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Clearing the air

Healthier hospital products let patients breathe easy

From the January ACP Hospitalist, copyright © 2007 by the American College of Physicians.

By Jessica Berthold

Sidebar: Tips for a Healthier Hospital

One of the first things newcomers remark upon when they walk into Boulder Community Foothills Hospital is that it doesn't smell like a hospital. No cleaning fumes, no whiff of disinfectant, no new-carpet smell.

"It smells like…nothing," said Kai Abelkis, the Colorado hospital's environmental coordinator.

That's because the 60-bed acute care facility was built in 2003 with an eye toward reducing the presence-and odor-of chemicals that studies suggest may be hazardous to one's health. Other health care facilities in the U.S. have done likewise, carefully selecting eco-friendly building materials, medical equipment and cleaners they believe will protect the health of patients, workers, visitors and the community at large.

According to the nonprofit group the Center for Health Design, about 180 health care facilities have recently been built, or are in progress, using guidelines like those in the Green Guide for Health Care, a manual for healthy and sustainable design.

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Architect's rendering of Children's Hospital of Pittsburgh of UPMC, opening in 2009.

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At Boulder Community Foothills Hospital, the flooring, adhesives and paint were selected because they emit no or low levels of the volatile organic compounds (VOCs) that studies suggest may cause cancer or damage to the liver, kidneys and central nervous system. VOCs are a class of chemicals like formaldehyde and benzene that easily evaporate into the air. They are found in standard building materials and furnishings.

As with many green hospitals, energy efficiency, water conservation and waste reduction are also high priorities at the Boulder facility. But the inside environment tops the list.

"Our big push is improving indoor air quality, because that has the most impact on patients and employees," Mr. Abelkis said.

Reducing VOC exposure is often a priority at hospitals. VOCs can cause dizziness and headaches, which reduce employee satisfaction and lead to more sick days, said Anna Gilmore Hall, executive director of Health Care Without Harm, a nonprofit group devoted to reducing pollution in the health care industry. Other considerations are providing adequate ventilation and decreasing dampness and humidity that can lead to mold.

"We are trying to dispel the myth that if you want to be sustainable, you must pay more for it." —Tom Cooper, Kaiser Permanente

Medical equipment is another area of concern. Hospitals have largely eliminated the mercury that used to be found in thermometers and blood pressure cuffs, but most IV bags and tubing are still made of polyvinyl chloride (PVC). PVC can leach phthalates, plastic softeners that animal studies have shown can damage the reproductive system, especially the developing testes. In 2002, the FDA recommended that hospitals avoid using PVC devices containing Di(2-ethylhexyl)phthalate (DEHP) for high-risk procedures on male neonates, pregnant women carrying male fetuses or peripubertal males. PVC can be found in anything from pillowcase covers, shower curtains and window blinds to the plastic dividers in patient charts. However, not everyone agrees that it's harmful: On its Web site, the industry group The Vinyl Institute states that studies and government reviews have failed to indicate that the DEHP from PVC is unsafe in vinyl medical products.

A few years ago, health care giant Kaiser Permanente challenged manufacturers to develop a PVC-free carpet (Collins & Aikman eventually succeeded). Kaiser Permanente's size and purchasing power have helped move the marketplace in other areas too, spurring inventions and lowering the price of green alternatives to standard products-which has helped pave the path for other hospitals to build green.

Kaiser Permanente's latest project, the Modesto Medical Center in Modesto, Calif., will be its crown jewel of green design when it opens in 2008, said Tom Cooper, program lead, design and construction standards, for Kaiser Permanente's National Facilities Services department. All carpeting in the facility will have PVC-free backing and be fully recyclable; the paints and upholstery will be low-VOC; the wall and corner guards will be PVC-free; and the flooring will be made of rubber, which means it won't leach toxins or need to be waxed and stripped with harsh chemicals.

Best of all, Kaiser Permanente is saving about $200,000 with its green methods. "We are trying to dispel the myth that if you want to be sustainable, you must pay more for it," Mr. Cooper said.

The Children's Hospital of Pittsburgh of UPMC, set to open in 2009, is also building green without breaking the bank, said Roger Oxendale, CEO.

"The majority of the flooring in hallways and patients' rooms and outpatient clinics is made of materials that are green and recycled and have no toxic adhesives. It's also essentially bacteria-free," Mr. Oxendale said.

Still, plenty of green products have yet to be made or are more expensive than their traditional alternatives. Wheatboard, a substitute for chemical-laden particleboard and plywood, is natural but costs more; so does the installation process for cotton insulation as opposed to fiberglass, Mr. Cooper said.

"There is a huge need for research and development into green chemistry alternatives," said Gilmore Hall, of Health Care Without Harm. She reported that according to noted green chemist John Warner, we can currently replace about 25% of toxic materials with existing safer alternatives, but new alternatives need to be developed for about 65% of the remaining toxic products and processes on the market; only about 10% of existing materials are benign.

Hospitals that can't afford to spend more, or need to win over reluctant administrators, can initially take small steps to go green, like switching to greener cleaning products, said Jan Stensland, a consultant on indoor environmental quality and sustainable design.

"Take baby steps first," Ms. Stensland advised. "You don't prepare for a marathon by running 10 miles."

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Tips for a Healthier Hospital

1. Reduce exposure to polyvinyl chloride. Audit devices in the hospital that might contain PVC. Health Care Without Harm has sample items on its Web site. Contact vendors to ask about PVC content if needed. Next, identify PVC-free alternatives to the devices. For help, go to www.noharm.org/us/pvcDehp/pvcFree.
2. Replace products that may contain mercury, like thermometers, batteries, fluorescent lamps and electrical equipment, with mercury-free alternatives. See www.noharm.org/us/mercury/alternatives for more information.
3. Choose cleaning and sterilizing products carefully, advises Hospitals for a Healthy Environment (H2E), a nonprofit organization that promotes environmental sustainability in health care. Ask vendors for a material safety data sheet (MSDS) for cleaning products and choose those listed as "mild irritants" rather than "severe irritants." Avoid products that contain carcinogens, as well as disinfectants containing quaternary ammonium compounds, which may lead to asthma.
4. Select materials wisely when building or renovating. Choose low VOC-emitting materials and those that are least likely to support mold growth. Try to pick materials that don't require harsh cleaning chemicals. Strive to ensure that a building's design, construction and operation discourage accumulation of moisture.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated