Nurses and the Greening of NICUs

Anna Gilmore HallHealth Care Without Harm

Sample Environmental Programs• Energy Efficiency

• Environmentally Preferable Purchasing

• Glutaraldehyde/ EtO Elimination

• Green cleaning/microfiber mops

• Green Construction, Renovation & Design

• HIPAA/Confidential Paper mgmt

• Integrated Pest Management

• Mercury elimination

• Pharmaceutical mgmt

• PVC/DEHP Elimination

• Red bag waste minimization

• Recycling programs

• Reusable sharps containers

• Single-Use Device Reprocessing

• Solvent Recovery

• Universal waste recycling

• Water Conservation

Process for Getting Started…

1. Pick a target issue

2. Educate yourself

3. Educate others (create a team)

4. Strategize on possible solutions

5. Investigate feasibility of alternatives (with help)

6. Present options to committees

7. Champion the cause!

8. Get recognition for your facility’s work

Phthalates and Pediatric Health

• Neonates face an increased risk from phthalates compared to adults.

• Developing metabolic pathways

• Rapid growth and development

• Small size = larger exposure dose

• Infants in medical settings (like the NICU) are exposed to physiologically relevant levels of phthalates through PVC medical devices.

• Lehmann et al (2004)

The Problem: Di-2-Ethylhexyl Phthalate (DEHP)

• Flexible PVC medical products contain plasticizer called DEHP.

• DEHP leaches into fluids, especially blood and lipids.

• DEHP: a developmental and reproductive toxin.

• Neonates in NICUs at highest risk for health effects from DEHP exposures.

Public Health Notification (2002)

• “PVC devices that do not contain DEHP can be substituted, or devices made of other materials … can be used, if available.”

• FDA recommends alternatives when – “high-risk procedures are to be

performed on male neonates, pregnant women who are carrying male fetuses, and peripubertal males.”

DEHP: The Solution

• Inventory the plastic products in your NICU.

• Identify products that contain PVC/DEHP.

• Work with venders to change to DEHP-free and PVC-free alternatives.

• Develop DEHP-free purchasing policies for your hospital.

Performance of PVC-free Alternatives

Safety• PVC-free plastics inherently flexible – no plasticizers• Chlorine-free w/exception of neoprene gloves• PVC-free plastics compatible with broader range of

drugs

Performance• Clear, flexible, often steam sterilizable

Costs• Bags: cost-competitive due to

“downgauging”• Tubing: can cost more, but may have longer

use life• Gloves: cost-competitive at large volume

WHAT CAN YOU DO?

Case Studies

• Staff initiated process to identify DEHP products in NICU, including evaluation of alternatives

• System-wide switch to non-DEHP products: – umbilical vessel catheters – PICC lines– enteral feeding products

2002 FDA public health 2002 FDA public health notification triggered action notification triggered action with ICN staffwith ICN staff

Internal PVC/DEHP audit Internal PVC/DEHP audit of NICU shelves and of NICU shelves and identified comparable identified comparable alternativesalternatives

Switched out virtually all Switched out virtually all products and replaced with products and replaced with non-DEHP alternatives non-DEHP alternatives

Commitment

of hospitals and health systems to reduce PVC and DEHP, especially in NICUs

conducts a PVC/DEHP audit reduces PVC/DEHP where feasible communicates the commitment

hospital wide

Committing to Action

Hospital or NICU:

– Start w/ HCWH’s list of common PVC/DEHP products

– Look for plastic bags & tubing

– Read labels– Fill-in data

Audit – Walk Through & Data Collection

PVC/DEHP Audit - Steps

– Work with purchasing / materials management

– Walk through of your dept– Fill in data– Identify alternatives– Engage decision makers:

nurses, doctors, product evaluation committees, green teams, your GPO

– Watch new purchases

Nurses Taking Action:DEHP/PVC Phase Out Process

Children’s Hospital and Regional Medical Center, Seattle, has phased out PVC medical devices containing DEHP in most IV systems and in process with enteral feeding products.

Evergreen Hospital Medical Center, Kirkland, WA has eliminated PVC products containing DEHP in most applications in its Special Care Nursery.

Group Health Cooperative in its Special Care Nursery, Seattle Capitol Hill campus, has phased out PVC devices containing

DEHP.

Miller Children’s Hospital achieved its goal of DEHP elimination for IV and Total Parenteral Nutrition (TPN) products, with a phase out plan underway for hospital-wide implementation.

Kaiser Permanente has made the transition to DEHP-free products for three commonly used NICU devices: Umbilical vessel catheters, PICC lines, enteral feeding products.

Lucile Packard Children’s Hospital at Stanford University, transitioned to DEHP-free IV systems, and saved $200,000.

• Health Care Without Harm www.noharm.org

• Going Green’s PVC Audit Tool www.noharm.org/goinggreen

• Sustainable Hospitals Project www.sustainablehospitals.org

• Inform Inc. www.informinc.org

• Practice Greenhealth www.practicegreenhealth.org

• Toxic-Free Legacy Coalition www.toxicfreelegacy.org

For More Information

“Nursing is a progressive art in which to stand still is to go back.”

Florence NightingaleFlorence Nightingale