How to treat a sick office: Go after hidden environmental factors
■ Beyond the germs that float around physicians' offices, poor air quality could be taking a toll.
By Kathleen Phalen Tomaselli amednews correspondent — Posted Dec. 18, 2006
The day was a grueling, back-to-back string of appointments. Now the patients have been seen, the office is quiet and the custodial crew gone. On the surface, all is peaceful.
But hidden from view, nestled in carpet fibers and chair foam, are thousands of microbes devouring dust the vacuum cleaner just stirred up. They have been lying in wait for the moisture from shoes, perspiring bodies and a child's spilled drink to mix into the perfect microbial cocktail -- a power drink to fuel their efforts to grow, replicate and reproduce. The new cabinets and carpet in renovated exam rooms also are making mischief, emitting formaldehyde gasses. And the half million spores from that dime-sized patch of mold in the well-baby play area will spew into the air as soon as someone walks across the spot.
"There are so many sources of bacteria and poor indoor air quality," says Jeffrey May, author of My Office Is Killing Me! and principal scientist for May Indoor Air Investigations in Cambridge, Mass. "Maybe the carpet got wet when it was cleaned or the fresh air vent is closed. If the relative humidity is too high, mildew starts growing."
Indoor air pollution consistently ranks among the top five environmental risks to public health, the Environmental Protection Agency says. Indoor levels can reach two to five times, sometimes 100 times, higher than outdoor levels. Often linked to the energy crisis of the 1970s, which spurred tightly sealed spaces, unhealthy indoor air occurs when there is little or no fresh air to dilute irritants.
Health care settings are uniquely vulnerable, says Al Draper, a toxicologist with LVI Services in Oklahoma City, which specializes in environmental remediation and infection control. Substances found in these places -- disinfectants, sterilants, solvents, building materials, equipment, dust and moisture -- are prescriptions for trouble.
So-called sick buildings can trigger asthma; nasal and upper respiratory ills; rashes and skin irritations; decreased cognition; forgetfulness; irritability; headaches; nausea; dizziness; unusual fatigue; or dry or burning nose, eyes or throat.
"This is a huge problem," says John Santilli, MD, chief of the division of allergies and immunology at St. Vincent's Medical Center in Bridgeport, Conn. "It affects 30% to 50% of the population."
Consider Boston's Brigham and Women's Hospital. At one point, officials closed 32 operating rooms to pull the ventilation system apart. But issues persisted. About 300 of 1,800 nurses reported symptoms, and 80 were on disability leave. After several years, experts determined the cause to be latex allergens, a lack of adequate ventilation, and emissions from sterilizing chemicals such as glutaraldehyde. "Now fresh air is delivered in every area of the hospital, and efficient local exhaust ventilation has been installed," May says. "They've got latex-free zones and carts."
Solvents are particularly harmful because they thrive on fats, May says. Photocopiers and laser printers, for instance, use toner and a solvent, and, therefore, produce volatile organic compounds -- VOCs -- in the unsafe range. "When solvent vapors are inhaled, they enter the blood and lungs and are distributed into the body's fat, where they have an immediate effect on the nervous system," May says. "People can feel nauseated, tingly, even inebriated. ... In too high a dose, it can be lethal."
Thus, it is important to inventory dangerous compounds in the office. Check the ventilation to make certain toxic fumes are pulled out and circulating fresh air is added. To test it, May suggests a child's toy called a Wizard Stick. "It makes smoke. I use it to test air flow. You think the exhaust is working fine, but maybe the pressure from the heat supply is greater, so it's not venting out."
Another problem is off-gassing of PVC-backed carpet and formaldehyde found in pressed wood products like particleboard.
Emissions are accelerated by heat and humidity, so better ventilation, increased fresh air and dehumidifiers help reduce levels. "A lot has to do with routine maintenance and air flow," says Rob Gallo, a board-certified indoor air quality manager and director of sales and marketing for Stamford, Conn.-based RTK Environmental Group, a testing services company.
Experts warn that poorly designed, operated or maintained ventilation systems contribute to problems. Fresh air vents often are blocked with furniture and equipment; filters are clogged with dirt; air intake vents bring in exhaust from parking lots, dumpsters or another office.
Sometimes air difficulties start with water. A National Institute of Occupational Safety and Health report outlines some tales from the trenches -- literally. For example, a leak in a water main below physician offices at the Dixie Regional Medical Center in St. George, Utah, caused flooding in the crawlspace, saturating the floor as well as cardboard left by construction crews. As mold grew, its musty odor got employees' attention. And when several experienced respiratory problems, a complaint to NIOSH prompted professional remediation. (See correction)
While standing water is a sure bet for mold, it's not the only cause. Perspiration, wet shoes or condensation from a window also encourage it. Mold under an office chair mat will release spores through the air each time the chair is rolled. Mold may be inside a wall or under carpeting.
Though there are conflicting opinions about the related physical harm, Dr. Santilli, who began studying the effects of mold 30 years ago, says it is a major allergy culprit. "You can get a chronic inflammation from molds, they are a big factor."
Legionnaire's disease and recent cruise ship illnesses are commonly known, but questions continue about sick building syndrome -- with some people believing it does not exist. And it's often far from physician radar when symptoms do not fit any particular pattern or when patients complain of symptoms mimicking colds or flu.
Still, Dr. Santilli says primary care physicians play an important role in helping identify such problems. Symptoms may include dizziness, fatigue, allergic rhinitis, sinusitis and cognitive problems. When patients have such issues, Dr. Santilli says, "Ask, 'Are you sick at work, at home? How bad are your allergies when you are away from the environment -- 30% better, 80% better?'
"When patients come in saying, 'My office is making me sick,' believe them," he adds. Dr. Santilli even goes so far as to test his patients' environment for mold.
Growing awareness about indoor air problems, is leading to building codes requiring better ventilation in hospitals, says David Neal, an architect with the S/L/A/M Collaborative in Atlanta. "With more sick building syndrome occurring, hospitals are now required to have 90% air filtration. Offices are still only at 30%."
Neal, citing the "Green Guide for Healthcare" (link), says a voluntary push for safer indoor air is spreading. "Make sure you are reducing VOCs and using more natural materials."
Kaiser Permanente was at the planning table when the Green Guide was developed and the managed care company has been pilot testing strategies since. At their under-construction medical center in Modesto, Calif., rubber flooring will replace vinyl to reduce emissions, carpet will be backed with recycled safety glass and permeable pavement materials will filter chemicals from rainwater runoff.
Kaiser plans on building or replacing 27 hospitals during the next nine years, and all are going green, says Susannah Patton, a senior media relations consultant for the health care giant. "It's part of our national strategy," she says. "It is part of our Safety by Design for patients, workers and the environment."