Healing Environments

All you have to do is take a walk in a large hospital to notice how bleak things must feel for patients and staff. White walls, standard fluorescent lighting, and institutional floors make the hospital feel more like a place of punishment than healing.  This wasn’t always the case, however. Over a thousand years ago, people understood that a person’s mental and physical well-being could be influenced by his surroundings. For example, monasteries in Europe in the Middle Ages had gardens to help bring pleasant, soothing environments to the ill. The idea of creating gardens to help people focus on nature and not their disease process was not limited to Europe. It was known in the East as well.

So how, then, did hospitals develop into such large institutions without addressing this critical aspect? Some speculate that it was in the early 1900’s when medical technology began to boom that hospital administrators sacrificed aesthetics in lieu of more efficient buildings that would incorporate the newest in medical technology and infection control. The next several decades were surrounded by growth and maximization of resources at the cost of environmentally soothing buildings.

Fortunately,  administrators and healthcare professionals have begun to recognize the impact of the physical environment in the healing process. Studies have shown that our environment can play a surprisingly significant role in a disease process. For example, “laboratory and clinical investigations have found that viewing nature settings can produce significant restoration within less than five minutes as indicated by positive changes, for instance, in blood pressure, heart activity, muscle tension, and brain electrical activity” (Ulrich, 1981; Ulrich et al., 1991).

More recently, studies have found that viewing natural settings can speed healing times in post-operative patients. The link is thought to be in part due to mitigation of stress. There was a series of interesting experiments done in Japan in the early nineties that analyzed alpha-wave rhythm activity in two groups of patients–one viewing natural settings, and the other, man-made settings. It was found that the EEG patterns in the two groups varied such that the group viewing natural settings showed EEG patterns suggesting relaxation while the group viewing man-made settings appeared stressed (Nakamura and Fujii). There are lots of other examples of studies that show similar findings.

With the growing body of evidence, hospitals have started to change. Gardens, for example, are becoming more commonplace. In fact, gardens have been found to have several positive outcomes: 1. they can foster social support and physical exercise 2. they can reduce stress among patients and staff 3. they can help decrease experience of pain.

Adding natural lighting to rooms, having windows, keeping plants, and providing scenes of nature are all simple ways to help a patient feel more calm and relaxed. The buzzword these days is “sustainable design.” Architects and healthcare institutions have teamed up to find ways to help make a hospital more green in the literal and figurative sense. They not only incorporate gardens and greenery, but also utilize evidence-based building designs to help institutions feel more like a place of wellness than a hospital.

Keep an eye out over the next few years for these much-needed changes. Hopefully, the days of plain walls and windowless rooms are out. Who knows, maybe the next hospital you visit will have gardens or waterfalls or better yet, look more like an outdoor setting than an institution. Either way, you’re bound to find healthier patients and happier staff.

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Regulated Medical Waste – What is it and Why Should We Care?

An Introduction to Regulated Medical Waste

Think about the last time you went to a hospital. Did you ever notice the plethora of trash cans, sharps containers, and special waste bins? Have you ever thought about how much waste is generated by our hospitals? Well, it turns out that our nation’s hospitals generate approximately 6,600 tons of waste per day! That’s a little over 2.49 MILLION tons a year! Surprising isn’t it? Contrary to what many believe, most medical waste isn’t infectious or dangerous at all. As a matter of fact, approximately 80% of that solid waste is non-hazardous, and like most solid non-hazardous waste, it can be recycled, composted, or diverted from a landfill or incineration. Regulated medical waste, on the other hand, must be disposed of properly for the safety of society.

So what is regulated medical waste?

According to the EPA, the Medical Waste tracking Act of 1988 defines medical waste as “any solid waste that is generated in the diagnosis, treatment, or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biologicals.”

A simpler way of thinking about it is that regulated medical waste is anything contaminated by blood, body fluids or other potentially infectious materials that poses a risk of transmitting infections.

Regulated medical waste must be disposed of in certain ways. And for most hospitals, that translates to incineration. However, the problem is that a lot of the waste that ends up in incinerators shouldn’t be there in the first place. Studies show that of all the waste generated by hospitals, no more than 15% should theoretically be RMW. Sadly, many hospitals are ending up with a lot more than that.

Incineration sounds safe–what’s the big deal?

Incineration might destroy the potentially harmful agents in RMW, but it’s at a tremendous cost (both financially and environmentally). Not only does disposal of RMW costs hospitals up to 10 times the amount compared to “normal” waste, it also produces toxic air emissions, toxic ash residue, and creates novel toxic compounds.  Thsee air emissions affect local communities and may even affect those hundreds, if not thousands of miles away, while Ash residue ends up in landfills where the pollutants can leach into the groundwater.  Even worse, burning of RMW can create novel toxic compounds such as dioxins which have been classified by the International Agency for Research on Cancer (IARC), an arm of the World Health Organization (WHO), as a known human carcinogen.  In fact, the EPA identified medical waste incineration as the 3rd largest known source of dioxin in air emissions and a contributor of approximately 10% of the mercury emissions to the environment.

A brief aside on Dioxin:

Dioxin (the compound found in Agent Orange) is one of the most toxic chemicals known. Exposure in humans occurs through the ingestion of foods, mostly meat and dairy products. This happens when cattle and dairy cows eat feed crops  that were contaminated by airborne dioxins that settle onto soil and plants. A scary thought is that dioxin has also been found to affect children in utero, and has been linked to birth defects, disrupted sexual development, and damage to the immune system.

If not incineration, then what alternatives?

Fortunately, the human endeavor to find alternative methods to incineration are ongoing, and some are already commercially available. I will only enumerate the different technologies below:

  • steam sterilization in autoclaves
  • post-treatment shredder or grinder
  • microwave treatment
  • alkaline hydrolysis
  • dry heat treatment

 So what can we do to help minimize RMW?

As always, the best action is prevention through education. And that applies to waste as much as anything else. For healthcare professionals, that means understanding where waste is coming from and how it is being disposed. Organizations such as Practice Greenhealth have developed tools for health facilities to track their waste to better understand waste management practices.  But tracking isn’t enough. Education is paramount. I have personally seen countless times staff throwing non-hazardous waste in hazardous waste bins. Does this mean that staff members don’t care about the environment? Of course not. It’s simply a reflection of the lack of education surrounding RMW. I was surprised to see that many physicians, nurses, and even custodial staff did not realize the impact of their actions.

Those not directly in healthcare can make a difference too. Next time you’re in a doctor’s office or a hospital and you see a staff member or other healthcare professional about to throw something non-hazardous into a hazardous bin, ask them about it. We are all stewards of the environment. We should all take the opportunity to teach and learn from each other. After all, those in healthcare are there for a reason–to help heal, and what better way to do that than to prevent the introduction of toxins into the environment.

Meds in our Water Supply – Part II – Green Strategies

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In my previous blog, I spoke about how drugs were ending up in our water supply. Although there are several causes by which this is happening, there are simple steps that we all can take to help mitigate the problem.

Responsible prescribing

There are several steps that prescribing physicians can take to reduce excess medications.

  1. Physicians should write scripts for smaller quantities, and should follow-up with patients closely to see if the specific medication prescribed is, indeed, appropriate.
  2. Physicians should follow evidence-based guidelines for prescribing meds.
  3. Physicians should minimize storing samples from pharmaceutical companies. Instead, they should insist that these companies provide coupons (even better: e-coupons) that patients could take to the pharmacies for a free sample. This would help streamline the supply of samples, and minimize the amount of “expired” samples that physicians have to throw away.
  4. Physicians should educate patients about their responsibility to use medications judiciously and to minimize the use of over-the-counter drugs.

Responsible disposal

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           There are now several methods by which patients, physicians, and other healthcare services can dispose of unused or expired medications. Remember: Most drugs should not be simply poured down the drain or flushed down the toilet! (The FDA has a list of drugs that can, or should be poured down the drain)

  1. Check with local city or county’s household trash and recycling service to see if they have a take-back program in the city.
  2. Check with local pharmacy to see if they have any local take-back programs available.
  3. If the drug label has specific instructions regarding the disposal follow that. Otherwise,
  4. Dispose of medications by a) removing them from their original packaging, b) sealing them in a container filled with an unpalatable substance such as coffee grounds or kitty litter, c) throwing them in the trash

Responsible consumption

           Ideally, reducing the amount of drugs coming into the system would reduce the amount being thrown out. If we were all to simply consume exactly what we need, there would be no excess. Of course, this is in an ideal situation, and like most things, ideal never translates into reality. However, as a consumer, we can be more judicious about our purchasing. Here are some ideas.

  1. Minimize the temptation to purchase large quantities of over-the-counter medications simply because it appears to be cheaper per unit. It may seem cheaper at first, but think of the cost of all those extra pills that weren’t consumed before they expired. Plus, having a smaller bottle is safer in case of over-ingestion.
  2. Take medications only when needed. This sounds a bit preachy, but I have seen a fair-share of patients who will over-consume medications simply thinking that more = better. Remember ALL drugs have a side-effect profile. Be smart about taking meds.

 

Medications in Our Water Supply! Part I

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In March of 2008, the Associated Press had released information showing that 28 out of 35 US watersheds tested had detectable levels of numerous drugs. Although the detectable levels tested were in parts per billion, the astonishing finding was that there were so many different compounds. In fact, in a preceeding study conducted by the United States Geological Service in 2002, it was shown that 80% of the samples obtained from 139 streams contained numerous widely used drugs! Here are just a few of them:

17-α Ethynyl Estradiol

This is a a synthetic estrogen present in oral contraceptives and is potentially responsible for the feminization of male fish. In fact, an article in Scientific American (June, 2009) stated that “estrogen exposure reduces a fish’s ability to produce proteins that help it ward off disease and pointed to a possible link between the occurrence of intersex fish…male fish carrying immature female egg cells in their testes.”

Acetaminophen

Also known to us as Tylenol, Acetaminophen has been widely used for pain relief among other things. Surprisingly, detectable levels of this drug have been found in 24% of tested waterways.

Other Steroids and Hormones

Other steriods as well has hormones and hormone-mimicking agents such as nonylphenol were found in 16% of tested waterways. Although the effects of these hormones and hormone-mimicking agents are still largely unstudied, one has to wonder if they are also having a negative impact on the fish populations in many of our waterways.

Diltiazem

Less known to the public, diltiazem is part of a group of drugs called calcium channel blockers used for the treatment of high blood pressure, angina, and some types of heart arrhythmias. Diltiazem works as a strong vasodilator–it increases blood flow and decreases the heart rate.

Codeine

Many people have at one time or another used codeine as part of a mixed preparation with acetaminophen or in cough syrup. It is a alkaloid found in opium and is a controlled substance due to its potential for being habit-forming. Codeine has several indications for use including  cough, diarrhea, pain, and IBS. Given its wide use, it is no surprise that it has been found in numerous waterways as well.

Antibiotics and Antimicrobials

This is perhaps another one of those categories of drugs that has received widespread media coverage given the increased occurence of antibiotic resistance. A variety of antibiotics including ampicillin, tetracycline, penicillin and erythromycin have been found in testable amounts in numerous waterways. Not surprisingly, wild Geese resistant to these antibiotics have been found.

Ibuprofen

Ibuprofen is a commonly used drug for the treatment of pain. It has been found in 10% of sampled waterways.

Detectable levels? So what?

Although many can argue that there is a difference between detectable and therapeutic or toxic levels, the fact remains that our waterways are being contaminated by “foreign” agents. We would be remiss to simply push this alarming fact aside and ignore the potential for slow accumulation in aquatic life. To be so bold as to say that since there have been no described human effects, there should be nothing to fear is short-sighted and foolish. Additive effects of pollutants, and the concept of increased bioconcentration as we move up the food chain have already been seen in other toxic compounds such as mercury. For example, mercury poisoning from fish is a well-described phenomenon. In fact, famous actor Jeremy Piven (Old School and Entourage) suffered from mercury poisoning following a high-fish diet that forced him to cancel working on the Broadway revival, “Speed-the-Plow.”

Ok, so we have contaminated waters. How did it happen?

As with any problem, the important question to address is how did it start in the first place. There are three main routes by which these contaminants enter our environment.

1. Excretion

As the name implies, drugs are excreted by the body in two main forms: urine and feces. Excretion of most drugs is primarily through urination, and comprises a continual low-level addition to the environment by many people.

2. Bathing

Many drugs are applied directly to the skin. These drugs are not completely absorbed, and are simply washed off during the process of bathing. Additionally, some drugs can be excreted in sweat and are also washed off during bathing. Again, this represents a continuous low-level contribution to environmental contamination.

3. Disposal

The final method of contamination is the direct disposal of drugs via toilets and trash. Although disposal is not a continuous source of contamination, it is episodic, and can be a significant source if disposed in large volumes by many people.

Now that we understand how we contaminate our waters, we should go back to the reason why this happens in the first place: mass prescriptions and improper consumption of medications. As a rising physician, I have seen countless examples of patients receiving medications such as antibiotics or pain relievers for conditions that cannot be appropriately treated through such means. Additionally, I have noticed a sense of undue dependence on the part of patients to medications that is simply astonishing. People expect medications to heal when in fact, many times they are better off without them. I am not saying in any way that people should not have access to medications, however, I do believe that the justified use of medications should be advised.

Another reason is that many people do not finish their prescriptions, or choose to buy them in large quantities. I have been guitly of this myself. A simple trip to a nearby wholesale retailer will prove my point–Tylenol is sold in large bottles in quantities exceeding 300 pills. The same goes for a variety of different drugs.  If we are to minimize our waste, then we must be more responsible about consuming what we need and not running after the cheapest deal. Large drug companies should also be more aware of this phenomenon and certain actions should be taken to minimize the sale of wholesale drugs. 

  So what can we do to minimize the problem?

I will discuss ways to reduce our environmental impact in my next blog. Stay tuned!

Understanding Sustainable Healthcare

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Sustainability has been defined as “meeting the needs of the present without compromising the ability of future generations to meet their own needs.

Although most of us are aware of the many efforts being devoted to bring sustainable measures into daily life, little is being done across the country to bring sustainable measures into mainstream healthcare. Sadly, the current health reform talks in Washington do not directly address this issue either.

So what exactly is sustainable healthcare? In the broadest sense it is changing the current practice of medicine to incorporate ways to reduce waste, conserve resources, improve environmental performance and provide a healthier, happier workplace for patients and providers of healthcare.

The benefits of sustainable healthcare are numerous. Costs can be reduced, physical and emotional health of patients can be improved, a safer and healthier clinical environment for staff and clients can be realized, a stronger workplace culture based on the values of prevention, wellness and environmental stewardship can be nurtured, and a more livable workspace with fewer stressors can be attained.

There are numerous ways to approach sustainable healthcare from both micro- and macro- perspectives. I plan on discussing both, starting with simple, actionable items and then addressing  large-scale ideas. My goal is simple: to help inspire others to adopt greener ways to treat patients and to bring sustainable measures to our burgeoning healthcare arena.

Welcome!

Hello Friends!

I’m so happy that you have stumbled onto this blog. Over the course of the next many months, I will be exploring ways to bring environmental sustainability to the healthcare world. Stay tuned as I share my insights and learning with you all. Feel free to share your ideas to bring sustainable measures to healthcare!