2. Nursing and the Environment: New Dimensions for Clinical Practice By Hollie Shaner RN, MSA, FAAN Nightingale Institute for Health and the Environment

3. Mercurywaste management DIOXINlatex Persistent bioaccumulative toxic substances Glutaraldehydehazardous pharmaceuticals PVCpurchasing decisions energy use Water conservationindoor air quality Patient safety worker safety

4. Nurses Roles Past, Present, Future “We won’t have a society if we destroy the environment.” - Margaret Mead

5. “No amount of medical knowledge will lessen the accountability for nurses to do what nurses do, that is, manage the environment to promote positive life processes” -Florence Nightingale

6. DEVER MODEL: Health Status of Populations Health Status Human Biology Lifestyle Health Care System Environment

7. What are the most important things for human life? Air –we can live about 4 minutes without it Water –we can live about 4 days without it Food –we can live about 3 weeks without it

8. Human Health & the Environment –Critical Condition: Human Health and the EnvironmentMIT Press 1993 –Generations at Risk: Reproductive Health and the EnvironmentMIT Press 1999 –Pediatric Environmental Health American Academy of Pediatrics 1999

9. Human Health & the Environment –Dr. Sandra Steingraber Living Downstream – Exploration of cancer & the environment Having Faith –The ecology of childbirth & breastfeeding

10. Human Health and the Environment –Bioscience October ‘98 David Pimentel, Cornell University –40% of deaths worldwide due to environmental pollution and degradation

11. Healthcare Industry Special Obligations Promote health & well being of community Treat the sick Act as responsible corporate citizen Provide employment

12. Ecological Footprint “Industrial metabolism” Resources: energy, water, materials Waste Outputs: solid waste, hazardous waste, biohazardous waste, radioactive waste, air emissions, waste water Resource Book: Our Ecological Footprint by Wackernagel and Rees

13. Environmental Implications of the Health Care Service Sector Environmental Implications of the Health Care Service Sector Terry Davies and Adam I. Lowe October 1999 http://www.rff.org/disc_papers/PDF_files/0001.pdf

14. Health Care Industry Footprint Energy: 365 days & 24 hours Water: sinks, toilets, showers, food service, landscape, equipment Materials: plastics, paper, glass, metals, mixed materials, equipment, bandages pharmaceuticals, foodstuffs

15. Health Care Industry Footprint Among the leading sources of MERCURY and DIOXIN pollution in the USA

16. By-products of Healthcare Understand the wastes generate Understand the relationship between the products we use and the toxicity and volume of wastes we create Understand helpful interventions we can make in our role as nurses

17. Waste Streams

18. Biohazard Waste Sharps Blood/blood products Pathological Trace Chemo Animal carcasses Hazardous Waste chemical hazards solvents U & P listed pharmaceuticals cytotoxics lead silver mercury ether Solid Waste Recyclable Waste cardboard paper confidential paper metal aluminum plastic pvc, hdpe, pet, ldpe, pp, ps,other glass medical, sodalime wood construction & demo food kitchen grease Universal Wastes Batteries Fluorescent light tubes Mercury switches Pesticides

19. Hospital Solid Waste Paper waste Plastic waste Glass waste Metal waste Food waste Wood waste Other waste paper plastic metal food other wood glass

20. Hospital Biohazard Waste Blood and blood products Sharps used and unused Cultures and stocks Pathological waste Blood contaminated items Wastes from patients in isolation from a known communicable disease

21. Hazardous Wastes Commonly Found in Hospitals Chemotherapy and anti-neoplastic chemicals Formaldehyde Radio nuclides Solvents Mercury Waste anesthetic gases Cleaning and Maintenance chemicals Other corrosives

22. Hazardous Wastes Not the same as biohazardous wastes Hazardous wastes are regulated federally in USA under the Resource Conservation and Recovery Act (RCRA) Require hospitals to characterize wastes prior to disposal Hospitals must determine their waste generator status – SQG, LQG

23. What Happens to all that waste????? Hazardous waste: requires special treatment depending on material type Universal waste some is recycled, recovered Solid waste: landfill, recycle, compost, incinerate Biohazard wastes: incinerate, autoclave, microwave, other *Medical Waste Incinerators sources of mercury & dioxin pollution by US EPA

24. PBT’s: Persistent Bioaccumulative Toxic Substances Problem pollutants from healthcare American Hospital Association MOU with US EPA calls on hospitals to address minimize PBT’s –To virtually eliminate mercury from healthcare wastes by 2005 –To reduce healthcare waste by 50% by 2010 –See www.h2e-online.org

25. Dioxin 2, 3, 7, 8- tetrachlorodibenzo-p-dioxin or TCDD

26. Dioxin: Sources Medical Waste Incineration –25% of all healthcare products made from PVC iv bags, blood bags, tubing, endotracheal tubes Municipal Waste Incineration –PVC plastics Copper smelters

27. Health Effects of Dioxin Immune System –Ah receptor Cancer Promoter –WHO IARC Committee: a proven human carcinogen Reproductive Toxin –birth defects –endometriosis Endocrine Disruptor

28. Dioxin travels Emissions from incinerators Land on terrestrial landscape, plants Consumed by animals Dioxin is lipo-philic & accumulates in fatty tissue of animals Humans eating animals get animal’s lifetime bioaccumlative dose of dioxin

29. Consumer Reports Article reports that a 2 oz. Jar of beef based baby food ( Heinz, Beechnut, Gerber) has up to 100x the safe exposure limit of dioxin Mothers milk is largest source of dioxin to infants. Despite this finding, breastfeeding is still recommended.

30. What is PVC plastic?? Polyvinyl Chloride Plastic

31. PVC & DEHP HCWH blue folder FDA alert –www.fda.gov click on alerts, click on July11 DEHP in medical productswww.fda.gov www.noharm.org

32. Mercury mercury in fish

33. Mercury: Sources Mercury containing healthcare products including –thermometers –sphygmomanometers –esophageal dilators –laboratory chemicals –fluorescent light tubes –batteries

34. Mercury: Sources Mercury containing healthcare products including –Boiler Switches –fluorescent light tubes –batteries

35. Mercury: Sources Mercury containing healthcare products including

36. Mercury Health Effects Depend on form of Hg, dose, route of exposure, stage of development –organic mercury impaired vision, hearing, taste, smell, speech low level fetal exposures interfere with normal brain development includes impaired memory, attention, and learning

37. Mercury Travels A single fever thermometer contains one gram of mercury 4 grams of mercury are sufficient to contaminate a small to medium sized lake rendering the fish in that lake unfit for consumption by women of child bearing age

38. Mercury Travels Improper disposal, either via incineration or down the drain, spreads mercury into the environment In ponds and streams, mercury is converted to organic mercury that is absorbed by fish and continues to bioaccumulate up the food chain Humans are exposed through diet

39. Mercury Spills Have you ever broken a mercury thermometer? –Sphygmomanometer? –Esophageal dilator? Have you ever cleaned up a mercury spill? Where did you discard the spilled materials?

40. Bowling Green University Video What really happens during a mercury spill

41. Key Actions Nurses Can Do To Reduce Mercury Pollution Mercury –phase out use of mercury products

42. Key Actions Nurses Can Do To Reduce Mercury Pollution Mercury –establish policies to eliminate purchase of mercury products in hospitals and clinics

43. Key Actions Nurses Can Do To Reduce Mercury Pollution Mercury –properly manage and dispose of mercury batteries thermometers

44. Key Actions Nurses Can Do To Reduce Mercury Pollution Mercury –Find out who is in charge of cleaning up mercury spills when they happen –How is the mercury disposed of? Mercury should NEVER be discarded in a sharps container or biohazard waste container, or the trash, or down the drain

45. Key Actions Nurses Can Do To Reduce Mercury Pollution Mercury –Does your hospital have mercury spill kits? –Have you been trained in how to use them? –Where is the cleaned up mercury discarded? It should be discarded as a HAZARDOUS waste, not biohazardous.

46. Make it Personal! Nurses as Environmental Consumers of Health Care www.nihe.org

47. For more information visit The Nightingale Institute for Health and the Environment www.nihe.org