hospitais saudÁveis sao paulo, brazil 12 november 2010 susan wilburn.pdf · hospitais saudÁveis...
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GO GREEN FOR HEALTH!
Susan Wilburn, MPH, BScNursing
Interventions for Healthy Environments
HOSPITAIS SAUDÁVEIS
Sao Paulo, Brazil
12 November 2010
Regional Office of the World
Health Organization
System of
the UNPAHOInter-American
System
Specialized
Health Agency for
the Organization
of American
States
12 November 20104 |
Outline
Global Burden of Disease from Environmental Exposures
Environmental health in health care setting
Occupational health of health workers
Climate Change and Health: Leading by example
12 November 20105 |
Public Health and Environment:
preventing disease through healthier environments
Reduce 25% of the global burden of
disease
Promote a healthier environment
– intensify primary prevention and
– influence public policies in all
sectors, so as to
– address the root causes of
environmental threats to health
Health impact assessment and
environmental burden of disease
Environmental health of the health
sector
Occupational health
Chemical Safety
Water, sanitation and health
Children's environmental health
Air pollution (in and outdoors)
Radiation safety
Climate change and health
12 November 20107 |
Go Green for Health!
First do no harm and leading by
example
Climate Mitigation
– Energy efficiency
– Green building design
– Alternative energy generation
– Transportation
– Food
– Waste
– Water
Chemical Safety
– Pesticides
– Disinfectants and sterilants
– Mercury elimination
– Dioxin
Occupational health of health
workers
12 November 20108 |
Resolution WHA 60.26 from 2007
Workers’ Health: Global Plan of Action
Bring occupational health care to those in biggest need:
• Work towards coverage of all workers with essential interventions and basic occupational health services
• Develop human resources for occupational health:
• Train primary care practitioners
• Attract and retain human resources for workers' health
• Build capacities for basic occupational health services
Provide occupational health care for health-care workers:
• Global campaign for immunization against Hepatitis B
• National programmes for occupational health and safety of healthcare workers
12 November 20109 |
Report of the Commission on the Social Determinants of
Health and its Knowledge Network on Employment Conditions
"Social injustice is killing people on a grand scale."
Improve Daily Living Conditions
Tackle the Inequitable Distribution of Power, Money and Resources
Measure and Understand the Problem and Assess the Impact of Action
www.who.int/social_determinants/final_report/en/index.html
Knowledge Network on
Employment Conditions
Fair Employment & Decent Work
– Action Area 3: Improve working
conditions for all workers to
reduce exposure to material
hazards, work-related stress, and
health-damaging behaviours.
12 November 201010 |
Health Workers
59.2 million full-time paid health workers worldwide1
21.7 million healthcare workers in the Americas1
Women represent 70% of the health workforce2
57 countries have a critical shortage of health human
resources1
– Without a healthy, safe and motivated workforce the
public health goals of the countries cannot be met
– Working conditions have an impact on the workforce and
quality of patient care
1 WHO 2006; 2 Cameron 2006
12 November 201011 |
Global shortage of health workers
57 countries, 36 of which are in Africa
Distribution of the global health workforce
12 November 201012 |
Sub-Saharan Africa:
11% of the world's population, 25% of the global burden of disease,
3% of the world's health workers, <1% of global health expenditure
Distribution of health workers by level of health and burden of disease,
WHO regions
0
5
10
15
20
25
30
35
0 5 10 15 20 25 30 35 40 45
% of global workforce
% o
f g
lob
al b
urd
en
of
dis
ease Africa
South-East Asia
Eastern Mediterranean
Western Pacif ic
EuropeAmericas
12 November 201013 |
Global crisis health care workforce shortage
push and pull mechanisms
Working conditions including occupational health are an important push factor for migration and leaving the profession
Inequities and "unfair" recruiting: 45 % of new graduates in Swaziland leave the country
25% of Nurses in Zambia died in one year
IMF Structural readjustments require cuts in social spending: nurses in Kenya, Tanzania and Zimbabwe are unemployed despite need
UK “ethical recruiting” guidelines were effective for first year only
New Code of Practice for Migration
12 November 201014 |
Extent to which H&S concerns influence nurses employment decisions
( 2001 ANA/Nursing World On-Line Health & Safety Survey n = 4826)
Not at all
12%
Great Extent
Moderate Extent
LimitedExtent
31%
26%31% 88% state that H&S
concerns influencetheir decision tocontinue in nursing.
12 November 201015 |
Hazards to health care workers
Hepatitis B, C
Anesthetics
Cytotoxic drugs
Latex
Mercury
Radiation
Noise
Repetitive movements
Heat
SARS
TB
HIV/AIDS
Rubella
MeaslesJob Insecurity
Workload Technology
Sodium hypochlorite
Influenza
Glutaraldehyde
Heavy lifting
Handling patients
Occupational &
environmental
risk factors
Physical/Ergonomic Chemical
Biological
Pesticides
Organizational,
Psychosocial
Violence
Tuberculosis
Ethylene
oxide
12 November 201016 |
Hierarchy of Controls
Most effective
Least effective
Elimination
Substitution
Engineering Controls
Administrative Controls
Work Practice Controls
Personal Protective Equipment
12 November 201017 |
Complete removal of a hazard from the work area
Preferred method to control hazards and should be selected
whenever possible
EXAMPLE:
Elimination
Needleless IV Systems
“Latex Free”
Environment
12 November 201018 |
Kazakhstan: Doctors, and
a Medical Procedure, on Trial in Kazakhstan
"It's insane. This kid needed no blood”,
Dr. Michael O. Favorov, CDC's Central Asia
program director who headed the outbreak
investigation, said of one HIV-infected infant. The
eight-month-old was given 25 unnecessary blood
transfusions, according to court documents.
Ilan Greenberg, New York Times (20.03.07)
12 November 201019 |
Replacing a conventional material or process with a less harmful alterative.
EXAMPLE:
– Glutaraldehyde – typically used as a cold sterilant to disinfect heat-sensitive equipment such as endoscopes, can cause asthma, conjunctivitis, & dermatitis. Less toxic disinfectants are equally effective and reduce the potential for adverse effects.
Substitution
12 November 201020 |
Removing or isolating a hazard through technology.
This measure focuses on the source of the hazard or the pathway of
transmission.
EXAMPLE:
Engineering Controls
Ceiling-Mounted Lift
12 November 201021 |
Policies aimed at limiting worker exposure to a hazard, typically
accomplished through work assignments
EXAMPLE:
– Workplace Violence: To prevent a patient from assaulting a nurse, staff
members may work in pairs when providing care to or transporting a
patient on a psychiatric unit. The presence of multiple staff members may
discourage patients from attacking.
Administrative Controls
12 November 201022 |
Reduce exposure to occupational hazards through the behavior of workers.
Example:
Work Practice Controls
Prohibiting Recapping
Used/Contaminated
Needles
Pouring cleaning agents
instead of spraying them to
avoid airborne exposure
12 November 201023 |
Clothing & equipment designed to be a barrier between worker and
hazard
Least effective measure of control
Should be last option when trying to reduce worker exposure, since it
doesn’t control the hazard itself
EXAMPLE:
Personal Protective Equipment
Gowns, gloves, masks, and
eye shields when caring for
a patient with SARS
Adapting the definition from the
Safe Injection Global Network (SIGN):
“A safe health care practice does no
harm to the recipient, does not expose
the provider to any avoidable risk, and
does not result in any waste that is
dangerous for other people”
12 November 201026 |
Occupational Exposure to Bloodborne Pathogens
Acidentes de trabalho com material biológico
Situação Mundial
2 million exposures per year
In Healthcare workers:
37% of Hepatitis B
39% of Hepatitis C
4.4% of HIV
Are due to needlestick injuries
Although only 1,000 hcw deaths per year from occupational HIV, all can and should be prevented!
And fear/stigma affects care and migration
WHO Environmental Burden of Disease, 2003
Risk of Virus Transmission
Following Percutaneous Injury
Virus Chance of HCW InfectionHBV 6 – 30 out of 100 people
HCV 3 – 10 out of 100 people
HIV 1 out of 300 people
12 November 201028 |
Hierarquia dos controles aplicados ao risco de
exposição a patógenos transmissíveis pelo sangue
Elimination or substitution of sharp (eliminate
unnecessary injections, jet injectors,
needleless IV systems, blunt suture needles)
Engineering Controls (A-D syringes, safer
needle devices, sharps containers)
Administrative (policies and training
programmes)
Work Practice Controls (Universal
Precautions, no recapping, provision &
placement & removal of sharps containers)
Personal Protective Equipment (gloves,
masks, gowns, etc)
See www.who.int/hiv/pub/prev_care/healthservices/en/index.html
Annex 4
Eliminação do perigoEliminação total
de um perigo da área de trabalho. A
eliminação constitui o método
preferencial de controlo dos riscos,
devendo ser seleccionado sempre que
possível. Exemplos: remoção de
objectos cortantes e perfurantese
agulhas e eliminação de todas as
injecções desnecessárias. Algumas seringas e agulhas podem ser substituídas
por dispositivos de injecção sem agulha.
Controlos técnicos Controlos que isolam ou
removem um perigo de um local de trabalho.
Controlos administrativos Políticas que
visam limitar a exposição ao perigo,tais como
as precauções universais
Controlos relativos às práticas de trabalho
Equipamento de protecção individual (EPI)
12 November 201029 |
Decline in HBV Cases Among Healthcare
Workers Following Vaccination
0
4'000
8'000
12'000
16'000
20'000
1983 1991 1995
OSHA mandates HBV vaccination
17,000
800
This regulation had the greatest impact in eliminating
HBV transmission among healthcare workers.
Mahoney F et al. Archives of Int Med 157 (1997): 2601-2603
12 November 201030 |
But . . . Over 80% of Healthcare Workers Remain
Unimmunized in many parts of the world
Despite 95% Efficacy
of HBV
Immunization
12 November 201032 |
WHO-ICN Protecting Healthcare Workers –
Preventing Needlestick Injuries project
Prevention of needlestick injuries in health care workers, to prevent infection with HIV and Hepatitis B and C, a collaborative effort lead by WHO and ICN, in close coordination with ILO
Pilot in South Africa, Tanzania, and Vietnam resulting in development of new tool kit, expansion throughout southern Africa, Egypt and Venezuela
Key elements– National collaborative planning (OH, NNA,
MOH)
– Assessment of products, practices then implement surveillance
– Needlestick prevention committee (using data for prevention)
– IEC, control measures, supplies (sharps containers, PPE, safer devices)
– HBV Immunization, PEP and Treatment
12 November 201035 |
REPORTING IS IMPORTANT including near misses
Reporting Ensures
Proper treatment & follow-up
Financial compensation, if necessary
Engineering or procedure changes
12 November 201036 |
Dramatic increase in incidence of Tuberculosis
Incidência Estimada de Tuberculose por 100.000 Habitantes em
Países Africanos em 1990 e 2005Dados da Organização Mundial da Saúde - Fonte: Chaisson et al 2008
12 November 201037 |
Estimated HIV prevalence in new TB cases, 2006
No estimate
0–4
20–49
50 or more
5–19
HIV prevalence in
TB cases, (%)
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the
part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning
the delimitation of its frontiers or boundaries.
Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
WHO 2006. All rights reserved
12 November 201038 |
Joshi et al. PLoS Med 2006
Health care workers are at risk of infection
and TB disease
Joint WHO-ILO-UNAIDS policy guidelines
for improving health worker access to HIV
and TB prevention, treatment and care
• Reinforce existing joint
guidelines and update
with new guidelines for
TB infection prevention
and control, 3 I’s
(intensified case finding,
IPC, Isoniazid preventive
therapy
• Links to global framework
for national occupational
health programmes for
health workers
• 2 year development with
30 countries participating
in process (Presentations
on systematic review and
14 statements in French)
• 21 countries surveyed
• Expert guidelines and
tripartite review
• Launch 25 November
2010 in Geneva
12 November 201042 |
Health Care Workers
Chemical Hazards
Latex allergies
– gloves
Ethylene oxide
– sterilization
Nitrous oxide
– anesthesia
Toxic chemicals
– Disinfectants
– Drug handling: antineoplastic and antiretroviral
– Lab workers: formalin
– Mercury
– Cleaning agents
NURSES’ HEALTH
A Survey on Health & Chemical Exposure
The 2006 online survey was designed to assess the relationships between nurses' health and their exposures to 11 different common health care hazards.
• Impact: – Support for the launch of
the NIOSH Occupational Exposure Survey
– Highlighted NORA and European Respiratory Disease research linking health workers to asthma
Some of the Known Hazards
• Chemotherapeutic Drugs
• Mercury
• Waste Anesthetic Gases
• Laser & Electrocautery Smoke
• Disinfecting and Sterilizing Agents
– Glutarlaldehyde and Ethylene Oxide
• Pesticides, Cleaners & Fragrances
• Latex products
Reasons to Eliminate
Glutaraldehyde
• Potent occupational skin irritant and sensitizer
• Causes occupational asthma
• Employees, patients and visitors may be needlessly exposed in patient rooms or clinic areas where soak pans are not covered
• Exposure limits set by regulators make substitution a practical option
Nurses’ Survey Finding ~
Sterilization & Disinfectant Agents
Glutaraldehyde
• 52 percent of more than
1,500 nurses surveyed
reported on-the-job
exposures. Nurses with
frequent, long-term
exposures to glutaraldehyde
(at least weekly for at least
ten years) reported 46
percent higher rates of
asthma than other nurses.
Royal College of Nurses (RCN)
Case Study in Advocacy• RCN identifies nurses with asthma related to exposure to
glutaraldehyde
• RCN represents nurses before compensation board to provide benefits
• RCN works to achieve safe exposure limits in 1999 (0.05 ppm) and to identify alternatives
• RCN educates occupational health representatives about the hazard and alternatives in 2000.
• RCN receives best practice award from National Health Trust for implementation of alternatives
• Manufacturer pulls glutaraldehyde off the market in the UK in 2002
Alternatives to Glutaraldehyde
• Substitute peracetic Acid/hydrogen
peroxide(H2O2)
• Sterris
• Sterrad
• CIDEX OPA Solution (0.55% ortho-
phthalaldehyde)
Nurses’ Survey Finding ~
Sterilization & Disinfectant Agents:
Ethylene Oxide
• 29 percent of more than 1,500 nurses surveyed reported on-the-job exposures. Nurses with frequent, long-term exposures to ethylene oxide (at least weekly for at least ten years) reported 45 percent higher rates of asthma than other nurses.
Reasons to Eliminate
Ethylene Oxide (EtO) • Known human carcinogen and probable
teratogen
• Inhaled EtO can cause nausea, vomiting and
neurological disorders
• In solution EtO can cause severe irritation and
burns to eyes, skin and lungs
• EtO may damage central nervous system,
kidneys, and liver
Alternatives to Ethylene Oxide
• Steris (just in time)
• Sterrad
http://www.sterrad.com/products_&_services/sterrad/index.asp
Latex Allergy
• Up to 12% health care professionals
allergic to latex
• Reactions to latex can range from
dermatitis to anaphylaxis
• Glove powder also problem
• Barrier protection needs
Glove Selection
• Barrier protection
– What is use?
– Viral barrier
– Bacterial barrier
– Chemical barrier
• Durability
Health Effects
– Latex allergy (type I)
– Additives allergy (IV)
– Powder
• Comfort and fit
– Flexibility
– Resilience
Reasons to Control Pesticides,
Cleaners and Fragrances (VOCs)• A surprising number of volatile organic compounds are
found in these chemical products
• VOCs accumulate and can contribute to poor overall indoor air quality (IAQ)
• EPA estimates that poor IAQ is one of the top five public health environmental risks
• Patients are particularly vulnerable to IAQ as they are already physically compromised and/or have chemical sensitivities
• JCI has expressed concern over the increasing number of respiratory problems in HCWs
What We Can Do
• Work with institutions to use the least toxic alternatives, negotiate environmentally preferable product selection
• Ensure Safety Data Sheets are available for all chemicals in use on all units and staff are trained according to the OSHA Right to Know Standard
• Join or start a “Green Team”!
• Encourage the use of EPP
• Help individuals keep away from the most toxic exposures, especially women of childbearing age
What We Can Do (2)
• Learn more!
• Advocate for governmental protections from
toxic chemicals: national and state policies,
exposure limits, precautionary policies
• Work with nursing, medical and other healthcare
associations to advance the goal of a healthy
environment
12 November 201058 |
WHO Climate and Health WHO Executive Board Report 124.R5, 22 January 2009:
Objective 4. Strengthen health systems to cope with the health threats posed by climate change, including emergencies related to extreme weather events and sea-level rise
– Action 4.4: “In addition, the development of programmes for health systems that will contribute to reducing their own greenhouse gas emissions will be supported.”
Objective 1. Advocacy and awareness raising.
“… Improved awareness will help health-sector professionals to provide leadership in supporting rapid and comprehensive strategies for mitigation and adaptation that will both improve health and reduce vulnerability.”
Action 1.1 Development of tools, guidance, information and training packages to support awareness and advocacy campaigns to protect health from climate change at national and regional levels. This action will target different population groups, especially health professionals.
Action 1.2 Develop and run a global awareness-raising and advocacy campaign aiming to put health at the centre of the climate change mitigation and adaptation agenda at the international level.
12 November 201059 |
Policies that cut greenhouse gas emissions
can also reduce:
The 800,000 annual deaths from urban air
pollution, and the 1.5 million from indoor air
pollution
The loss of 1.9 million lives, and 19 million years
of healthy life, from physical inactivity
The 1.2 million deaths and over 50 million injuries
from road traffic accidents
-WHO, 2002, 2006
Highlighting the potential for immediate, local and large health
cobenefits
12 November 201061 |
4. Mitigation: leading by example
Healthy hospitals –healthy planet: How the health sector can
reduce its climate footprint
12 November 201062 |
Seven elements of a climate-friendly hospital
1. Energy efficiency – Reduce hospital energy consumption and costs through efficiency and conservation measures.
2. Green building design – Build hospitals that are responsive to local climate condtions and optimized for reduced energy and resource demands.
3. Alternative energy generation – Produce and/or consume clean, renewable energy onsite to ensure reliable and resilient operation
4. Transportation – Use alternative fuels for hospital vehicle fleets; encourage walking and cycling to the facility; promote staff, patient and community use of public transport; site health-care building to minimize the need for staff and patient transportation
5. Food – Provide sustainably grown local food for staff and patients
6. Waste – Reduce, re-use, recycle, compost; employ alternatives to waste incineration
7. Water – Conserve water; avoid bottled water when safe alternatives exist
12 November 201063 |
Opportunities for Action:
health-care facility examples
Energy efficiency – Reduce hospital energy consumption and costs through efficiency and conservation measures. Brazil: 101 hospitals in Sao
Paulo cut energy use by 25%
Mexico: Centro Medico Nacional La Raza education to turn off lights, computers
Alternative energy generation –Produce and/or consume clean, renewable energy onsite to ensure reliable and resilient operation
– Liberia
– Tanzania (shown – off grid electricity with solar panels)
12 November 201064 |
Green building design – Buildhospitals that are responsive to local climate conditions and optimized for reduced energy and resource demands.
– Italy: Meyer Children`s Hospital consumer 35% less energy for heating and cooling and 36% less electricity than standard
– Singapore: Changi General Hospital saves US$800 000 per year
– Hong Kong: Granthan Hospital Natural Ventiliation for TB control since 1957
12 November 201065 |
Transportation – Use alternative fuels for hospital vehicle fleets; encourage walking and cycling to the facility; promote staff, patient and community use of public transport; site health-care building to minimize the need for staff and patient transportation
UK Addenbrook hospital with interest-free bicycle loans and bus passes reduced cars on hospital campus by 16% and staff car use by 22%
Sweden: « eco-driving » reduced fuel use by 10% among ambulances and 50% less insurance claims
12 November 201066 |
Food, waste, water
Food – Provide sustainably grown local food for staff and patients
Waste – Reduce, re-use, recycle, compost; employ alternatives to waste incineration
Water – Conserve water; avoid bottled water when safe alternatives exist
– India Bhopal Sambhavna Trust Clinic rainwater harvesting
12 November 201067 |
Global Partnership co-led by WHO and HCWH
Component of the UNEP Products Partnership
Goal:
By 2017, to phase out the demand for mercury-containing fever thermometers and sphygmomanometers by at least 70% and to shift the production of all mercury-containing fever thermometers and sphygmomanometers to accurate, affordable, and safer non-mercury alternatives.
1,000 hospitals in Asia, Africa, Latin America moving toward phase-out.
Develop and disseminate global training/train-the-trainers module.
12 November 201068 |
What can nurses and doctors do?
Learn more about the health impact of climate change and prepare yourself, your health system and professional organization to recognize and care for the patients suffering ill effects
Put health in the forefront of climate discussions and negotiations
Advocate for strong national and global climate treaties
Lead by example (mitigate) to reduce your carbon footprint at home and at work
12 November 201069 |
Successes
Get the lead out! Of gasoline resulted in decreased lead levels in children
NR32 enforced 18 Nov 2010
Closure of 700 medical waste incinerators led to reductions in dioxin emissions and body burden
OSHA PEL on EtO
DDT ban resulted in the Bald Eagle’s removal from endangered species list
“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.”
Margaret Mead
12 November 201070 |
Strengthening Institutional Capacity
WHO Global Network of CC in Occupational Health
Technical level
12 November 201071 |
• Workers’ Health and Safety in the Health Sector: A Manual for
Managers and Administratorshttp://www.bvsde.ops-oms.org/sde/ops-sde/bv-saludtrab.shtml
• Comprehensive online course for healthcare workers
•Joint ILO/WHO guidelines on health services and HIV/AIDS
•Joint WHO/ILO guidelines for occupational and non-
occupational PEP (HIV)
•HIV and Global Workforce Alliance
•Treat, train and retain initiative
• Geolibrary http://www.uic.edu/sph/glakes
• Preventing Needlestick Injuries Toolkithttp://www.who.int/occupational_health/activities/pnitoolkit/en/index.html
WHO Technical Resources
12 November 201072 |
Obrigada
Thank you
Collaboration, Coordination,
Commitment and Cooperation