By Kelly M. Pyrek
While it provides the great capacity to heal, the healthcare industry is a sizable consumer of natural resources. According to Practice Greenhealth, the healthcare sector uses more than 800 trillion Btu of energy annually, costing $6.5 billion each year. Hospitals that have as many as 500-plus beds can use up to almost 300,000 gallons of water annually, and they can generate more than 6,500 tons of waste per day, costing $15 billion each year for solid waste disposal alone. There's no dispute that the healthcare sector, comprising 17 percent of the gross national product (GNP), leaves a significant environmental footprint.
In this article, we'll look at how healthcare facilities can engage in environmentally preferred purchasing, reduce chemical use, actively seek alternative sustainable products, engage in green building, reduce consumption of energy, water and raw materials, minimize waste, engage in recycling programs, transition to renewable energy sources; eliminate incineration, and improve transportation strategies. These activities, however, hinge upon whether or not a healthcare institution makes sustainability an organizational priority with support that trickles down from the C-suite level. Experts say that sustainability must be integrated into all areas of the organization and its activities, internally and externally through leadership, education, and accountability and engagement in public policy and community education. Additionally, hospital leadership must encourage and incorporate sustainability as an essential element in the culture of the organization.
"I think that the 'greening' of facilities is something that is taking hold in the healthcare sector," says Anna Gilmore Hall, executive director of Practice Greenhealth, a nonprofit membership organization founded on the principles of positive environmental stewardship and best practices by organizations in the healthcare community. "It is not a passing fad, it’s here to stay, and so it becomes very important for all healthcare professionals to understand the implications this has on hospital operations and medical practice. It's critical to think about the link between healthy people and the environment that is growing ever stronger. There is growing evidence that 70 percent of expenditures are related to taking care of chronic disease, which can be exacerbated by the environment. Exposure to environmental contaminants is a huge burden on the healthcare sector, so whatever we can do to reduce that burden is in the best interest of all of us in the community. One of the things we have been working on with hospitals is ensuring that nurses, physicians and other healthcare professionals understand that link."
Gilmore Hall continues, "It's about the health of people now and the health of future generations. Safer for patients, staff and leverage what's going on in healthcare better for the communities we serve. We are seeing more hospitals take up the banner of sustainability and examine their practices because of that. The healthcare sector, which is 17 percent of the GDP, is a huge employer, a huge user of resources -- water, electricity -- what we do in healthcare really impacts a lot of other people, employees and the community. So we can be role models for sustainability."
Going green requires a culture change that is embraced by everyone in the hospital's workforce, from patient-care units to the executive suite. It also requires a commitment from time-pressured healthcare professionals, and that takes education to boost awareness of environmentally friendly practices. "When I was an operating room nurse, I was very busy and I didn't think about where the red bag waste went or how much it cost for that red bag waste," Gilmore Hall says. "When you realize that it is twice as expensive to take care of red bag waste than it is normal trash, and that hospitals need those funds for investment in patient care, you suddenly become more careful about waste disposal. Hospitals have realized by reducing the volume and toxicity of their medical waste, they can significantly reduce their carbon footprint as well as the amount of trash they are putting into landfills or sending to incinerators. And they can save money."
"Nurses and others in healthcare are not a very wasteful group of people," Gilmore Hall adds. "If we recycle at home, shouldn't we recycle at work in the hospital? If we are turning off our lights at home, why wouldn't we be doing that in the hospital? Many times we didn't do it because we didn't think about the cost implications of it and we didn't think about the environmental impact of our actions. But when we understand the impact on the environment and on people's health, we see conservation as part of our job, and we take the extra step necessary to put that pizza box or coffee cup into the normal trash receptacle and not put it in the red bag waste. It's a key change in habits. It does require a corporate culture change; people at all levels of the hospital, and particularly the C-suite, must see this as important and part of their mission for the organization. And the CEO must ensure that everyone in the organization understands this is part of their job and part of their responsibility. Together, across the organization, a significant impact can be made. That goes a long way toward a safer, healthier environment for patients and staff and the communities we serve."
Strategies for Going Green
There are a number of ways that hospitals can implement environmentally friendly activities:
Address waste. Practice Greenhealth makes the following suggestions for waste minimization, segregation, and recycling in hospitals:
- Establish a "green team" comprised of nurses, administrators, environmental services staff and others who are responsible for waste handling and occupational and environmental health and safety.
- Conduct a waste audit by examining what comes into the hospital and what (and how it) leaves. Observe red bag waste, solid waste, food waste, laboratory chemicals, and chemotherapeutic and pathological waste. Use the results of the audit to identify wasteful practices and develop a waste management strategy that incorporates waste reduction, reuse, and recycling measures. Segregating the waste at the point of generation, before treatment or disposal, is critical.
- Educate all hospital staff about the safe and appropriate segregation of waste for recycling, reuse and disposal. Cardboard, glass, office paper, cans, newspapers, magazines, and certain plastics are commonly recycled. Place signage at the point of waste disposal (trash cans, garbage bins, recycling containers, battery capturing receptacles) to reinforce the directions for proper segregation and disposal.
- Combine waste management strategies with sound purchasing practices to select reusable versus disposable products, as well as less hazardous products and products with less packaging.
Address regulated medical waste. The industry standard for optimal regulated medical waste (RMW) disposal rates is 15 percent or less of total waste, according to Practice Greenhealth, and best performers routinely hit rates less than 10 percent. For example, Practice Greenhealth suggests that the director of the hospital's environmental services, in collaboration with the infection preventionist, will spearhead the effort for better medical waste segregation, appropriate container placement and education and signage for clinical staff. The healthcare organization can then track RMW volumes over the course of the year and compare to baseline to determine percentage reduction. Other sample waste goals might include: establishing a waste baseline within six months; developing a viable, effective recycling program on patient floors within 12 months; increasing recycling to 20 percent of total waste generated within one year; implementing a reusable sharps container program within 12 months; and piloting a composting program for pre-consumer waste in the kitchen by end of the third quarter.
Hospitals are also encouraged to review their sharps disposal processes to determine if sharps are being disposed of with the RMW, and they should also consider a sharps container reuse program as part of their review of their current sharps-disposal process. Additionally, facilities should review how they handle suction canisters and whether they are rendered non-infectious and disposed with the regular solid waste. Hospitals can consider cost-effective suction canister treatment programs that render the contents non-infectious and non-toxic, does not impact the sewer system, and can be used with relatively little effort by healthcare workers.
Address misuse of red bag waste. Medical waste is typically deposited in red bags and is therefore known as red bag waste that is incinerated on- or off-site. The challenge is that if regular trash is thrown indiscriminately into these red bags, there is a significant cost involved. Practice Greenhealth encourages hospitals to observe their waste stream in operation by reviewing how and where trash is disposed of in each department, and to ensure that regular solid-waste containers are available wherever there are RMW receptacles to avoid inappropriate waste segregation. It is critical that only truly infectious waste be deposited in red bags so that the vast majority of hospital waste can be recycled appropriately instead of being incinerated or sent to the landfill. The process of incinerating hospital waste creates pollution, with two particularly worrisome pollutants--dioxin and mercury. Dioxin, a known carcinogen, poses a host of health problems as it is bio-accumulated in the environment and eventually consumed by people. Mercury has already sufficiently accumulated in our waters that it has made some fish dangerous to eat in even modest quantities. Careful waste segregation provides an opportunity to select the most environmentally safe disposal for each category of waste.
Engage in appropriate incineration. The burning of medical waste, whether on- or off-site, presents an enormous challenge due to the creation of toxic air pollution and toxic ash. The incineration of regulated medical and general hospital waste results in air and water emissions of dioxin, mercury, other toxic metals, particulates, and sulfur dioxide. The EPA has identified medical waste incineration as a significant source of dioxin air emissions and as the contributor of about 10 percent of the mercury from human activity. Plastics comprise approximately 15 percent to 30 percent of the medical waste stream, roughly twice as much as is found in municipal waste streams. There are a variety of alternatives to incineration for the treatment of waste. Although each of them has advantages and disadvantages, none creates the same level of environmentally unhealthy consequences as incineration. The alternatives include autoclave/steam sterilization, microwave, and chemical disinfection. When any of these methods are chosen, the treated waste is then placed in a landfill.
Participate in a recycling program. Practice Greenhealth encourages healthcare facilities to "prevent, reduce, reuse and recycle" with the following suggestions:
- Continue to monitor, and educate staff, and reduce wastes.
- Talk to procurement administrators, contractors, and vendors and require “less packaging” and “take back” policies for deliveries that include components such as shrink wrap, strapping, and pallets, or use reusable crates for all shipments instead of corrugated boxes.
- Learn from other source/waste/toxics reduction programs run by hospitals, industry, and government. What works for them ma work for your facility.
- Whenever possible, phase in re-useables and buy recycled products.
- Start in-house material and chemical exchange programs.
- Start recycling programs for corrugated paper, computer and mixed paper, metal cans, and glass bottles.
- Institute food composting and make food donations to food banks.
- Tie waste contracts to market prices for recyclable commodities, as print
Address environmental health hazards. For a number of years now, hospitals have been eliminating patient-care products that contain mercury, especially mercury thermometers. Another toxic substance is the chemical compound Di(2-ethylhexyl)phthalate, or DEHP, which is contained in common plastic products used in the healthcare setting. It is in a category of toxic chemicals known as pthalates, which are added to polyvinyl chloride (PVC) plastic to make the plastic product flexible and strong. It is frequently used in the manufacture of IV tubing, IV bags and feeding tubes. Because DEHP does not bind with plastic, it can leak out of PVC medical products during medical procedures, or it can off-gas from vinyl products. Another toxic chemical is dioxin, which is primarily a product of waste incineration of plastics.
Consider adopting chemical products that are less hazardous. Although there is still debate as to whether healthcare facilities can ever be truly "green" in their use of detergents and sterilants, some efforts can be made to ensure that environmentally healthier and safer chemicals for cleaning, disinfecting and sterilizing devices and surfaces are selected and used.
"Practice Greenhealth has done some work with a few groups around the topic of green cleaners," Gilmore Hall says. "We know that exposure for staff is less when they use green cleaners, and that there are fewer issues relating to asthma and allergies when using green cleaners. We have learned that when a hospital has a green team in place, they tend to look at green cleaners as a solution. We know that housekeepers and environmental services personnel are part of the infection control team and that their job is more than mopping the floor, their job is providing an environment so we can better manage infections in hospitals because of better cleaning processes. As part of the discussion about green cleaners, there has been increased discussion about infection prevention and we have seen significant evidence of increased communication between environmental services staff and nurses around the importance of cleaning. As an example, one hospital was surveyed by the Joint Commission and performed terribly on environmental cleaning. After we conducted a program around green cleaning, at the next site visit by the Joint Commission, they were blown away by the improvement. We are not saying it was because of the use of green cleaners, we are saying that the green cleaning conversations led to better cleaning and reduced exposure to employees. It was the green team approach that increased the entire performance of their cleaning process."
Gilmore Hall acknowledges the current debate about whether green cleaning can fully achieve sufficient pathogen kill rates. "Healthcare-associated infections (HAIs) are a serious problem for hospitals that must be addressed, but do you do that at the risk of other unintended consequences or overuse of chemicals," Gilmore Hall says. "We don't want to use bleach on everything but there may be a time you have to -- knowing when to use it and how to use it and to balance it -- a lot of integrated pest management programs in hospitals -- do you want to spray the hospital kitchen with a pesticide or do you just want to put the food away in the fridge so it doesn't lure ants and other pests? Some things just make good common sense that we need to do in the hospital.
Engage in environmentally preferable purchasing. Environmentally preferable purchasing is the process of purchasing products and services whose environmental impacts are less damaging to the environment and human health when compared to competing products and services. Reducing waste can begin before a medical supply is even used, thus address environmental responsibility on the front end. Essentially, healthcare facilities can learn to reduce the number of medical supplies or office supplies by being mindful about consumption habits; they can select reusable products instead of disposables when appropriate; they can recycle products when reuse is not feasible; and they can optimize disposal methods. By understanding how the products are made, including the occupational and environmental health risks posed by their production processes, as well as the impacts of their final disposal, healthcare professionals can understand the full "life cycle" of the products and their potential impacts. According to Practice Greenhealth, environmentally preferable products are generally less toxic; minimally polluting; more energy efficient; safer and healthier for patients, workers and the environment; higher in recycled content; packed in less packaging material; and fragrance-free.
"It's great to take care of the waste at the end of the life of the product, but the more we can get involved in the purchasing decisions of hospitals and systems to buy environmentally preferable products in the first place, the less we don't have to worry as much about the end of life issues or how much is going into the landfill or how much volume in waste because smart purchasing in the first place can reduce packaging, the toxic chemicals in products, do a lot at the front end of the process," Gilmore Hall says.
"Practice Greenhealth is very involved in leveraging the purchasing power of our member healthcare facilities to work with manufacturers to change products," Gilmore Hall adds. "We realized that DEHP, which is a chemical additive to plastics to make them more flexible and easier to use, and PVC, which is a known source of dioxin in the environment, were two chemicals that should be reduced or eliminated in the healthcare environment. But it's a challenge to do so. In order to make IV tubing and IV bags more flexible, manufacturers add DEHP; over time it leaches out and into the IV solutions and into the patients. NICUs are a site where there are lots of plastics and IV and endotracheal tubes are used; scientists have told us that baby boys are particularly susceptible to DEHP and they have pointed to some of the adverse outcomes from exposure to DEHP. So we have been able to work with companies that manufacture IV products to demonstrate that the healthcare sector would be very interested in purchasing IV supplies that don't have DEHP in them if they would produce them. Over the last two years we have seen hospitals stand behind their commitment by demanding that kind of change from IV-product manufacturers. Now, Hospira and several other manufacturers are first out of the gate to offer DEHP-free products, and that is a growing segment of their business. One of the things we try to do with industry is help them understand where the healthcare sector wants to go with sustainability practices and why it's in their best interest as a business to be involved in conversations with the healthcare sector."
As another example, Gilmore Hall adds, "Practice Greenhealth was working with Kaiser Permanente as they were getting ready to do a significant refurbishing project. They wanted to purchase carpeting that didn’t have PVC backing but their supplier didn’t have it. Kaiser said they would award a contract to manufacturers who would come forward with this new product. Three manufacturers responded and as a result of that situation, you and I can go to the store today and we can buy a carpet that doesn't have PVC backing. Think of the implications for all of the kinds of purchases that the healthcare sector makes -- furniture, food, medical commodities -- so as we signal the market about where we want to go, I think we can be very influential."
Practice Greenhealth is also helping foster new dialogue in the environmentally preferable purchasing arena. "At a recent CleanMed conference we brought together hospitals and group purchasing organizations (GPOs) and agreed we'd come up with a standardized set of questions that we'd like to ask manufacturers and suppliers to respond to," Gilmore Hall says. "We would signal the marketplace about where we were going with future products that we wanted to become more environmentally preferable. That conversation has continued to escalate; a scorecard has been developed by Kaiser Permanente that we are going to be using as a foundation document. We hope that many hospitals and GPOs will agree to these standardized questions and that we will be able to leverage the purchasing power of healthcare to move toward safer, less toxic medical products."
Examine waste management in the operating room. As hospitals across the country look for ways to reduce environmental impact, it makes sense to start with the departments that have the largest environmental footprints. The operating room (OR) is the epicenter of today’s hospital with a recent study by the McKesson Group estimating that the OR generates 42 percent of the hospital’s revenue. A primary source of hospital admissions, the OR also drives significant costs related to equipment, supplies and personnel— the OR is the leader in medical supply usage for the entire hospital. A recent study estimated supply costs at 56 percent of the total budget of the OR —dwarfing salary costs at 35 percent. The OR also is one of the largest users of supplies within the hospital as well as one of the largest producers of waste. Case studies have estimated that between 20 percent and 30 percent of the total waste generated by the hospital comes from the OR. A number of leading healthcare institutions have begun to tackle this problem by identifying a set of best practices that can reduce costs while also reducing waste, energy and worker and patient exposure to hazardous chemicals. The Greening the OR Initiative is a collaborative effort to envision what the green operating room of the future might look like, and what kinds of products, programs and best management practices hospitals can focus on as a means of getting there. Practice Greenhealth is committed to working with its partners and endorsing hospitals to provide the data, tools and resources necessary to substantiate these best practices as a critical step to widespread adoption across the sector.
"We have 125 hospitals who have enrolled in Practice Greenhealth's Greening the OR Initiative since the launch less than a year ago and we are thrilled with what these hospitals are doing to reduce their environmental footprint," says Gilmore Hall "For example, Fletcher Allen Medical Center achieved a 38 percent recycling rate in 2010. The nurses in the OR who were the initiators of the OR recycling program were able to collect about 50 tons of recycling materials and they saved $6,000. Another example is Spectrum Health, which initiated a medical plastics recycling program in its 45 ORs in 2007 and by 2010, they were recycling 42,500 pounds of blue wrap -- in just one department they saved $1,300 and avoided a significant amount of waste. Since then, they have expanded their program and have saved about $200,000 and reduced waste that would have normally gone into the landfill by 2,900 tons."
The Greening the OR Initiative is looking at interventions in the OR that reduce environmental impact, reduce cost, increase efficiency, and improve worker or patient safety—or some combination of these. There are a range of interventions that have been looked at by the initiative, and participating hospitals will continue to define additional interventions as they are piloted and implemented at different institutions. Initial interventions include:
- Regulated medical waste reduction and segregation
- Fluid management systems
- Single-use device reprocessing
- OR kit reformulation
- Reusable surgical gowns and basins
- LED lighting and power booms
- Displacement ventilation
- Waste anesthetic gas (WAG) capture and reclamation
- Medical plastics recycling
- Reusable hard cases for surgical instruments
