. romoiing a^onmentally

I Responsible Health CareEnvironmentally responsible health care is gaining momen-

tum in today's society (Health Care Without Harm, 2002).

The international coalition Health Care Without Harm (2004) is

focusing attention on the three main toxins that are polluting

the air at high levels and are poisonous to people: dioxin,

polyvinyl chloride (PVC) and di(2-ethylhexyll phthalate (DEHP).

The purpose of this feature article is to discuss these toxins

and their destructive role in the environment and propose

ways in which nurses can advocate for, and protect, society.

Our interest in environmentally responsible health care grew

from our daily experience of witnessing the disposal of tV

bags and tubing, gloves, packaging materials and containers.

We questioned why so much was being wasted, so little was

being reused and nothing was being recycled. As we exam-

ined the issue, we discovered that there are many disposal

options available and that toxins and incineration are important

environmental topics in health care.

In October 2004, leading international health-care profes-

sionals met in Vienna, Austria, to agree on a far-reaching plat-

form for environmentally responsible health care. At this

conference, Manfred Muhlberger, president of the Institute

for Sustainable Healthcare of Vienna, made reference to the

future of health-care facilities as being PVC-free. Suggestions

included replacing harmful equipment made from PVC

and DEHP, reducing incineration practices in order to reduce

dioxin emissions and reducing the consumption of materials,

products, energy and water. From his statement, the Vienna

Declaration of Environmental Standards for Healthcare was

developed, paving the way for countries to implement legisla-

tion regarding environmentally responsible health care. This

declaration is crucial in developing compulsory international

environmental health standards for the health-care sector

(Health Care Without Harm, 2004).

22 C A N A D I A N nufse

Nurses can play an active role through

education, advocacy and the implementation

of measures to reduce medical wastage and

exposure to chemical toxins.

PEER-REVIEWED FEATURE

JACQUELINEGAUDRY,

RN, BScN

KIMBERLYSKIEHAR,RN, BScN

1

Poiyvinyi chioride and dii2'etfT/ihexyi) phthaiate. PVC is a plas-

tic widely used to make 25 per cent of hospital equipment (The

Nightingale Institute for Health and the Environment |NIHE|, 2002).

It is used in synthetic medical devices, including blood, intra-

venous, and total parenterai nutrition bags and tubing, nasogastric,

hemodialysis and endotracheal tubing, as well as respiratory

masks, examination gloves and plastic food wrap (Green, Hauser,

Calafat, Weuve, Ringer, Huttner, & Hu, 2005).

PVC is firm and fragile. To make it pliable, DEHP is added

(Gilmore Hall, 2006). PVC plastics contain between 17 and 41 per

cent of DEHP by weight (Women's Health & Environmental Net-

work [WHENL 2006) Because DEHP does not bond to the PVC, it

can leach into fluids inside bags and tubing and also into the sur-

rounding environment (WHEN, 2006).

Research on animals has shown that DEHP exposure can lead

to a number of adverse effects. These include decreased fertility

and sperm production, ovarian dysfunction and damage to the liver,

kidneys and lungs (Gilmore Hall, 2006; Rais-Bahrami, Nunez,

Revenis, Luban, & Short, 2004).

Children are more susceptible to DEHP toxicity due to their

increased metabolic demands, which heightens their absorption of

the chemical (Health Care Without Harm, 2005). In 1998, a Health

Canada advisory called for the disposal of small, soft vinyl teething

rings and rattles (Health Canada, 1998). The advisory warned par-

ents and caregivers that children sucking or chewing on toys con-

taining PVC for extended periods — three or more hours per day,

every day — could result in potential risks to young children. Health

Canada is now partnering with toy retailers and manufacturers to

provide PVC-free alternatives.

Dioxin. Dioxins are byproducts of incineration, industrial

processes and uncontrolled burning (Chlorine Chemistry Council,

2006). In lab animals, a correlation has been found between dioxin

and toxicity, cancer, reproductive disorders, decreased immunity

and altered developmental function. The results have been linked

to humans, with heart disease and diabetes being major risks

of dioxin exposure (National Institute of Environmental Health

Sciences [NIEHSI, 2006).

Dioxin is introduced into the body when PVC is incinerated

(NIHE, 2002). Upon incineration, dioxins are released into the envi-

ronment, rained back down into the ground, drained into water

sources and absorbed by plants. Animals and ultimately people

become the consumers of these altered plants (WHEN, 2006).

According to the Chlorine Chemistry Council, fish, meat and dairy

products contain the highest levels of dioxin (2002).

Dioxin accumulates in human fat tissue. This is because the

body is slow to excrete this harmful substance (NIEHS, 2006).

Breast milk, which has a very high fat content, is responsible for

passing large amounts of dioxin to infants (WHEN, 2006).

ABSTRACT

Dioxins, polyvinyl chloride and di(2-ethylhexyl) phthalate are the

three main toxins interfering with the goal to maintain a healthy

environment, according to the international organization Health

Care Without Harm (2004). Exposure to these chemicals has been

linked to cancer, as well as reproductive, cardiac, hepatic and devel-

opmental disorders (Tickner, Schettler, Guidotti, McCally, & Rossi,

2001). Health-care clients are potentially exposed to these toxins

every day: polyvinyl chloride equipment, such as IV bags and tub-

ing, is widely used in hospitals, and medical incineration practices

emit dioxins into the air (Chlorine Chemistry Council, 2006). Nurses

are uniquely positioned to play an active role in environmentally

responsible health care through education, advocacy and the imple-

mentation of measures to reduce medical wastage and exposure

to these chemical toxins (Canadian Nurses Association, 2005).

KEYWORDS

chemical toxins and health care, environment, environmental strate-

gies, environmentally responsible health care, green health care

January 2007 23

ENVIRONMENTAL WASTAGE AND THE

HEALTH-CARE MOVEMENT

The Philadelphia, U,S.-based Women's Health & Environmental

Network (WHEN; www.wiien.org) increases public awareness and

encourages action against the harmful effects of environmental

pollutants through education, research, action and prevention. The

regional organization is part of Health Care Without Harm, an inter-

national coalition whose members are primarily concerned with the

two main harmful chemicals, dioxin and DEHP, as well as mercury.

The organization is advocating that hospitals eliminate toxins in

their facilities by using better waste management protocols, ensur-

ing staff are well educated and developing purchasing contracts for

environmentally safe health-care products. Currently, WHEN is

working with hospitals to identify and remove DEHP-containing

materials.

The Canadian Nurses Association and the Canadian Medical

Association issued a joint position statement addressing environ-

mentally responsible activity in the health-care sector. As the posi-

tion statement indicates, both associations believe that health-care

professionals have a duty to encourage Canadians to undertake

accountability for their environment. They can play an active role in

lobbying the federal government to ban toxic chemicals and reduce

carbon dioxide emissions by supporting environmentally friendly

and energy-efficient sources and by purchasing non-polluting and

non-toxic materials (CNA and CMA, 2005).

The International Council of Nurses (ICN) is a federation of

national nursing organizations from more than 128 countries (ICN,

2006). Its goals are to advance nurses and nursing worldwide and

to influence health policy, with one of its priorities to encourage

the reduction of hazardous effects caused by improper medical

waste management (ICN, 2004). iCN supports the standardization

of nursing competencies in environmental health, the continua-

tion of nursing education programs in environmental toxins and

waste management, and safe waste disposal options to decrease

incineration.

THE ROLE OF NURSING IN ENVIRONMENTALLY

RESPONSIBLE HEALTH CARE

Environmental waste management is the key to sustaining a

safe health-care system (CNA, 2005). Given their direct involvement

in a majority of client care, nurses are on the front line of waste dis-

posal procedures (ICN, 2004). They are, therefore, in a position to

maintain and advance human life by advocating for the reduction of

chemical use and toxic waste (WHEN, 2006); by requesting and pro-

moting PVC-free aiternative products (NIHE, 2002); and by actively

participating in policy development dealing with incineration, pur-

chasing and waste management practices {ICN, 2004).

CNA recognizes the importance of the five Rs in environmen-

tal safety: reduce, reuse, recycle, recover and re-educate. Nurses

can re-educate themselves about healthy environmental practices

for their clients' and family's well-being, as guided by the code of

ethics. With further education, nurses will have better judgment as

to the types of IV tubing to use and for what period of time, proper

disposal of materials and knowledge of the harmful effects of plas-

tics used in common items (Loiselle, Profetto-McGrath, Polit, &

Beck, 2006).

By engaging in research on the environmental determinants of

health, including contaminants, their safe disposal and their

24 CANADIAN nurse

adverse effects, health-care professionals, including nurses, can

help the population to incorporate environmentally responsible

v\/ays in dealing with activities of daily living through education and

the provision of incentives for the use of non-polluting materials

and effective waste management (CNA, 2005}. It is also important

for health-care professionals to lobby at the provincial, territorial

and federal levels for the creation of strict laws that address toxic

emission reduction and waste management, both of which will

lead to safer, healthier communities (ICN, 20041.

Individually, nurses can take a step towards reducing, reusing

and recycling (CNA, 2005). For example, we have started to pro-

mote environmental responsibility by educating our co-workers,

families and friends about recycling options and the dangers of PVC

products. At the organizational level, nursing groups can form coali-

tions with other professional groups in the community to lobby for

more environmentally responsible action (ICN, 2004),

LTERNATIVE APPROACHES

The Vienna Declaration calls for hospitals to act as leaders in

society by creating more environmentally friendly environments,

with an emphasis on less toxic waste management. Strategies

include using renewable energy resources and PVC-free products,

purchasing reusable items, autoclaving all reusable items and devel-

oping environmental policies (Health Care Without Harm, 2004).

Health Care Without Harm suggests providing PVC-free prod-

ucts as a standard approach to dealing with environmental health

care. Products that can be substituted in hospitals include IV and

blood bags, examination gloves, and IV, oxygen, feeding and

suction tubing (2005). Equally effective PVC-free alternatives are

available for all but three per cent of PVC medical supplies

(Klausbruckner, 2003). An exception is red blood cells, which are

inadvertently preserved by the DEHP in PVC bags and thus benefit

from the chemical (Ruzickova, Cobbing, Rossi, & Belazzi, 2004).

Presently, polyurethane tubing is being used in Sweden to

replace PVC tubing at virtually no increased cost and with no health

risks. Other alternative materials include silicone, ethylene vinyl

acetate, polypropylene, polyethylene, other polyolefins and lami-

nate plastics. These choices do not pose risks to the environment

and public during the disposal phase, as they do not release dioxins

(Ruzickova Btal., 2004).

Infectious waste — that which requires special treatment —

constitutes 15 per cent of hospital waste (Sustainable Hospitals,

2005). Pathological waste is estimated to be two per cent of all hos-

pital waste, leaving 13 per cent of waste being incinerated and

releasing dioxins for no reason (Health Care Without Harm, 2000).

Autoclaving or microwaving is a safe and practical alternative to

needless incineration (Sustainable Hospitals).

CONCRETE MEASURES

PVC tubing is used in almost all drugs administered to people,

yet with chemotherapy agents, non-PVC materials are suggested

and strict protocols are followed. Studies also indicate that the risk

of exposure to DEHP can be increased when smaller diameter

tubing — mainly that used to administer neonate drugs —- is used-

With older tubing, more DEHP is available to seep into the contents

going to the client. Research also shows that when PVC tubing is

coated with inert polymers, the release of DEHP is prevented. This

type of tubing is currently available in Canada and the United

States, but there is an increased cost (Hancock, 2001).

Clients at greatest risk for DEHP exposure are pre-pubertal

males, children, infants, cardiopulmonary bypass patients, and those

receiving total parenteral nutrition, hemodialysis and lipophilic drugs.

To help reduce dioxin emissions and manage environmental

waste better in the hospital setting, nurses can employ and/or

lobby for the following measures (Health Care Without Harm, 2002;

Tickner, Schettler, Guidotti, McCally, & Rossi, 2001):

• use larger diameter tubing;

• ensure the tubing has not expired;

• use PVC tubing coated with inert polymers as much as possible;

• store solutions at lower temperatures and for shorter time periods;

• ensure blood and platelets receive less mechanical agitation, as

agitation promotes DEHP movement into the suspension; and

• label all DEHP products so that medical staff and clients are

aware of the risks associated with their medical equipment.

The Vienna Hospital in Austria, a leader in environmentally

responsible health care, has adopted a safe purchasing policy that

calls for the removal of all PVC products from the hospital's waste

disposal system (Hancock, 2001). Consequently, the hospital has

decreased its use of PVC materials from 10 per cent to 0.37 per

cent over 10 years.

COfMCLUStON

Dioxin, PVC and DEHP are three main concerns when

addressing environmentally responsible health care (Health Care

Without Harm, 2004). In people, these substances lead to such

harmful effects as cancer and reproductive disorders (Rais-Bahrami

et al,, 2004). People are exposed to these toxins through medical

incineration byproducts in the environment and PVC products while

receiving health care (Hancock, 2001),

Community health nurses have an important role to play in

responsible health care. As the main educators of the public, they

can speak to children in schools about the dangers of these

chemicals and educate prenatal women about the use of plastics

within the home. Community health nurses can also lobby for

environmentally responsible health-care practices by holding

January 2007 25

seminars about PVC and DEHP and proposing ways that people

can eliminate these toxins from their homes.

In addition to the health benefits supporting environmentally

responsible health care, it is also important to look at the ethical

component. The health sector needs to be aware of the impact its

operations have on the environment and should strive to be envi-

ronmentally responsible. For this reason, nurses have a responsi-

bility to advocate for the environment and safety of clients. By

educating themselves and others about dangerous toxins and

their effects on the human body, nurses can begin to make

changes in their own workplaces that will reduce harm to their

clients. (CNA, 2005).

JACQUELINE GAUDRY, RN. BScN, IS A NURSE iN CARDiOSCiENCES AND

PEDIATRICS AT THE REGiNA GENERAL HOSPITAL REGINA. SASKATCHEWAN.

KIMBERLY SKiEHAR. RN, BScN, IS A NURSE IN ORTHOPAEDICS AT THE

REGINA GENERAL HOSPITAL, REGINA

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26 CANADIAN