Cleaners, Disinfectants and Sterilants
Since Florence Nightingale’s time, nurses have been well aware of the importance of cleanliness to promote our patients’ healing process and to maintain quality health care. Unfortunately, in an effort to achieve the highest level of cleanliness hospitals may be undermining their own good intentions. Many of the cleaners, disinfectants and sterilants we use, while effectively avoiding the possible spread of infection, may cause other serious health-related problems. Not only do they put the vulnerable patient population at risk, but due to constant chronic exposures, many health care workers may be at risk as well.
Toxic chemicals are used for routine cleaning on every surface in the hospital environment. Disinfectants can contain very toxic active ingredients including quaternary ammonium compounds, bleach, ethyl and isopropyl alcohol, formaldehyde and phenolic compounds (Culver et al, 2002). Many floor care products used in hospitals, including wax strippers, contain know hazardous substances. Chemicals included in these products are diethylene glycol ethyl ether, apliphatic petroleum distillates and nonyl-phenol ethoxylate, ethanolamine (a known sensitizer), butoxyethannol, and sodium hydroxide (lye). (HCWH, [on-line]. Available: www.noharm.org. see Going Green).
Use of some cleaners can contribute to poor indoor air quality and create health risks, including: respiratory irritation and asthma; eye and skin irritation; nausea; headache; difficulty in concentration; and even cancer. Work-related asthma associated with exposure to cleaning products is dramatically documented in a recent article in the Journal of Occupational and Environmental Medicine. This study looked at 1,915 confirmed cases of workrelated asthma, and determined that 12% (236) were associated with workplace exposure to cleaning products. Medical settings are the most common workplace in which these exposures take place and the occupations most commonly affected are janitors/cleaners, nurses/nursing aides, and clerical staff (Rosenman et al, 2003).
Industrial strength cleaners often require diluting before use. Janitorial staff, whose first language may not be English or who have literacy problems, may have difficulty in following written directions for dilution. Problems with acute exposures to cleaning problems can occur if full strength solutions are used. Pour-and-wipe applications decrease the types of airborne exposures that may occur when spray bottles, aerosol cans, or mechanical devices are used. Adequate ventilation, well-trained cleaning staff who understand the correct dilution ratios and methods, and choosing the least toxic chemicals can significantly reduce the risks of health effects and injuries.
There are several municipal initiatives to reduce the use of toxic cleaning products by public workers, including the Sustainable City Program of Santa Monica, California. In an effort to purchase less harmful products, the program evaluated cleaners for their environmental and human health effects. As a result, they reduced the use of hazardous products, saved money, and reduced worker complaints.
* Avoid caustic or corrosive products (very low or high pH)
* Avoid unnecessary fragrances (which can affect people with asthma or chemical sensitivity)
* Choose products with reasonable packaging. This will limit your waste stream.
Many facilities are evaluating the use of microfiber mops to reduce chemical and water use, reduce cleaning time, and reduce staff injuries. In a study completed by the University of California Davis Medical Center, they compared the use of traditional large, loop mop heads with microfiber heads. The microfibers are about l/16th the thickness of a human hair. The density of the material allows it to hold 6 times its weight in water making it more absorbent than cotton loop mops. In current practices, with traditional mops, janitors change the cleaning solution after every two or three rooms-requiring the disposal and replenishing of cleaning solutions. Fewer changes are required because the used mop is never placed back in the solution. The study found that using the microfiber mops reduced chemical use and disposal, reduced cleaning time in patients’ rooms, and reduced custodial staff injuries and worker’s compensation claims. Further, a 60% savings in lifetime mop costs were achieved, a 95% reduction in chemical costs, and 20% labor cost reduction. To see more about the microfiber mops and the study, go to the Cleaning section on the Sustainable Hospitals website: http://sustainablehospitals.org.
Hospitals also use a variety of methods to disinfect and sterilize surfaces and equipment and some can have serious health effects. Two of the most commonly used are glutaraldehyde and ethylene oxide (EtO).
Among its other uses in industry, ethylene oxide is used in the healthcare industry as a sterilant for equipment or supplies that are heat or moisture sensitive. EtO can enter the body when inhaled. The acute toxic effects in humans and animals include acute respiratory and eye irritation, skin sensitization, vomiting, diarrhea, neurological disorders, and even death at high concentrations. Chronic effects observed in workers exposed to EtO at low levels for several years are irritation of the eyes, skin, and mucous membranes, neurological damage, and cataracts. Reproductive effects have been noted in animal studies and some evidence exists that exposure to ethylene oxide can cause an increased rate of miscarriages in female workers. The Environmental Protection Agency (EPA) considers ethylene oxide to be a probable human carcinogen and some studies have shown elevated cases of leukemia, stomach and pancreatic cancer, and Hodgkin’s disease in workers exposed to EtO by inhalation in hospital sterilization rooms. In addition, EtO is flammable and explosive.
The National Institute for Occupational Safety & Health (NIOSH) recommends that EtO be considered a mutagenic and a potential human carcinogen and recommends eliminating all unnecessary and improper uses of EtO in medical facilities whenever possible, and safe alternatives should be used to minimize occupational exposure to it. There is currently an Occupational Safety and Health Standard for ethylene oxide because of its health risks.
Glutaradehyde, a disinfectant, is a potent skin irritant and sensitizer known to trigger asthma (Nethercott, 1988; Di Stefano, et al. 1999). Whenever possible, a less hazardous disinfectant should be used. For guidance in selecting an alternative, see “10 Reasons to Eliminate Glutaraldehyde” on the Sustainable Hospitals website: http://www.sustainablehospitals.org/HTMLSrc/IP_ factsheet_contents.html#glut). The Occupational Safety and Health Administration is currently developing an occupational exposure standard for glutaraldehyde because of its health risks.
As nurses and other hospital employees become more educated about health risks from chemicals in their environment, we will see more and more opportunities to decrease the risks by making informed decisions about our everyday practices and purchases. Nurses can play a key role in improving occupational and environmental health threats in our health care facilities. The Nurses’ Workgroup of the national Health Care Without Harm Campaign is committed to this effort. We welcome you to join us in this effort. see the Nurses’ section of the Health Care Without Harm website: http://noharm.org/tools/nurses.
Culver et al. (2002) Cleaning for Health: Products & Practices for a Safer Indoor Environment. [On-line]. Available: http://www.informinc.org/cleanforhealth.php.
Di Stefano, R, Siriruttanapruk, S., McCoach, J. & Serwood Burge, P. (1999). Glutaraldehyde: An occupational hazard in the hospital setting. Allergy. 54. 1105-1109.
Nethercott JR, Holness DL, Page E. Occupational contact dermatitis due to glutaraldehyde in health care workers. Contact Dermatitis. 1998 Apr: 18(4): 193-6.
Rosenman et al. (2003) Cleaning Products and Work-Related Asthma. Journal of Occupational and Environmental Medicine.: 45:556-563.
by Barb Sattler, RN, DrPH & Marian Condon, RN, MS
About the Authors:
Barbara Sattler, RN, DrPH, is the Director of the Environmental Health Education Center at the University of Maryland School of Nursing Bsattler@sn.umaryland. edu or www.cnviRN.umaryland.edu.
Marian Condon, RN, MS, is a graduate of the Community/Public Health Masters program at the University of Maryland and currently works as a Research Project Manager at the Occupational Health Program at the University of Maryland School of Medicine.
Many thanks to the Maryland Nurses Association for sharing this article.
Copyright South Carolina Nurses’ Association Oct-Dec 2003
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