Eco-Friendly Infection Control-Understanding the Balance

practical applications for going green and “doing no harm”

WHAT DOES GOING GREEN MEAN?

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Adopting practices that reduce your overall impact on the environment. Adding sustainability principles and considerations into the planning process of work or

personal lifestyle.

What is Dentistry’s Environmental Footprint – More than you think

The Environmental Impact of Dentistry Every Year Dental Practices Generate

•680 million disposable infection control barriers

•1.7 billion instrument and sterilization pouches •28 million liters of toxic x-ray fixer •4.8 million lead foils Dental vacuum systems

waste 9 billion gallons of water a year.Reference Eco Dentistry

Issue 1: Amalgam Is the Most Important Problem

• EPA estimates 3.7 tons of mercury waste per year from dental offices

• Only 11 states and 19 localities require amalgam separators

• EPA’s separator requirements only in 10 states

Issue 2: Photochemical Waste

Issue 3: Reducing Your Carbon Footprint

What if it was really simple?

• I am the ONLY person RESPONSIBLE for my behavior.

• I choose to change the environment…to make the world better place for everyone.

Amalgam Solution – Very Simple and Greatest Step Towards Green

• Capture and recycle• Install an Amalgam Separator. • Switch to Composites.

Amalgam – Capture & Recycle• Scrap amalgam and amalgam waste include any left over bulk amalgam, spent

capsules, and disposable chairside-traps. • Dentists should collect and store all contact and non-contact scrap amalgam for

recycling.• It is important to note that not all recyclers can handle mercury. Indeed mercury

waste cannot be landfilled or incinerated as this releases the toxins in the atmosphere and groundwater.

• Mercury waste needs to be sent to an approved recycler that can reprocess the mercury.

• These need to be appropriately labeled and stored in tightly closed containers for recycling.

Amalgam – Install a Separator

• Install an Amalgam SeparatorThe BENEFITS:• Amalgam separators are solids collectors installed on the vacuum lines of dental offices. They

capture the amalgam before it reaches the sewers. • The ADA estimates that 25% of amalgam waste still makes it to the wastewaters even after

the use of chair-side traps and other capturing methods. • The ADA’s best management practices (BMP) recommend the use of amalgam separators

which are certified to collect over 98% of amalgam waste.

Amalgam – Separator Solutions

• Install an Amalgam SeparatorAvailable SolutionsShow SolmeteX and ECO IIPureLife Incentive Program

Amalgam - Regulations

• Install an Amalgam SeparatorThe Regulations• Current States• EPA Regulation

Amalgam Alternatives – Switch to Composites

• Switch To Composites• Switch to Composites. One sure-way of reducing mercury waste is to switch from mercury

amalgam to non-mercury alternatives (i.e. composites, gold, ceramics). These are certainly more challenging to do as procedures but also carry with them higher price premiums (from 1.5x to over 8x compared to amalgam as shown in the exhibit below) and so can be accretive to a practice’s top line. But mercury alternatives can be slightly less resistant to wear and tear and in the case of composites or glass monomers have been know to have lower longevity, not to mention higher costs to the patient. As such, mercury amalgam remains pervasive in the dental industry and measures need to be put in place to control the extent of amalgam related pollution. It is also important to note that all-composite practices that perform procedures on patients with amalgam fillings

Photochemical Waste Solution

• Shift to Digital X-Rays• About 50% of dentists have already shifted to digital x-ray equipment. Digital x-rays do not

require film fixer and developer, both of which are known for creating highly toxic waste. While typical digital X-ray systems are capital intensive, costing on average 3-4x conventional film X-ray systems, they have lower operational costs namely due to reduced amount of consumables (fixer, developer etc.) associated with the development of film X-ray, not to mention significant cost savings in reduced waste management and recycling. In fact depending on the office, digital X-ray systems can pay for themselves in as little as 2-3 years. Digital systems also provide more tools for the dental practitioner and offer an enhanced service to the patient. Digital X-ray systems also deliver up to 80% less radiation to the patient. For more information on the potential cost savings afforded by the shift to digital x-ray, please refer to <our Lean Mean and Green article…>

Photochemical Waste Solution

• Implementing a Proper Waste Compliance Program.

• Waste from x-ray procedures such as fixer, developer, lead-foil and lead aprons are toxic and potentially harmful and need to be handled, stored and disposed of or recycled in accordance with strict and detailed OSHA compliance rules, which can vary from state to state. Solutions are available from many recyclers in the form of pickup services or more affordable mail-in services. Not all recyclers will deal with all types of waste and so, practices need to balance for themselves the pros and cons of using one single provider and whether the added convenience of a pick up service outweighs the extra costs vs. mail-back programs. Most programs also include a sharps/bio-hazard service which is mandatory by law.

Reduce CO2 FootPrint

• 3.1 Buy Eco-Friendly Products • 3.2 Improve Energy Efficiency• 3.3 Source from Eco-Friendly Suppliers

Reduce CO2 FootPrint

• 3.1 Buy Eco-Friendly Products • 3.2 Improve Energy Efficiency• 3.3 Source from Eco-Friendly Suppliers

Reduce CO2 Footprint

• Buy Eco-Friendly Products • Products featuring reduced packaging or recyclable packaging with lead-free ink• Products made from biodegradable or recyclable materials – focus on high volume disposable

items (i.e. barrier sleeves, syringe tips, plastic cups etc.) • Autoclavable products vs. disposables when practical (i.e. stainless steel suction tips, prohy

angles and prophy cups)• Certified carbon neutral or carbon free products – products whereby the manufacturer or

distributor has donated a portion of profits to offset or cancel the effects to the environment.

Reduce CO2 Footprint

• Improve Energy Efficiency• Install energy efficient HVAC system• Use natural light as much as possible• Use efficient lighting (i.e. halogen or LED) when possible• Install energy efficient windows, save over 30% of energy costs• Turn off all electrical equipment when not in use

Reduce CO2 Footprint

• Source from Eco-Friendy Suppliers• Use suppliers that have taken real tangible steps towards being more eco-friendly• Use suppliers with eco-friendly products• Use carbon-neutral suppliers with offset programs• Important Note: Always consider patient care first when considering green products – not all

green substitutes are appropriate within an infection control and dental setting.

Some other Simple Ideas that Work

• Source from Eco-Friendy Suppliers• Use suppliers that have taken real tangible steps towards being more eco-friendly• Use suppliers with eco-friendly products• Use carbon-neutral suppliers with offset programs• Important Note: Always consider patient care first when considering green products – not all

green substitutes are appropriate within an infection control and dental setting.

Get a Recycling Bin66 million tons of Garbage NOT in the Landfill

Plastic bags..Don’t have to be eaten to

harm the animals

Statistics on the Amount of Time Items Take to Decompose

Paper: 2.5 monthsMilk Carton: 5 yearsCigarette Butt: 10-12 yearsPlastic Bag: some say 10-20 years…other sources say 100 yearsDisposable diapers: 75 years -450 yearsTin Can: 100 years-200 yearsPlastic Bottle: 450 yearsGlass Bottle: 1,000,000 yearsStyrofoam: NEVER

Other Benefits of Going Green

• Save Green

Other Benefits of Going Green

• Benefits of Digital X-Ray

Other Benefits of Going Green

• Benefits of Energy Efficiency

Other Benefits of Going Green

• Some Companies Offer Subsidies

Other Benefits of Going Green

• Improve and Grow Your Practice

Green Infection Control and Understanding the Balance

Your Responsibility

Goals

• Define the concept of going green and its relevance to infection control in the dental setting

• Understand the practical application of the chain of infection to going green

• Identify the solutions for maintaining infection control standards and going green

• Develop a plan for changes in infection control in the dental setting to minimize the impact on the environment

OUR responsibility

• Follow the Medical Model-Wellness based• Reduce and Save• Stay up to date

Where did you start?Medical Model

• Good • Better• Best

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Going Green Means

• You uses the safest materials available that have the least impact on the environment

• Going green means you do not cross contaminate and end up sending someone to the hospital!

Misconceptions

• Green products cost more• Green products are not as effective• Green cleaning is too complicated• Green is difficult to implement

Reality

• Green products are competitively priced/cost neutral “green saves green”

• Green products can be more effective and have higher return on investment

• A good program is easy to monitor, train and maintain

• You may already be doing some green things you do not know about

But what about doing no harm?

“Green infection control and safety is disease prevention and safety procedures and products that further reduce adverse health and environmental impacts”. Chris Miller DDS

SO what next?

• Reduce waste where possible and when not possible use environmentally friendlier supplies that feature recyclable materials or packaging.

• Buy from suppliers who are environmentally friendly or have eco-friendly initiative such as carbon offset programs as a way to reduce waste or offset that waste.

Green Products

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Green Products 2

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Green Products 3

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Green Companies

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PROVIDE PURELIFE PROFILE AND OTHER COMPANIES

Green Companies 2

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Green Companies 3

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In the Long Run

• Improves health

• Helps reduce Worker’s Comp claims and premiums

• Helps reduce turnover, which in turn impacts:

– Recruiting– Hiring– Training– Impact of service

5 Simple Steps for Change

• Determine the need• Involve the team and Develop a plan• Acquire “Green” products and equipment &

Provide training• Implement the plan, products & procedures• Re-evaluate

How can reductions be made?

1) Behavioural Changes

2) Policy and Process Changes

3) Technological Changes

How can I get others to change?In order to make a change after receiving

information you must:

• See the need• Know the action• Value the action• Repeat the action

UNDERSTANDING CHAIN OF INFECTION AND STANDARDS OF INFECTION CONTROL

AND GOING GREEN

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Chain of Infection

Pathogen

Source

ModeEntry

Susceptible Host

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Universal Precautions, 1980’s: Protects against exposure to blood, some other body fluids

Hand washingPersonal protective equipmentControls to prevent injuriesProper management of patient care

items and environmental surfaces

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Standard Precautions 1990’s: protect against exposure to blood, body secretions, excretions, nonintact skin, mucous membranes

• Hand washing• Personal protective equipment• Controls to prevent injuries• Proper management of patient care items

and environmental surfaces

Exposure Prevention Strategies

• Engineering controls• Work practice controls• Administrative controls

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Practical Application

• Behavior and techniques• Sustainable equipment: Recycle, Reuse• Disposables• Do no Harm• Resources for Change• Evaluation of supplies and materials green

factors• Safe disposal of chemicals

Behavior and techniques

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The single most important way to reduce the risk of disease transmission.

Washing Your Hands

Clean HandsSave Lives

88% of disease spread through hand contact

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Update Hand washing statistics

Hand hygiene

• Hand washing• Hand antisepsis• Surgical hand antisepsis• Hand care • Preventive measures

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Hands Need to be Cleaned When

• Visibly dirty• After touching

contaminated objects with bare hands

• Before and after patient treatment (before glove placement and after glove removal)

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• Transient microorganisms: acquired through direct contact, on surface layer

• Resident Flora: Usually normal flora of skin, attach to deeper layers

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Efficacy of Hand Hygiene Preparations in Reduction of

Bacteria

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Good Better Best

Plain Soap Antimicrobial soap

Alcohol-based handrub

Source: http://www.cdc.gov/handhygiene/materials.htm

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Gloving is not a substitute for

Hand washing!

Hand Hygiene Definitions

• Handwashing– Washing hands with plain soap and water

• Antiseptic handwash– Washing hands with water and soap or other detergents

containing an antiseptic agent

• Alcohol-based handrub– Rubbing hands with an alcohol-containing preparation

• Surgical antisepsis– Handwashing with an antiseptic soap or an alcohol-based

handrub before operations by surgical personnel

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Hand washing• Lathering: Pulls

microorganisms away form the skin’s crevices and suspends them

• Rinsing: washes them off your hands

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How do we get the message out?

• Facts? Ethics? Understanding? Culture?

• It make you sick, there are germs involved?

• Decrease in COMPLIANCE, 2.0 female, 21.5 males

Everyone understands

Something everyone can relate to…

Direct to the Point

Simple Concise

So what worked?• Grossness• Increased hand washing in females

26 percent 8 percent in males • SO what do we do?

How does it apply?

• Preach in a toilet?• How can I transfer this to practice?• Do I bring gross examples with me?• A minute in the MORNING

How can I get others to change?In order to make a change after receiving

information you must:

• See the need• Know the action• Value the action• Repeat the action

Your hands are only as clean as the towel you use to dry them

Disposables

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Barrier surface protection

• Speedy turnaround• Safety and efficiency• Available for almost all surfaces• Eliminate the wait time• Limit chemical exposure and release to the

atmosphere

Barrier Protection

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Create a Barrier

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Wipe wipe wipe What are you Breathing?

• OSHA exposure limits to these chemicals is governed by OSHA time weighted average (TWA) for these chemicals.

• For information on work place exposure and methods for reducing exposure go to OSHA.org

TWA!

Toxicological, environmental and occupational concerns associated with disinfection and

sterilization practices

Disposal of chemical need to be addressed Some chemicals can be neutralized by reaction

with chemicals such as sodium bisulfite or glycine.

• Establish a program for monitoring occupational exposure to regulated chemicals that follows federal, state, and local regulations. This must include the key factors to assess the risks of chemical exposure including duration, intensity, and route of exposure.

• Ensure that no employee is ever overexposed to the TWA. • Material and Safety Data Sheet (MSDS) information must be available for all

products that are in the dental setting. MSDS sheets include information on TWA. • All employees must be educated, and the purpose of the HazCom standard is to

ensure that hazards of all chemicals produced or imported be evaluated and that employers transmit the information concerning such hazards directly to employees. Information is conveyed through a comprehensive hazard communication program. The program includes a written clinic/office program manual, container labeling and other forms of warning, Material Safety Data Sheets (MSDSs), and employee training.

And So?

Do No Harm

Aspiration Pneumonia ICU one DAY~$14,401

An incentive spirometer is $250Pulse ox is $150Admission kit is $150, IV tubing is $80One dose of 650 mg of Tylenol is $10Antibiotics PRN $720ICU rooms are averaging $13,041 24 hours Staff, Transportation, uniforms, sheets, drapes, single

use supplies

Resources for Change

Safe disposal of chemicals

Resources

State environmental agencies• www.epa.gov/epahome/state.htmHealthcare Environmental Resource Center• http://www.hercenter.org/dentistwastes.cfmHealthcare Without Harm• www.noharm.org

Sources• recycleitnow.net• OSAP.ORG• DONOHARM.ORG• CDC.ORG • plasticsresource.com • pbs.org/pov/borders/2004/water/water_disposable.html • refillnotlandfill.org • bottledwaterblues.com • sks-bottle.com • www.earth911.org• www.thedailygreen.com

APPENDIX

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So what is a Carbon Footprint?

• A carbon footprint is a measure of the impact our activities have on the environment in terms of the amount of green house gases produced, measured in units of carbon dioxide equivalents (CO2e).

What is Carbon?

• The base for all life (as we know it)• Graphite is soft and most common carbon

allotrope• Diamond is very hard & expensive!• Coal and Oil (are carbon based)

– When burnt with air causes carbon dioxide to be emitted

What’s Carbon Dioxide (CO2)

• It’s a gas (at standard room temperature and pressure)• We breathe it out• Used by plants in photosynthesis• Makes drinks fizz• Colourless and odourless (in low concentrations)• Trace gas in the Earth’s Atmosphere (0.039%)• A Greenhouse Gas

Greenhouse Gases

• A “blanket” keeping our planet warm• Without them Earth would be very different and too

cold to support life (over 30oC colder)

Where is the CO2 coming from?

• 40% of gas emitted from Volcanoes is CO2

• Volcanoes emit about 130 – 230 million tCO2 /year• Human activity is about 130x that of volcanoes

– 27 billion tCO2/year

• Other natural sources emit about 1000x as much as volcanoes

Look closely at:

• Extraction• Production and transportation of raw

materials• Manufacture and service provision• Distribution• End use• Disposal and Recycling

Want to know your foot print?Resources for change…

• http://www.epa.gov/climatechange/emissions/ind_calculator.html

Simple concepts

• US grown Organic Cotton• Biodegradable• Natural fibers chlorine free

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SO what next?

• Reduce waste where possible and when not possible use environmentally friendlier supplies that feature recyclable materials or packaging.

• Buy from suppliers who are environmentally friendly or have eco-friendly initiative such as carbon offset programs as a way to reduce waste or offset that waste.

How can reductions be made?

1) Behavioural Changes

2) Policy and Process Changes

3) Technological Changes

How can I get others to change?In order to make a change after receiving

information you must:

• See the need• Know the action• Value the action• Repeat the action