Bad Chemistry
Nurses sensitive to respiratory irritants lead the charge in reducing exposure to chemical hazards in the workplace

By Donna Hemmila
April 11, 2003

During her 30 years in a hospital, Nancy Mucciaccio, RN, rarely had a sick day. Besides working in an ambulatory surgery unit, she regularly traveled in Asia and Africa as a volunteer. She even hiked in the Andes. Then in 1997, her active work and lifestyle crashed to a halt, brought down by debilitating occupational asthma and nerve damage in her right arm and leg.

The source of her injuries, she said, is something most nurses aren't aware can harm them-common sterilizing and disinfecting chemicals used in hospitals.

"Every time I walked by a cleaning cart, I would have chest tightness and start wheezing," she said. "I didn't connect the dots until I got very ill." Mucciaccio was out of work for 10 months collecting workers compensation benefits until, diagnosed with occupational asthma, she finally had to leave her job.

"I was so overwhelmed," she said. "It was really frightening to me. I'm a single person. I worked in hospitals all my life. All of a sudden my life was taking a [180]-degree turn."

She has become so sensitized to respiratory irritants she feels like Howard Hughes, the reclusive millionaire with a legendary fear of germs. Mucciaccio leaves for work extra early in the morning to avoid crowds of commuters. She can't visit a house with candles or a fireplace burning and, in the spring when pollen explodes, she hides indoors as much as possible.

Now working as an occupational health nurse, Mucciaccio rates the potential hazards of cleaning chemicals as just as serious a problem for nurses as latex allergies. Yet many nurses, she said, are only starting to wake up to the possibility that chemicals at work could be triggering their coughs, headaches, dizziness and other discomforts.

Chemical hazards

In the 2001 American Nurses Association's Health & Safety Survey, only 6.7 percent of the more than 4,000 respondents identified chemical exposure as one of their top health concerns.

That's not surprising. Nurses may be aware of the hazards of potent chemotherapy drugs, and latex and mercury contamination and know how to deal with them, but people don't think about cleaning products harming them, said Laura Brannen, co-director of Hospitals for a Healthy Environment.

Yet the National Institute of Occupational Safety and Health classifies many of the sterilizing and disinfecting products used in health care institutions as hazardous chemicals. Ethylene oxide and glutaraldehyde used in instrument sterilization; quarternary ammonium compounds and benzalkonium chloride found in floor and surface cleaning products; and ethanolamine, petroleum distillates and lye found in floor strippers and buffing compounds are among the chemicals nurses say can turn the work shift into a wheezing, coughing, painful experience.

Brannen's organization, supported by the Environmental Protection Agency, the American Hospital Association, the American Nurses Association and Health Care Without Harm, is part of a growing movement to promote less hazardous product and application alternatives. The group provides resources on alternative cleaning and sterilizing products and is working with the EPA to start a "greener, cleaner" task force to look at floor strippers and buffing products.

Brannen acknowledges it's an enormous task to change the way an institution operates, but it's a responsibility everyone in health care should take on, including nurses.

"Thinking about this stuff should be part of our job," she said. "Health care workers should be leaders in making the environment healthy."

Nurses are more at risk for chemical exposure and poor air quality health risks than many realize, said Janice Homer, RN, who has been diagnosed with occupational asthma and speaks at conferences around the country. When they do suffer health problems, she said, many nurses are reluctant to complain. "Nurses will just keep going even if they're sick as dogs," Homer said.

In 1989, she was working as an evening charge nurse in a nursery when she noticed a burning stench from the ventilators.

"Within 20 minutes, I couldn't feel my arms and legs," she said. "I was basically high. The other nurse couldn't see. I felt like a flea that's been dipped. My arms and legs were numb."

She and two other nurses spent the night in the ER and the nursery was evacuated. They later traced the problem to a cement sealer being used in the medical office building under construction next door.

That was a life-changing event for Homer. But it wasn't until a few years later when she developed occupational asthma that she became a crusader for environmental safety for nurses. Homer attributes her illness to the buffing chemicals used to shine hospital floors and the toxic cleaning chemicals.

The number of respiratory incidents attributed to toxic agents among hospital workers has been rising. According to Department of Labor statistics, the number of incidents in hospitals per 10,000 full-time workers increased from 3.2 incidents in 1996 to 5.2 in 2001. A National Institute of Occupational Safety and Health report of work-related asthma studied 1,101 reported cases in California, Michigan, Massachusetts and New Jersey.

Registered nurses accounted for 4.8 percent of the cases. Cleaning chemicals and glutaraldehyde were the most common asthma triggers.

A Massachusetts Department of Public Health study released in January 2000 found registered nurses made up the work group with the most reported cases of occupational asthma. Poor indoor air quality, latex and cleaning products were the most frequently reported asthma triggers for nurses.

Homer attributes the increased chemical exposure problems in part to the increased concern over hospital infections. Facilities are using greater amounts and varieties of disinfectants and cleaning agents.

"I got a copy of all the products being used in one unit," she said. "There were 27."

Hospital buildings, she said, lack fresh air from open windows and may have poor ventilation systems. She also blames lack of training for housekeeping workers, particularly when hospitals use outside contractors rather than their own staff. Sometimes, workers can't read product labels or haven't been properly trained in handling the chemicals.

The hospital where Homer now works doesn't buff the floor in her unit, and she said that she hasn't had to use her inhaler in two years, an indication that her former work environment may have triggered her asthma.

Yet some are skeptical about blaming cleaning chemicals for occupational asthma.

"If nurses are reacting to chemicals on a cleaning cart, why aren't the housekeepers falling over?" said Lori Schaumlefel, RN, COHN-S, coordinator of employee health at Mercy Hospital of Folsom, a 500-employee hospital in Northern California.

Nurses could have underlying health conditions that cause their respiratory problems or have an allergic reaction to a substance without that developing into a lifelong health condition, Schaumlefel said. "In California, industrial-induced asthma is a difficult compensatory claim to prove," she said.

Multiple exposure

The causes of occupational asthma are sometimes difficult to pinpoint because so many triggers exist outside the workplace. Animal dander, mold, pollen and smoke can set off asthmatic reactions. Health department definitions recognize two types of occupational asthma: Immunological asthma can develop over a period of time when a person becomes sensitized to an agent in the workplace, and irritant-induced asthma can occur after an intense exposure to an irritant present in dust or fumes. Some people can experience a reaction when others in the same environment don't, and reactions are sometimes delayed.

A nurse could have a psychological reaction as well, said Jean Randolph, RN, COHN-S, manager of employee health at Children's Healthcare of Atlanta and a member of the Association of Occupational Health Nurses.

Her system employs 5,500 workers at two hospitals and 22 clinics. Some workers complain about the floor stripper chemicals, she said, but she doubts that cleaning chemicals can cause asthma. Chemicals used in hospitals are carefully screened, she said. To avoid mishandling of products, her hospitals switched to premixed solutions in drums with automatic dispensing systems. This eliminates the possibility of a worker who can't read the label mixing a solution incorrectly, she said. Her skepticism isn't unique.

Nurses can have a difficult time proving their sickness is caused by something at work, said Cynthia Spry, MA, MS, RN, that's why it's important to document incidents of exposure. "Nurses will complain to each other, but they need to document," Spry said. "The thing administration responds to is data."

Spry, an international clinical consultant for Advanced Sterilization Products, a Johnson & Johnson company, does believe cleaning products are mishandled, mixed incorrectly, put into unlabeled spray bottles or overused.

Despite stringent guidelines for using sterilizers, she said, ethylene oxide, a known carcinogen, and glutaraldehyde, a known irritant sensitizer, represent other potential hazards for nurses. It's important to read the product literature and to make sure instruments are properly aerated after sterilization, she said, no matter how rushed a nurse is.

"You should wear gloves, you should wear a gown, you should wear goggles and nurses do that," Spry said. "Today, we're so short staffed and so short of time they may take shortcuts."

Alternative sterilants are on the market, and Spry believes that, in time, hospitals will stop using glutaraldehyde. Organizations like Health Care Without Harm, Sustainable Hospitals and the Nightingale Institute for Health and the Environment are pushing for changes in health care, and hospitals are responding.

The University of California, Davis Medical Center reduced its floor-cleaning chemical use by 90 percent when it switched to microfiber mops, said Eugene Labrie, manager of environmental services. The hospital, which employs more than 7,000, tossed its old buckets and string mops as a time-saving measure, he said, but another benefit has been a drop in chemical use.

When a few hospital workers complained about floor buffing, Labrie said, he arranged the buffing schedule in their units to be done during the hours when they aren't working.

Such simple, no-cost changes in procedures can go a long way to curtailing chemical exposure risks. Brannen recommends switching from spraying cleaning solutions to wiping down surfaces with solution applied with a cloth.

Most importantly, she said, nurses need to learn what is used around them and advocate for safer alternatives.

At Tulare District Hospital in California, nurses circulated a survey among themselves to find out how many experienced headaches, wheezing and chest pains at work, said Karen Roberts, RN, a clinical manager in the ICU/cath lab. Nurses responded with comments such as "I'm fine until I come to work, then I get sick," and "I do better on my days off."

The nurses planned to ask the hospital to look into the causes for their symptoms."Nurses shouldn't be afraid to ask, 'What's in this?' " Brennan said. " 'Why are we using this stinky stuff that's making me sick?' "

One way to get information about hazardous chemicals is through the OSHA-required Material Safety Data Sheets. Products used by housekeepers probably won't show up on a nursing unit's MSDS, Brannen said, but nurses have a right to information about everything used in their workspace-even if it means hunting it down in other departments.

Contact Donna Hemmila at dhemmila@prodigy.net