Many strong chemicals are used in healthcare settings, for a variety of reasons: to treat patients (medications and anesthetic agents); to clean, disinfect, and sterilize surfaces and supplies (cleansers/disinfectants); and to kill insects and other pests (pesticides). We often forget, however, that the drugs used to treat patients can have unintended consequences for workers who are exposed to them when they prepare and administer solutions or are exposed to the off-gassing of anesthesia and aerosolized breathing treatments. Indeed, pharmaceuticals can be a hazard to the community at large when they are improperly disposed of. According to two experts on hazardous drugs, “There is no other industry where hazardous chemicals are taken so lightly as the healthcare industry.”

All chemicals are potentially hazardous. The traditional discipline of toxicology has related the dose of a chemical to its toxic potential, but as more information about endocrine disruption becomes known, the evidence shows that very small doses of some chemicals, especially during windows of physiologic vulnerability, can have a damaging impact on health.

Since bacteria and viruses must be controlled to prevent nosocomial (or hospital-acquired) infections and occupational exposure, toxic chemicals are used as disinfectants and sterilants. Applying the industrial hygiene hierarchy of controls (see sidebar) will lead to using the least toxic chemical disinfectant that will get the job done. When less toxic chemicals are not available or not practical, it is important to ensure that the chemicals used are diluted to appropriate concentrations and that exposure-control measures are employed.

This article provides a review of the categories of chemicals used in healthcare settings and helps healthcare providers identify safer alternatives.

Cleaners and Disinfectants

Everyone expects a hospital to be clean. However, many traditional cleaning products, floor strippers, and disinfectants present a variety of human health and environmental concerns. They often contribute to poor indoor air quality and may contain chemicals that cause cancer, reproductive disorders, respiratory ailments (including occupational asthma), eye and skin irritation, central nervous system impairment, and other human health effects.

In addition, some of these products contain persistent bioaccumulative toxins (PBTs), are classified as hazardous waste, or otherwise contribute to environmental pollution during their manufacture, use, or disposal. Less toxic, environmentally friendly maintenance products exist for almost all healthcare facility needs, and more such products are being developed all the time.

For example, using unscented “green” cleaners can reduce maintenance costs, help protect the environment, safeguard the health of building occupants, increase employee productivity, and improve indoor air quality. Green Seal's Industrial and Institutional Cleaners Standard GS-37 (see http://www.greenseal.org/certification/standards/gs37.pdf) is a good place to start for identifying environmentally preferable cleaning products.

While cleanliness of floors is important, it may not be necessary to apply wax to make the floors shiny; and if wax is not used in the cleaning process, then toxic wax strippers, a common cause of occupational asthma in healthcare settings, can be avoided.1

Hospitals also use a variety of methods to disinfect and sterilize surfaces and equipment. Steam sterilization under pressure (or autoclave) is the most effective, least-toxic method for sterilizing instruments. However, because some pressure-sensitive devices such as transducers are damaged by the autoclaving process, chemical agents are used instead. Some of the most commonly used chemical products, such as glutaraldehyde and ethylene oxide, have been shown to cause serious health effects.

Glutaraldehyde serves as a cold sterilant to disinfect heat-sensitive equipment such as dialysis and surgical instruments, suction bottles, bronchoscopes, endoscopes, and ear, nose, and throat instruments. Staff members most at risk for exposure to glutaraldehyde are healthcare professionals working in operating rooms, dialysis departments, endoscopy units, laboratories, and intensive care units, where the chemical is used for infection control.

Several disabling health effects have been reported among hospital workers exposed to glutaraldehyde, including asthma and breathing difficulties, headaches, nausea, rashes, and other symptoms. Several hydrogen peroxide–, peracetic acid–, and ortho-phthaladehyde–based high-level disinfectant solutions can be used to replace glutaraldehyde. Visit http://www.sustainablehospitals.org to learn more about alternatives.
Especially vulnerable to the toxic effects of pesticides are the elderly, pregnant women, chemically sensitive individuals, and infants and children.

Table 1. Addressing chemical hazards

Method of Control

Examples

Elimination—Complete removal of a hazard from the work area. Elimination is the method preferred in controlling hazards and should be selected whenever possible.

  • Stop waxing floors to eliminate floor strippers that remove wax.

  • Purchase only fragrance-free products and set policy to ask employees and visitors to avoid wearing fragrances and use fragrance-free personal care products.

  • Eliminate chemical sterilants by using thermal methods such as autoclaving.

Substitution—Replacing a conventional material or process with a less harmful alterative.

  • Substitute peracetic acid– or hydrogen peroxide–based disinfectants for glutaraldehyde.

  • Substitute vinegar-based cleaners for chlorine.

  • Use sticky traps instead of pesticides to kill insects.

Engineering—Removing or isolating a hazard through technology.

  • Use ethylene oxide, glutaraldehyde, and peracetic acid only in a closed ventilated system.

  • Provide anesthesia in a closed system.

  • Use smoke evacuators at laser or electrocautery sites.

  • Mix antineoplastic agents in a laminar flow hood with exhaust ventilation (Class II biological safety cabinet).

Administrative—Policies aimed at limiting worker exposure to a hazard, typically accomplished through work assignments, and work practice controls reduce exposure to occupational hazards through the workers' behavior.

  • Establish a policy of environmentally preferable selection and purchase of cleaning and disinfecting products and apply the hierarchy of controls.

  • Provide information and training to all staff about the nature of chemical hazards and how to mix, dilute, and apply chemicals to reduce exposure.

  • Pour cleaning agents on a cloth for application instead of broadcasting the chemical by spraying.

  • Do not touch chemical disinfectants or cleaning solutions by hand; use forceps to deposit instruments for disinfection in chemical solutions.

Personal Protective Equipment (PPE)—The least effective measure of control in the hierarchy. PPE includes clothing and equipment designed to be a barrier between worker and hazard. This measure should be the last option when trying to reduce worker exposure, since it doesn't control the hazard itself.

  • Use synthetic gloves with special chemical-barrier protection (latex and vinyl gloves are inferior chemical barriers compared with nitrile and other synthetics) when handling chemotherapeutic agents and cleaning chemicals.

Other Asthmagens

The air in a healthcare institution may contain irritating and sensitizing chemicals and particles that can cause or aggravate asthma. According to the Massachusetts Department of Health, 2poor air quality has been identified as the most frequent cause of work-related asthma in healthcare workers. The reactions can be immediate or delayed, sometimes for hours after one leaves the setting where the product is used. The following chemical substances, among others, can trigger asthmatic symptoms:

  • latex (primarily from powdered latex gloves)

  • glutaraldehyde

  • ammonia and chlorine, used in cleaning and disinfecting solutions

  • dust and irritating particles from construction and remodeling projects

  • perfumes and scented personal care products worn by patients, visitors, and coworkers

  • isocyanates (a class of extremely hazardous substances) found in orthopedic casting materials

  • pharmaceutical drugs such as psyllium, rifampin, penicillin, and tetracycline

  • formaldehyde, used in specimen preparation

Pesticides

Pesticides are chemicals formulated to kill or prevent reproduction of pests such as insects, rodents, and weeds, as well as microbes. In addition to being harmful to pests, these chemicals can cause acute symptoms in humans, including nausea, headaches, rashes, and dizziness. Many are also linked to chronic diseases and conditions such as cancer, birth defects, and neurologic and reproductive disorders, and to the development of chemical sensitivities. Especially vulnerable to the toxic effects of pesticides are the elderly, pregnant women, chemically sensitive individuals, and infants and children.

A method of pest control called Integrated Pest Management (IPM) eliminates or greatly reduces the use of these hazardous pesticide products. IPM focuses on preventing and managing pest problems, both inside and outside a healthcare facility, through nontoxic methods such as improved sanitation and structural maintenance, mechanical and biological controls, and cultural practices.IPM strategies include eliminating sources of pest food, water, and shelter; blocking pest entry into buildings; and maintaining healthy soil and plants. Chemical pesticides are used only as a last resort, and preference is given to the least toxic pesticide that will accomplish the job. On the rare occasion that a toxic pesticide is used, ample notification is given to staff, patients, and the public.

For more information about IPM and finding pest control vendors that employ it, see the report “Healthy Hospitals: Controlling Pests without Harmful Pesticides,” at http://www.noharm.org/us/pesticidesCleaners/issue

Conclusion

In general, more information is needed about the health effects of chemicals available for use in healthcare. For most chemicals on the market, there are no health or safety data available. For more of the information that does exist about the health problems associated with chemicals, and what healthcare providers and hospitals are doing to reduce risk to workers, patients, and society at large, see http://www.noharm.org. CD

Susan Wilburn, MPH, RN, is Coordinator of the American Nurses Association's RN No Harm Project and Technical Officer for the World Health Organization.

References

  1. Coyle B., Polovich M Handling hazardous drugs: How safe are you? American Journal of Nursing 2004; 104 104.
  2. Pechter E, Davis LK, Tumpowsky C, et al. Work-related asthma among health care workers: Surveillance data from California, Massachusetts, Michigan, and New Jersey, 1993–1997. American Journal of Industrial Medicine 2005; 47 265–75

Sidebar

Hierarchy of Controls

Occupational safety and health professionals use a framework called the “hierarchy of controls” to select ways of managing workplace hazards. The hierarchy of controls systematically identifies hazards and prioritizes intervention strategies. It is based on the premise that the best way to control a hazard is to eliminate or remove the hazard, rather than relying on reducing the potential for exposure. Additional means can be used but offer less protection.

The following control measures are listed from most effective to least effective: elimination, substitution, engineering controls, administrative controls, work practice controls, and personal protective equipment. The table below describes their practical application.