American College of Physicians: Internal Medicine — Doctors for Adults ®

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Fixing patients and the planet

Health care goes green with Healthier Hospitals Initiative

From the August ACP Hospitalist, copyright © 2013 by the American College of Physicians

By Stacey Butterfield

Hippocrates probably never thought about polyvinyl chloride or power cogeneration.

But many hospitals' current use of toxic chemicals and fossil fuels may violate his oath to do no harm, say health care sustainability experts. Numerous choices made by hospital administrators and clinicians, such as whether to serve organic produce in the cafeteria or reuse medical devices, can have downstream effects on the health of current and future patients.

Image by Thinkstock.

Image by Thinkstock.



“I don't believe health care wants to be contributing to the environmental problems that we're treating our patients for, but we unwittingly do,” said John Messervy, director of capital and facilities planning for Partners HealthCare in Boston.

“Environmental sustainability is unique [in importance] to the health care industry…There is a moral imperative to the work we do,” agreed Seema Wadhwa, director of program management for the Healthier Hospitals Initiative (HHI).

The HHI is a response to that imperative, an effort launched in April 2012 by 13 sponsoring health systems and three non-profit organizations to reduce the health care industry's contribution to environmental degradation and to spur sustainable change. To date, more than 700 hospitals have committed to the data collection and greening effort, which is planned to last three years.

The initiative has seen some major successes in its first year, but program leaders are eager for hospitals and their staffs, including hospitalists, to push for more environmental improvements. “This is an opportunity to not only make a change in your hospital with your patients, but a large-scale change toward population health,” said Ms. Wadhwa.

Top issues

Providing healthier food is one of the HHI's six primary issues, and one for which it's been relatively easy to rally physician support.

“Due to really big concerns about food security issues, cost issues, local and national epidemics of obesity and diabetes, there's a real move of hospitals toward healthier food options for their patients and employees,” said Gary Cohen, founder of the HHI and president of Health Care Without Harm, an international campaign for environmentally responsible health care.

Although physicians have been encouraging individual patients to eat healthy foods for a long time, there's a growing interest in working on a bigger scale, Mr. Cohen added. “Just dealing with it at the individual clinical level is not going to solve it. We have to make the healthy choice the easy choice, in patient trays, cafeterias, vending machines and even by supporting farmers' markets in the community. We see a lot of physicians getting engaged in that piece,” he said.

At one health system, a physician led the effort to establish an onsite farmers' market to increase access to healthy food. Other hospital projects in this arena have included eliminating sugar-sweetened beverages from patient menus, serving less meat, and cooking more cafeteria food from scratch using local and/or organic ingredients. In some cases, the healthy eating efforts have extended substantially outside the hospital.

“Our executive chef who used to spend all of his time working inside the walls of our organization doesn't anymore,” said Jeffrey E. Thompson, MD, chief executive officer of Gundersen Health System in La Crosse, Wis. “Now he's out in the schools teaching little kids how to cook rutabagas.”

Some of Gundersen's other greening projects have also affected the community as much as staff and patients. Working toward the HHI goal of “less waste,” the health system made a commitment to have 85% of its construction debris recycled. There were initial concerns that the requirement would scare off local builders, but there have been no such problems.

“They ordered materials differently. They figured out ways to dispose of materials differently. They're running now at 95% to 97% of everything used in construction recycled,” said Dr. Thompson.

Hospitalists may not have much of a say in construction strategies, but they can definitely help reduce hospital waste, both red-bag and regular, the experts said. “Single-use device reprocessing is a key example. It really does need to be physician-driven or physician-supported to be successful,” said Ms. Wadhwa.

This practice, which involves a vendor reprocessing for reuse a device initially intended to be disposable, has caught on in recent years. The HHI reports that 185 participating hospitals saved more than $32 million by reprocessing.

“Ten years ago, it was a very nascent industry and the biggest medical manufacturers were vehemently opposed to it,” said Mr. Cohen. “In the last three years, two of the largest medical device manufacturers have actually bought the reprocessing companies. They've decided that they might as well join in.” The involvement of manufacturers could lead to redesign of their products to be even better suited to reuse, he noted.

Health care sustainability advocates are also hoping to push industry on the issue of safer chemicals, another HHI target. The Initiative encourages hospitals to switch to greener cleaning supplies and reduce their use of products containing polyvinyl chloride (PVC) and di (2-ethylhexyl) phthalate (DEHP), common components of intravenous tubing and bags.

“There are quite a few studies showing that DEHP leaches out of the plastic,” said Mr. Messervy. “These chemicals are classified by the EPA as a probable human carcinogen and don't belong in the patient.”

Changes in the chemicals used to clean hospitals could potentially affect clinicians as well as patients, according to Mr. Cohen. “We don't have enough data on this, but if you can show that eliminating toxic chemicals in cleaners and sterilants can reduce nurses' asthma, that would be huge. Nurses have some of the highest asthma rates of any profession,” he said.

This effort is still in its infancy—only one HHI health system has reported its PVC/DEHP reduction efforts—but Mr. Cohen hopes it could follow the path of the issue with which his organization began over a decade ago.

“At the time, mercury was the gold standard in blood pressure devices and thermometers,” he said. “We pretty much eliminated the market for medical devices containing mercury over many years.”

A shift in the purchasing of chemical-containing products likely requires action by a hospital's administration, one of the reasons that “engaged leadership” is a goal of the HHI.

But hospital physicians can be effective advocates for that engagement, said Amy Collins, MD, an emergency department (ED) physician at MetroWest Medical Center in Massachusetts who is now the chair of its Go Green committee.

Her personal environmental commitment was spurred by her young son's push to green their home. “It was very uncomfortable living one way at home and another way at work,” said Dr. Collins, who tried to change things at the hospital by suggesting a recycling program in the ED.

“Someone told me that recycling in the hospital was illegal,” she said. After some research, “I realized that not only was recycling not illegal, but there was a lot more that our hospital should be doing as far as energy efficiency, waste and toxicity reduction, and promoting healthier foods.”

So she shared her research with hospital administrators in an e-mail. “It was positively received and I was given permission to run with it….I started our green team back in 2007,” she said. “I had a CEO who was intrigued. He didn't know a lot about this. He hadn't thought about it a lot, but he viewed sustainability as an opportunity.”

Selling points

Experts said health care sustainability efforts are actually a major opportunity for hospital administrators to achieve one of their biggest goals—reducing expenditures.

“People believe that it's either be environmentally sound or save money,” said Dr. Thompson. But, in fact, his health system has achieved significant cost savings from greening, especially on energy use reductions. “We spent $2 million on having an audit, changing out some lights, changing pumps, changing some controls. We will save $1.2 million every single year. That's a pretty good return,” he said.

Not every sustainability effort is a cost saver, Dr. Thompson acknowledged. “Getting rid of the Styrofoam wasn't the easiest thing. That cost us for a while. But we make money on other things in the balance.”

Mr. Messervy agreed. “There are some solid business reasons—many opportunities to both be a good environmental sponsor and also save money,” he said.

Changes to a hospital's energy use—an HHI target—can also have safety benefits, as proven during Hurricane Sandy. “When the grid was down in New York City, the hospitals in and around the area that had onsite power generation through cogeneration stayed open,” said Mr. Cohen.

Sustainability projects can also build goodwill with the community and employees. “I get a lot of comments and notes from employees saying they're very proud that we've won national awards and that we're working hard with the local folks to try and make the community better,” said Dr. Thompson.

Physicians' role

Despite the example of Dr. Collins, those interested clinicians don't tend to be physicians. “Because they're on the front line, the nurses are much more engaged than the physicians as a group,” said Mr. Cohen.

“We've found it pretty difficult to connect in a consistent way with medical staff across our hospitals,” agreed Mr. Messervy. “It's not that they aren't interested in these issues. It's perhaps that they're pretty busy on a day-to-day basis dealing with the situations patients are presenting with.”

When hospital physicians take the time to get involved in sustainability efforts, they're highly effective. “Physicians have been slower, but they have a lot of clout. In places where we do have physicians that are playing important roles, they are very, very critical change agents,” said Mr. Cohen.

Taking a sustainability leadership role, such as starting a hospital green team, is time-consuming, Dr. Collins acknowledged. “Not all physicians will have the interest or time to take on a leadership role, but there are many other opportunities for physicians to be engaged in the sustainability movement [such as] advocate for programs that promote improved health and health care delivery,” she said.

Such advocacy could entail pushing hospital administrators on one specific issue, whether it's offering healthier food or eliminating certain chemicals. “Reach out to the leadership and help identify this as a health issue,” said Ms. Wadhwa.

Physicians are also needed to lead the sustainability movement's research arm. “There's a research agenda that we're trying to get the federal government organized around. We want to be able to provide very strong data that health care reducing its intensive use of fossil fuels improves general health,” said Mr. Cohen.

There's also a need for continuing medical education centered on these issues, according to Dr. Collins. “That's an opportunity for physicians and physician engagement,” she said.

Finally, hospitalists can make a difference in the environment in their individual patient interactions. “One way I try to do it is with my prescribing practices. I write small quantities of medications with limited refills and educate patients about proper medication disposal…When we had our medication takeback event a couple of years ago, it made me realize how patients don't necessarily take the medications we give them and most don't know how to dispose of unused medications,” Dr. Collins said.

She also talks to patients about links between the environment and health. “When appropriate, I try to educate patients about environmental exposures, especially when caring for children, asthmatics and pregnant women…things such as pesticide and mercury avoidance, choosing safer cleaning and personal care products, the public health impacts of climate change and healthy food and beverage choices,” Dr. Collins said.

It may feel awkward at first to delve into sustainability issues during a medical visit, but Ms. Wadhwa expects that to change as the HHI expands toward its goal of engaging 2,000 hospitals by 2015.

“I think the growth of physician engagement in sustainability is going to be exponential over the next five-plus years,” she said. “With there being more and more evidence around the environmental impacts on health, they are not going to have much of a choice but to be engaged. It will become more naturally built in to what they do.”

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