Sustainable Healthcare Wendi Shafir US EPA Region 9 June 2010

Outline Outline Sustainability – definition Why Healthcare? Environmental Concerns Opportunities and Priorities Resources

Sustainability – what does it mean? “Meeting the needs of the present without compromising the ability of future generations to meet their needs”

Sustainability – 3 Aspects Economic Equity Environmental

Why Healthcare ? Large environmental footprint Many opportunities – waste, toxics, energy, water Purpose – First do no harm - Provide healing environment

Health Care Footprint 1 of every 7 dollars spent Energy ~ $6.5 billion each year Medical Incinerators 3rd largest source of dioxin 4th source of mercury emissions 50X more mercury in medical waste Water – often largest users in community Over 2 million pounds of waste per year

Benefits Reduces costs Improves efficiency Reduces environmental impacts Improves human health Reduces liabilities

Environmental Concerns Air Pollution Trash Water Pollution Water Shortage Energy Usage Toxic Chemicals

Waste in Healthcare

Toxics in Healthcare ?

Toxics in Healthcare Sterilants and Disinfectants Mercury and other PBTs Pesticides Cleaning Chemicals Laboratory Chemicals Radiologicals Pthalates Some affect patients – pthalates in IV tubing and bags affect neonates, pesticides Some affect staff: sterilants and disinfectants, cleaning chemicals Some affect the general population: mercury, pesticides, dioxins in burning medical waste

PVC, DEHP, Pthalates In many medical products for flexibility, ex. IV bag, tubing DEHP: Developmental toxicant Dioxins– from production and incineration DEHP leaches from the PVC FDA recommends use of alternatives to DEHP when exposures may be excessive (esp. neonates) Catholic Healthcare West announced in Nov. 2005 that it has awarded a 5-year, $70 million contract to B. Braun to supply its 40 hospitals with PVC-free and DEHP-free intravenous systems. In addition, Microsoft, Kaiser Permanente, Crabtree & Evelyn, Firestone Building Products, Hewlett-Packard, Wal-Mart, Shaw Industries, J&J, and others have announced elimination or phase-out of use of PVC in packaging, commercial roofing, & carpet backing. They are all choosing to use alternatives to PVC that are safer to consumers & the environment. PVC is dangerous throughout its entire life cycle of production, use, and disposal, releasing chemicals such as mercury, dioxins, & phthalates.

Mercury in Healthcare Medical Devices Building Products Thermometers Sphygmomanometers Dental Amalgam Cantor, Miller Abbot, Dennis tubes Building Products Thermostats Many switches Boiler Guage controls Fluorescent Bulbs

Mercury Toxic effects- Long term exposure can permanently damage brain, kidneys and developing fetus Health care industry a major consumer Persistent, Bioaccumulative, Toxic = PBT

Mercury Toxicity – Fish Connection

Pharmaceuticals Emerging Issue Water Quality Impacts – Human - Reuse Aquatic species Many pharmaceuticals in lakes & rivers

Now we know why - What can we do ?

Opportunities Waste Reduction Improved Pharmaceuticals Management Mercury / Toxics Reduction Recycling Energy / Water Efficiency Healthy Food

Waste Reduction Strategies Waste Characterization Waste Segregation Best Practices Minimization of Infectious/Biohazard Waste Paper Management Recycling EPP for Waste Minimization

Pharmaceuticals Pharmaceutical Waste Management & Minimization Plan EPA, State guidance Swedish model – change prescribing patterns

Mercury and Toxics Reduction Mercury: Inventory and eliminate Less toxic cleaning products Less toxic sterilants + disinfectants Distill and reuse lab solvents & fixatives

Mercury Elimination a Primary Goal 100s of hospitals virtually eliminated it Many state/local programs Dental opportunities as well Eliminate through: Substitution Elimination Environmentally Preferable Purchasing

Mercury Reduction – How to Mercury Reduction 10-step guide http://cms.h2e-online.org/ee/hazmat/hazmatconcern/mercury/10step/ Reducing Mercury Use in Health Care Plan http://www.sustainablehospitals.org/HTMLSrc/IP_Mercury.html Mercury Assessment Tool http://www.cdph.ca.gov/certlic/medicalwaste/Pages/HospitalPollutionPrevention.aspx

Alternatives to DEHP There now are effective alternatives PVC-free/ Non-PVC DEHP-free / Non-DEHP Assessment tools and alternatives lists http://www.hcwh.org/us_canada/issues/toxins/pvc_phthalates/ http://www.sustainablehospitals.org/cgi-bin/DB_Index.cgi?px=M

Why? Sustainable Food in Healthcare Support patient, staff and visitor health Educate patients, community Provide healthier food (Farmer’s Markets) to community Combat Antibiotic Resistance Reduce food production’s environmental footprint Energy, water, pesticides, soil conservation, fishery depletion

Healthy Food in Healthcare Pledge From Healthcare Without Harm (www.noharm.org) Sample Language provided Over 250 hospitals have signed up Healthcare without Harm – provides resources American Medical Association (AMA) approved a policy resolution in support of sustainable food health care systems

HOW? Food Policies Locally sourced foods Hormone/antibiotic free animal products, rBGH Free Dairy Sustainably harvested foods, fair trade Organic and other certified food

What else can you do? Healthier vending machines Serve meals lower on the food chain - less meat, vegetarian options Healthy Cooking Classes and demonstrations Sustainable Food service – energy, water, waste Farmers Markets Onsite Gardens

Paper Reduction Copy & print double-sided Go Paperless - electronic records Fewer Copies Recycle office paper separately Recycling can still be HIPPA compliant!

More Recycling ! Reduce costs, generate revenue Cardboard, paper, glass, plastic Sterile Blue Wrap – new pilot in N. CA Recycling/Reuse – Worksheet II If you are not recycling paper or cardboard, paper is about 25% of your total waste stream and will often generate revenue in rebates. Start there. Are you generating revenue for any of the recyclables? If not, particularly for cardboard and white paper, now that you know your weights, negotiate a rebate. Does the data provide information to help determine operational changes, new equipment needs, additional items to add to the list of recyclables? (For example can you estimate cardboard revenues and avoided disposal costs that justify purchase of a compactor?) Ask your current vendor what other materials they collect. Can you add another material? Are you using net benefit to help describe the benefits of your recycling program?

Electronics FEC, EPEAT, Energy Star Both purchasing and disposal important UNIVERSAL Waste Reduced disposal costs Reduced energy costs

Environmentally Preferable Purchasing or EPP Selecting products or services that have a lesser or reduced effect on human health and the environment All Areas – medical, surgical, office supplies, maintenance, etc. Group Purchasing Organizations (GPOs) provide leverage, efficiency for EPP

Other Opportunities Water Conservation Energy Conservation Renewable Energy Green Building Dental Reduce flow or frequency; replace with water-efficient models; reuse once-through water Minimizing water usage can reach savings of 40%, which catches eye of CFO

A Role for Everyone Purchasing Facilities Housekeeping Administrative Nursing Food Service Facilities Administrative Pharmacy

What Can You Do at Your Hospital? Listen and learn today Identify some things to work on Make a commitment to just one! Get support – co-workers, mgmt. Imagine, if we all do this…

From sustainablematerials2020.com

The End Wendi Shafir USEPA Region 9 Shafir.wendi@epa.gov 415-972-3422