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Greening in healthcare

Laustsen, Gary PhD, RN, FNP-BC

Nursing Management (Springhouse): November 2010 - Volume 41 - Issue 11 - p 26–31
doi: 10.1097/01.NUMA.0000389012.82998.5d
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You play a key role in developing a more environmentally sustainable professional practice.

Gary Laustsen is an assistant professor at Oregon Health and Science University, School of Nursing, La Grande, Ore.

You play a key role in developing a more environmentally sustainable professional practice.

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Concerns for global ecosystems and an increase in general ecological beliefs are becoming more commonplace, both in personal and in professional practice. The nursing field is no different, as healthcare facilities are in need of environmentally sound policies. According to the Environmental Protection Agency (EPA), healthcare organizations spend more than $8.5 billion on energy each year to meet patient needs.1 Healthcare facilities and practices contribute to the degradation of healthy environments, which, in turn, can cause more disease in humans.

Ecological behaviors in the nurse's professional environment can help develop more environmentally friendly, or "green," nursing practices. This can improve local and global environments by decreasing the amount and costs of waste disposal, as well as reducing potential human or environmental health threats. Ultimately, such activities seek to promote a sustainable human ecosystem. Nurses can play a key role in developing a more environmentally sustainable professional practice.

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What is it?

Greening has come to mean any activity—whether personal, group, or through established organizations—that seeks to improve and minimize negative effects on the environment while producing sustainable changes. One way to measure the effect of activities on the environment is the ecologic footprint, which is an estimate of the land area needed to maintain resource consumption and waste assimilation requirements for a person or population.2 Because consumption of resources releases carbon dioxide, primarily from the use of fossil fuels, the ecologic footprint is sometimes referred to as the carbon footprint.

Activities that may reduce a person's ecologic footprint include recycling or reducing energy consumption. Nurses and healthcare facilities that seek to reduce their ecologic footprint should examine professional work habits and facility systems that may be contributing to environmental degradation. The understanding of how certain actions affect the environment can help identify areas of improvement to reach the goal of long-term ecologic sustainability.

Concern for the environment has been a prominent concept in nursing practice since Florence Nightingale recognized the "five essential points" important to good health: air, light, cleanliness, water, and drainage.3 Before the environmental movement of the 1960s, nursing knowledge and awareness of environmental concerns were focused only on the patient's immediate surroundings. The environmental movement of the late 1960s and early 1970s shifted society's view, as well as nursing's view, of the environment.

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Greening your facility

The OR has a high level of energy and technology use, including increased lighting, when compared with other hospital units.4 Proper selection and use of equipment can decrease the OR's electrical energy consumption, which will also reduce its costs. Improved lighting technology, in addition to reducing energy usage, can also reduce carbon emissions. Equipment and computers can be "powered down" or turned off when not used for a significant period. TV or monitor screens consume a large amount of energy and should be turned off when not in use.

Another option to consider is delivered green power or green tags. The use of renewable sources of energy or green power, such as wind power, can improve the carbon footprint of the OR by reducing the amount of carbon dioxide emissions generated. Delivered green power is electricity produced by renewable sources directly transmitted to the purchaser's facility.5 If delivered green power isn't available, green tags allow electrical consumers to purchase green power produced outside their local area. Green tags, also called carbon offsets or renewable energy certificates, help offset the costs of renewable energy. The use of either delivered green power or green tags has a similar result—a reduction in carbon emissions and decreased negative environmental effects.5

The physical structure of the building or room can also have an effect on the environment. Although the higher costs of constructing a green building have been a deterrent, improved construction and technology are reducing these costs to be more in line with those of standard construction. And after construction, green buildings provide financial benefits that conventional buildings don't, including energy and water savings, reduced waste, improved indoor environmental quality, and lower operations and maintenance costs. Green buildings also offer the added benefits of greater employee productivity and reduced employee health costs.6

Improving the facility during new construction or remodeling provides another opportunity. According to an EPA study, the top five green building strategies for healthcare include energy efficiency, process water efficiency, sustainable flooring material selection, selection of materials for indoor air quality, and lighting efficiency.7

An already-standing area can be adapted to better the environment by improving wall insulation, using nontoxic paint and wall surfaces, using sustainable products for floors and furniture, and increasing natural lighting through windows or light tubes. A valuable resource for facilities considering green construction is the U.S. Green Building Council's LEED (Leadership in Energy and Environmental Design) certification program, which is an internationally recognized green building certification system that provides third-party verification.8

Results of these changes are tangible. For example, since 2004, the OR staff at the Oregon Health & Science University (OHSU) hospital has sought ways to decrease wastes and increase its energy efficiency. The ORs have been refitted with light-emitting diode lights and low-mercury lamps, which have saved an estimated 340,000 kilowatt-hours (kWh) of energy annually. This also saves approximately $40,000 a year, for an average cost of $0.12 per kWh.9 By purchasing green tag renewable energy certificates for the OR, OHSU has also decreased its carbon output by 265,000 lb each month by replacing traditional polluting energy sources of electricity with clean and sustainable sources of energy.9

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Greening the equipment

According to Health Care Without Harm, a nonprofit organization that promotes environmentally based, healthy options to replace healthcare practices that pollute and cause disease, these products are usually less toxic; are more energy efficient; are safer and healthier for patients, workers, and the environment; and have a higher recycled content with less packaging. They also produce less pollution.10

Supplies. Disposable products and supplies are prevalent in areas such as the OR. Deciding whether to use disposable supplies and instruments or to purchase and resterilize surgical pieces can be a challenge. Some considerations are the initial cost and longevity of nondisposable supplies and instruments, the cost and availability of water for cleaning the supplies and instruments, the cost of waste handling and disposal, and the cost of personnel to handle, sterilize, and repackage nondisposable supplies and instruments.

There's also the issue of accumulating unneeded supplies and instruments. Disposable surgical trays and packs often contain supplies or instruments not used by the OR staff because of surgeon preference or the specific need of the particular surgical case. ORs that order a large number of disposable trays could negotiate with the product supplier to eliminate items in the trays that aren't typically used or needed. Locating local or international organizations to recycle noninfectious supplies can reduce waste disposal costs and effects. Finding supplies that are encased in minimal packaging, using equipment that can be sterilized for reuse, and opening procedural supplies only when needed can decrease the amount of waste. This can save the hospital both purchasing and disposal costs.

Replacing traditional products with environmentally preferable purchasing (EPP) in a facility may require participation from multiple groups throughout the organization. Switching to EPP may also require new written policies.

Waste products. Medical waste disposal poses a threat to the environment through the contamination of water, soil, and air. Waste reduction and management is perhaps the most effective and practical area for promoting the green OR. The four general areas for waste reduction are precycling, recycling, reducing, and reusing. To begin the process of waste reduction, conducting a waste audit of the facility's waste stream can identify opportunities for improvements and enhance environmental and waste programs.

Recycling waste products may be difficult because of additional concerns and regulations dealing with regulated medical waste or biohazardous materials. However, many supplies don't come into contact with blood or body fluids. Cardboard, office and printer paper, glass, and plastic bottles are some of the more easily recyclable products.

Blue sterile wrap and plastic film are common coverings in OR supplies. In one study, blue sterile wrap comprised 19% of all surgical waste.11 Some hospitals have found opportunities and cost savings in recycling these materials. Dominican Hospital in Santa Cruz, Calif., started a program to recycle blue sterile wrap and plastic film in 2001, and recycled an average of 1,300 lb/month.11 The Legacy Hospital System in Portland, Ore., used a similar recycling program to divert 3.5 tons of blue wrap each month.11

An unrecognized recycling opportunity is the disposal of electronic equipment, or e-waste. Electronic devices that are incinerated or dumped in landfills can produce heavy metal and other pollutants. Much of the e-waste from the United States is exported to Asia where people are exposed to the hazardous chemicals and fumes while processing this waste.12 To minimize e-waste and its potentially harmful effects on human health during disposal, healthcare facilities should purchase more environmentally preferable computers and electronic devices, and recycle old and discarded electronics in an environmentally and socially responsible way.13

Improving waste management may be as simple as increasing the number of waste receptacles or relocating some of them. The prominent accessibility and larger size of the regulated medical waste receptacles often result in the disposal of regular trash into these containers. As part of a research project in a Denver, Colo., hospital, the contents of a redbag receptacle were inventoried after a single OR case. Of the contents, 92% (by weight) was regular trash that should have been placed in regular trash receptacles.14 Regulated medical waste must be rendered noninfectious through energy-intensive methods, and the cost for this is approximately 10 times greater than regular trash disposal. Reducing the inappropriate disposal of regular trash in these bags can decrease waste disposal expenses and environmental effects resulting from the decontamination of regulated medical waste. Educating OR staff, providing larger and better locations for regular trash receptacles, and placing signage on receptacles can help improve waste segregation.

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Greening the staff

Changing professional behavior may be difficult because of the security associated with a familiar and consistent way of working. In addition, changing practice-related behaviors that may improve the environment must also meet the standards of "do no harm" to patients. Nurses must adhere to their facilities' policies and procedures. If these policies or procedures conflict with proposed greening activities, policy changes are necessary (the Association of periOperative Registered Nurses offers documents to guide perioperative nurses who wish to promote environmentally responsible practices in their OR).15

One way to address the issue of waste from excess equipment and supplies for surgical procedures is to precycle, or reduce, the incoming waste stream. In preparing for surgical procedures, nurses often open surgical packs and trays that may not be used—anything opened even if it wasn't used must still be discarded. By anticipating what will be needed, nurses can only open what's necessary.

Educating the members of the OR staff about appropriate waste segregation and disposal can produce a significant impact on a hospital's waste stream. In addition to regulated medical waste receptacles, a significant amount of inappropriate items are also found in sharps containers. Drug or saline vials aren't biohazardous and shouldn't be discarded in sharps containers. The OR staff, in consultation with the facility's infection control manager, should review the guidelines for what items are appropriate for placement in sharps containers.

Suction canisters are a third type of regulated medical waste that may offer alternative and greener options for disposal. In some cases, the contents of the suction canisters may be rendered noninfectious and nontoxic and allow for disposal as regular trash.

Nurses often need to dispose of liquid medications when a patient's dose is less than what's in the container. Most nurses dispose of the extra medication in a sink or toilet, which can result in the contamination of downstream water systems. A 2002 U.S. Geological Survey research study found traces of many commonly used medications and hormones in analyzed water samples from 139 streams in 30 states during 1999 and 2000.16 In Europe, aquatic animals have been found with altered reproduction and body structures because of the influence of drug-contaminated water. The relationship between these chemicals and health effects from ingestion is still relatively unknown; however, if there are alternatives, there's no reason to continue a practice that might very well be harmful.16 In September 2009, the EPA announced that it will be monitoring the situation and may begin to regulate certain pharmaceuticals, including hormone replacement therapy and erythromycin, found in the water.17

Liquid medications should be disposed of in regular trash receptacles because regular trash is sent to contained and controlled landfills where the drug won't directly enter the local or downstream water systems. A facility's pharmacy department may also offer other solutions for disposal of excess liquid medication.

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The color of change

Nurses can also suggest turning lights and equipment off if not in use, minimize the use of washable linen and water. They can also initiate the creation of a facility-wide "green team" to evaluate and implement possible green policies. Because many nurses may support environmental practices on a personal level, when working in a facility that encourages similar activities, their general demeanor toward the facility often improves.

Caring for others is a core value for nurses. In a world that's environmentally connected, nurses should extend their caring efforts to encompass the earth and its inhabitants. Unfortunately, very little healthcare research has investigated or evaluated the safest and most effective green activities. Seeking a greener healthcare profession is a proactive way to reduce the negative effects of environmental degradation on human health.

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Suggested resources for healthcare greening

Alliance of Nurses for a Healthy Environment (AHNE)

http://e-commons.org/anhe

ANA: The Center for Occupational and Environmental Health

http://www.nursingworld.org/MainMenuCategories/OccupationalandEnvironmental.aspx

AORN. AORN Perioperative Nursing Video Library: #1820 Regulated Medical Waste Management. AORN, Inc.2170 S Parker Road Suite 300, Denver, CO 80231, custserv@aorn.org (800) 755–2676 or (303) 755–6304

Association of periOperative Registered Nurses. AORN guidance statement: Environmental responsibility. Perioperative Standards and Recommended Practices. Denver, CO: AORN; 2010:533–540.

Hospitals for a Healthy Environment (H2E) has created a self assessment guide that helps guide facilities in completing a waste audit at http://www.noharm.org/lib/downloads/waste/H2E_Self-Assessment_Guide.pdf.

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Programs promoting ecofriendly and environmentally aware healthcare practices

Clean Med http://www.cleanmed.org

Health Care Without Harm http://www.noharm.org

PharmEcology http://www.pharmecology.com

Practice Greenhealth/Hospitals for a Healthy Environment http://www.practicegreenhealth.org/

Sustainable Hospitals Program http://www.sustainablehospitals.org/HTMLSrc/Project.html

Teleosis Institute: Health Care Professional in Service of the Global Environment http://www.teleosis.org/

The Green Guide for Health Care http://www.gghc.org

The Nightingale Institute for Health & the Environment http://www.nihe.org

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REFERENCES

1. Environmental Protection Agency (EPA). Energy Star for healthcare .
2. Wackernagel M, Rees W. Our Ecological Footprint: Reducing Human Impact on the Earth. Gabriola Island, BC, Canada: New Society Publishers; 1996.
3. Nightingale F. Notes on Nursing: What It Is, and What It Is Not. Philadelphia, PA: JB Lippincott Company; 1992.
4. Houghton A. Green guide for health care: best practices for creating high performance healing environments. Version 2.2, 2007 .
5. Environmental Protection Agency (EPA). Green power: tags vs. delivered product .
6. Kats GH. Green Building Costs and Financial Benefits. Massachusetts Technology Collaborative; 2003 .
7. Environmental Protection Agency (EPA). Building healthy hospitals: top 5 green building strategies for healthcare .
8. U.S. Green Building Council. Intro–what LEED is .
9. Saver C. Staff spearheads an OR's green effort. OR Manager. 2009;25(1):24–25.
10. Health Care Without Harm. Issues: green purchasing .
11. Environmental Protection Agency (EPA). Environmental best practices for health care facilities: reusable totes, blue wrap recycling and composting. 2002 .
12. Puckett J, Byster L, Westervelt S, et al. Exporting Harm: The High-Tech Trashing of Asia. The Basel Action Network and Silicon Valley Toxics Coalition; 2002 .
13. Health Care Without Harm. Issues: electronics.
14. Laustsen G. Promoting nurses' ecological behavior through action research [unpublished doctoral dissertation]. Denver: Nursing, University of Colorado; 2005.
15. Association of periOperative Registered Nurses. AORN guidance statement: environmental responsibility. Perioperative Standards and Recommended Practices. Denver, CO: AORN; 2010:533–540.
16. Kolpin DW, Furlong ET, Meyer MT, et al. Pharmaceuticals, hormones, and other organic wastewater contaminants in U.S. streams, 1999–2000: a national reconnaissance. Environ Sci Technol. 2002;36(6):1202–1211.
17. Environmental Protection Agency (EPA). Drinking water contaminant candidate list 3–final. September 2009 .
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