Healthy Hospitals: A Transformation
MCS
Health care establishments should be among
the healthiest of environments. People who are ill go to hospitals for
treatments, operations, and therapies with the hopes of getting well.
Though hospitals are generally considered sterile environments, this might not
be in the best interests of the environment or human health. Many
hospitals do not use environmentally preferable purchasing policies, follow
environmentally conscious waste management strategies, attempt to decrease the
use of chemical pollutants, or promote the use of healthy foods, let alone
provide leadership in environmental stewardship.
Individuals with
multiple chemical sensitivity (MCS) may find hospitals hostile
environments, not only because of the environment itself, but also
because the staff often dismisses their complaints as trivial, adding
emotional stress on top of medical problems. Products that MCS
patients react to include any quantity of exposures to pesticides, secondhand
smoke, alcohol, fresh paint, scented products, perfumes, candles, fragrances,
food preservatives, flavor enhancers, aerosols, tap water, cosmetics, personal
care products, new carpets, petroleum products, formaldehyde, outdoor
pollutants, newspaper ink, cleaning compounds, printing and office products,
and other synthetically derived chemicals. In a hospital setting,
disinfectants and floor wax are among many common, and often unavoidable,
irritants. The truth remains that many of these chemical pollutants. which can be found within the hospital
setting, impact both staff and patients, especially those with
asthma, immunodeficiency, allergies, and MCS.
A recent article published in the Online Journal of Nursing states that
"while it is commonly understood that the quality of the air we breath and
the water we drink can impact our health, it is often more difficult to
recognize that our choices of the health care products, along with the way we
dispose of them, and the chemicals we spray on our foods or use to clean and
disinfect may actually compromise the environment and consequently our
health" (Sattler & Hall, 2007). Hospitals are in need
of standard guidelines to transform into environmentally healthy and safe
places.
In order to create environmentally preferable purchasing policies one must
understand how products impact the environment in three stages:
production, use, and disposal. For example, a product that
is effective in the hospital, but is a persistent organic pollutant after
it is disposed of may not be the best all around choice.
Keep in mind that vast sectors of
industry have a high stake in the purchasing power of hospitals... food,
equipment, paper and office products, batteries, linens, construction products,
medicaments, cleaning products, and more. Each sector of industry has
vested interests in the purchasing power of hospitals across the country.
When environmentally preferable purchasing policies are established, industry
will vie for continued business and may even make vehement objections,
downplaying the importance of environmentally healthier products.
A good example Sattler & Hall (2007) cite is the mercury thermometer
experience, where nurses employed strategic use of their purchasing
power to affect positive change in hospital environments by pressing for the
use of mercury free thermometers in the hospital and offering to exchange
mercury thermometers for mercury-free versions as a public service. In
this way, nurses used their purchasing power to influence industry and now the
market has many mercury-free thermometers.
Greener Choices for the Environment
The following products are cited as environmentally preferable purchasing
requests (Sattler & Hall, 2007):
· Reduced
packaging
· Bulk buying to reduce packaging
· Double-sided copiers
· Reusable (versus single-use) products
· Products with recycled content
· Latex-free products
· Mercury-free products
· Polyvinyl chloride–free products
· Diethyhexyl
phthalate–free products
· Unbleached paper products
· Use of stainless steel which can be sterilized and
reused rather than disposable plastics which contaminate the environment.
In addition, waste management is encouraged. The "3 R's"
are:
· Reduce – less waste through less packaging and single use
devices, and bulk purchasing without packaging, and fewer single-use devices.
· Reuse – eliminate
single-use devises whenever possible and select products that are more durable.
· Recycle – select products that can be recycled.
While this is all
really nice, great for the macro environment, and commendable, it does little
to reduce chemical incitants that impact everyone, including both
staff and patients, especially those with asthma, immunodeficiency’s,
allergies, and MCS. Chemical pollutants must also be reduced.
Chemical Pollutants
"Many of the chemicals we once thought useful in providing safe care
in hospitals have been found to be dangerous for patients and health care
workers alike. These include, among
others, chemicals called persistent organic pollutants (POPs),
which are some of the most dangerous chemicals that have been created by man
and include pesticides, industrial chemicals, and chemical by-products. They are sustained in the environment for
long periods of time, hence the descriptive term "persistent.” Also included are compounds found to be
asthma triggers, chemicals in the plastic family called di(2-ethylhexyl)
phthalate (DEHP), and pesticides" (Sattler & Hall, 2007). These chemicals are both dangerous and
polluting.
Persistent Organic Pollutants (POPs),
primarily pesticides, are still in current use and include insecticides,
including (Sattler & Hall, 2007):
· Aldrin and Chloradane for termites
· DDT for mosquitoes
· Heptachlor for mosquitoes and fire ants
· Dieldrin and Endrin for crops
· Toxaphene for ticks and
mites
· Hexachlorobenzene as
a fungicide
· Poly
chlorinated biphenyl (PCBs) for capacitors, transformers, and hydraulic
and heat transfer systems, weatherproofing, carbonless copy paper, paint,
adhesives, and plasticizers in synthetic resins.
These POPs have been linked to reproductive
disorders, developmental disorders, suppression of the immune system,
dysfunction of the nervous system, and cancer. Integrated Pest
Management (IPM) is a safer, relatively new approach to managing pests that
involves monitoring, treating only the affected areas rather than the entire
property, and keeping close records.
Hospital Induced Asthma
& MCS
According to Sattler
& Hall (2007), "given the prevalence of asthma in both children
and adults in the US, the last thing one would want, or expect to encounter in
a hospital setting, would be a chemical associated with causing asthma or
triggering asthma symptoms", yet asthma inciting chemicals are quite
common. Hospital trigger risks include cleaners, disinfectants,
sterilizers, ethylene oxide, formaldehyde, glutaraldehyde,
natural rubber latex gloves, pesticides, and other volatile organic
compounds. This is compounded by fragrancesm
such as scented cleaners, fragrance-emitting devices (air fresheners), and
people wearing perfume or scented lotions. Any one of these items alone
could bring on a life threatening breathing reaction or cause dizziness and
fatigue. Combined, they create a significant health hazard.
But that's not all. Add in phthalates, plastics, tobacco smoke
residues on the clothing of smokers, mold, fungus, pollen, dust, cockroaches,
fluorescent lights, an assortment of pharmaceuticals, and food that many
consider unfit for human consumption. It would seem that a hospital is
not the safest place to be for an individual with asthma or MCS.
Sattler & Hall (2007), explain that "transforming hospitals into
environmentally healthy places necessitates forging and building relationships
among various departments within a facility." It takes a coordinated
effort and the caring concern of all staff members. Administrators must stand
behind the effort and ensure that training of staff who have an influence in this area is mandatory.
Staff should be encouraged to join committees and give their input.
Sattler & Hall (2007) state that "over time these changes to
protect human health may also have a positive impact on the bottom line of the
facility as the facility learns how to be reimbursed for recyclables, explores
free composting services for food waste, rethinks reusable products, and
ultimately reduces the waste stream." However there is still more.
Additional Challenges for MCS Patients
One thing that was left out of the review by Sattler & Hall (2007)
is patient comfort and safety. Often hospitals can be cold and
frightening places. Patients are not feeling well and may be may be
agitated and concerned about their needs. Patients with MCS in specific
often have their needs overlooked. Carolyn Cooper (2007) presented
an excellent review that was published in the American Journal of
Nursing. She explained simple ways to take care of patients with MCS to
avoid unnecessary discomfort and make for a better working relationship
with the patient. Among her tips was to heed patient concerns. She affirmed that it is never really
appropriate not to heed a patient's concerns. Regardless of etiology, a patient should be
made as comfortable as possible.
In her review,
Cooper discusses Mr. Norris, a man with MCS under her care who
she was able to accommodate during his hospital stay through various measures,
including a warning sign on his door, a scent free nurse, a "sniff
test" by Mrs. Norris before entering his room, and a respirator when
needed. Cooper recommends a hospital protocol and staff training to
include the policies quoted
below (Cooper, 2007):
General
· Don't use perfume,
aftershave, or scented lotion.
· Keep free of the
odor of cigarette smoke.
· Wear a long-sleeved
cotton surgical gown (and cap if necessary) to mask odors if you know you smell
of a potential irritant and no other caregiver is available.
· Knock first and wait
to be admitted to the patient's room.
Surgery
· When a patient with
MCS is scheduled for surgery, notify perioperative areas well in advance. It is
particularly important that the anesthesiologist confer with the patient before
a surgical procedure so that medication sensitivities can be considered. Perioperative clinicians must be prepared to
carefully reassure patients that safety measures will be taken on their behalf.
· Schedule
the procedure as the first case of the day to minimize exposure to
environmental irritants that will be stirred up during the day.
· A
ceramic or porcelain oxygen mask may be indicated to deliver anesthesia.
· Povidone
iodine is generally a safe antiseptic solution, but isopropyl alcohol should be
used sparingly.
· Use
paper tape for surgical dressings (or assess the patient's reactions to other
adhesives 24 to 48 hours in advance by using patch tests).
· Use only latex-free gloves.
Diet
· Until a dietitian's
evaluation has taken place, nurses should allow patients to provide their own
“safe food supplies,” when appropriate. Be particularly watchful for asthmalike
symptoms that may progress to bronchospasm in response to irritants.
· Intolerance
for peanuts, soy products, and dairy products is common in those with MCS.
· Avoid
plastic and Styrofoam containers; use glass or ceramic containers.
· Bottled
drinking water should be provided with meals.
· Dyes,
preservatives, artificial sweeteners, and monosodium glutamate may not be
tolerated.
· Avoid processed or prepackaged foods
that contain preservatives.
Medication
· Based
on your initial assessment, you may find it necessary to ask the physician for
“as needed” orders for medications the patient usually uses to alleviate
hypersensitivity symptoms, including oxygen or nebulizer treatments. Other important considerations include the following:
· Ensure
that the pharmacist is aware of the patient's specific allergies,
sensitivities, and possible intolerance to preservatives.
· Confer
with the pharmacist and physician if you have concerns about medications. Enforce a “no substitutions” policy for medications
ordered in order to avoid unexpected reactions.
· Some patients may be sensitive to chemicals
that leach from plastic IV bags; glass bottles may be necessary for iv fluid administration in such cases.
Preparing the Hospital Room
· Though not always
possible, a private room is ideal. In the ED, ICU, or perioperative area, use
existing isolation cubicles to protect the patient from odors that could
trigger a reaction.
· A sign on the door
will alert staff to the patient's sensitivities (confer with the patient first
to ensure consent and protect privacy).
· The patient's own
respirator mask, if needed—or an R95 respirator if your institution carries
them and fit testing can be performed—should be available for the patient to
wear when being transported within the clinical setting. (The R95 mask contains
a carbon filter that provides both odor and organic-vapor filtration. Other
masks do not filter odors.)
· The soap dispenser
should contain unscented soap only. If unscented soap is not available, empty
the dispenser and place a bar of Ivory brand or another brand of unscented soap
in the room.
· Place a new sharps
container in the patient's room (the old container may contain odor-producing
trash along with sharps).
· Remove latex glove
boxes and replace with latex- and powder-free gloves until the patient's
sensitivities can be assessed.
· If necessary, use a
negative pressure machine and a high-efficiency particulate air filter, or a
reverse isolation room to avoid exposure from air that enters from the hallway.
(A rolled towel placed underneath the door can be used as a temporary measure.)
· The room should be
free of carpeting and cloth draperies (gasses may be released from the
synthetic materials).
· The room should not
have been recently painted or wallpapered. There should be no floor wax
removal, floor waxing, or pesticide use near the patient's room for the
duration of the stay.
· Allow patients to
bring linens from home. Otherwise, you may request a sterilized linen pack from
your facility's housekeeping department if the patient cannot tolerate lingering
traces of detergent on sheets.
· Inform the
housekeeping staff that only fragrance-free disinfectants may be used when
cleaning the patient's room; that means no bleach, ammonia, or aerosols may be
used. MCS patient advocates have suggested using a moist cotton cloth and
baking soda to clean surfaces if unscented products are not available, but you
must collaborate with the infection control and housekeeping departments to
determine an appropriate course of action.
Choosing Equipment and Supplies
· Avoid fragrances and
deodorizers. (Be aware that “hypoallergenic” doesn't necessarily mean fragrance
free.)
· Don't
bring standard admission packs with plastic basins and patient-hygiene items
into the patient room until the patient's sensitivities are known.
· Latex-free
products are often indicated.
· The
patient might bring her or his own oxygen tubing from home and choose to use it
instead of new tubing from a sealed package. (The
odors released from new plastic materials may irritate.)
· Patients
may request that a metal “butterfly” needle be used for iv
therapy instead of a plastic cannula.
· Have
paper tape conveniently available—other adhesive tapes may not be tolerated.
· Don't use pens or markers with strong-smelling
ink in the patient's vicinity.
Health care establishments should be among the healthiest of
environments. With a little caring, concern, and thought, they can
be.
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References
Cooper, C. Multiple
Chemical Sensitivity in the Clinical Setting: Although the cause
and diagnosis of this condition remain controversial, the patient's concerns
should be heeded.
Sattler, B., Hall, K. Healthy Choices: Transforming Our Hospitals
into Environmentally Healthy and Safe Places. OJIN: The Online Journal of
Issues in Nursing. May 31, 2007;12(2)(3).
About the Author
Copyrighted © 2008 MCS