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By Jack S. McGurk, MPA, REHS
In response to the memorandumof understanding between the American Hospital Association (AHA) and the UnitedStates Environmental Protection Agency (EPA), hospitals are beginning toinitiate pollution prevention (P-2) programs. At the heart of this agreement isthe goal to reduce solid and medical wastes generated by hospitals and eliminateall mercury from these facilities. Implementation of P-2 programs provideshospitals opportunities to realize positive benefits through systemimprovements. The infection control nurse must play a major role in the P-2activities if the program is to be successful.
Through an EPA grant and funding from an interagency agreement with theCalifornia Department of Toxic Substances Control, the California Department ofHealth Services (DHS) has been able to implement a pilot P-2 project with sixBay Area hospitals. Many of the experiences and early lessons learned areincluded in this article. The six California hospitals participating in the P-2project are:
The P-2 project includes a safe harbor provision under which regulatorsworking on these activities will not cite the participating facility forviolations observed while at the hospital, but do point them out for immediatecorrective action. This provision has proven valuable in reducing the anxietylevel of hospital staff while working with regulators and allowing candidconversations as to how best to separate the medical and solid waste streams.
The University of California, Los Angeles, is also working with DHS to buildits new medical school hospital as a mercury-free facility. The decision todevelop a mercury-free hospital was an outgrowth resulting from several costlymercury spills at the current medical school on the UCLA campus.
Common to all participating hospitals is support from top administration forthe project and designation by the administrator of a contact person to lead P-2efforts for the facility. Managers of either environmental services or healthand safety were most often tasked with overseeing implementation of the P-2project. However, activities in the P-2 project took place not only within theseunits, but cut across organizational boundaries and staffing hierarchy withinhospitals. One incidental benefit of implementing P-2 activities is the teambuilding that takes place as participants from different disciplines within thehospital undertake project tasks together and work to design improved systems.
It is essential that the status of the systems operating within the hospitalbe documented during the initial implementation of P-2 activities. This baselinedata can then be used to measure the outcomes from P-2 interventions. Thedocumentation of solid and medical waste generation for a hospital is based onthe amounts being produced over a specific period of time. In contrast, thebaseline documentation for mercury is obtained through an inventory of bulkmercury and mercury-containing devices within the facility.
The Mercury Mission
A small team conducted the mercury audit of the facility. A team of two orthree persons, including a representative from environmental services/health andsafety and the infection control nurse, was found to be the most effective andefficient. A team of that size and composition was not disruptive to ongoingoperations, had familiarity with the layout of the facility, and was able toengage in dialogue with staff from different areas surveyed. This approach oftenresults in the discovery of mercury-containing devices that might have otherwisegone undetected.
Virtual elimination of mercury as recognized by the EPA/AHA memorandum ofunderstanding calls for the replacement of mercury-containing devices wherenon-mercury equivalents are available. However, where non-mercury replacementsare not available or when mercury-containing devices or medicines are requiredfor patient care, their use should continue. The P-2 project found thatnon-mercury alternatives are available for the types of equipment containing thehighest quantities of mercury.
The P-2 project worked with participating facilities to inventorymercury-containing devices such as sphygmomanometers, thermometers, bougies,barometers, barostats, and thermostats that could be replaced. They thendeveloped a business plan with cost estimates for replacement. Calculations weremade for the amount of mercury contained in fluorescent tubes. The fluorescenttube calculations, as well as those for thimerosal used in pharmaceuticals, wereincluded in the inventories although no substitutes are currently available. Anew California regulation requires fluorescent tubes to be sent for recyclingwhen replaced.
A compound widely used in hospital laboratories is B-5 fixative. Thismercury-containing fixative is used in histology to aid in identifying certaincell types. The tissue being examined is placed into a container with B-5fixative, which penetrates the tissue. The tissue is next stained and placed ona slide for microscopic examination. During the rinse process, mercury may bedischarged into the sewer system. Several brands of B-5 fixative have beendeveloped that use zinc chloride instead of mercury. Laboratory suppliers shouldbe able to provide listings of these substitute brands.
Potentially overlooked sources of mercury in hospitals are cleaning products.Although many cleaning products contain low levels of mercury in parts permillion or billion, the large amount of cleaners used in hospitals can result inmercury being placed in wastewater systems. Hospital purchasing departmentsshould be aware of this situation and request mercury-free product verificationfrom their suppliers.
When mercury-containing devices are changed-out at hospitals, they shouldhave secondary containment to avoid spills and be transported to the hazardouswaste storage area and held there for recycling or disposal as a hazardouswaste. Mercury devices must never be placed into red medical waste bags orsharps containers. It is important to have individuals available to respond atthe facility who are trained and familiar with handling mercury spills.
Once mercury sources have been removed from the hospital, the next challengeis to prevent new sources of mercury from entering the facility. Personneltasked with purchasing supplies and equipment serve as the first line of defenseagainst mercury sources entering the hospital. They must continually updatetheir familiarity with mercury-free alternatives. It should become commonpractice for departments that order materials or equipment that contain mercury,to provide justification that mercury-free alternatives are not available orapplicable.
The department has recently published a 79-page publication entitled: AGuide to Mercury Assessment and Elimination in Health Care Facilities. Thisdocument is available at the Department's Web site at: www.dhs.ca.gov.
Table 1 provides a composite of the P-2 project's findings for mercury at thesix participating facilities. The P-2 project developed an assessment"toolkit" that summarizes findings for mercury and presents them on aPareto chart. The assessment toolkit is also available at the department's Website.
Solid and medical waste audits have been performed at the five hospitals thathad agreed to participate in this portion of the project. Most have initiatedcardboard recycling and several are bailing substantial amounts of cardboard.This process requires expenditure of personnel resources to break down thecardboard containers and transport them to an area where bailing takes place.One hospital receives supplies and pharmaceuticals from its regionaldistribution center in reusable plastic containers and totes. This reduces theamount of cardboard waste at the hospitals.
The cardboard recycling process provides an excellent example of how a systemcan be analyzed and improved. As a result, the P-2 project is encouraging othersuppliers to send their supplies to the hospitals in reusable plastic containersand totes.
The hospitals have also initiated other strategies to reduce the amounts ofsolid waste being sent to their community landfills. Several are working withtheir solid waste authorities to implement recycling programs that allow allrecyclable materials to be placed into a single container. This is possible whenthese materials are sent to a central materials recovery facility in thecommunity for sorting. One strategy being implemented is to utilize a smallsolid waste receptacle for wet garbage and large conveniently locatedreceptacles for recyclable materials.
Efforts to reduce the medical waste stream most frequently focus oneliminating solid wastes that are being incorrectly placed into medical wastecontainers. This must be an ongoing effort and include training of health carepractitioners that generate this waste stream. The location of medical wastecontainers can determine whether non-medical wastes are placed within them. Amedical waste container located next to a hand-washing sink, for example,increases the likelihood that soiled paper towels will be errantly placed intothe medical waste stream.
The P-2 project has been working on several interventions that hold promisefor significantly reducing the medical waste stream. Several hospitals are inthe process of converting to reusable sharps containers. These containers are ofa far more durable construction than traditional sharps containers and areexpected to last five years or longer. After being dumped by mechanical means,the empty sharps containers are washed and disinfected before being returned tothe hospital for reuse. A 250-bed hospital participating in the P-2 projectreviewed its 1999 purchase records and determined that approximately 18,000sharps containers were used. The weight of each type of empty sharps containerwas recorded and calculations were completed that documented the hospital coulddivert 13 tons of medical waste annually by switching to reusable sharpscontainers. The department also recently approved a safety needle device as asingle use sharps container that allows the device's placement directly into thered bag waste stream. This device also eliminates the need for sharpscontainers.
Hospitals benefit in many ways by introducing pollution prevention programs.They reduce wastes, free their facilities from mercury, improve the environment,save money and increase employee morale by demonstrating that the hospital is aresponsible neighbor in the community. Additionally, as members from across thespectrum of professions working within the hospital participate jointly on teamsto study pollution prevention strategies, new ideas often surface for systemsimprovements that can strengthen the fiscal condition of the hospital while alsoimproving working conditions.
Jack S. McGurk, MPA, REHS, is Chief of the Environmental Management Branchof the California Department of Health Services in Sacramento, Calif. He iscurrently leading a pollution prevention partnership program with six Bay Areahospitals to reduce solid and medical waste and eliminate mercury from wastestreams. McGurk is a member of the Infection Control Today Editorial AdvisoryBoard.
|Other GI||6||0.1||Blakemore, Cantor tubes|
|Flourescent tubes||39,843||0.9||calculated as 4-foot tubes, based on lighted floor area|
|Switches||90||0.3||switches from thermostats, barostats, boilers, X-ray tubes and safety tip-over devices|
|Thermometers||254||0.6||laboratory, fever, refrigerator, boiler|
|Total (Kg)||93.7||sum of device totals|
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