SHT GreenChecklist
SHT GreenChecklist
SHT GreenChecklist
H
ospitals use the greatest proportion of energy during daily operations, when energy needs for
heating water, lighting and telecommunications are most acute. Studies suggest that between 70
and 80% of greenhouse gas emissions (GHG) are released during this period. Because of the high
level of carbon impact associated with the operational phase, it is essential to identify low-cost (often
non-structural) measures that can be easily implemented. The Smart Hospitals Toolkit helps existing
hospitals identify and implement low-cost adaptation measures.
Several green building rating systems exist: LEED (developed by the United States Green
Building Council) and BREEAM (United Kingdom BRE Environmental Assessment Method) are two of
the more well-known certification systems. Recognizing that health facilities require special atten-
tion due to the nature of their operations and services (often with strict regulatory requirements, 24/7
operations, and specific programmatic demands), LEED joined forces with the Green Guide for Health
Care, a self-certifying toolkit that sets forth special requirements for hospitals and similar institutions,
to create the rating system LEED for Health Care, which maintains close alignment to LEED for New
Construction.
The Green Checklist developed for this Toolkit has adapted existing green building rating
systems to the Caribbean context, ensuring that it covers both the building itself and the facility’s
operations. Achieving certification under existing green building rating systems will be difficult in the
Caribbean, due to the systems’ strict requirements, the absence of Caribbean environmental policies,
as well as the cost and technical capacity available in the region. The Green Checklist outlines feasible
areas and applies to planned renovation projects, which are an ideal opportunity to introduce ‘smart’
measures.
Consult the Green Checklist below or download the form through this link.
39
SMART HOSPITALS INITIATIVE
GREEN HOSPITALS CHECKLIST
CATEGORY TITLE INTENT ACHIEVABILITY
Yes Planned No
Renovations
Water Water Use Reduction • Are you able to monitor water usage
throughout your facility?
• Have you added a rainwater capture system?
• Are faucets and plumbing water efficient
(e.g. low-flow faucets; dual flush toilets, etc.)?
• Does your facility have an educational pro-
gram that highlights the need to conserve
and use water efficiently?
Water-efficient Land- • Have you captured rainwater and installed a
scaping (no potable drip irrigation system for landscaped areas?
water used) • Do you have space to install an aerobic sew-
age treatment system so that the effluent
can be used for irrigation?
• Have you utilized local, drought-resistant
species and mulch plantings?
Energy and Renewable Energy: • Do you have an energy conservation plan?
Atmosphere On-site Generation • Has the facility’s roof been assessed to en-
sure that it can accommodate a PV system
and/or a solar hot water heater?
• Does your roof face south/southwest to al-
low for maximum solar exposure?
• Is your rooftop energy system secure against
natural hazards?
Efficient Equipment/ • Have you conducted an energy audit?
Fixtures/Appliances • Do you have an energy conservation plan?
• Are equipment and appliances energy-
efficient rated (US/EU standards)?
SMART HOSPITALS TOOLKIT
Operations
Chemical Manage- Chemical Manage- • Has a national chemical management policy
ment ment Policy that aims to reduce the purchase and use of
hazardous chemicals been developed?
Community Contami- • Have you documented the purchase,
nant Reduction: Leaks delivery, storage and use of all hazardous
and Spills chemicals and substances stored onsite?
• Have you provided secondary containment
and security for substances stored outdoors,
42 above ground or underground?
• Have you educated staff on proper handling
and storage of chemicals and the proper
procedures for spills/leaks?
SMART HOSPITALS INITIATIVE
GREEN HOSPITALS CHECKLIST
CATEGORY TITLE INTENT ACHIEVABILITY
Yes Planned No
Indoor Chemical • Has a national policy been developed that
Contaminant Reduc- prohibits the disposal of chemicals down
tion: Hand Hygiene drains?
Products, Sterilization • Have you phased out the use of Ethylene
and High Level Oxide and high level disinfectants (glutar-
Disinfection aldehyde and other hazardous substances)
and replaced them with safer alternatives?
• Have you ensured that all sterilizing and
disinfecting appliances are top-of-the-line
and efficient?
• Have you replaced manual disinfection with
automatic machine washers/disinfectors?
Pharmaceutical Mini- • Have you created a policy that establishes
mization, Manage- procedures for procuring, storing, dispens-
ment and Disposal ing and proper disposal of all
pharmaceuticals?
• Have you ensured that pharmaceuticals are
ordered on an as-needed basis to minimize
expiration and that expired/unused pharma-
43
SMART HOSPITALS INITIATIVE
GREEN HOSPITALS CHECKLIST
CATEGORY TITLE INTENT ACHIEVABILITY
Yes Planned No
Solid Waste and • Have you made waste reduction a goal and
Material Management: ensured that all of your purchases—from
Waste Prevention and high-end machinery and equipment to food
Reduction and office supplies—are aligned with this
goal?
• Have you streamlined and computerized
procedures, printing on both sides of paper
and purchased paper that contains recycled
content?
• Have you procured or leased photocopiers
and printers that are capable of printing on
both sides?
• Have you made arrangements to ensure that
biodegradable waste such as paper, card-
board, plant-based waste and food waste
can be composted on-site, in the commu-
nity or at a municipal or commercial facility?
Regulated Medical • Have you established a waste management
Waste Reduction policy that seeks to reduce overall waste
generation, ensures that all waste gener-
ated is properly segregated and stored and
ensures that staff is aware of and trained in
the requirements of the waste plan?
• Do you avoid mixing infectious and other
medical waste with regular garbage?
• Have you ensured that plastics, anything
containing PVC, batteries, mercury-con-
taining products and materials treated with
flame retardants are not incinerated along
with other medical waste and that an effort
SMART HOSPITALS TOOLKIT
44
SMART HOSPITALS INITIATIVE
GREEN HOSPITALS CHECKLIST
CATEGORY TITLE INTENT ACHIEVABILITY
Yes Planned No
Environmental Environmentally • Do you procure cleaning products and
Services Preferable Cleaning: materials that are environmentally benign or
Products, Materials that are less toxic than other products and
and Equipment that still maintain the high level of cleanli-
ness required in the facility?
• Have you ensured that disposable paper
products, like paper and hand wiping tow-
els, contain recycled content?
• Do you prohibit products that are manu-
factured with carcinogens, mutagens and
teratogens; aerosols; asthma-causing agents,
respiratory irritants, benzene-based solvents,
very acidic or alkaline products; anti-micro-
bial hand soaps; persistent, bioaccumulative
and toxic chemicals (PBTs); and products
requiring disposal as hazardous waste?
Integrated Pest • Have you or the agency responsible for
Management maintaining your facility developed and
implemented an Integrated Pest Manage-
46
Green Checklist
Discussion Guide
Renovations
Water
Overview
One of the key benchmarks of environmental sustainability is the use of potable water. Reducing
the amount of potable water used not only conserves water and saves money but also reduces emis-
sions associated with pumping and treatment. Including a rainwater capturing system in your health
facility is pivotal to reducing potable water use. Captured rainwater from roofs can be used to flush
toilets, irrigate landscaping, and for other non-potable uses. Given the changing rainfall patterns, it is
prudent for health facilities to consider the installation of cisterns and other rainwater capturing de-
vices/features. These must be constructed/installed in compliance with building codes and regulations
to ensure their safety against natural hazards (see the Guide for Evaluation of Small and Medium-Sized
Facilities in Section 1).
Implementation Strategies
conserve water. Highlight the fact that captured rainwater is used for all non-potable 47
uses in your facility and point out the high-efficiency devices/appliances/fixtures.
Things to Remember
• Have your roof inspected by an engineer to ensure that it can support the weight of a solar
water heater.
• Have a licensed plumber inspect your plumbing, faucets and water-using devices.
• Consult Hospital Safety Index for further guidance.
• Refer to the Smart Hospital Baseline Assessment Tool (BAT) in Section 2 for a water audit work-
sheet.
• If you plan to install a cistern, ensure that it is not located in an area prone to flooding.
Resources
Rainwater Harvesting in the Caribbean: http://www.cehi.org.lc/Rain/index.html; http://cehi.
org.lc/Rain/docs.html.
A Toolbox on Rainwater Harvesting In the Caribbean: http://bit.ly/13H03kQ.
United States of America Environmental Protection Agency Water Sense Program: http://www.
SMART HOSPITALS TOOLKIT
epa.gov/watersense.
Energy and the way it is used is the most significant contributor to climate change. Energy conser-
vation and utilizing renewable energy will be significant factors in making your health facility ‘smarter.’
In the health sector, energy is consumed by lighting, large and small specialized equipment and devic-
es, appliances and transportation. Although large specialized pieces of equipment are integral to the
48
health sector, they consume a lot of energy. Significant savings can be achieved by ensuring
that all electronic equipment, devices, appliances and fixtures are certified and labeled as
energy efficient under American and European labeling system.
Changing from incandescent or other inefficient lights bulbs to more energy-efficient
options can result in cost savings and reduced energy usage which results in reduced emis-
sions and reduced demand. However, simply switching to more efficient light bulbs is not enough.
Energy conservation must be an overarching goal. If your country has not yet phased out the use of in-
candescent light bulbs, replacing them with efficient bulbs, consult the U.N. Environment Programme’s
en.lighten initiative (http://www.enlighten-initiative.org/).
Implementation Strategies
Establish baseline energy usage by examining electricity bills or usage information from your util-
ity company for at least the three previous years. Refer to the Smart Hospital Baseline Assessment Tool
(BAT) for the energy audit worksheet.
Photovoltaic (PV) systems capture energy from the sun and convert it into electricity, thereby
reducing energy generated via fossil fuels. Consult with your utility company to determine any poli-
cies and safeguards regarding the installation of a PV system. For safety reasons, a grid-connected PV
system will not be operational when the grid is offline Therefore, although going completely off-grid
is possible, the cost of purchasing and maintaining the batteries that store the energy from the PV sys-
tem will be significant. Improved battery technology may make this option more feasible in the near
future.
Note: Ensure that you have sufficient space on your roof, that the roof can support the
weight of the system, is secure against natural hazards and that the roof faces the south/
southwest to allow for maximum solar exposure. (Panels can be tilted if required.) Roof
assessment can be guided by the Hospital Safety Index. Also note that in countries where
there is a volcanic hazard, panels can be affixed to the walls of the structure or on hip
roofs that are designed to allow the ash to fall off during a volcanic event. All systems
must be properly secured to withstand the natural hazards that affect the Caribbean.
If space, location, prevailing wind direction and building codes allow, consider installing wind
Note: Roof assessments can be guided by the Hospital Safety Index. Any roof-mounted 49
solar hot water heaters must be properly secured to withstand natural hazards
that affect the Caribbean.
Refrigerant Management
Ensure that all refrigerant-containing equipment and appliances do not use CFCs and plan to
phase-out/upgrade existing equipment that contains CFCs. Weigh carefully refrigerant op-
SMART HOSPITALS TOOLKIT
tions, as some chemicals that do not contribute to ozone depletion contribute significantly to
global warning. Opt to buy equipment that uses refrigerants that contain less potent ozone-
depleting substances (ODSs) and with reduced global warming potentials (GWPs).
Have trained professionals service your refrigerant-containing equipment on a regular basis in
Do not install fire suppression systems that contain ozone-depleting substances (CFCs, HCFCs
or Halons).
50
Ozone Depleting (ODP) and Global Warming Potential (GWP) of Refrigerants
Refrigerant ODP GWP Common Building Application
Chlorofluorocarbons
CFC-11 1.0 4,680 Centrifugal chillers
CFC-12 1.0 10,720 Refrigerators, chillers
CFC-114 0.94 9,800 Centrifugal chillers,
CFC-400 0.605 7,900 Centrifugal chillers, humidifiers
CFC-502 0.221 4,600 Low-temperature refrigeration
Hydrochlorofluorocarbons
HCFC 22 0.04 1,780 Air-conditioning, chillers
HCFC-123 0.02 76 CFC-11 replacement
Hydrofluorocarbons
HFC-23 ~0 12,240 Ultra-low-temperature refrigeration
HFC-134a ~0 1,320 CFC-12 or HCFC-22 replacement
HFC-245fa ~0 1.020 Insulation agent, centrifugal chillers
HFC-404A ~0 3,900 Low-temperature refrigeration
HFC-407C ~0 1,700 HCFC-22 replacement
HFC-410A ~0 1,890 Air conditioning
HFC-507A ~0 3,900 Low-temperature refrigeration
Things to Remember
• Have your roof inspected by a structural engineer to ensure that it can support the weight of a
PV system and/or a solar water heater.
• Check with your utility company to determine policies and regulations regarding PV systems
• Consult the Hospital Safety Index for further guidance.
• Refer to the Smart Hospital Baseline Assessment Tool (BAT) in Section 2 for an energy audit
worksheet.
Resources
51
United States Environmental Protection Agency and Department of Energy, Energy
Star Program Product Guide: http://1.usa.gov/ZSaUbI.
United States Environmental Protection Agency Ozone Layer Protection-Science:
http://www.epa.gov/ozone/science/ods/index.html.
Materials and Resources
Overview
The selection of materials and resources used during construction or renovations, as well as the
interior furnishings and furniture, offers a significant opportunity to reduce your carbon footprint and
overall environmental impact and make your facility ‘smart’ and ‘green.’ Utilizing rapidly renewable
wood and products that contain recycled components helps to protect virgin resources and reduces
the impact of extraction, transportation and processing.
Debris from construction or renovation activities can be significant. Most of the waste likely ends
up in a landfill or incinerator, where is can contribute to environmental degradation. However, proper
construction management can eliminate some of the waste generated or redirect certain items to
organizations, groups and individuals.
Toxic chemicals that can be found in building products and materials are of concern. Mercury, for
instance, is known to be harmful to humans, especially to developing fetuses. It is also one of several
chemicals cited as persistent bioaccumulative and toxic chemicals (PBTs). With no program in place
for handling mercury-containing waste, it is likely that these products would be incinerated or placed
in landfills, where they can pollute soil and water. Burning mercury releases it into the atmosphere.
Health Care Without Harm (HCWH) and the World Health Organization are working to eliminate
mercury from the health sector and find safer alternatives. Other PBTs specifically addressed include
dioxins, cadmium and lead, all of which are known to be harmful to human health and are found in
building products.
Implementation Strategies
Procurement choices impact your indoor environmental quality and the environmental, so consid-
er the components of your building materials, furniture and furnishings. Construction debris, furniture,
furnishings and other material that are incinerated release greenhouse gases and other pollutants and
chemicals into the atmosphere. The ash that remains after incineration is hazardous waste and should
SMART HOSPITALS TOOLKIT
be properly handled and disposed of. When this material is disposed of in landfills, it can lead to land
and water pollution and the release of gases into the atmosphere.
Mercury Elimination
Specify and install low-mercury fluorescent lamps or LED light bulbs that contain no mercury.
Keep in mind that fluorescent and LED light bulbs use less energy.
Note: Mercury is released into the atmosphere when mercury-containing bulbs are
broken. Handle with care, ensuring that the area is well ventilated and they are properly
disposed of. Disposing mercury-containing bulbs in landfills may result in land contami-
nation. Likewise, incineration releases methlymercury into the atmosphere.
Green Guide for Health Care Technical Brief PBT Elimination from Building Materials (Lent, 2007, p. 5)
also notes the uses of some PBTs containing materials and alternatives.
Lead
Lead is used in solder, roofing, gutter and flashing products, radiation shielding, and batteries and
as a stabilizer in PVC products. In the past, it was used in paints and pipes and is considered a hazard in
older buildings and demolition projects.
Specify 100% lead-free solders. (Note that solders marketed as ‘lead-free’ can still legally con-
A major use of lead in PVC products is in the insulation jacketing for wiring. Specify lead-free
53
jacketing where available. (Also note that Teflon®-jacketing should be avoided).
Green Seal certified paints are assured to be free of cadmium and lead.
Cadmium
Cadmium is used in paints, coatings, and batteries and as a stabilizer in PVC products.
While lead has been largely eliminated from paints, cadmium remains a widely used pigment.
Green Seal certified paints are assured to be free of cadmium and lead.
Review material MSDS sheets if concerned that a material may contain cadmium.
The Green Guide for Health Care (hCare, 2007) asks to “[c]onsider materials that are not manu-
factured with chlorine or other halogens. Options include (but are not limited to) TPO, EPDM, and
FPO [thermoplastic polyolefin, ethylene propylene diene monomer, flexible polyolefin] for roof mem-
branes; natural linoleum, rubber, or alternate polymers for flooring and surfacing; natural fibers, poly-
ethylene, polyester and paint for wall covering; polyethylene for wiring; wood, fiberglass, [high density
polyethylene] HDPE, and aluminum with thermal breaks for windows; and, copper, cast iron, steel,
concrete, clay, polypropylene and HDPE for piping.”
Resources
Articles, case studies, etc. on green building products:
http://www.buildinggreen.com/
http://www.mercuryfreehealth care.org/
http://noharm.org/all_regions/issues/toxins/mercury/
Sustainable Hospitals – Alternatives to mercury-containing equipment: http://www.
sustainablehospitals.org.
Green Guide for Health Care, Technical Briefs: http://www.gghc.org/tools.technical.php.
54
Indoor Environmental Quality
Overview
Indoor Environmental Quality (IEQ) is important in health facilities because it can nega-
tively impact the health of staff, patients and visitors. IEQ is related to ventilation, which
is related to building design, window placement, prevailing winds, and energy use (in cases where
mechanical ventilation is used). Many factors impact indoor air quality: building products, furnishings,
furniture, paint, floor coverings, sealants, adhesives, varnishing, equipment, mold and other biologi-
cal agents, cleaning products, tobacco smoke, chemicals, etc. Without proper ventilation, the levels of
gases, chemicals and particulates can be higher indoors than outside.
Of importance to IEQ are the products and materials used on and in the building’s interior and
the chemicals they contain. Proper ventilation or choosing safer alternatives can significantly reduce
indoor pollution.
Implementation Strategies
When choosing products and materials for your structure, consider the components, who uses
the facility and may potentially be exposed, if there is adequate ventilation to move gases, particulate
matter and pollutants out of the structure and if safer alternatives are available on the market.
Natural Ventilation
Ensure that all windows are operable to take full advantage of prevailing breezes.
Note: Despite the energy savings and reduced environmental impact, it may not be
practical to use natural ventilation at all times. Therefore, buildings should be constructed
with mechanical and natural ventilation in mind. Certain areas of the hospital must be
mechanically ventilated, while natural ventilation is appropriate for other areas of the
hospital and could be coupled with ceiling/destratification fans to improve occupant
comfort (without having to actually reduce the ambient temperature of a space).
A properly maintained mechanical ventilation system will likely provide better air quality than
outdoor air, as the filtering process will remove a number of particulates, etc.
Things to Do
• Encourage regional paint manufacturers to have their products Green Seal or GREENGUARD
certified.
Note: If onsite waste incineration cannot be avoided, locate the incinerator downwind
from facility and ensure that there are no air intakes nearby.
Operations
Chemical Management
Overview
Chemicals are prevalent in the health sector. They are used in building maintenance, infection con-
trol and in the overall provision of health care to patients. Some components of the pharmaceuticals,
products and devices used are considered to be harmful and toxic.
Chemicals and fuels in or around the health care facility should be used with caution to prevent
contamination and reduce exposure to staff, patients, visitors and the surrounding community. It is
not safe to dispose of liquid waste that contains cleaning or disinfection agents down drains and this
method of disposal is not recommended under any circumstances. Antibacterial/antimicrobial prod-
57
ucts and sterilization and disinfecting chemicals also are commonly used in the health sec-
tor. However, the effects of some of these chemicals on living organisms are coming to light.
The effects of exposure to these agents needs more study, but they should raise concern.
Pharmaceuticals minimization, management and disposal is also of concern because
medicine intended for human use may have completely unexpected and unwanted effects
on other organisms, so proper management and disposal are required. Neither disposal in landfills nor
incineration is appropriate for pharmaceuticals because of the potential for land, air and water con-
tamination. Pharmaceuticals should never be disposed of down drains.
Implementation Strategies
Chemical management in a health care setting should be a priority, given the potential negative
ecological and human impact. Every effort should be made to ensure that all chemicals and pharma-
ceuticals are used and disposed of properly.
dures.
58 Indoor Chemical Containment Reduction: Hand Hygiene Products, Sterilization and High-Level
Disinfection
Ensure that a policy exists that prohibits the disposal of chemicals down drains and
that training for staff is included.
Phase out the use of Ethylene Oxide and the high-level disinfectant (HDL) glutaralde-
hyde and other hazardous substances and replace with safer alternatives.
Note: Alternatives to Ethylene Oxide include other low temperature sterilization methods
such as vaporized hydrogen peroxide, hydrogen peroxide-gas plasma, liquid peracetic
acid, and ozone.
Purchase non-hazardous chemicals and/or determine opportunities to reduce highly hazard-
ous materials.
Ensure that all sterilizing and disinfecting appliances are top-of-the-line and efficient in an ef-
not appropriate, as chemicals can contaminate soil and groundwater. Incineration also releases
chemicals into the atmosphere and the residue from burning may be considered hazardous
such as products that contain no mercury or PBTs, to the extent possible. Procure products
with less packaging, especially if they contain hazardous chemicals/components, as the pack-
aging could be considered hazardous as well.
Although not all of the following are applicable to the Caribbean setting, GGHC (Care G. G.,
2008, pp. 8-26) recommends these measures to minimize the generation of pharmaceutical
waste:
Improve inventory control processes.
Reduce the number of pharmaceuticals dispensed and returned that cannot be re-pre-
scribed.
Substitute less toxic pharmaceuticals or mechanical methods for products containing
Minimize personal protective equipment waste. Mix chemicals in batches, minimize spills,
Things to Remember
• Ensure that lab equipment functions properly and works efficiently in respect to the chemicals
required and that plans are in place to upgrade inefficient/outdated equipment.
• Include an education component in the policy, as it is important that all members of staff are
aware of usage, storage and handling requirements and proper disposal practices.
• Encourage and work with your government to develop a national pharmaceutical manage-
ment and disposal policy.
Resources
Material Safety Data Sheets: http://www.msds.com/.
Centers for Disease Control and Prevention: Guideline for Disinfection and Sterilization in
Health Care Facilities, 2008: http://www.cdc.gov/hicpac/Disinfection_Sterilization/toc.html.
Centers for Disease Control and Prevention: Hand Hygiene in Health Care Settings: http://
SMART HOSPITALS TOOLKIT
www.cdc.gov/handhygiene/.
Health care Environmental Resource Center: http://www.hercenter.org/hazmat/steril.cfm.
Practice Greenhealth: Sterilants and Disinfectants: http://practicegreenhealth.org/topics/
chemicals/sterilants-disinfectants.
World Health Organization (WHO), Hand hygiene guideline: http://www.who.int/patientsafety/
events/05/HH_en.pdf.
Sustainable Hospital Project, “List of Mercury-free Alternatives in the Lab.” http://www.
sustainablehospitals.org/cgi-bin/DB_Report.cgi?px=W&rpt=Cat&id=18.
60 Labs for the 21st Century, http://www.labs21century.gov.
Practice Greenhealth: Chemicals: http://practicegreenhealth.org/topics/chemicals.
Green Guide for Health Care Technical Briefs: Pharmaceutical Management Technical
Brief: http://www.gghc.org/tools.technical.php.
Practice Greenhealth: Pharmaceutical Waste http://practicegreenhealth.org/topics/
waste/waste-categories-types/pharmaceutical-waste.
Solid Waste Management
Overview
Health care facilities generate large amounts of waste, most of which is regular, solid waste that
can be handled and disposed of normally. All waste should be separated at the point of origin in prop-
erly labeled containers that can be sealed to avoid pests; waste should be stored in a secure location
and transported to a secure disposal or incineration site.
Because of space constraints, incineration is likely the disposal method of choice in the Caribbean
region, but there are serious issues associated with burning waste. (Harm, Waste Management) “[i]n
many developing world hospitals, all of this trash is mixed together and burned in low tech, highly pol-
luting incinerators, or in the open with no controls whatsoever. It is now well established that inciner-
ating medical waste produces large amounts of dioxin, mercury and other pollutants. These end up in
the air, where they can be transported thousands of miles to contaminate the global environment, or
in the ash, which is frequently dumped without thought for the load of persistent toxins that it car-
ries.” The World Health Organization (2012) recommends the following for the incineration of medical
waste:
Good practices in incinerator design, construction, operation (e.g., pre-heating and not over-
loading the incinerator, incinerating only at temperatures above 800°C), maintenance and
lowest emissions;
The use of waste segregation and waste minimization practices to restrict incineration to ap-
bags, IV tubes, etc.) or heavy metals such as mercury (e.g., broken thermometers) should never
be incinerated.
Implementation Strategies
Any efforts to manage waste should include efforts to reduce overall waste. Waste minimization
practices can be achieved through training, policy changes and procurement practices. Phasing out
and computerizing forms along with double-sided printing will reduce paper waste. Importantly, mini-
mizing the amount of waste that is disposed of also depends on a national recycling program. Paper,
plastic, metal and glass can all be recycled and turned into useful products.
61
Recommended Action Points
Solid Waste Land Disposal
Reduce sources of waste as much as possible.
Establish a policy and guidelines to achieve zero waste through composting and/or recycling
and align your operations and procurement with this goal in mind.
Note: The policy should include requirements and guidelines for composting organic,
non-infectious waste and recycling.
Keep waste properly segregated at all times and stored in a secure location until it is collected
for disposal.
Ensure that the solid waste facility that accepts your facility’s waste is well-managed, thereby
reducing the potential for soil and groundwater contamination. It may be necessary to work
with the government so that landfills are adequately constructed, lined, secure and safely
operated.
Biological waste should be disposed as recommended by national regulations.
buy paper that contains recycled content and print on both sides. Procure or lease photocopi-
ers and printers that are capable of printing on both sides.
Biodegradable waste, such as paper, cardboard, plant-based waste and food waste, can be
materials treated with flame retardants are not incinerated along with other medical waste,
as they release toxic and carcinogenic compounds into the air when incinerated. Additionally,
SMART HOSPITALS TOOLKIT
the ash that remains when these materials are burnt is hazardous itself. Put policies in place to
reduce the purchase, use and disposal of these materials.
Consider using alternative medical waste treatment technologies in an effort to reduce the
volume of waste that is incinerated or disposed of in landfills. The following table provides a
brief description, the capacities and approximate costs in $US of some the alternative waste
treatment technologies.
62
Alternative Health Care Waste Management Treatment Technologies
Type of Description General operating process Range of Approximate
Technology capacities capital cost
in USD
Standard Technology consists of a pressure ves- • Waste is placed inside the auto- 20 kg/hr to $30,000 to
gravity-fed sel, typically cylindrical or rectangular, clave. 3000 kg/hr; 200,000;
autoclave with or without steam jacket and • Pressurized steam is introduced at a smaller units small units
designed to withstand elevated pres- minimum of 121°C. are available cost about
sures. Steam is introduced by gravity • Waste is exposed to the steam. $100
displacement • Waste
Standard Technology consists of a pressure ves- • Waste is placed inside the auto- 15 kg/hr to $30,000 to
prevacuum sel, typically cylindrical or rectangular, clave. 1000 kg/hr 500,000
autoclave with or without outer steam jacket • A vacuum is used to remove air.
and designed to withstand elevated • Pressurized steam is introduced at a
pressures. A vacuum is used to remove minimum of 121°C.
air and then steam is introduced. • Waste is exposed to the steam.
• Steam is removed as condensate.
• Waste is removed and processed in
a shredder if desired.
• Some technologies compact the
waste.
Pulse-Vacuum Technology consists of a pressure ves- • Waste is placed inside the auto- 21 kg/hr to $120,000 to
autoclave sel, typically cylindrical or rectangular clave. 84kg/hr 240,000
with or without outer steam jacket • A vacuum is used to remove air.
63
Alternative Health Care Waste Management Treatment Technologies
Type of Description General operating process Range of Approximate
Technology capacities capital cost
in USD
Hydroclave Technology consists of a cylindrical • Waste is placed in the hydroclave. 20 kg/hr to $70,000 to
pressure vessel with an outer steam • Steam is injected in the outer jacket 1000 kg/hr 550,000
jacket and an internal mixing drum until the inner chamber is heated
arm, designed to withstand elevated to 1320C.
pressures • Internal mixing arm breaks the
waste containers and mixes the
waste.
• Steam is removed as condensate.
• Waste is removed and processed in
a shredder.
Steam treat- Technology consists of a cylindrical • Waste is placed in the vessel. 40 kg/hr to $190,000 to
ment with or hemispherical pressure vessel with • Steam is introduced at 1320C to 200 kg/hr 470,00
internal shred- an internal shredder and other steam 1380C.
ding jacket. Some systems are designed on • Waste is shredded internally and ex-
mobile units posed to steam. Steam is removed
as condensate
• Waste is cooled.
• Waste is removed
Steam clean- Technology consists of a rectangular • Waste is placed in the vessel. 68 kg/hr $200,000
ing with container with a treatment vessel con- • Steam and hot water are intro-
continuous nected to a pump-grinder and liquid duced.
internal mac- separator. • Waste slurry is re-circulated through
eration the grinder and held at 1380C.
• Cold water is injected and the slurry
is passed through a liquid separator
to filter out the waste.
• Waste solids are captured in dispos-
able bags.
Semi-contin- Technology consists of a hopper, • Waste is automatically dumped into 140 kg/hr to $300,000 to
uous steam shredder, rotating auger, dehydrator a sealed hopper. 1800 kg/hr 1,800,000
SMART HOSPITALS TOOLKIT
Things to Remember
It will be difficult to reduce the amount of waste generated if there is no recycling or composting
program in place. Metals, plastic, glass and paper can all be recycled, but there has to be a national
policy that mandates such. Despite the fact that recycling may be difficult for small nations to
undertake, several islands may be able to join together to make it feasible. Work with the govern-
ment to formulate regulations that call for recycling and composting. The resulting compost can
be used in the community or sold locally. Biodegradable waste that ends up in a landfill or incin-
erator adds to greenhouse gas emissions and serves no useful purpose. As compost, it can enrich
soil and reduce the need for artificial inputs, some of which are harmful to the environment.
Resources
SMART HOSPITALS TOOLKIT
Maintaining a clean environment in and out of health care facilities is important to control infec-
tions and pests. It is also important to limit exposure of staff, patients and visitors to chemicals that
could irritate, trigger medical conditions or cause serious harm. Attention needs to be paid to the
components of cleaning agents, pest management chemicals and all other substances used inside
and outside the facility. If products currently used contain toxic components, they should be phased
out and safer alternatives found. Cleaning products should be environmentally benign or less toxic or
harmful than products being used and still provide the high level of cleanliness required in the facility.
Also, janitorial paper products should be evaluated for recycled content and to ensure that they do not
contain harmful components.
Chemicals used to control pests indoors and outdoors can potentially affect staff, patients, visi-
tors and applicators. Integrated Pest Management (IPM) is a concept of pest management that seeks
to reduce the use of harmful chemicals, target specific pests, increase the use of safer alternatives and
techniques and limit exposure of applicators, humans and other organisms to harmful substances. It is
a proactive approach with the premise that if the food and habitat are not provided for the pests, they
will look elsewhere. In addition, if chemicals have to be applied as a last resort, then the least hazard-
ous chemical is applied in the lowest possible concentration and by trained personnel.
All aspects of a health care facility’s operations come into play with regards to the overall ‘greening’
of the facility. Cleaning and pest control is especially important because they usually involve the use of
chemicals that are respiratory irritants, toxic and harmful.
than other products while still maintaining the high level of cleanliness required in the facility.
Ensure that disposable paper products, such as paper and hand wiping towels, contain re-
cycled content.
Prohibit “products that are manufactured with carcinogens, mutagens and teratogens; aero-
sols; asthma-causing agents (asthmagens), respiratory irritants, and chemicals that aggravate
existing respiratory conditions; neurotoxins; endocrine modifiers; benzene-based solvents, 67
butoxyethanol, chlorinated organic solvents, and paradichlorobenzene; very acidic
or alkaline products; anti-microbial agents in hand soaps for patients and visitors;
persistent, bioaccumulative and toxic chemicals (PBTs); and products requiring
disposal as hazardous waste,” and “[u]se combination cleaner/disinfectants and dyes
judiciously and only as necessary or where appropriate.” GGHC (Care G. G., 2008, pp.
10-11).
Integrated Pest Management
Develop an IPM program or request that the agency responsible for maintaining your facility
develops one that incorporates the following principles and practices, as noted by Practice
Greenhealth (Greenhealth, 2012):
Design, construct, and maintain buildings to be as pest resistant as possible.
Ensure that roof parapets and caps are sealed, any other devices on roofs, such as traps
or bait stations, are placed at documented locations and regularly checked, and nets for
bird/pigeon activity are checked on a regular basis.
Eliminate cracks and holes to keep pests out. Lightly dust gaps between walls and other
clean, and in good working order. Rodents do not like dusty and unclean bait stations.
Use physical barriers to block pest entry and movement (such as door sweeps, screens at
areas.
Resources
Green Seal: http://www.greenseal.org.
Environmental Choice CCD-113 for Drain or Grease Traps Additives: http://www.ecologo.org.
United States Environmental Protection Agency- Integrated Pest Management (IPM) Principles:
http://www.epa.gov/pesticides/factsheets/ipm.htm.
University of Minnesota-Radcliffe’s IPM World Textbook: http://ipmworld.umn.edu/.
United States Environmental Protection Agency- PestWise An EPA Partnership Program: http://
www.epa.gov/pesp/publications/index.html.
Beyond Pesticides-Healthy Hospitals Controlling Pests Without Harmful Pesticides: http://www.
SMART HOSPITALS TOOLKIT
beyondpesticides.org/hospitals/Healthy_Hospitals_Report.pdf.
Food Services
Overview
Agriculture and food systems have a significant impact on the environment and on human health.
Large inputs of energy and chemicals lead to degradation of soil, water and other natural resources.
The use of energy releases pollution into the atmosphere and contributes to climate change. Planting,
68 reaping, transportation, processing, packaging, shipping and the use of manmade inputs make the
global farming system unsustainable. With livestock, the system is similarly unsustainable
because most animal food is processed using energy, some animals are housed in controlled
environments and the animals themselves contribute greenhouses gases to the atmosphere
and pollute other resources as well.
In an effort to achieve an environmentally-friendly food system, health facilities must strive to
eliminate the use of disposable food containers and bottled water. If no national recycling program
is in place, plastic from food services and bottled water will likely end up in a landfill or incinerated.
Paper products such as napkins are often used in food services, but they consume natural resources
and generate additional waste. Paper products with recycled content offer a better, more sustainable
option. Additionally, food waste can be removed from the waste stream and composted on-site, in the
community or in a municipal or commercial facility. Compost can be reused in farms and add to the
overall sustainability of the agriculture sector.
Implementation Strategies
In an effort to make health facilities and the overall health sector more sustainable, changes must
be made to how food services are provided and to ensuring that the food acquired has been produced
in an environmentally safe and sustainable manner. The Caribbean is a net importer of food. In order
for this change to occur, agriculture must be improved locally and regionally. Governments will need
to get involved, as this requires national effort. Health care systems have large purchasing power and
can use that leverage to advocate for local change.
Reusable and Non-Reusable Products: Food Service Items, Non-Food Service Items and Bottled
Water Elimination
Eliminate the use of disposable products in food services. If there is a need for disposable
products, use biodegradable/compostable food service wares available on the market.
Reduce the use of non-food service paper products such as paper towels and nap-
69
kins or use efficient dispensing systems to control the amount of these products
used. Seek out products made from recycled/natural fibers.
Eliminate or reduce the use of bottled water for patients. If there is no national recy-
cling program in place, work with the government to institute a program. A recy-
cling program will significantly reduce the amount of plastic bottles and other items
tossed about, disposed of in landfills or incinerated. The concerns related to burning plastics
were discussed earlier.
remains at the end of daily operations to food banks, churches and other community groups
rather than disposing of it.
Join with the community and staff to start an organic garden onsite, if space permits. Use
organic refuse from food services to create a compost pile and reuse material in the garden. If
space does not allow for a garden, a simple compost pile may be possible. Donate compost to
community members.
Note: Commercial composters are available on the market that can turn discarded food
into compost. Coordinate with waste management companies or authorities to establish
if such a device can feasibly be used. Keep in mind that the compost can be sold locally
or regionally. A national food composting initiative that includes health care facilities,
restaurants, schools and other institutional uses that generate food waste can be incorpo-
rated into the program.
Resources
Practice Greenhealth, Sustainable Food: http://practicegreenhealth.org/topics/sustainable-
food.
Health Care Without Harm, Healthy Food Global Overview: http://noharm.org/all_regions/
issues/food/.
Prevention Institute, Cultivating Common Ground: Linking Health and Sustainable Agriculture:
http://noharm.org/lib/downloads/food/Cultivating_Common_Ground.pdf.
SMART HOSPITALS TOOLKIT
Environmentally-Preferable Purchasing
Overview
There is no doubt that the products, pharmaceuticals, equipment, fixtures, food, and cleaning
and other general supplies purchased for or by health facilities have a significant impact on the facili-
ties’ carbon footprint. Unused or expired pharmaceuticals, chemicals disposed of in an irresponsible
manner, and packaging and other materials add to the waste stream and contribute to environmental
degradation. Environmentally conscious purchasing decisions can, therefore, significantly improve
70
sustainability. Keep in mind that, the farther away the source of the goods/products/materi-
als, the greater their carbon footprint. Therefore, a facility that strives to make its operations
more sustainable will make purchasing decisions with this goal in mind.
The global movement Health Care without Harm notes that products purchased with
the environment in mind should:
Be less toxic
Be minimally polluting
Be more energy efficient
Be safer and healthier for patients, workers, and the environment
Contain higher recycled content
Have less packaging
Be fragrance-free
Implementation Strategies
not limited to: cell phones, pagers, walkie-talkies, hand-helds, televisions, fax
machines, copiers, monitoring equipment, medical equipment.
If donating retired equipment, ensure that it is mercury free, in working condition, and
has all parts necessary to be of use in other locations where extra parts and servicing
might not be available.
and/or distributors.
Require take back or leasing programs for televisions, copiers, computers, telephones and
content and increased recyclability in product or packaging if not in place. For example,
request recycled paper packaging instead of foam plastic packaging and containers
made from plastics #1 and #2, to increase potential for recycling when a reusable option
is unavailable.
Review packaging and shipping materials to identify materials used and reduction op-
portunities.
Establish a program to divert furniture and supplies from the waste stream through dona-
ties.
SMART HOSPITALS TOOLKIT
To further reduce solid waste generation, GGHC (Care G. G., 2008, pp. 12-10 - 12-11) also points
out that consideration should be given to using reusable alternatives for the following:
Toters for material delivery from receiving/storeroom to user areas.
Linens, including underpads (chux), pillows, isolation gowns, barrier protection, surgical
drapes, stainless sterilization containers (versus blue wrap), lab coats and linen bags.
Mattresses—eliminate disposable ‘eggcrate’ foam mattresses.
Things to Remember
Resources
• Mercury-Free Health Care: http://www.mercuryfreehealthcare.org/.
• Health Care without Harm—Mercury Issues: http://noharm.org/all_regions/issues/toxins/
mercury/.
• Sustainable Hospitals – Alternatives to mercury-containing equipment: http://www.
sustainablehospitals.org.
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