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CRITERIA AIR POLLUTANTS AND EMERGENCY NURSING Authors: Jessica Castner, PhD, RN, CEN, Sarah Gittere, BSN, and Jin Young Seo, MS, RN, WHNP, Buffalo, NY
utdoor air pollution is associated with an increased risk of morbidity and mortality from lower respiratory infections, chronic respiratory diseases, cardiovascular and circulatory diseases, and cancer. 1 Roughly 130 million Americans live where air pollution does not meet healthy air quality standards, with air pollution disproportionately affecting those who have low incomes and are ethnic minorities, women, and children. 2 Outdoor air pollution is one of the top 20 leading risk factors associated with loss of healthy life-years in North America. 1 Globally, outdoor air pollution ranks ninth in risk factors associated with loss of healthy life-years. 1 Emergency nurses are frontline providers for those affected by environmental exposures, caring for persons who suffer as a result of suboptimal community environments. Although air pollution impacts the practice of emergency nurses, the health outcomes from outdoor air pollution are insidious. Thus, education and practice related to chronic exposures to outdoor air pollution have not been a routine part of the emergency nursing specialty. In this article we present an overview of common air pollutants and health effects at chronic background levels, along with clinical implications for emergency nurses. The Environmental Protection Agency has labeled 6 main air pollutants as “criteria” pollutants. These pollutants were selected because of evidence that they are harmful to human health, they are widespread, and they come from multiple sources. 3 The criteria pollutants are sulfur dioxide, nitrogen oxides, particulate matter, ozone, lead, and carbon monoxide. Although emergency nurses may encounter each
O
Jessica Castner Member, Western New York Chapter, is Assistant Professor, School of Nursing, University at Buffalo, The State University of New York, Buffalo, NY. Sarah Gittere is Graduate Nurse, School of Nursing, University at Buffalo, The State University of New York, Buffalo, NY. Jin Young Seo is PhD Candidate, School of Nursing, University at Buffalo, The State University of New York, Buffalo, NY. For correspondence, write: Jessica Castner, PhD, RN, CEN, University at Buffalo, The State University of New York, 212 Wende Hall, 3435 Main St, Buffalo, NY 14214; E-mail: [email protected].
of these pollutants in situations that involve acute poisoning, in this article we focus on the health effects of chronic, low-level exposures from poor outdoor air quality. Lead is not discussed in this article because the main exposure to lead is through ingestion and not through ambient air inhalation. In general, persons at highest risk of experiencing the health effects of air pollutants are those at each end of the age spectrum (ie, children and older adults), as well as persons who are overweight or smoke cigarettes. In addition, a medical history that includes heart or vascular disease, diabetes, or chronic lung disease increases the potential sensitivity to air pollutants. 4 Table 1 provides an overview of the appearance, odor, and common sources of each pollutant. 4–6 Sulfur Dioxide
Most commonly, sulfur dioxide comes from industrial emissions and power plants that use fossil fuels. 7 Sulfur dioxide exposure has been correlated with increased overall ED use and visits for asthma, chronic obstructive pulmonary disease (COPD), upper respiratory infection, pneumonia, dysrhythmia, hypertension, abdominal pain, depression, and headache. 8–20 Chronic exposure affects the eyes, skin, and upper respiratory system. The lower respiratory system may also be affected, especially when the individual breathes through the mouth rather than through the nose. Health effects and symptoms related to sulfur dioxide include burning to the nose and throat, sore throat, difficulty inhaling deeply, altered sense of smell, and increased susceptibility to respiratory infections. The chronic irritation from sulfur dioxide is also correlated with bronchial irritation, chronic cough, increased sputum production, and wheezing—symptoms accompanying chronic bronchitis. Finally, sulfur dioxide has been linked to an accelerated decline in lung function, which is a special concern for developing children and persons who have underlying COPD, asthma, or other chronic respiratory diseases. 21
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Nitrogen Oxides
Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2014.08.011
Another common type of pollutant with a constant presence in our communities is nitrogen oxides. Although they are
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TABLE 1
Common characteristics of criteria pollutants Sulfur dioxide
Nitrogen oxides
Particulate matter
Ozone
Carbon monoxide
Appearance/odor
Colorless/ pungent odor
Colorless to reddish-brown/ strong, sweet odor
Colorless to blue/pungent odor
Colorless/ odorless
Common sources for outdoor air pollution
Burning coal or oil, industrial emissions
Automobile exhaust, burning of coal, oil, or natural gas
Small (“fine”) and large (“course”) particle sizes/ variable odor, may be odorless Diesel exhaust, wood stoves, power plants, smog, pollen
Sunlight acting on nitrogen oxides or other compounds
Automobile exhaust, smoking, gasoline-fueled equipment
Data from US Environmental Protection Agency. Air quality index: a guide to air quality and your health. http://airnow.gov/index.cfm?action=aqibasics.aqi. Updated May 22, 2014. Accessed September 10, 2014; Agency for Toxic Substances and Disease Registry. Toxic substances portal. ToxFAQs. http://www.atsdr.cdc.gov/toxfaqs/index.asp. Updated July 23, 2014. Accessed September 10, 2014; and US Environmental Protection Agency. AIRTrends 1995 summary, particulate matter (PM-10). http://www.epa.gov/airtrends/aqtrnd95/pm10.html. Updated January 5, 2012. Accessed September 10, 2014.
naturally occurring, they are also human-made, with the most common human-made source of these pollutants being automobile exhaust and burning of fossil fuels (such as by fossil-fuel–based power plants). 22 Inhalation is the most common route of exposure for nitrogen oxides, with hazardous effects to the respiratory system and mucous membranes. As with sulfur dioxide, even low levels of nitrogen oxide exposure can lead to irritation of the eyes, nose, throat, and lungs. Chronic exposure has been linked to an increased risk for worsened lung function and underlying restrictive or obstructive respiratory diseases, cough, shortness of breath, pulmonary edema, childhood respiratory infections, chest pain, and arrhythmias. For many persons, chronic exposure is also related to cigarette smoking or second-hand smoke. Increased levels of nitrogen oxides have been correlated with increased use of the emergency department overall and specifically for asthma, COPD, respiratory infections, otitis media, cardiovascular diseases, hypertension, dysrhythmia, abdominal pain, depression, and headache. 8,11,12,14–20,23,24
Particulate Matter
Particulate matter (PM) is composed of solids or liquids such as smoke, dirt, dust, mold, toxic organic compounds, smog, heavy metals, and pollen. 25 The varying chemical forms, shapes, and sizes affect the visibility of PM. The size of the particles can determine the extent of the health impact. For example,
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ultrafine PM appears to have the most severe health consequences because it can cross directly into the bloodstream to affect internal blood vessels and tissue. 26 Health effects are mainly seen in people with underlying lung or heart disease. PM has been linked to symptoms of chest pain, arrhythmia, shortness of breath, and fatigue in older adults with pre-existing heart disease. 4 Increases in ED visits for cardiac arrest, general cardiac and respiratory diseases, ischemic heart and cerebrovascular events, thromboembolism, dysrhythmia, hypertension, asthma, upper respiratory infections, abdominal pain, and headache have been linked to increases in outdoor levels of PM. 11,12,14–16,23,27–43 PM also aggravates underlying respiratory disease and increases susceptibility to respiratory infections. Finally, persons who are otherwise healthy may also experience short-term coughing and shortness of breath when fine PM levels are high.
Ozone
Ground level ozone is created by a chemical reaction from sunlight and other pollutants. The risk of this pollutant is higher in the late afternoon when the sun is out and the weather is warm. 44 Ozone, a colorless to bluish gas, can be very harmful and is a major concern for children, older adults, and persons with pre-existing respiratory diseases. 4 Ozone can damage the respiratory tract and worsen existing respiratory issues such as asthma and COPD; however, even healthy persons can be affected when exposed to high
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levels of ozone. The narrow airways of children make this population more vulnerable to the effects of ozone. Increases in outdoor ozone levels are linked to increases in ED visits for cardiac arrest, general cardiac and respiratory complaints, asthma, arrhythmia, depression, and dermatitis. 17,31,38,45–53 Symptoms of ozone exposure include eye, nose, and throat irritation, cough, shortness of breath, and chest pain. The resulting inflammation and respiratory irritation has been linked to pneumonia and asthma exacerbation. Carbon Monoxide
Carbon monoxide poisoning is the most common type of fatal air poisoning in many countries. 54 Although acute poisonings are often caused by combustion and poor indoor ventilation, carbon monoxide levels in outdoor ambient conditions may also adversely affect health. Carbon monoxide has been linked to increases in ED visits for angina, acute myocardial infarction cardiovascular disease, dysrhythmia, asthma, pneumonia, gastrointestinal disorders, depression, headache, and otitis media. 15–19,23,24,35,39,51,55–57 Because carbon monoxide interferes with the body’s oxygen-carrying capacity, patients
with pre-existing cardiovascular disease and anemia are most at risk. Exposure to high outdoor levels of carbon monoxide, especially during exertion, can lead to chest pain, shortness of breath, and other common signs of poor oxygenation. Carbon monoxide can affect mental alertness in otherwise healthy individuals. 58 Strategies for Emergency Nurses
Emergency nurses, alone or in collaborative teams, can apply several interventions to protect persons in their communities from health effects of outdoor air pollution. The detrimental health effects from outdoor air pollution exposure are commonly seen in the emergency setting, compelling emergency nurses to address air quality as a part of their practice. We provide an overview of initial tools and strategies for emergency nurses to (1) assess criteria air pollutant levels in the community in which they live and work, (2) educate patients on air pollution and health, and (3) intervene to improve air quality. The American Nurses Association established Principles of Environmental Health for Nursing Practice with Implementation Strategies 59 to provide a guiding framework for the role of nurses in environmental health in 2007
TABLE 2
American Nurses Association’s principles of environmental health for nursing practice Principle 1 Knowledge of environmental health concepts is essential to nursing practice Principle 2 The Precautionary Principle guides nurses in their practice to use products and practices that do not harm human health or the environment and to take preventive action in the face of uncertainty Principle 3 Nurses have a right to work in an environment that is safe and healthy Principle 4 Healthy environments are sustained through multidisciplinary collaboration Principle 5 Choices of materials, products, technology, and practices in the environment that impact nursing practice are based on the best evidence available Principle 6 Approaches to promoting a healthy environment respect the diverse values, beliefs, cultures, and circumstances of patients and their families Principle 7 Nurses participate in assessing the quality of the environment in which they practice and live Principle 8 Nurses, other health care workers, patients, and communities have the right to know relevant and timely information about the potentially harmful products, chemicals, pollutants, and hazards to which they are exposed Principle 9 Nurses participate in research of best practices that promote a safe and healthy environment Principle 10 Nurses must be supported in advocating for and implementing environmental health principles in nursing practice ©2003 American Nurses Association. Reprinted with permission. All Rights Reserved. ANA’s Principles of Environmental Health with Implementation Strategies is currently out of print. http://www. nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Nurse/ANAsPrinciplesofEnvironmentalHealthforNursingPractice.pdf. Accessed September 10, 2014.
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(Table 2). These principles clarify how relevant it is for emergency nurses to understand the health effects of criteria pollutants and use initial strategies to assess the air quality, educate patients, and intervene to improve air quality. Emergency nurses can use several tools publicly available in the United States to assess current and forecasted air quality. This information is useful to emergency nurses, who can anticipate additional patient presentations for respiratory and cardiac diseases. Emergency nurses may also include information about air quality in discharge education for vulnerable populations, including recommendations to limit outdoor activity and monitor their condition more closely and reminders for routine selfcare measures (such as use of prescribed inhaled corticosteroids for persons with asthma). One example of a tool that can be used is AirNow (http://www.airnow.gov/). This Web site provides a snapshot of current air quality conditions, and users can enter their ZIP code to view local conditions. The main feature of the site is a colorcoded map to visually identify the local air quality as good, moderate, unhealthy for sensitive groups, unhealthy, very unhealthy, and hazardous. To place the current pollution levels in historical context, nurses may also wish to view the 20 + year trend in their geographic region for each criterion pollutant at http://www.epa.gov/airtrends/where.html. Typical air quality assessments only include the criteria pollutants previously discussed. However, human health may be at risk from thousands of pollutants from industrial sources in any given area. For an additional assessment of the chemicals that are released in the local community and the quantities that are released, nurses can use the publicly available Toxic Release Inventory. Several interfaces with the Toxic Release Inventory are available, including http:// toxmap.nlm.nih.gov/, which includes a map of emitting facilities, a list of the regulated chemicals and amounts, and a link to information on the health effects. For more information on additional toxins, the Agency for Toxic Substances and Disease Registry offers information for the layperson and the health professional at http://www.atsdr. cdc.gov/substances/index.asp. Once the nurse has assessed the environmental air quality in his or her local community, the information can be included in patient education. Emergency nurses can enhance their discharge and self-care instruction forms to provide information that outlines how persons most vulnerable to the health effects of exposure can modify their behaviors and home environments. Patient teaching to reduce exposures must be sensitive to individual patient values and circumstances. Patients who are not homeowners may not be able to modify their home environment, whereas persons nearest to industry and heavy traffic need to
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weigh the risk of physical inactivity with the risk of exposure to pollutants. As with many health issues, emergency nurses should apply smoking cessation counseling to reduce the compounded effects of indoor and outdoor air quality issues. Nurses can encourage children and persons with asthma who live near industrialized areas to monitor and limit outdoor time when sulfur dioxide levels are high to reduce respiratory risk. To enhance asthma control, one strategy includes a trial to reduce consumption of foods preserved with sulfites (often found in wine, processed meats, dried foods, and pre-prepared meals). High-risk groups should avoid strenuous outdoor activities during poor air quality days and reduce activities near major roadways, especially in the late afternoon and early evening periods on hot days. Patients should be instructed to ensure good ventilation to reduce common home exposures near stoves, heaters, small lawn/garden engines, and vehicles. Additional patient education posters, handouts, and resources provided by the Environmental Protection Agency (http://www.epa.gov/apti/ozonehealth/tools.html) can aid in patient education. Given the scale and complexity of outdoor air pollution exposures, nursing educational interventions that focus on the individual or home environment can only partially mitigate the problem. The socio-ecological model, seen in the Figure, depicts how individual health is nested within the contextual layers of family, organizational, community,
FIGURE The socio-ecological model 60,61.
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and public policy factors. 60,61 Although emergency nursing practice most often intervenes at the individual and family level, emergency nurses also are in key positions to apply the nursing process to the organizational, community, and public policy level as well. At all levels of intervention, the individual emergency nurse can serve as a powerful, pragmatic, and experienced voice about the human health effects of poor air quality. Emergency nurses can relay information about the patient experience with respiratory disease exacerbation, cardiovascular events, and the many social challenges patients face in trying to manage these diseases in suboptimal air quality conditions. Emergency nurses can work to improve outdoor air quality through their employing hospitals. For example, emergency nurses can partner with management and the interdisciplinary team in their own hospital to reduce harmful waste and emissions. Healthcare Without Harm and Practice Greenhealth are sister organizations that offer toolkits that emergency nurses could use to initiate programs in their own employing hospitals to reduce harmful waste and emissions. Initial resources can be found at https://noharm-uscanada.org/issues/us-canada/wastemanagement and https://practicegreenhealth.org/topics/ waste. Often, the first step for the busy bedside emergency nurse is to approach his or her nurse manager, practice improvement council, or quality improvement committee with the initial idea and toolkit resources. Finding and emphasizing the initiative’s fit with the hospital’s mission and vision can help prioritize any proposed action within internal governance and management. The bedside emergency nurse can then continue to act as a champion and change agent in his or her organization by consistent advocacy and follow-up, as well as offering to present frontline practice experience with related environmental health conditions to hospital leaders who are not engaged in patient care. Emergency nurses can also work to improve outdoor air quality through their professional organizations. ENA efforts at the local, state, and national levels can begin to incorporate the American Nurses Association’s Principles of Environmental Health for Nursing Practice with Implementation Strategies. 59 Because professional organizations play a key role in professional development, practice standards, and advocacy, movement toward adapting environmental health principles into all nursing specialty organizations is a key step toward advocating for improved air quality. Joining or partnering with nursing organizations such as the Alliance of Nurses for Healthy Environments (ANHE) opens opportunities for ongoing professional development and organization-level initiatives. More information on ANHE’s nursing education, practice, policy, and research resources can be found at http://envirn.org/.
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Emergency nurses can make a powerful and unique contribution to multidisciplinary teams working to improve air quality at the community and public policy levels. Because emergency nurses see firsthand the effects of failed public health and prevention efforts, public health advocacy is a key direction for emergency nursing practice. 62 Emergency nurses can turn these firsthand accounts from their practice into public health advocacy by writing letters to the editor of their newspaper or to their elected officials. Emergency nurses can also join ongoing efforts in their community by contacting local grassroots environmental organizations, faith community initiatives, or local elected officials. On the state and national levels, the ENA 411 program and policy initiatives through ANHE provide advice and structure to advocate for improved air quality. Within multidisciplinary community and public policy efforts, the emergency nurse can contribute a unique and powerful perspective through civic engagement. Emergency nurses can effectively advocate for their patients by adding their clinical expertise and stories of their practice experiences toward efforts to improve air quality. Although it is essential to protect patient confidentiality, the nurse can discuss general practice experiences and nursing knowledge. Using the bedside clinical experience, emergency nurses can expertly explain and bring health issues to the forefront for policy makers and the public. For example, a composite story of all of the challenges impoverished families experience in managing a child’s chronic asthma (or what is involved in the ED visit for someone with chronic obstructive pulmonary disease exacerbation necessitating intubation) can add a powerful voice to the public discourse on issues that affect air quality.
Conclusion
In this article we aimed to provide an overview of air quality issues relevant to emergency nursing practice. Information was presented on the following criteria of outdoor air pollutants: sulfur dioxide, nitrogen oxides, particulate matter, ozone, and carbon monoxide. Specific action strategies were provided for emergency nurses, including assessing the local and regional air quality, patient education, and initial interventions to improve air quality. REFERENCES 1. Lim SS, Vos T, Flaxman AD. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2013;380(9859):2224-2260. 2. US Department of Health and Human Services. Environmental Health. http://www.healthypeople.gov/2020/topicsobjectives2020/overview.
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CRITERIA AIR POLLUTANTS AND EMERGENCY NURSING Authors: Jessica Castner, PhD, RN, CEN, Sarah Gittere, BSN, and Jin Young Seo, MS, RN, WHNP, Buffalo, NY
utdoor air pollution is associated with an increased risk of morbidity and mortality from lower respiratory infections, chronic respiratory diseases, cardiovascular and circulatory diseases, and cancer. 1 Roughly 130 million Americans live where air pollution does not meet healthy air quality standards, with air pollution disproportionately affecting those who have low incomes and are ethnic minorities, women, and children. 2 Outdoor air pollution is one of the top 20 leading risk factors associated with loss of healthy life-years in North America. 1 Globally, outdoor air pollution ranks ninth in risk factors associated with loss of healthy life-years. 1 Emergency nurses are frontline providers for those affected by environmental exposures, caring for persons who suffer as a result of suboptimal community environments. Although air pollution impacts the practice of emergency nurses, the health outcomes from outdoor air pollution are insidious. Thus, education and practice related to chronic exposures to outdoor air pollution have not been a routine part of the emergency nursing specialty. In this article we present an overview of common air pollutants and health effects at chronic background levels, along with clinical implications for emergency nurses. The Environmental Protection Agency has labeled 6 main air pollutants as “criteria” pollutants. These pollutants were selected because of evidence that they are harmful to human health, they are widespread, and they come from multiple sources. 3 The criteria pollutants are sulfur dioxide, nitrogen oxides, particulate matter, ozone, lead, and carbon monoxide. Although emergency nurses may encounter each
O
Jessica Castner Member, Western New York Chapter, is Assistant Professor, School of Nursing, University at Buffalo, The State University of New York, Buffalo, NY. Sarah Gittere is Graduate Nurse, School of Nursing, University at Buffalo, The State University of New York, Buffalo, NY. Jin Young Seo is PhD Candidate, School of Nursing, University at Buffalo, The State University of New York, Buffalo, NY. For correspondence, write: Jessica Castner, PhD, RN, CEN, University at Buffalo, The State University of New York, 212 Wende Hall, 3435 Main St, Buffalo, NY 14214; E-mail: [email protected].
of these pollutants in situations that involve acute poisoning, in this article we focus on the health effects of chronic, low-level exposures from poor outdoor air quality. Lead is not discussed in this article because the main exposure to lead is through ingestion and not through ambient air inhalation. In general, persons at highest risk of experiencing the health effects of air pollutants are those at each end of the age spectrum (ie, children and older adults), as well as persons who are overweight or smoke cigarettes. In addition, a medical history that includes heart or vascular disease, diabetes, or chronic lung disease increases the potential sensitivity to air pollutants. 4 Table 1 provides an overview of the appearance, odor, and common sources of each pollutant. 4–6 Sulfur Dioxide
Most commonly, sulfur dioxide comes from industrial emissions and power plants that use fossil fuels. 7 Sulfur dioxide exposure has been correlated with increased overall ED use and visits for asthma, chronic obstructive pulmonary disease (COPD), upper respiratory infection, pneumonia, dysrhythmia, hypertension, abdominal pain, depression, and headache. 8–20 Chronic exposure affects the eyes, skin, and upper respiratory system. The lower respiratory system may also be affected, especially when the individual breathes through the mouth rather than through the nose. Health effects and symptoms related to sulfur dioxide include burning to the nose and throat, sore throat, difficulty inhaling deeply, altered sense of smell, and increased susceptibility to respiratory infections. The chronic irritation from sulfur dioxide is also correlated with bronchial irritation, chronic cough, increased sputum production, and wheezing—symptoms accompanying chronic bronchitis. Finally, sulfur dioxide has been linked to an accelerated decline in lung function, which is a special concern for developing children and persons who have underlying COPD, asthma, or other chronic respiratory diseases. 21
J Emerg Nurs 2015;41:186-92. 0099-1767
Nitrogen Oxides
Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2014.08.011
Another common type of pollutant with a constant presence in our communities is nitrogen oxides. Although they are
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TABLE 1
Common characteristics of criteria pollutants Sulfur dioxide
Nitrogen oxides
Particulate matter
Ozone
Carbon monoxide
Appearance/odor
Colorless/ pungent odor
Colorless to reddish-brown/ strong, sweet odor
Colorless to blue/pungent odor
Colorless/ odorless
Common sources for outdoor air pollution
Burning coal or oil, industrial emissions
Automobile exhaust, burning of coal, oil, or natural gas
Small (“fine”) and large (“course”) particle sizes/ variable odor, may be odorless Diesel exhaust, wood stoves, power plants, smog, pollen
Sunlight acting on nitrogen oxides or other compounds
Automobile exhaust, smoking, gasoline-fueled equipment
Data from US Environmental Protection Agency. Air quality index: a guide to air quality and your health. http://airnow.gov/index.cfm?action=aqibasics.aqi. Updated May 22, 2014. Accessed September 10, 2014; Agency for Toxic Substances and Disease Registry. Toxic substances portal. ToxFAQs. http://www.atsdr.cdc.gov/toxfaqs/index.asp. Updated July 23, 2014. Accessed September 10, 2014; and US Environmental Protection Agency. AIRTrends 1995 summary, particulate matter (PM-10). http://www.epa.gov/airtrends/aqtrnd95/pm10.html. Updated January 5, 2012. Accessed September 10, 2014.
naturally occurring, they are also human-made, with the most common human-made source of these pollutants being automobile exhaust and burning of fossil fuels (such as by fossil-fuel–based power plants). 22 Inhalation is the most common route of exposure for nitrogen oxides, with hazardous effects to the respiratory system and mucous membranes. As with sulfur dioxide, even low levels of nitrogen oxide exposure can lead to irritation of the eyes, nose, throat, and lungs. Chronic exposure has been linked to an increased risk for worsened lung function and underlying restrictive or obstructive respiratory diseases, cough, shortness of breath, pulmonary edema, childhood respiratory infections, chest pain, and arrhythmias. For many persons, chronic exposure is also related to cigarette smoking or second-hand smoke. Increased levels of nitrogen oxides have been correlated with increased use of the emergency department overall and specifically for asthma, COPD, respiratory infections, otitis media, cardiovascular diseases, hypertension, dysrhythmia, abdominal pain, depression, and headache. 8,11,12,14–20,23,24
Particulate Matter
Particulate matter (PM) is composed of solids or liquids such as smoke, dirt, dust, mold, toxic organic compounds, smog, heavy metals, and pollen. 25 The varying chemical forms, shapes, and sizes affect the visibility of PM. The size of the particles can determine the extent of the health impact. For example,
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ultrafine PM appears to have the most severe health consequences because it can cross directly into the bloodstream to affect internal blood vessels and tissue. 26 Health effects are mainly seen in people with underlying lung or heart disease. PM has been linked to symptoms of chest pain, arrhythmia, shortness of breath, and fatigue in older adults with pre-existing heart disease. 4 Increases in ED visits for cardiac arrest, general cardiac and respiratory diseases, ischemic heart and cerebrovascular events, thromboembolism, dysrhythmia, hypertension, asthma, upper respiratory infections, abdominal pain, and headache have been linked to increases in outdoor levels of PM. 11,12,14–16,23,27–43 PM also aggravates underlying respiratory disease and increases susceptibility to respiratory infections. Finally, persons who are otherwise healthy may also experience short-term coughing and shortness of breath when fine PM levels are high.
Ozone
Ground level ozone is created by a chemical reaction from sunlight and other pollutants. The risk of this pollutant is higher in the late afternoon when the sun is out and the weather is warm. 44 Ozone, a colorless to bluish gas, can be very harmful and is a major concern for children, older adults, and persons with pre-existing respiratory diseases. 4 Ozone can damage the respiratory tract and worsen existing respiratory issues such as asthma and COPD; however, even healthy persons can be affected when exposed to high
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levels of ozone. The narrow airways of children make this population more vulnerable to the effects of ozone. Increases in outdoor ozone levels are linked to increases in ED visits for cardiac arrest, general cardiac and respiratory complaints, asthma, arrhythmia, depression, and dermatitis. 17,31,38,45–53 Symptoms of ozone exposure include eye, nose, and throat irritation, cough, shortness of breath, and chest pain. The resulting inflammation and respiratory irritation has been linked to pneumonia and asthma exacerbation. Carbon Monoxide
Carbon monoxide poisoning is the most common type of fatal air poisoning in many countries. 54 Although acute poisonings are often caused by combustion and poor indoor ventilation, carbon monoxide levels in outdoor ambient conditions may also adversely affect health. Carbon monoxide has been linked to increases in ED visits for angina, acute myocardial infarction cardiovascular disease, dysrhythmia, asthma, pneumonia, gastrointestinal disorders, depression, headache, and otitis media. 15–19,23,24,35,39,51,55–57 Because carbon monoxide interferes with the body’s oxygen-carrying capacity, patients
with pre-existing cardiovascular disease and anemia are most at risk. Exposure to high outdoor levels of carbon monoxide, especially during exertion, can lead to chest pain, shortness of breath, and other common signs of poor oxygenation. Carbon monoxide can affect mental alertness in otherwise healthy individuals. 58 Strategies for Emergency Nurses
Emergency nurses, alone or in collaborative teams, can apply several interventions to protect persons in their communities from health effects of outdoor air pollution. The detrimental health effects from outdoor air pollution exposure are commonly seen in the emergency setting, compelling emergency nurses to address air quality as a part of their practice. We provide an overview of initial tools and strategies for emergency nurses to (1) assess criteria air pollutant levels in the community in which they live and work, (2) educate patients on air pollution and health, and (3) intervene to improve air quality. The American Nurses Association established Principles of Environmental Health for Nursing Practice with Implementation Strategies 59 to provide a guiding framework for the role of nurses in environmental health in 2007
TABLE 2
American Nurses Association’s principles of environmental health for nursing practice Principle 1 Knowledge of environmental health concepts is essential to nursing practice Principle 2 The Precautionary Principle guides nurses in their practice to use products and practices that do not harm human health or the environment and to take preventive action in the face of uncertainty Principle 3 Nurses have a right to work in an environment that is safe and healthy Principle 4 Healthy environments are sustained through multidisciplinary collaboration Principle 5 Choices of materials, products, technology, and practices in the environment that impact nursing practice are based on the best evidence available Principle 6 Approaches to promoting a healthy environment respect the diverse values, beliefs, cultures, and circumstances of patients and their families Principle 7 Nurses participate in assessing the quality of the environment in which they practice and live Principle 8 Nurses, other health care workers, patients, and communities have the right to know relevant and timely information about the potentially harmful products, chemicals, pollutants, and hazards to which they are exposed Principle 9 Nurses participate in research of best practices that promote a safe and healthy environment Principle 10 Nurses must be supported in advocating for and implementing environmental health principles in nursing practice ©2003 American Nurses Association. Reprinted with permission. All Rights Reserved. ANA’s Principles of Environmental Health with Implementation Strategies is currently out of print. http://www. nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Nurse/ANAsPrinciplesofEnvironmentalHealthforNursingPractice.pdf. Accessed September 10, 2014.
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(Table 2). These principles clarify how relevant it is for emergency nurses to understand the health effects of criteria pollutants and use initial strategies to assess the air quality, educate patients, and intervene to improve air quality. Emergency nurses can use several tools publicly available in the United States to assess current and forecasted air quality. This information is useful to emergency nurses, who can anticipate additional patient presentations for respiratory and cardiac diseases. Emergency nurses may also include information about air quality in discharge education for vulnerable populations, including recommendations to limit outdoor activity and monitor their condition more closely and reminders for routine selfcare measures (such as use of prescribed inhaled corticosteroids for persons with asthma). One example of a tool that can be used is AirNow (http://www.airnow.gov/). This Web site provides a snapshot of current air quality conditions, and users can enter their ZIP code to view local conditions. The main feature of the site is a colorcoded map to visually identify the local air quality as good, moderate, unhealthy for sensitive groups, unhealthy, very unhealthy, and hazardous. To place the current pollution levels in historical context, nurses may also wish to view the 20 + year trend in their geographic region for each criterion pollutant at http://www.epa.gov/airtrends/where.html. Typical air quality assessments only include the criteria pollutants previously discussed. However, human health may be at risk from thousands of pollutants from industrial sources in any given area. For an additional assessment of the chemicals that are released in the local community and the quantities that are released, nurses can use the publicly available Toxic Release Inventory. Several interfaces with the Toxic Release Inventory are available, including http:// toxmap.nlm.nih.gov/, which includes a map of emitting facilities, a list of the regulated chemicals and amounts, and a link to information on the health effects. For more information on additional toxins, the Agency for Toxic Substances and Disease Registry offers information for the layperson and the health professional at http://www.atsdr. cdc.gov/substances/index.asp. Once the nurse has assessed the environmental air quality in his or her local community, the information can be included in patient education. Emergency nurses can enhance their discharge and self-care instruction forms to provide information that outlines how persons most vulnerable to the health effects of exposure can modify their behaviors and home environments. Patient teaching to reduce exposures must be sensitive to individual patient values and circumstances. Patients who are not homeowners may not be able to modify their home environment, whereas persons nearest to industry and heavy traffic need to
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weigh the risk of physical inactivity with the risk of exposure to pollutants. As with many health issues, emergency nurses should apply smoking cessation counseling to reduce the compounded effects of indoor and outdoor air quality issues. Nurses can encourage children and persons with asthma who live near industrialized areas to monitor and limit outdoor time when sulfur dioxide levels are high to reduce respiratory risk. To enhance asthma control, one strategy includes a trial to reduce consumption of foods preserved with sulfites (often found in wine, processed meats, dried foods, and pre-prepared meals). High-risk groups should avoid strenuous outdoor activities during poor air quality days and reduce activities near major roadways, especially in the late afternoon and early evening periods on hot days. Patients should be instructed to ensure good ventilation to reduce common home exposures near stoves, heaters, small lawn/garden engines, and vehicles. Additional patient education posters, handouts, and resources provided by the Environmental Protection Agency (http://www.epa.gov/apti/ozonehealth/tools.html) can aid in patient education. Given the scale and complexity of outdoor air pollution exposures, nursing educational interventions that focus on the individual or home environment can only partially mitigate the problem. The socio-ecological model, seen in the Figure, depicts how individual health is nested within the contextual layers of family, organizational, community,
FIGURE The socio-ecological model 60,61.
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and public policy factors. 60,61 Although emergency nursing practice most often intervenes at the individual and family level, emergency nurses also are in key positions to apply the nursing process to the organizational, community, and public policy level as well. At all levels of intervention, the individual emergency nurse can serve as a powerful, pragmatic, and experienced voice about the human health effects of poor air quality. Emergency nurses can relay information about the patient experience with respiratory disease exacerbation, cardiovascular events, and the many social challenges patients face in trying to manage these diseases in suboptimal air quality conditions. Emergency nurses can work to improve outdoor air quality through their employing hospitals. For example, emergency nurses can partner with management and the interdisciplinary team in their own hospital to reduce harmful waste and emissions. Healthcare Without Harm and Practice Greenhealth are sister organizations that offer toolkits that emergency nurses could use to initiate programs in their own employing hospitals to reduce harmful waste and emissions. Initial resources can be found at https://noharm-uscanada.org/issues/us-canada/wastemanagement and https://practicegreenhealth.org/topics/ waste. Often, the first step for the busy bedside emergency nurse is to approach his or her nurse manager, practice improvement council, or quality improvement committee with the initial idea and toolkit resources. Finding and emphasizing the initiative’s fit with the hospital’s mission and vision can help prioritize any proposed action within internal governance and management. The bedside emergency nurse can then continue to act as a champion and change agent in his or her organization by consistent advocacy and follow-up, as well as offering to present frontline practice experience with related environmental health conditions to hospital leaders who are not engaged in patient care. Emergency nurses can also work to improve outdoor air quality through their professional organizations. ENA efforts at the local, state, and national levels can begin to incorporate the American Nurses Association’s Principles of Environmental Health for Nursing Practice with Implementation Strategies. 59 Because professional organizations play a key role in professional development, practice standards, and advocacy, movement toward adapting environmental health principles into all nursing specialty organizations is a key step toward advocating for improved air quality. Joining or partnering with nursing organizations such as the Alliance of Nurses for Healthy Environments (ANHE) opens opportunities for ongoing professional development and organization-level initiatives. More information on ANHE’s nursing education, practice, policy, and research resources can be found at http://envirn.org/.
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Emergency nurses can make a powerful and unique contribution to multidisciplinary teams working to improve air quality at the community and public policy levels. Because emergency nurses see firsthand the effects of failed public health and prevention efforts, public health advocacy is a key direction for emergency nursing practice. 62 Emergency nurses can turn these firsthand accounts from their practice into public health advocacy by writing letters to the editor of their newspaper or to their elected officials. Emergency nurses can also join ongoing efforts in their community by contacting local grassroots environmental organizations, faith community initiatives, or local elected officials. On the state and national levels, the ENA 411 program and policy initiatives through ANHE provide advice and structure to advocate for improved air quality. Within multidisciplinary community and public policy efforts, the emergency nurse can contribute a unique and powerful perspective through civic engagement. Emergency nurses can effectively advocate for their patients by adding their clinical expertise and stories of their practice experiences toward efforts to improve air quality. Although it is essential to protect patient confidentiality, the nurse can discuss general practice experiences and nursing knowledge. Using the bedside clinical experience, emergency nurses can expertly explain and bring health issues to the forefront for policy makers and the public. For example, a composite story of all of the challenges impoverished families experience in managing a child’s chronic asthma (or what is involved in the ED visit for someone with chronic obstructive pulmonary disease exacerbation necessitating intubation) can add a powerful voice to the public discourse on issues that affect air quality.
Conclusion
In this article we aimed to provide an overview of air quality issues relevant to emergency nursing practice. Information was presented on the following criteria of outdoor air pollutants: sulfur dioxide, nitrogen oxides, particulate matter, ozone, and carbon monoxide. Specific action strategies were provided for emergency nurses, including assessing the local and regional air quality, patient education, and initial interventions to improve air quality. REFERENCES 1. Lim SS, Vos T, Flaxman AD. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2013;380(9859):2224-2260. 2. US Department of Health and Human Services. Environmental Health. http://www.healthypeople.gov/2020/topicsobjectives2020/overview.
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