by Jessica Boehland
What we do to our environment, we do to ourselves, the saying goes. Nowhere is this principle played out more dramatically than in our hospitals, where doctors and nurses work the front lines against environmental illness, treating patients for cancers caused by exposure to toxic materials, asthma triggered by breathing dirty air, and heat stroke brought on by heat waves made more severe by climate change.
Sadly, the connection between hospitals and illness does not end with treatment. Even as healthcare professionals go to heroic lengths healing the sick among us, the very buildings in which they work forestall and unravel their efforts. Burning fossil fuels to power healthcare facilities contributes to climate change, allowing disease vectors to invade new habitats. Relying on ozone-depleting refrigerants to cool them increases the potential for skin cancer. Using mercury-based instruments to measure body temperature and blood pressure contributes to air and water pollution, increasing rates of brain damage from mercury poisoning. Clearing rainforests to provide wood for furniture contributes to the extinction of species that might have yielded life-saving medications. Furnishing interiors with materials manufactured using carcinogens perpetuates the spread of cancer; such materials are common even in radiation and chemotherapy treatment rooms.
“The healthcare industry is always worried about saving lives, because that’s their prime directive,” says Robin Guenther, AIA, principal of Guenther 5 Architects in New York City. Concurrently, “there’s an idea that sustainability means deprivation and doing with less,” she says, “and that runs headlong into this culture of never sparing resources to get the job done.” This interpretation of sustainability has led some health professionals to resist the idea of designing healthcare facilities to be more environmentally responsible.
The History and Future of Greening the Healthcare Industry
The connection between the healthcare industry and the environment was illuminated in 1994, when the U.S. Environmental Protection Agency (EPA) identified medical waste incineration as the largest source of dioxin, considered to be the most potent human carcinogen manufactured. The irony of this situation inspired the formation of Health Care Without Harm (HCWH), a nonprofit that now boasts more than 375 member groups in 40 countries.
Another milestone in the push to green the healthcare industry was the 1998 memorandum of understanding between the American Hospital Association and EPA, which laid out three goals for the healthcare industry: to eliminate mercury-containing waste, to reduce the overall volume of waste, and to identify hazardous substances for pollution-prevention opportunities. This agreement launched the nonprofit Hospitals for a Healthy Environment (H2E), a joint project of the American Hospital Association and EPA, along with HCWH and the American Nurses Association.
Within the last five years, interest in greening healthcare has moved beyond operations to encompass the design and construction of healthcare facilities themselves. To guide a new sustainable design category in its annual awards program, the American Society for Healthcare Engineering (ASHE) published the Green Healthcare Construction Guidance Statement in January 2002, updated in 2004. It is considered the first document to incorporate health considerations into design guidance.
Prompted by an impending healthcare construction boom in response to California’s new seismic regulations, Gail Vittori, co-director of the Center for Maximum Potential Building Systems in Austin, Texas, convened a group of green building and health experts in 2003 to develop a more prescriptive set of design guidelines. The collaboration resulted in the Green Guide for Health Care, which was released in pilot form in late 2004.
Though modeled on the U.S. Green Building Council’s LEED Rating System, the Green Guide does not involve third-party certification. It is also broader than LEED, identifying environmental considerations in the planning, design, construction, operations, and maintenance of healthcare facilities and summarizing how each consideration relates to health and well-being.
More than 30 healthcare facilities are registered through LEED, and two have achieved certification: Boulder Community Foothills Hospital in Boulder, Colorado, became the first LEED-certified hospital when it earned a Silver rating in 2003, and the Patrick H. Dollard Discovery Health Center earned Certification in 2004.
Kaiser Permanente Takes the Lead |
| Kaiser Permanente is the largest nonprofit health-maintenance organization (HMO) in the country. “We look beyond someone catching a disease, to what are the root causes of that disease, and what can we do to affect that,” says Tom Cooper, Kaiser’s manager of strategic sourcing and technology. “There’s such a direct link between chemicals, the environment, and healthcare, that it’s only natural.” The organization’s Environmental Stewardship Committee, created in early 2001, divides its work into environmentally responsible purchasing, sustainable operations, and green building. Kaiser’s green building efforts are progressive reflective roofing, daylighting and sunshades, energy-efficient elevators, and zoned HVAC systems are among its standard design strategies. The organization is currently considering changing its standards from PVC piping to high-density polyethylene (HDPE), from fiberglass insulation to cotton, and from conventional casework to that without added urea-formaldehyde. Following two and a half years of testing and research, in 2004, Kaiser decided to forsake vinyl composition tile and sheet vinyl, opting instead for Stratica resilient flooring and Nora rubber flooring. Kaiser was concerned about the environmental and health effects of not only PVC but also the chemicals associated with maintaining vinyl flooring. Kaiser expects a pay-back period of five years, because eliminating stripping and waxing reduces maintenance costs by about 80%. “The biggest challenge is first cost,” says Cooper, noting that Kaiser’s usual payback cutoff is three years. “We’re primarily trying to deliver healthcare, and if we spend too much on the building side, we’re taking away money that could be spent on healthcare.” The organization is working to predict payback more accurately, taking into account issues such as staff turnover rates and workplace safety. They are studying the effect that the less-slippery Stratica and Nora flooring have on patient falls, for example. Kaiser has engaged directly with manufacturers in search of building materials. “We’re committed to market transformation,” says Cooper. C&A Floorcovering, Inc., for example, developed a recycled polyvinyl butyral carpet backing in response to Kaiser’s desire for a PVC-free carpet system. The development earned C&A a sole-source contract with Kaiser and made Ethos-backing available to anyone seeking a replacement for PVC. Similarly, the C/S Group developed Acrovyn 3000, a PVC-free material for wall and corner guards, in response to Kaiser’s interest. “We’re giving th ese manufacturers a market for these products, but we’re assuming there are other folks interested as well,” says Cooper. “That’s one of the good things about being the 8,000-pound gorilla.” |
Meanwhile, the next version of the AIA Guidelines for the Design and Construction of Healthcare Facilities is due out in 2006. Parts or all of the AIA Guidelines have replaced individual state codes in 42 U.S. states, according to Guenther, who is participating in the revision. While the current version includes only one paragraph about green designfocused on energy conservationthe next version will include an entire chapter on therapeutic environments and sustainability issues.
America’s last hospital-building boom occurred just after World War II and much of that building stock is in need of renovation. The U.S. currently spends $17 billion on healthcare construction each year; by 2010, that number is expected to reach $25 billion, so this is the time to rethink the way we design and build our healthcare facilities.
What Makes Healthcare Unique?
To a large extent, healthcare facilities can be thought of as just another building type, especially administrative offices and patient waiting areas.
But healthcare facilities also stand apart from other building types. First, they’re big. At 168,200 ft2 (15,626 m2), the average inpatient healthcare facility is more than 11 times the size of the average commercial building, according to the Energy Information Administration’s 1999 Commercial Buildings Energy Consumption Survey. Healthcare facilities are also highly regulated and expensive to build. They often operate around-the-clock, and they experience long ownership. They use tremendous amounts of energy and need backup power for emergencies, they require a lot of water, and they create huge amounts of waste, some of it hazardous or infectious. They are stressful environments, and many of their occupants have depressed immune systems. Perhaps most important, they function explicitly to restore and protect health.
Indoor Environmental Quality
Because restoring and safeguarding health is the unequivocal purpose of healthcare facilities, indoor environmental quality is generally considered the critical issue in greening healthcare design. Providing a healthy and pleasant indoor environment is also important in the recruitment and retention of employeesespecially nurses, whose national average turnover rate currently stands at 20% each year.
Daylight and views. Exposure to daylight and views of the natural environment are proving important for patients’ well-being and capacity to heal. “Investigators have consistently reported that stress-reducing or restorative benefits of simply viewing nature are manifested as a constellation of positive emotional and physiological changes,” according to the 2004 Center for Health Design report, which goes on to note that when patients view nature, “stressful or negative emotions such as fear or anger diminish while levels of pleasant feelings increase.”
The stress reduction resulting from daylight and views also benefits hospital employees. An unpublished 1996 master’s thesis found that intensive-care-unit nurses whose breakroom had a view to the outside experienced reduced stress and made, on average, 40% fewer mistakes than their coworkers whose breakroom had no windows.
Bright light and darkness. The Center for Health Design report also points out that bright light, either natural or artificial, can reduce depression and agitation, improve the quality of sleep, and shorten hospitalizations for dementia and seasonal affective disorder (SAD).
Darkness can be just as important as light, and proper timing is required to balance human circadian rhythm. For patients, this means providing light during the day and darkness at night – no small feat in a building that operates around the clock. For staff, this means fostering alertness at all times.
In a credit explicitly addressing circadian rhythm, the Green Guide suggests that healthcare organizations eliminate rotation shift work (where an individual’s work schedule rotates among day, evening, and nighttime shifts), which disrupts the body’s ability to establish routines in sleep and alertness.
Proper acoustics are also important to patients and staff, as loud noises and vibrations can interfere with both rest and work. The Center for Health Design report cites several studies that correlate noise with decreased oxygen saturation; increased blood pressure, heart rate, respiration rate, and stress; and interrupted sleep.
Unfortunately, hospitals are typically noisy, with sounds ranging from paging systems and alarms to ice machines, cardiopulmonary monitors, and pneumatic tubes. Hard surfaces, typical in hospital settings, are easier to clean but also less effective at absorbing sound waves. They cause sounds to echo, overlap, and linger or have long reverberation times, according to the report, which suggests reducing noise sources, providing single-occupancy patient rooms, and selecting sound-absorbing ceiling tiles and, where possible, sound-absorbing flooring materials.
Materials
The healthcare community is also turning its attention to the materials used in its buildings and the health implications of the production, use, and disposal of those materials. The Green Guide includes credits related to reducing pollution from mercury, dioxin, and di(2-ethylhexyl) phthalate (DEHP).
Despite its role as a reproductive toxin and neurotoxin, mercury is still commonplace in the healthcare industry. A sampling of mercury-containing products includes some thermometers, blood-pressure devices, fluorescent lamps, cleaners, and batteries.
H2E has made the elimination of mercury from the healthcare industry one of its primary goals. “There’s still work to be done,” says Laura Brannen, executive director of H2E, “but we have really changed the way people think about mercury. If a mercury thermometer breaks, now people freak out and close down the room. Ten years ago, people swept it up, threw it in a red bag, and, often, incinerated it.” More than 100 facilities have received H2E’s Making Medicine Mercury Free award, and, according to HCWH, more than 1,000 U.S. healthcare institutions have committed to eliminating mercury from their facilities.
HCWH and H2E have been working to phase out the use of chlorinated plastics in healthcare facilities because these materials can produce dioxin if they are burned. Polyvinyl chloride (PVC), the most common chlorinated plastic, can be found in medical products ranging from blood bags, gloves, and identification bracelets to wall-protecting guards and flooring.
The concern over PVC derives from its connection not only to dioxin, but also to DEHP, a phthalate plasticizer used to make PVC more flexible. DEHP is listed by the U.S. National Toxicology Program as a probable human carcinogen and endocrine disruptor that causes reproductive problems, making it especially dangerous for male babies and fetuses.
“I tell cli
ents they don’t have to decide if they agree or disagree with the science of PVC,” Guenther says. “People don’t need to take a position, but they need to watch what’s going on in the marketplace. The environmental movement is having an impact on the way PVC is seen in the world, and that can have repercussions in the way people view their buildings.” Guenther also pointed out that the long ownership of healthcare facilities makes clients skittish about using controversial materials.
“Healthcare owners can’t disconnect from the downstream impact of these building materials.” Due in part to their experience with lead paint and asbestos abatement, she notes, “I think they’re a little risk- averse. Insofar as there are high-performance, cost-competitive materials that don’t have that uncertainty, it just seems to me to be using the air of precautionnot even scientific precaution, just business precautionto look at those alternatives.”
Waste
According to H2E, the U.S. healthcare industry generates more than 2.4 million tons (2 million tons) of waste per year, or 1% of all municipal waste. Healthcare waste can be separated into four main categories, according to H2E’s Brannen: regulated medical waste (also called red-bag waste or biohazard waste), which has the potential to transmit disease; hazardous chemical waste; waste that can be recycled or reused; and everything else, or conventional solid waste.
Very few healthcare facilities are aware of how much waste they produce or how much it costs, Brannen told EBN. “They’re paying the bills, but they’re not capturing the information and analyzing it.”
If waste is separated correctly, that is, if all recyclable material is removed from the solid waste, and if all conventional solid waste is removed from the regulated medical waste, recycling should account for at least 30-40% of all healthcare waste, by weight, according to Brannen. Hazardous chemical waste should account for less than 1%, and regulated medical waste should make up about 15%. The Green Guide includes one credit for bringing that amount below 10%.
Since disposing of regulated medical waste typically costs ten times as much as disposing of conventional solid waste, ensuring accurate separation can yield dramatic financial savings in addition to the environmental benefits.
A healthcare facility can reduce its waste stream most through purchasing decisions by preferring durable, recyclable products with minimal packaging, for example. A healthcare facility can also limit waste through operations policies by training staff in proper waste separation, for example, or by donating medications just past their expiration date for use in Third World countries.
Designing healthcare facilities in anticipation of the need to separate waste is also important, and often overlooked. According to Guenther, lack of space is the number one obstacle for hospitals trying to implement recycling programs. “A hospital might have four or five bays for receiving,” says Brannen, “but the corresponding trash area might have one bay.”
The industry has come a long way in just a few years in improving the disposal of medical waste. In 1996, the U.S. had about 5,600 medical incinerators. Today, that number has dropped below 100. Most of the incinerators that were shut down couldn’t meet EPA regulations for control technologies, says Brannen, and released pollutants, including mercury and dioxin, into the air. Facilities today are reducing the amount of waste they produce, doing a better job of separating it, and using better technologies to handle it. Sterilizing regulated medical waste in onsite autoclaves, for example, allows healthcare facilities to handle it as conventional solid waste.
Energy
Healthcare facilities use lots of energy- about double that of office buildings, on a per-unit-area basis, on average, and several times more for equipment-intensive facilities. Together, healthcare facilities account for 9% of all commercial energy consumption in the U.S., according to the Energy Information Administration (EIA).
Because these buildings carry so many other expenses, however, energy typically represents a small fraction of the total operating costs. “When you look at a hospital operating budget, they’re spending thousands of dollars per square foot on labor each year and only dollars per square foot on energy,” says Kim Shinn, director of sustainable design at TLC Engineers in Nashville, Tennessee. “It’s hard to get them to do green things even when we can show some payback.”
Another reason energy efficiency has received little attention within the healthcare community is because, unlike indoor environmental quality or materials considerations, it is not directly connected to the health of a building’s occupants. But burning fossil fuels contributes to health hazards ranging from air pollution to climate change. “There’s talk in the healthcare industry now about needing to pay attention to those connections in how they fulfill their mission,” says Steven Guttmann, P.E., principal at Guttmann & Blaevoet Consulting Engineers in San Francisco, California.
Space heating, space cooling, lighting, and medical and office equipment are the four most energy-intensive activities in hospitals, according to the EIA. Much of a hospital’s heating and cooling load is driven by ventilation. “The prevailing attitude in healthcare design has been to increase ventilation rates to improve indoor air quality,” says Guenther. She notes that mechanical infrastructure can represent nearly half the entire construction cost of a hospital. The best way to minimize the energy impact of high ventilation rates is to use recovered energy to pre-heat or pre-cool outside air, says Guttmann.
Many of the energy-saving opportunities in hospital mechanical systems are no different from those in other building types, except that the high demand gives these strategies added importance. Guttmann notes opportunities in variable-frequency-drive chillers, oversized cooling towers, variable-flow pumps, and ground-source heat-pump systems.
Commissioning also carries added importance. “It’s been said that no single effort brings as much energy savings to a hospital as commissioning” says Shinn. Hospitals are differentiated, however, by their high, continuous demand for electricity, hot water, and cooling, and by their need for redundancy and emergency backup power. These factors support the use of technologies, such as combined heat and power (CHP) and thermal storage, which might not be cost-effective in other buildings.
With CHP (also known as cogeneration), a facility burns a fueltypically natural gas, to limit onsite emissionsand utilizes both the electricity and the excess heat that would otherwise be wasted. Waste heat can also provide cooling through the use of absorption chillers. The Green Guide offers up to four credits for using CHP systems.
With thermal storage, energy is stored during off-peak hours in the form of chilled water or ice, allowing that energy to be recovered during peak periods, when electricity is in greater demand and more expensive.
Everything from desktop computers to major diagnostic machines, such as MRIs, falls into the building’s process load, which can be considerable in healthcare facilities. “For an equipment-intensive hospital, the process load could be equal to the building-system load,” according to Guttmann. Both the construction and operations portions of the Green Guide include a point for purchasing efficient process-load equipment. Unfortunately, the efficiency of most medical equipment is not rated. “EPA is in the initial research stages to determine if Energy Star should enter the market for certain kinds of medical equipment,” according to Clark Reed, EPA
‘s national healthcare manager for Energy Star.
In late 2001, Energy Star launched an energy-performance rating tool for acute-care hospitals. The top 25% of hospitals, in terms of energy efficiency, are eligible to receive the Energy Star label. Although only 44 hospitals across the country have earned the Energy Star label, according to Reed, about a third of the acute-care hospital market has used the rating system for guidance. EPA more recently released a similar tool for medical office buildings.
Water
Only about 30% of a typical hospital’s water use is domestic, used for toilets, sinks, and showers, according to Vittori. Thus, common water-conserving strategies, such as installing low-flow toilets or sensor-controlled faucets, have less impact on total water consumption as they do in other buildings.
Flow restrictors, for example, can trap bacteria, says Vittori, so “they don’t work for a hospital.” The fact that appropriate flow restrictors aren’t readily available, for example, doesn’t mean that one couldn’t be designed, she says, but no one has posed that challenge to the industry. Foot- and knee-controls for faucets, on the other hand, are appropriate for hospitals and are gaining significant market penetration.
Other water uses in healthcare facilities range from sterile processing and cooling towers to radiology and landscape irrigation. Among the Green Guide’s construction prerequisites is one for eliminating the use of potable water for once-through cooling for equipment. The Green Guide also includes credits for reducing the use of potable water for building-system equipment and landscape irrigation and for providing for the continuous measurement of 11 distinct uses of potable water within the project.
Healing Gardens
Healing gardens have recently become vogue in healthcare design. The Green Guide includes a credit for dedicating 5% of the building’s program area to “places of respite with direct connection to the natural environment” and ensuring that at least one outdoor, nonsmoking space is provided for staff away from patients and visitors.
As with other green design strategies, healing gardens are most successful when they result from early, integrated planning. “I don’t want to think of them as isolated components of the design,” says Kamp.
Final Thoughts
The design of healthcare facilities is now at a juncture. As we envision a new generation of healthcare facilities, we are also learning more about how to use green design strategies to improve patient health and well-being, as well as staff performance and satisfaction.
Through careful design, construction, and operations, our healthcare facilities can reduce their contribution to human and ecological sickness and more fully embody their mission to heal.
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Excerpted FROM Environmental Building News, a SustainableBusiness.com Content Partner
For more information:
American Society for Healthcare Engineering : click on products to download the Green Healthcare Construction Guidance Statement.
Green Guide for Health Care
Health Care Without Harm
Hospitals for a Healthy Environment
U.S. Environmental Protection Agency Energy Star for Hospitals
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