Infection Connection

The real cost of toxic chemicals in healthcare

by Larry Weiss, MD.

According to the Bureau of Labor Statistics, hospitals and nursing facilities are among the most hazardous work environments. Every year, on average there are about seven occupational injuries or illnesses for every 100 employees and about half will result in lost worktime1. Working with or exposure to toxic chemicals is the single largest contributing risk factor associated with occupational illness and injury in healthcare. In addition to the human cost, the economic cost associated with these injuries and illnesses is staggering. The majority of the toxic exposure in healthcare occurs with the use of cleaners and disinfectants by aids and housekeeping staff. Purchasing decisions for these products often involve input from a number of hospital departments and may ultimately be made by outside cleaning contractors. 

Historically, indirect costs due to toxicity and corrosion have not been taken into consideration when choosing disinfectants. Consequently, purchasing decisions are often based on the lowest bid. As complicated as the financial modeling of the indirect costs of toxic chemicals may be, there is compelling evidence that reducing toxic exposure in the workplace is a good business decision that can result in a significant return on investment.

Many institutions have records that may track these costs but have yet to connect them to the underlying cause, toxic exposure. Purchasing managers are uniquely qualified to identify these costs, involve the respective departments to reduce toxic exposure and then benchmark the actual return on investment. By taking a leadership role in this effort, purchasing managers have an opportunity to significantly improve both the physical health of the workforce and the financial health of the institution. 

Background
At a recent international infection control meeting, a prominent physician was asked how germicides and disinfectants were chosen at his institution. After giving it some thought, he responded that he had no idea. This is emblematic of the problem that faces healthcare purchasing when making a buying decision has direct and indirect impact throughout the institution. The purchase of disinfectants and germicides is particularly complicated because they are regulated as hazardous materials and involve input from departments beside the end-user.

Compliance with JCAHO, OSHA, EPA, and local water districts necessitates an ongoing program of training and monitoring particularly since there tends to be high turnover among the aids and housekeeping staff that make up most of the users. Input into the product specifications and requirements for germicides and disinfectants often come from infection control, risk management, environmental compliance and housekeeping. This can be further complicated if individual clinical departments insist on specific germicides. Increasingly, emerging infectious diseases and resistant organisms present ongoing challenges that may necessitate the reexamination of infection control practices and subsequent changes in purchasing. Relationships with GPOs and existing vendors may limit the alternatives or bundle desirable products with a compromise product, solving one problem and creating another. At the center of this, and tasked with finding win-win solutions within an increasingly tight budget, is hospital purchasing. 

Purchasing: An opportunity to lead
To many, this complicated process may not reflect their experience when it comes to disinfectant purchasing decisions. The choice of products has remained largely unchanged in many if not most institutions, with the exception of switching between manufacturers or vendors on the basis of a lower bid or a value-added service. To the departments that had input on the specifications of the product prior to the decision making process, the use of the product goes essentially unnoticed. Unless there is an outbreak or some other pressing need to reevaluate the cleaning and disinfecting practices, very little attention is paid to disinfectants that are used by the aids and housekeeping staff. Moreover, even in the event of an outbreak, the most common of which today are due to the resistant staph MRSA, enterococcus VRE, or norovirus, the most likely agent of transmission are the unwashed hands of the professional staff.

Without a pressing demand from the involved departments, it is understandable that there has been little incentive to invite the reconsideration of disinfectants. In fact, it is the complicated process and the number of involved constituencies that has served as a disincentive to open up this can of worms. The recent introduction of a new class of disinfectants which address the dual problems of toxicity and material incompatibility, based on nanotechnology, and used in combination with microfiber cleaning materials presents the first real advance in hospital infection control. It has the potential to improve practice, simplify the workload, eliminate hazmat exposure and reduce both direct and indirect costs. This represents a win-win solution for the entire institution and an opportunity for purchasing to take a leadership role. 

Roadmap to success
Like most examples of change in healthcare, the opportunity to bring about the reduction in toxic exposure will require leadership and interdepartmental cooperation. Because of the central role in materials selection, it is appropriate that the purchasing department take the leadership role in the process.

The first step is the formation of a working group that involves the departments that are users and influencers as well as those departments that pay for the real cost of toxic exposure. In almost every industry where it has been studied, the indirect costs of bringing a hazardous material onsite are significantly higher than the cost of the material itself but in most cases the end users are insulated and thus unaware of the total cost of their practice. Simply putting the users in touch with these costs can be a powerful motivating force for change. Just as often, they are unaware of potential solutions that can reduce costs and improve productivity. A team approach that presents alternatives in an open discussion, the outcome of which is a trial or a series of trials that are to be objectively considered is a proven formula for success. 

Hazmat concerns when choosing disinfectants
It has long been a principle of disinfectant and biocide action that there is a direct relationship between efficacy and toxicity2. The most effective disinfectants and sterilants have also been the most toxic and as a result the most difficult and expensive to use and ultimately, dispose of properly. Accordingly, infection control professionals have to balance the spectrum of pathogens that were likely to result in outbreaks of clinical illness within their particular setting, with the potential toxicity of the disinfectant needed to control those agents. Disinfectants that fell within that balance were then selected on the basis of direct cost and availability. 

Last August, 37 eminent clinicians signed a controversial article that appeared in the American Journal of Infection Control challenging the use of disinfectants in hospitals. Concluding, “there are insufficient scientific data to support the strong recommendation to routinely disinfect environmental surfaces in healthcare facilities except in certain high risk areas (e.g., isolation units) or possibly to prevent transmission of high-risk organisms’ they raised a number of salient issues that need to be examined”.

The essence of this report was that in the absence of data supporting a measurable benefit in terms of patient outcomes (reduced nosocomial infections) the risk from toxic exposure to disinfectants was unjustified. They raise an important question: On what scientific basis have we chosen to poison ourselves? Citing occupational diseases including dermatitis, asthma, chemical sensitivity as well as the environmental contamination due to quaternary ammonium compounds, they recommend instead the use of detergents except in high risk areas. The adverse health and environmental consequences from disinfectants are well-documented and beyond question. Nevertheless, they conclude, it is doubtful that many hospitals will change their practice and replace disinfectants with detergents. 

Common practices today
Most U.S. hospitals use disinfectants that are based on quaternary ammonium chemistry, commonly known as “quats.” Since their introduction in the middle of the last century, quats have largely displaced the more toxic phenolic and chlorine (bleach) based disinfectants. Quats are considered to be low-level disinfectants because they have efficacy against most bacteria and the enveloped viruses but are not generally tuberculocidal. The accepted mechanism of action for the quats is that they are surfactants and disrupt and dissolve the cellular membrane that surrounds bacteria and some viruses. Unfortunately, the same mechanism is implicated in the toxic effect quats have on human cells, resulting in dermal, ocular and pulmonary irritation. This may also be responsible for the sensitization and dermatitis that can occur in about 2 percent of healthcare workers exposed to quats3. A recent report in the American Journal of Industrial Medicine found that janitorial workers have the highest rate of occupational asthma (625 cases per million workers) attributable to disinfectants,4 most of which were quats. Environmentally, quats are poorly biodegradable and can be found in rivers, streams, and many municipal water systems5. 

A smaller segment of the hospital disinfectant market is occupied by a variety of oxidizing agents including hypochlorites (bleach), and accelerated peroxides. Many of these are intermediate level disinfectants and some are high-level disinfectants. Included in this group, in addition to the hypochlorites, are peracetic acid, peroxymonosulfate, a number of stabilized forms of hydrogen peroxide, and a device that makes superoxidized water. The basis for the disinfectant action in this group is the oxidation or chemical “burning” of the bacterial or viral organism. Again, this same effect is nonspecific and human toxicity can range from skin, eye, or pulmonary irritation to serious chemical burns and poisoning. The use of oxidizing agents, particularly the hypochlorites, has been implicated in occupational asthma. In addition they are highly corrosive and will degrade most materials, especially when used on a regular basis. For this reason the oxidizing agents have generally been reserved for outbreak response and are not an appropriate choice for routine disinfection.

The future: Nanotechnology germicides and economic impact
Almost two years ago the EPA granted approval to the first nanoemulsion disinfectant. Starting in the mid-1990s scientists working independently at the University of Michigan and EnviroSystems Inc, a California biotech company, observed that nanoemulsions, suspensions of very small oil droplets in water, exhibited the unexpected property of killing bacteria and inactivating enveloped viruses. The size, physical properties and chemical composition of the oily droplet appeared to be crucial to this antimicrobial activity.

EnviroSystems focused its efforts on developing their nanoemulsion as a targeted delivery device for the biocide PCMX6. The PCMX-loaded nanoemulsion has a broad spectrum of activity against bacteria including TB, both enveloped and non-enveloped viruses, and fungi. This has resulted in a commercially available emulsion sold under the trade name EcoTru, which is an intermediate-level disinfectant. Its current label lists efficacy against 22 organisms including a five-minute TB claim, gram positive and gram negative bacteria, enveloped and nonenveloped viruses, and two fungal species.

Because nanoemulsions are targeted, there is no toxicity in any of the required EPA testing. Notably, this is the first time the EPA has approved a disinfectant without requiring cautionary warnings on the label. By comparison, most of the widely used disinfectants with this range of coverage recommend the use of some degree of personal protective equipment. Additionally, by their very nature, nanoemulsions have broad materials compatibility and are noncorrosive. This was recently tested and confirmed when the aviation giants Boeing and Airbus added a nanoemulsion disinfectant cleaner to their approved products list. Previously, although they had tested many disinfectants, none had passed the corrosion standard and there were no approved disinfectants for use on civilian or military aircraft. This testing consists of a battery of ASTM tests on a wide range of metals, plastics, painted surfaces, fabrics, vinyl, and leather, covering essentially any material that might be found in a clinical environment. 

Another recent advance in infection control is the development of microfiber materials for cleaning and disinfections. These materials have a very fine structure on the order of several microns which has been demonstrated to very efficiently clean and remove as much as 99.9 percent of the bacterial contamination from surfaces. Microfiber cloths transfer bacterial to the cloth where disinfection than takes place, rather than on the environmental surfaces. The current practice of using a bucket and string mop to clean and disinfect floors is both wasteful and inefficient, resulting in cross contamination and occupational injuries from mopping and lifting.

Alternatively, a clean microfiber mop head and cloth are used to clean each room, eliminating cross contamination. The mop heads and cloths can be washed hundreds of times with an institutional cost savings of over 60 percent annually. An EPA study of microfiber mops at the University of California Medical Center at Davis found significant reductions in disinfectant use, labor costs, and worker’s compensation costs7. Combined with a nanoemulsion disinfectant, the net effect is to reduce toxic exposure and occupational injuries while using a reduced volume of disinfectant solution to achieve an overall improvement in cleaning and disinfection. 

Post-purchase costs of toxic chemicals
Hazmat costs and compliance costs include training, monitoring, JCAHO, OSHA and EPA compliance and personal protective equipment. Hazmat risks can be broken down into several broad categories: occupational health risks, materials incompatibilities, flammability and environmental risks. Some of these costs (materials incompatibility) are spread throughout the institution and may be difficult to track while others (occupational injury and illness) have statutory reporting requirements and can be benchmarked.

Risk management and human resources
Early involvement of the hospital risk management and human resource departments is a key to success. Although there many indirect costs associated with toxic exposure, occupational health and associated absenteeism are both the largest and the easiest to benchmark. Compliance with OSHA regulations requires that every occupational injury or illness be entered into the OSHA 200 log and most will trigger a worker’s compensation claim. Every such claim has the potential to increase the hospital’s experience modifier, which multiplies insurance premiums.

Injuries or illnesses that result in lost work time or reduced work time are also recorded. Add to this the cost of absenteeism and hiring and training replacements. Estimates by IBI, an independent study group, find that each lost workday can cost the institution as much as $1,500 and absenteeism due to injury or illness can account for as much as 15 percent of payroll8. Dermatitis and asthma associated with disinfectants and cleaners are the most common occupational illness in healthcare workers in hospitals and nursing homes. Many persist for six months or more. Chronic dermatitis is the most common chronic occupational illness in healthcare workers9. They can cost an average of 11 workdays annually and over 70 percent are associated with the use of harsh disinfectants and cleaners. Lifting heavy buckets and mopping injuries, while less common are costly and can easily be eliminated by converting to a microfiber system. Even a small reduction in these costs can have a significant impact on overall productivity because of reductions in absenteeism and hazmat related work activities. 

Housekeeping
The majority of the hazardous chemicals in healthcare are used by aids and housekeeping staff and, correspondingly, they suffer the majority of the ill effects from toxic exposure. Early involvement of either the housekeeping mangers or the outside contractor is essential to achieve “buy-in” and success. Among their greatest challenges when considering change is that there is high turnover and a lower educational level among their employees. The task of maintaining ongoing training for new employees and monitoring for compliance must be considered whenever proposing change. Emphasizing that training, practice and compliance can be streamlined at the same time as occupational illnesses and injuries can be reduced will often be enough of an incentive to bring them to the table. For outside cleaning contractors, the same worker’s compensation and efficiency considerations translate directly into improved productivity as well as better employee relations. 
Infection control

In most hospitals, the infection control officer has broad responsibilities among them setting a standard for the infection control products and practices. Once this standard has been established, purchasing was tasked with getting sign-off by housekeeping and then finding the most competitive price. In most cases, the standard is defined by a list of required organisms and kill times.

From the perspective of most infection control officers, the number one problem is compliance. Transition to a safer and simpler practice is an effective tool in improving compliance. Although some infection control practitioners may feel that their involvement in considering a less toxic alternative ends when the defined efficacy is met, it is nevertheless important to make every effort to make them part of the team. Success is dependent on solving problems early and making everyone a problem solver. 

Compliance 
Compliance with the JCAHO, OSHA, EPA and local water district regulations concerning hazardous chemicals is time-consuming and expensive. The responsibilities for compliance may be distributed throughout the institution and it may be more difficult to identify a specific department or individual for involvement on the team. In many cases there are regulations concerning the shipping, storage and disposal of hazardous chemicals. However, assigning a dollar value may be difficult or impossible. If there is a compliance officer or a community liaison with an interest in reducing the hazardous waste stream it may make sense to either alert them to the process or involve them directly. Generally, indirect costs related to the use of toxic disinfectants are those that are necessary to comply with JCAHO, OSHA and EPA regulations.

Chronic exposure
While MSDS may provide a basis for comparison between products, the longer-term consequences due to exposure are poorly understood. In healthcare settings, disinfectants are used on a daily basis and the exposure for staff is measured in terms of years or, in some cases, decades. A recent CDC report found 147 industrial chemicals and pesticides in the blood and urine of 5,000 volunteers10. Connecting the exposure to any particular chemical to a subsequent health problem would be difficult if not impossible. That the connection may be unknowable should not be interpreted as grounds to dismiss the possibility and, in fact, is a strong argument that the least toxic alternatives should be used. 

Opening the can of worms
The forces for institutional change are often challenged by passive inertia; it takes more effort to change things than it does to leave them alone. Every new advance in disinfectant or germicidal technology since Dr. Simmelweis recommended hand washing has been met with a certain degree of skepticism. While it has not historically fallen to the purchasing departments to advocate for change, the move to value purchasing that takes a more global view of costs argues for purchasing to take a more of an activist role.

By strategically examining the broader implications of purchasing decisions in light of new products and technologies, purchasing managers can take a leadership role in preventing illness, improving the quality of care and reducing costs. Reducing the use and exposure to hazardous chemicals is an example of a can of worms that is clearly worth opening. In addition to the tangible economic benefits, improved employee and union relations, protecting the environment and promoting the hospital as a good corporate citizen are possible and should be considered.

The potential benefits of interdepartmental team problem solving focused on common goals to reduce the use and exposure to hazardous chemicals go far beyond solving this specific problem. Success in this effort will go along way toward setting a new standard for change that emerges from specific departmental needs through collaboration to improve global institutional productivity. Through the expertise and experience within hospital purchasing, departments are uniquely positioned to rise to the increasingly complicated economic challenges facing healthcare. 

HPN

Dr. Larry Weiss, a senior scientist with EnviroSystems Inc., a San Jose, CA-based manufacturer of bio-protection and disease reducing technologies, is a board certified anesthesiologist and has practiced both anesthesiology and critical care medicine in several Western states. He was a NIH Fellow in physiology and biophysics at the Cornell University Medical College and is the author of numerous scientific articles and abstracts in the areas of chemistry, physiology, biophysics and clinical pharmacology. He also served as assistant professor of anesthesia at the University of Arizona. Dr. Weiss holds a B.S in bio-organic chemistry from Cornell and an M.D. from the Stanford University School of Medicine.

Footnotes
i BLS Incidence rates1 of nonfatal occupational injuries and illnesses by industry and selected case types, 2000, 
ii McDonnell, G., Russell, A.D., Antiseptics and Disinfectants: Activity, Action, and Resistance, Clin Micro Rev, 12:1 147-179, 1999.
iii Schnuch A, Uter W, Geier J, Frosch PJ, Rustemeyer T. Contact Allergies in Healthcare Workers.
Results from the IVDK. Acta Derm Venereol 1998;78:358-63.
iv F. Reinisch et al., Physician Reports of work-related asthma in California, 1993-96, American Journal of Occupational Medicine, July 1999, 49:5, 72-83
v Swisher RD. Surfactant biodegradation. 2nd ed. New York: Marcel Decker; 1991.
vi www.envirosi.com 
vii USEPA Using Microfiber Mops in Hospitals: Environmental Best Practices for Health Care Facilities (Spring 2002)  
viii http://www.ibiweb.org/ 
ix A Proposed Strategy for Prevention of Occupational Dermatological Conditions (ASPH/NIOSH 1988)
x www.cdc.gov/exposurereport 

(Endnotes)
1 BLS Incidence rates1 of nonfatal occupational injuries and illnesses by industry and selected case types, 2000,  
2 McDonnell, G., Russell, A.D., Antiseptics and Disinfectants: Activity, Action, and Resistance, Clin Micro Rev, 12:1 147-179, 1999.
3 Schnuch A, Uter W, Geier J, Frosch PJ, Rustemeyer T. Contact Allergies in Healthcare Workers.
Results from the IVDK. Acta Derm Venereol 1998;78:358-63.
4 F. Reinisch et al., Physician Reports of work-related asthma in California, 1993-96, American Journal of Occupational Medicine, July 1999, 49:5, 72-83
5 Swisher RD. Surfactant biodegradation. 2nd ed. New York: Marcel Decker; 1991.
6 www.envirosi.com 
7 USEPA Using Microfiber Mops in Hospitals: Environmental Best Practices for Health Care Facilities (Spring 2002)  
8 http://www.ibiweb.org/ 
9 A Proposed Strategy for Prevention of Occupational Dermatological Conditions (ASPH/NIOSH 1988)
10 www.cdc.gov/exposurereport 

September
2003