Asthma triggers in hospitals lead to ER visits, employee absenteeism

'Any hospitalization or ER visit for asthma is preventable.'

There's a hazard in hospitals that hits every hot button for employee health. It causes occupational illness and even fatalities, raises the costs of medical claims, and increases absenteeism. Because it's in the air we breathe, it could affect significant numbers of employees — and could even harm vulnerable patients.

Indoor air quality is an important focus for occupational health, wellness, and the "greening" of America's hospitals. Asthma triggers in hospitals include chemicals, medications, cleaners, and even baking products in the cafeteria. An estimated 10% to 23% of new onset asthma is caused by occupational exposures.1 And hospitals have among the highest rate of occupational asthma, surveillance data show.2

"There are several hundred chemicals that are asthmagens known to be capable of causing asthma in people who have never had it before. Many of those same chemicals can trigger an asthma attack in someone who's already been diagnosed with it," says Polly Hoppin, ScD, research professor and program director of the Lowell Center for Sustainable Production at the University of Massachusetts-Lowell. Many of those chemicals, such as glutaraldehyde, formaldehyde, and ethylene oxide, are found in hospitals.

Hoppin and her colleagues analyzed the business case for prevention and better care for asthma in the workplace. An asthma quality improvement program that provides education and encourages self-management can save $1.52 to $9.84 for every dollar invested, they found.3

Uncontrolled asthma leads to unnecessary emergency room visits and hospitalizations. It also is the fourth leading cause of work absenteeism. Employees with asthma have medical costs that are 2.5 times higher than those without asthma.4

Addressing asthma requires a multi-pronged approach that includes employee health as well as wellness/health promotion and the involvement of human resources. "If you're going to tackle asthma across the hospital, there needs to be an integrated approach that takes into consideration three arenas — insurance coverage, a workplace-based wellness program, and ensuring that the work environment is asthma friendly," says Hoppin.

Success story: Latex alternatives

Hospitals already can point to a major accomplishment in the efforts to reduce occupational asthma: Eliminating powdered latex gloves and substituting them with powder-free, vinyl, nitrile and other alternatives. One study found a two-fold increase in asthma risk from latex gloves from 1992 to 2000 but not after 2000, when hospitals began moving away from powdered-latex gloves.5

That is a model for use of substitutions to reduce or eliminate exposures to other respiratory hazards, says Margaret S. Filios, SM, RN, a captain in the U.S. Public Health Service and epidemiologist with the Surveillance Branch of the Division of Respiratory Disease Studies at the National Institute for Occupational Safety and Health in Morgantown, WV.

"It reduced the incidence of work-related asthma in hospitals. That was a real success story," says Filios, noting that substitution is at the top of the "hierarchy of controls" as the preferred way to address a hazard.

Now, hospitals are switching to "greener" chemicals for cleaning, although Hoppin cautions that some products that claim to be "green" may still have asthmagenic properties. Look closely at ingredients for known asthmagens and look for products that have "green" certification, she advises.

The U.S. Federal Trade Commission recently issued a new "Green Guide" to clarify what kinds of environmental claims manufacturers can make about their products. Green Seal, a non-profit that certifies products and services, tightened its standard for cleaning products. Among other criteria, the products cannot contain asthmagens as identified by the Association of Occupational and Environmental Clinics.

Green purchasing becomes easier as more consumers demand the products. Several states as well as large employers such as Kaiser Permanente require green cleaners. "There's really an increased understanding of the impact of cleaning chemicals on janitorial staff," says Hoppin.

Disinfecting and sterilizing agents, such as glutaraldehyde, continue to cause respiratory problems in hospitals. But even safer substitutes require careful handling. A Health Hazard Evaluation at a hospital in Buffalo, NY, found that poor ventilation contributed to complaints of headaches, eye irritation, and shortness of breath among employees who worked in a GI Lab Steris Room with a peracetic acid processor.

Meanwhile, there are a myriad of other potential asthma triggers. Administering aerosolized medicine doubles the risk of developing asthma, one study found.5 Dietary workers could be at risk from flour dust, and maintenance workers may be exposed to volatile organic compounds in paint, varnish, or other building materials.

Manage employees' asthma

Hospitals also have a role to play in helping employees with asthma manage their symptoms. In Massachusetts, two-thirds of adults with asthma had symptoms in the last month and 14% had at least one visit to the emergency room or an urgent care center, according to surveillance data.6

"Any hospitalization for asthma or any emergency department visit for asthma is preventable," says Hoppin. "There is really no reason why someone should have to end up in the emergency room or the hospital. Everyone with asthma should be living active vibrant lives. They should not be missing work. They should not be impeded by their breathing. That's the expectations people should have for their asthma."

Medical claims data provide a snapshot of the burden of asthma in the workplace. For example, greater use of "rescue" medications as opposed to asthma controllers indicates that asthma is not being well-managed, says Hoppin. Employers can encourage the appropriate use of asthma medications with lower co-pays, she says.

Wellness programs should include asthma as one of their goals to identify and manage chronic diseases among employees, she says. Asthma education can help employees control their asthma — and can provide information they need to better manage asthma symptoms of their children.

Awareness is a key to prevention, says Christine Pontus, MS, RN, COHN-S/CCM, associate director of Health & Safety for the Massachusetts Nurses Association in Canton. Nurses need to be aware of the symptoms and the possible connections to the hospital environment. Nurses may be exposed to "a chemical soup," she says. "You've got cleaning chemicals, people treated with hazardous drugs, perfumes. It becomes a mixture within a closed space."

Employee health should be represented on the hospital's purchasing committee and considered when selecting products, Pontus advises. Material safety data sheets should be readily available on products.

Reducing hazards, providing insurance benefits that encourage good symptom control, and offering asthma support through wellness programming will pay off, says Hoppin. Ultimately, the result is "a healthy work environment, cost-savings for the hospital, a commitment to health and also innovation," she says.


1. Clapp R, Culver A, Donahue S, et al. Risks to asthma posed by indoor health care environments. Health Care Without Harm. 2006. Available at Accessed on November 24, 2010.

2. Pechter E, Davis LK, Tumpowsky C, et al. Work-related asthma among health care workers: Surveillance data from California, Massachusetts, Michigan, and New Jersey, 1993–1997. Am J Ind Med 2005;47:265–275.

3. Hoppin P, Stillman L, Jacobs M. Asthma: A business case for employers and health care purchasers. The Lowell Center for Sustainable Production, University of Massachusetts Lowell & Asthma Regional Council. February 2010. Available at [Accessed on November 24, 2010.]

4. Birnbaum HG, et al. Direct and indirect costs of asthma to an employer. Jrl Allergy Clin Imm 2002;109:264-270.

5. Delclos GL, Gimeno D, Arif AA, et al. Occupational risk factors and asthma among health care professionals. Am J Respir Crit Care Med 2007;175:633-634.

6. Jacobs M, Hoppin P, Sperrazza K, et al. Asthma related chemicals in Massachusetts: An analysis of Toxics Use Reduction Act data. Lowell Center for Sustainable Production, University of Massachusetts Lowell, July 2009. Available at [Accessed on November 24, 2010.]