-2044.2009.06102.x.
14. Huang S, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013; 368:2255–2265.
16. US Food and Drug Administration, Center for Devices and Radiological Health. Safety Assessment of Di(2-ethylhexyl) Phthalate (DEHP) Released From PVC Medical Devices. Rockville, MD: US Food and Drug Administration; 2001 .
17. National Toxicology Program, Center for the Evaluation of Risks to Human Reproduction. NTP-CERHR Expert Panel Update on Reproductive and Developmental Toxicity of Di(2-ethylhexyl) Phthalate. Alexandria, VA: National Toxicology Program, Center for the Evaluation of Risks to Human Reproduction; 2005 .
18. National Toxicology Program, Center for the Evaluation of Risks to Human Reproduction. NTP-CERHR Monograph on the Potential Human Reproductive and Developmental Effects of Di(2-ethylhexyl) Phthalate. Research Triangle Park, NC: National Toxicology Program, Center for the Evaluation of Risks to Human Reproduction; 2006 .
20. Klevens RM, Edwards JR, Richards CL, et al. Estimating health care-associated infections and deaths in US hospitals, 2002. Public Health Rep. 2007; 122:160–166.
21. Scott RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Atlanta, GA: Centers for Disease Control and Prevention; 2009 .
24. Environmental Working Group, Health Care Without Harm, American Nurses Association, & University of Maryland School of Nursing. Nurses' health and workplace exposures to hazardous substances. http://www.ewg.org/research/nurses-health
. Published December 11, 2007 . Accessed June 28, 2013.
25. Rutala WA, Gergen MF, Weber DJ. Room decontamination with UV radiation. Infect Control Hosp Epidemiol. 2010; 31:1025–1029. doi:10.1086/656244.
27. Zorrilla LM, Gibson EK, Jeffay SC, et al. The effects of triclosan on puberty and thyroid hormones in male Wistar rats. Toxicol Sci. 2009; 107:56–64.
28. Gee RH, Charles A, Taylor N, Darbre PD. Oestrogenic and androgenic activity of triclosan in breast cancer cells. J Appl Toxicol. 2008; 28:78–91.
29. Calafat AM, Ye X, Wong LY, Reidy JA, Needham LL. Urinary concentrations of triclosan in the US population: 2003–2004. Environ Health Perspect. 2008; 116:303–307.
31. National Toxicology Program. Report on Carcinogens, Twelfth Edition. Research Triangle Park, NC: Public Health Service, National Toxicology Program, US Department of Health and Human Services; 2011 .
32. Dodson RE, Nishioka M, Standley LJ, Perovich LJ, Brody JG, Rudel RA. Endocrine disruptors and asthma-associated chemicals in consumer products. Environ Health Perspect. 2012; 120:935–943.
35. Bello A, Quinn M, Perry M, Milton D. Characterization of occupational exposures to cleaning products used for common cleaning tasks-a pilot study of hospital cleaners. Environ Health. 2009; 8:11.
36. Healthcare Without Harm. Why Healthcare Is Moving Away From the Hazardous Plastic Polyvinylchloride (PVC). Arlington, VA: Healthcare Without Harm; 2006 .
38. Sattler B, Afzal B, Baier-Anderson C. Report on Public Health Concerns-phthalates and Bisphenol-A. Baltimore, MD: University of Maryland; 2008 .
40. Pugh RJ, Griffiths R. Noise in critical care. Care Critically Ill. 2007; 23:105–109.
41. US Environmental Protection Agency. EPA Identifies Noise Levels Affecting Health and Welfare. Washington, DC: US Environmental Protection Agency. http://www.epa.gov/history/topics/noise/01.html
. Published 1974 . Accessed June 28, 2013.
42. Ely E, Gautam S, Margolin R, et al. The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med. 2001; 27:1892–1900.
43. Choiniere DB. The effects of hospital noise. Nurs Adm Q. 2010; 34:327–333.
44. Thompson DR, Hamilton DK, Cadenhead CD, et al. Guidelines for intensive care unit design. Crit Care Med. 2012; 40:1586–1600.
45. Ulrich R. View through a window may influence recovery. Science. 1984; 224:224–225.
46. Cooper Marcus C, Barnes M. Healing Gardens: Therapeutic Benefits and Design Recommendations. New York, NY: John Wiley & Sons; 1999 .
48. Mellon M, Benbrook C, Lutz Benbrook K. Hogging It: Estimates of Antimicrobial Abuse in Livestock. Cambridge, MA: Union of Concerned Scientists; 2001 .
52. Alliance of Nurses for Healthy Environments. http://envirn.org
. Accessed June 28, 2013.