MWM 1st Quarter 2011

VOL. VII NO. 1

Jan-Mar 2011

Medical Waste Management www.medicalwastemanagementnews.com

Serving Healthcare Facility Waste Management Professionals

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Drug War: Responsibility for Take-Back Programs at Issue

H

By P.J. Heller

ospitals, healthcare facilities and pharmacies concerned about the proper disposal of prescription and over-the-counter drugs have launched efforts to get the public to clean out their homes of unwanted, unused and expired drugs.

Such programs — whether one-day “takeback” events, installation of secure drop boxes for ongoing collections, or mail-back efforts — are designed to help reduce substance abuse as well as keep the drugs from polluting the environment.

“Collecting unused medication is important for both public safety and environmental protection,” notes the Ohio Hospital Association.

“Prescription and over-the-counter medication can be inadvertently consumed by children and misused by adults . . . Drugs released into the water supply impact fish and other wildlife.”

The problem of prescription-drug overdoses has become so severe that 16 states now report that drug-related incidents caused more deaths than automobile crashes, according to the Centers for Disease Control and Prevention.

“The United States is in the grip of an epidemic of prescription drug overdoses,” the CDC reports. “Prescription drugs are now involved in more overdose deaths than heroin and cocaine combined.”

Attempts by state legislatures from Maine

to Washington to enact legislation requiring pharmaceutical companies to participate in or fund drug take-back programs — similar to stewardship programs required of some other industries —have met with little success. Such legislation is a bitter pill for drug manufacturers to swallow. They argue that such mandated programs would drive up the cost of drugs and that there is no proof of any significant environmental damage or of health threats from discarded medications. They further contend that their awareness campaigns, following federal guidelines for disposal of unused or expired medications in landfills, are sufficient.

The U.S. Environmental Protection Agency notes that “studies have shown that pharmaceuticals are present in some of our nation’s water bodies. Further research suggests that there may be some ecological harm when certain drugs are present. To date, no evidence has been found of human health effects from PPCPs (pharmaceuticals and personal care products) in the environment.”

Concern about public safety and the environment has prompted some healthcare facilities, such as Group Health Cooperative in Washington and OhioHealth in the Buckeye state to implement their own take-back programs.

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Drug War: Responsibility for Take-Back Programs at Issue Continued from page 1 provide a community benefit, so we’re always looking at ways to improve the health of our community,” says Lea Blackburn, system director for community partnerships at OhioHealth.

“That’s the priority for us.”

“My focus was really around patient safety, preventing these drugs from getting into the wrong hands, but it fits very nicely with the [state] Department of Ecology and many of the environmental nonprofits,” adds Shirley Reitz, associate director of pharmacy clinical services for Group Health Cooperative, which provides medical coverage and care to more than 654,000 residents in Washington state and northern Idaho. Its facilities include one hospital, 26 primary care medical centers and six specialty care units.

OhioHealth, which has been serving patients in central Ohio since 1891, is a family of not-for-profit, faith-based hospitals and healthcare organizations, consisting of 18 hospitals, 23 health and surgery centers, homehealth providers, and medical equipment and health service suppliers.

Blackburn says she was inspired to start a one-day take-back program in 2009 at five hospital sites in Columbus after learning that 96 percent of unintentional poisoning deaths in Ohio from 2003 to 2006 were due to drugs/ medication. Ohio is also among the 16 states where more people die from unintentional drug medication poisonings than from automobile accidents.

Working with local law enforcement, OhioHealth took in 1,212 pounds of medications in its first effort, which ran from 10 a.m. to 2 p.m. on a Saturday; the following year, the program, which started an hour earlier, collected 1,508 pounds of meds. The pills — 34 percent of which were prescription pain medications — were incinerated by police. The containers they came in were shredded.

The program was designed to only take in medications from private households.

“A significant number of individuals [who dropped off drugs] were caregivers of someone who had died, either a spouse or a parent,” Blackburn says. “They had these medications and they weren’t sure how to dispose of them.

They just wanted to get rid of them because they were years and years old and they just didn’t know what to do.”

In at least one case, a medication dated to 1940. Other prescriptions were at least 20 years old.

“The interesting thing to me was that they actually had the awareness not to flush them down the toilet or randomly put them in the trash,” Blackburn says.

One unexpected cost of the program was having to pay for the destruction of liquid medications, which cost OhioHealth about

$2,200. It did not have to pay for the required law enforcement presence, relying instead on the police department’s community liaison officers who normally work on Saturday and its own security forces, all of whom are sworn officers.

OhioHealth plans to hold another event on April 30, as part of the U.S. Drug Enforcement Agency’s second nationwide prescription drug take-back day. The first DEA event, held Sept.

25, 2010, resulted in more than 242,000 pounds of prescription drugs turned in for disposal at some 4,000 take-back sites nationwide.

“The take-back campaign was a stunning nationwide success that cleaned out more than 121 tons of pills from America’s medicine cabinets, a crucial step toward reducing the epidemic of prescription drug abuse that is plaguing this nation,” said recently named DEA administrator Michele M. Leonhart. “Thanks to our state and local law enforcement and community partners — and the public — we not only removed these dangerous drugs from our homes, but also educated countless thousands of concerned citizens about the dangers of drug abuse.”

Reitz of Group Health Cooperative tells a similar story of people dropping off medications that dated to the 1950s and 1960s.

“When we’ve done surveys, people have said, ‘We know we’re not supposed to put it down the drain or flush it down the toilet, but we don’t know what to do with it,’” she says. “They were waiting for something like this.”

Group Health Cooperative launched a twoyear pilot program at seven clinics in 2006 with several environmental and nonprofit groups for collecting medications in the Seattle area. The program quickly expanded to 25 locations in the state, which is among the 16 states nationwide where accidental deaths from prescription drug overdoses exceed the number of deaths from car crashes.

Secured containers were placed in the waiting areas of Group Health pharmacies allowing people to simply deposit their medications (controlled substances were not allowed). When the containers were filled — about 700 pounds of drugs are deposited every two weeks — the meds are collected and incinerated.

“Overall in the last 4 1/2 years, we’ve collected close to 60,000 pounds,” Reitz estimates.

At the end of the two-year pilot, which was funded by a grant, Group Health continued the program.

“The reason that we chose to continue to do this is because we felt it was important and there was a community benefit to doing this, not only for environmental reasons but keeping medications safely out of the hands of children and others who might be using them Continued on page 8

jan-mar 2011 Medical Waste Management

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medical waste management

HWI Reviews Critical Issues Facing the Healthcare Waste Industry

By Alice P. Jacobsohn

I

n the world of politics, no one company can be effective operating on its own. For large companies with employees dedicated to compliance, they may find the need for industry support to accomplish their goals. For small companies, they may not have the capability to hire employees dedicated to tracking changes in the law. Despite fierce competition among companies, a seat at the table of a trade association offers a means of making sure a company’s voice is heard, ensures that relevant information is analyzed and distributed quickly creating a potential market advantage, provides a community network for sharing business knowledge and, perhaps more importantly, offers a social group for industry leaders to associate with like-minded people.

The Healthcare Waste Institute (Institute) is a policy-making group within the National Solid Wastes Management Association (NSWMA) and Waste Equipment Technology Association (WASTEC), serving the needs of healthcare waste management entities across the United States.

Members are transporters, facility owners and operators (public and private), equipment and product manufacturers and distributors, and consultants. Our mission is to facilitate responsible healthcare waste management from all types of generators, to be the resource network for technical and regulatory assistance, and be respected as a proactive, responsive, and credible organization.

The activities of the Institute include the ability to deal with companyspecific and industry-wide issues with the support of others in the industry and Institute staff, develop guidance documents and educate members on various regulations, advocate before legislators and regulators for key industry positions and about industry operations, and build relationships with the generator community.

Recently, the Institute has been working on a number of critical industry issues. A few of them are highlighted below.

Occupational Safety and Health

O

n May 6, 2010, the U.S. Occupational Safety and Health Administration (OSHA) published a “Request for Information on Infectious Substances” looking for information and comments on occupational exposure to infectious agents in healthcare and healthcare-related settings (75 Fed. Reg. 24835). Specifically, OSHA wanted information on strategies that were being used to mitigate the risk of occupationally-acquired infectious diseases. The information request included facilities and tasks potentially exposing workers to risk, successful employee infection control programs, control methodologies being used (engineering controls, work practices, administrative controls, and personal protective equipment), medical surveillance programs, and training. The intent of the request was to determine what, if any, action OSHA should take to limit the spread of occupationally-caused diseases.

On May 14, 2010, OSHA published a “Request for Comments on a Regulatory Flexibility Act Review of the Bloodborne Pathogens Standard” (75 Fed. Reg. 27237). Readers will recall that the Bloodborne Pathogens Standard was published as a final rule on December 6, 1991 and successfully remained in place following a lawsuit decided in 1993 (ADA v. Martin). In 2001, the standard was revised based on the Needlestick Safety and Prevention Act when safety needle devices became a requirement for entities subject to the standard and employers were required to maintain sharps injury logs.

In the 2010 review, OSHA asked for comments on the complexity of the standard; extent of overlaps and conflicts with other agencies (federal, state, and local); economic impacts; whether the safety needle requirements should remain in place, be expanded, or be eliminated; what the impacts of the standard were on non-hospital settings; and whether there were new or emerging health risks that OSHA should consider.

The Institute commented that blood and bodily fluids remain a hazard in healthcare settings. Only 25 states have established OSHA4

Medical Waste Management jan-mar 2011

approved State Plans, many of which have adopted OSHA standards.

Therefore, without the Bloodborne Pathogens Standard, very little worker protection would exist. The Institute also commented that training requirements should change to allow for refresher training when the regulated community can focus on changes and problem areas rather than the current requirement of comprehensive training each year.

Motor Carrier Safety

T

he current focus of the Federal Motor Carrier Safety Administration (FMCSA) is on preventing accidents caused by distracted drivers.

In 2010, the FMCSA replaced the SafeStat system that monitored the driving record of commercial, trucking operations in favor of a system that tracks data from all out-of-state service inspections and accidents.

The results will be used by the agency to provide “intervention” where unsafe conditions are found. Also finalized, as of October 27, 2010, texting by a commercial motor vehicle driver is prohibited when the vehicle is moving. This federal law emphasizes efforts by state and local authorities to ban text messaging and cell phone use while driving. The penalties for violations of distracted driving laws are significant as is the liability for accidents caused by drivers who were text messaging and using cell phones.

In August, 2010, the U.S. Department of Transportation’s (DOT) Pipeline and Hazardous Materials Safety Administration issued a Safety Advisory Notice to remind offerors and carriers of hazardous materials of the risks associated with the use of personal electronic devices (PEDs) by individuals operating motor vehicles that contain hazardous materials. The notice stated, that operators of vehicles transporting hazardous materials should be aware that the use of a PED while driving constitutes a safety risk to themselves, other motorists, and bystanders. The consequences of using PEDs while driving can include state and local sanctions, FMCSA fines, and possible revocation of commercial driver’s licenses.

Currently in play at the FMCSA are several rulemakings. On December 29, 2010, the FMCSA proposed a change to the Hours of Service requirements to replace the current 34-hour restart provision with a restart period that includes two consecutive rest periods between midnight and 6:00 a.m. (75 Fed. Reg. 82170) Comments are due on February 27, 2011. On February 1, 2011, the FMCSA proposed a rule to expand coverage of requirements for electronic on-board recorders to those required to maintain “Records of Duty Status” for Hours of Service recordkeeping (76 Fed. Reg. 5537).

Other Transportation Issues

F

ollowing an internal inspection of the U.S. Department of Transportation’s (DOT) Special Permits Program, the DOT has been reviewing existing special permits to determine if a valid showing of safety was provided by the applicant. In addition, following a May 4, 2010 DOT Policy Statement, new procedures were developed to ensure an appropriate level of safety occurs with the issuance of special permits.

The Institute under its former name Medical Waste Institute holds a special permit (DOT-SP 14479) that allows for the use of the technical name “Regulated medical waste” instead of “Regulated medical waste n.o.s.” under certain circumstances and authorizes a change in orientation marking on packaging to allow for the use of black or white arrows on red packaging instead of the regulation that requires red arrows. Only Institute members or parties applying separately to be included may use the special permit.

Through President Obama’s January 18, 2011, Executive Order 13563 titled, “Improving Regulation and Regulatory Review,” the DOT (and other federal agencies) is conducting a review of existing regulations Continued on next page

medical waste management Continued from previous page to evaluate whether they are crafted effectively to solve current problems.

The public will have an opportunity to provide the DOT with comments on existing regulations as well as the agency’s procedures for reviewing regulations in March.

www.rotonics.com/medicalwaste.html

Pharmaceutical Waste Management

O

ver the last few years, agencies have increased their focus on the disposal of pharmaceutical waste because of the injuries, illnesses, and deaths associated with drug abuse, particularly by teenagers. On September 8, 2010, the U.S. Environmental Protection Agency (EPA) published draft guidance, “Best Management Practices for Unused Pharmaceuticals at Health Care Facilities” (75 Fed. Reg. 54627). Ninety-three comments were submitted to EPA. Based on these comments, EPA says it will publish an updated draft sometime this spring for additional comments. The draft guidance focused on preventing discharges of pharmaceuticals to wastewater systems. Some studies have shown negative, environmental health effects from pharmaceuticals in drinking supply systems and U.S. water ways. Wastewater treatment systems are unable to manage these materials.

The Institute commented that some of EPA’s proposed practices were not appropriate, such as disposal directly to municipal solid waste landfills and combining pharmaceuticals with an undesirable material such as kitty litter and coffee grounds. The EPA also ignored current healthcare waste management options such as disposal at regulated medical waste and infectious substance management facilities.

On December 2, 2008, EPA published a proposed rulemaking that would add pharmaceuticals to the Universal Waste Rule under the Resource Conservation and Recovery Act with the intent to relieve some regulatory burdens on generators (73 Fed. Reg. 73520). The agency received 210 comments, including a significant number of states that indicated they were not willing to consider this approach. There is not any official word from EPA, but this proposal does not appear to be going anywhere.

The U.S. Drug Enforcement Administration (FDA) held a two-day meeting in January, 2011 to receive comments on how the agency should implement the Secure and Responsible Drug Disposal Act of 2010 signed

by President Obama on October 12, 2010. The law is intended to expand who can collect controlled substances, e.g., patients and long-term care facilities, such that unused controlled substances can be delivered to appropriate entities for disposal. Currently, only law enforcement officials can collect controlled substances from ultimate users. The focus of the law is to make more options available to state and local authorities to create collection programs and, ultimately, to prevent drug abuse. Through these initial comments, the DEA will publish a proposed rulemaking outlining how the administration plans to create more options without increasing the risk of diversion.

Conclusion

F

urther discussion on the topics covered in this article will take place at the annual Healthcare Waste Conference at the Dallas Convention Center in Dallas, Texas on May 11 and 12. For more information, go to www.healthcarewasteconf.com. The program this year includes a transportation workshop designed by the Institute where attendees will meet in small groups to pursue solutions to in-the-field conflicts. Institute members will hold a lunch meeting immediately following the conference to develop next steps on implementing some of the solutions proposed during the conference.

Become a member of the Healthcare Waste Institute either through NSWMA (service interests) or WASTEC (equipment and product manufacturers and distributors) by downloading an application at www.environmentalistseveryday.org/councils-and-institutes/index.php.

For more information, contact the Institute at 202-364-3724 or alicej@ envasns.org.

Alice P. Jacobsohn is a licensed attorney and Director of the Healthcare Waste Institute. She also is the Director for Education at NSWMAWASTEC responsible for the development of the annual Healthcare Waste Conference.

medicalwaste@rotonics.com

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CleanMed2011 Creating Healing Environments

April 6-8, 2011

Sheraton Phoenix Downtown Hotel Phoenix, Arizona

Involved in Hospital Waste Management?

Then you need to attend CleanMed 2011.

The fun is about to begin again! CleanMed 2011 promises to be another exciting conference filled with information on sustainable health care— including a number of sessions on reducing hospital waste. From the pre-conference Greening the OR sessions to a presentation on the business case for waste reduction strategies, CleanMed 2011 will appeal to those aiming to reduce waste and waste management costs Come learn…network…share…and have fun with Green Team members from across the country.

This conference is one you don’t want to miss!

And don’t forget: Practice Greenhealth member staff receive half-price registrations.

CleanMed 2011 Highlights CleanMed, the nation’s most important and influential conference on sustainable health care, will hold its 2011 conference in Phoenix, Arizona on April 6-8, 2011. CleanMed 2011 will feature: ● More than 40 educational sessions, most with CEUs available for multiple disciplines ● Three major pre-conference sessions on The Hospital of the Future, Greening the OR and Infrastructure & Process for Sustainability in Healthcare ● Exhibits and Exposition showcasing sustainable products and services for the health care sector ● Special forum on the Healthier Hospitals Initiative ● Keynote address by Lloyd Dean, President/Chief Executive Officer of Catholic Healthcare West

See more details and register online at www.cleanmed.org!

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Medical Waste Management jan-mar 2011

medical waste management

Eliminating Mercury from Healthcare

by Tom Badrick, Badrick Consulting

M

ost people in healthcare agree that eliminating mercury is important for human health and safety, and to protect the environment. But that’s often where the conversation stops.

For many years mercury has been used to perform a variety of useful and critical functions. Many readers may remember the long wait for the mercury thermometers to register their temperature. Today, we recognize there are better alternatives to mercury – alternatives with much less risk to our health and the environment.

The Dangers of Mercury

W

hen people hear “mercury exposure,” their first thought is often of a broken thermometer. When spilled, especially in warm or poorly ventilated areas, mercury can vaporize, creating a health risk. Exposure to mercury vapor can harm the human body’s central and peripheral nervous systems, lungs, kidneys, skin and eyes. It is also mutagenic, meaning it can affect the immune system as well.

Making Medicine Mercury-Free

O

rganizations such as Healthcare Without Harm (HCWH) have long advocated for the elimination of mercury use in healthcare. Other organizations, such as Practice Greenhealth, use their technical resources to assist hospitals across the country to eliminate mercury from their facilities. Practice Greenhealth is also very active in mercury awareness outreach and gives its Making Medicine Mercury-Free Award to hospitals that make eliminating mercury an organizational priority.

One such hospital is Bon Secours St. Francis in Greenville, South Carolina. Bon Secours was recognized with the mercury-free award in 2010 after taking numerous steps to eliminate mercury in its facilities. Karen Schwartz, FACHE, Vice President of Support Services says, “We felt it was the right thing to do for our patients, our employees and our community.

It was a project that took effort, but it was one where we knew we could achieve our goals. Winning the award was icing on the cake.”

Getting Started

O

nce you decide to remove mercury from your facility, your first step should be to identify all the places you have mercury. There are a number of resources to help you identify where in your facility mercury is likely to reside, including the Practice Greenhealth webpage.

Once you have identified all the mercury in your facility, you should consider developing an action plan for elimination which would include finding alternatives for mercury devices. It is critical that you modify your purchasing policies to prevent new sources of mercury from coming into your facility.

Although the ultimate goal is to be mercury-free, you may not be able to eliminate it all at once. Try replacing items that contain mercury but are only accessible to a small number of staff. You can replace these items gradually over time to avoid spending a lot of money for low-risk situations.

Mercury Devices and Where They Reside: Mercury thermometers Zenkers stain and B5 stain Esophageal dilators Fluorescent light tubes and Compact fluorescent light bulbs Alkaline batteries Thermostats and Blood Pressure devices Control switches

Clinical area’s like patient exam rooms, labs, pharmacy Labs, pathology Endoscopy Throughout a facility Throughout a facility Temperature control units Patient exam rooms Air handling systems

Are Alternatives Available?

A

ll of the mercury-based items listed in the table above have viable alternatives with one exception. Clinical devices in particular have alternatives readily available, from digital thermometers and blood pressure devices to esophageal dilators that utilize liquid tungsten instead of mercury. Chemicals used in the lab such as B5 stain and Zenkers stain have accepted alternatives as well. Mercury-free alkaline batteries are also available.

The one common mercury-containing product on the list that is a challenge to replace is fluorescent light bulbs. Both fluorescent tubes and compact fluorescent bulbs, (CFLs) contain mercury, although low-mercury (green tip) fluorescent tubes are now readily available. Because alternatives are limited it is critical to manage disposal of fluorescent tubes and CFL’s properly, as a universal waste. Many recycling/disposal companies offer recycling of fluorescent tubes and CFLs.

Next Steps

O

nce you have completed your inventory, identified alternative products and developed purchasing policies, it’s time to replace your old mercury-based products with mercury-free products. To do this properly, you’ll need safety procedures in place as well as a method to dispose of the mercury items you collect. They will fall into either of two categories: universal waste or hazardous waste.

Make sure you are prepared for any hazardous material process in which you engage. It will minimize the risk of accidents. Plan ahead for spills and other accidents, and make sure any staff members that will be Continued on page 14

Need Help Setting Up Your Hospital’s Sustainability Program?

— Call Tom Badrick — Tom is a recognized speaker in the healthcare sustainability field. He has also crafted and directed one of the most successful healthcare facility sustainability programs in North America, and has guided and assisted many other organizations in creating and expanding their programs.

Tom Badrick, President 1725 NE 118th Ave. Portland, OR 97220 503-539-8704 tbadrick@aol.com www.badrickconsulting.com

jan-mar 2011 Medical Waste Management

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medical waste management

Drug War: Responsibility for Take-Back Programs at Issue Continued from page 3

www.buschsystems.com Info Request #113 8

inappropriately,” Reitz explains.

The program in 2009 cost Group Health approximately $67,000, which included materials, transportation and incineration.

Reitz and others are hoping that a bill currently in the Washington legislature will be approved requiring drug companies to foot the bill for the take-back program. Past attempts have been unsuccessful. “It goes against their bottom line,” Reitz says. “There is a lot of pressure to prevent these kinds of bills from going through.”

“A comparatively small investment by the industry to provide safe and secure medicine collection and disposal is not just the right thing to do. It’s also good business,” contends Jim Williams, executive director of the Washington Poison Center in an op-ed piece in the Seattle Times. “Failure to act is a prescription for disaster.”

“It’s time for drug companies to step up and fund a statewide program for collection, transport, and disposal of unwanted medications,” agrees assistant majority whip Fred Finn. “For a couple of pennies per medication sold, every county in our state could have a take-back program in place. We’d be able to clear out our medicine cabinets, protect our environment, let law enforcement focus on public safety, and, most importantly, keep potentially deadly drugs out of the hands of our children.”

A coalition called Take Back Your Meds which supports the legislation says the cost to pharmaceutical companies to fund a take-back program would only be one cent for every $16 in sales. An organization comprised of drug manufacturers would oversee the program.

“We’re not saying it’s going to eliminate all overdoses or all abuse of drugs,” notes spokesman Sean Baze. “That’s not going to happen. But it’s certainly going to help.

“The sooner the pharmaceutical industry gets on board and realizes it’s a service to their customers the better off they’re going to be,” he adds. “But right now they’re doing everything they can to stop it.”

Reitz says the drug industry would gain a lot of good publicity by agreeing to support a take-back program. “I think it’s a great PR piece for pharma,” she says. “They could actually see some benefit for themselves by saying, ‘We care about the environment. We care about the safety of medications and how they’re used and how they’re kept and stored in homes. We’re going to help fund the process of getting rid of these if they’re no longer used.’”

Among those opposed to the legislation is the conservative Washington Policy Center.

“If passed, these drug take-back proposals would not benefit the environment in any significant way, but would increase the cost of medical care for people who need life-saving

Medical Waste Management jan-mar 2011

drugs,” it says. “Lawmakers should instead focus their efforts on policies that will provide the greatest environmental benefit.”

Baze and others point to British Columbia, which in 1996 implemented a mandated takeback program funded by drug companies. The program allows the public to return expired or unused medications at more than 95 percent of participating pharmacies in the province. Metro Vancouver and the City of Vancouver both ban disposal of medications in household garbage.

“Our neighbors in British Columbia have partnered with drug manufacturers, who support and fund such a program,” Williams notes. “In 2009, the B.C. program safely disposed of more than 50 tons of hazardous unused medicines.

The price tag? $391,000 (U.S.). That’s well less than one penny per safely returned container.”

Even with the program, however, half of British Columbians flush their unused medications or throw them in the trash, according to the Vancouver Sun newspaper, quoting a survey to be released in June. It also reported that 51 percent of respondents to a survey by the Post-Consumer Pharmaceutical Stewardship Association, which administers the program in British Columbia, said they were unaware they should be returning unused and expired medications to pharmacies.

Bruce Lott, director of state government relations for Mylan, one of the world’s leading generic pharmaceutical companies, contended in a 2010 presentation that mandated programs that did not require consumer participation would serve little purpose.

“None of the legislation proposed would have mandated that consumers participate in the take-back program; they would have only mandated that the program be created,” he said. “As a result, you would have a very costly program created that would likely have little or no impact on the drugs flushed, put in landfills or kept in medicine cabinets.”

State and federal laws must be met when instituting a drug take-back program. “While such take-back programs are popular and very effective, there are several laws that complicate the development and implementation of pharmaceutical take-back programs,” notes the Ohio Hospital Association. “Hospitals and other entities preparing take-back programs must be aware of these laws and plan accordingly.”

Information about implementing take-back programs can be found at various sources on the Internet. A comprehensive toolkit, including case studies of take-back programs, is available from the Ohio Hospital Association at http://www. ohanet.org/SiteObjects/584CA5F1094E7F1FCB 45BA3DA238270C/MedicationTakeBackEvent. pdf.

news briefs

Going Green in the Operating Room

Study Shows Ways to Reduce Hospitals’ Carbon Footprint, Save Money

J

ohns Hopkins researchers say they have identified practical strategies to implement environmentally friendly practices in operating rooms and other hospital facilities that could result in vastly reduced health care costs and pose no risk to patient safety.

Experts say health care facilities are second only to the food industry in contributing to waste products in the United States, producing more than 6,600 tons per day and more than four billion pounds annually. Operating rooms and labor-and-delivery suites together, the researchers say, account for nearly 70 percent of hospital waste.

Reporting in the February issue of the Archives of Surgery, the Johns Hopkins team said hospital operating rooms notoriously open sterilized equipment that is never used, install energy-sucking overhead lights and fill red bags that are labeled as medical waste with harmless trash that could be more cheaply disposed.

“There are many strategies that don’t add risk to patients but allow hospitals to cut waste and reduce their carbon footprints,” says study leader Martin A. Makary, M.D., M.P.H., an associate professor of surgery at the Johns Hopkins University School of Medicine. “If we’re going to get serious as a country about being environmentally conscious, we need to look at our biggest institutions. When an individual decides to recycle or dispose of waste differently, it has an impact. But when a hospital decides as an organization to go green, the impact is massive.”

For their report, Makary and his team first reviewed previously published research about hospitals’ environmental practices, looking in depth at 43 studies. Then, they convened a panel of experts to generate a list of practical strategies that could be implemented by surgical units to cut the waste they identified. The panel’s top five strategies were reducing and segregating operating room waste, reprocessing singleuse medical devices, making environmentally conscious purchasing choices, managing energy consumption and managing pharmacy waste.

In surgical suites, for example, two kinds of disposal bags are used to separate waste: red bags for infectious and pathologic waste and clear bags for noninfectious waste. Makary says that as much as 90 percent of what ends up in red bags does not meet the criteria for

red-bag waste, which costs far more to process.

“Although hazardous and regulated medical waste (equivalent to infectious waste) makes up only 24 percent of medical waste, they account for 86 percent of costs,” the study team concluded.

Makary says the volume of medical waste could be decreased by more than 30 percent solely by proper waste separation.

Makary says many discussions of green initiatives — such as recycling single-use medical equipment — have been framed as a choice between what is best for the environment and what is best for patients, with patients the obvious priority. But the team’s research, he says, shows there are ways to be green without compromising patient safety.

One medical center, the authors note, instituted a system of making clear plastic bags more readily available during surgical preparation and then replacing them with red bags just before the patient was wheeled into the operating room, when most red-bag waste is generated. The center also began washing and reusing all of its surgical scrubs and jackets.

These two changes made up the lion’s share of a 50 percent reduction in medical waste volume over seven years, and Makary says patient safety was not compromised.

The Hopkins team says wider adoption of the pratice of recycling medical equipment is a potentially big saver of health care dollars and landfill space. Such equipment includes laparoscopic ports and durable cutting tools typically tossed out after a single use, Makary says. With proper sterilization, recalibration and testing, previous experience has shown that reprocessing equipment is safe, he adds. Often in surgery, items are taken out of their sterile packaging — sometimes in duplicate — in order to be quickly available should they be needed over the course of an operation. That practice needs to be reconsidered, he says.

“The overall carbon footprint of the hospital has not been a priority in the past,” Makary says. “But we live in a much more costconscious medical climate now and there is a lot that hospitals can do to go green.”

This research was supported by philanthropy from Mr. and Mrs. Chad and Nissa Richison.

Gabriel A. Brat, M.D., M.P.H., of Johns Hopkins also participated in this study.

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news briefs

Virginia Hospital Scores Big With Recycling Efforts

T

he only healthcare facility finalist in the 2010 Northern Virginia Technology Council Green Awards, Inova Loudoun Hospital was recognized for its Going Green campaign, reports loudountimes. com. This started in the 1990s with recycling cardboard and now recycles 134 tons of paper, plastic, glass and metal last year. The hospital also focuses on energy and water efficiency projects such as low flow water fixtures, new lighting technologies and paper shredding days. One special target specific to healthcare: Inova Health System’s Sustainability Engineer, Seema Wadhwa, said that staff members are trained on how to manage pharmaceutical waste so that the waste doesn’t end up in nearby bodies of water or streams. Several operating room staffers designed a reusable tote bag made of blue surgical wraps, and the staff made Christmas stockings and nearly 250 tote bags from the plastic wrap.

C. Difficile Infections Rising in U.S. Hospital Pediatric Patients

I

nfections by the bacteria Clostridium difficile are becoming more frequent in hospitalized children in the United States, says a May article in Archives of Pediatrics & Adolescent Medicine, reports sciencedaily. com. Also on the rise are a number of hospitalizations and associated deaths in children, as well as the severity in adults, though not in children.

These data were based on a national database of patients discharged from the hospital in 1997, 2000, 2003 and 2006, in which, of 10.5 million patients, about 0.2 % had C. difficile infection, with the number of cases increasing about 15 percent each year, from 3,565 in 1997 to 7,779 in 2006.

The increased risk of C. difficile infection may be due to a widespread dissemination of a more virulent strain of the bacteria or because of increased awareness among health care providers, leading to increased testing in symptomatic patients. The study supports previous reports that C. difficile infection is increasing among hospitalized children and provides a background for understanding changing trends and risk factors of C. difficile infection in children.

Scrubs: Not for Street Wear Anymore

S

crubs have long been a fashion statement for casual wear, but there is a big movement to ban the wearing of hospital goods, the ones that have actually been in use in health care facilities, outside into the street, reports pittsburghlive.com. The Committee to Reduce Infection Deaths in New York City notes that common bacteria such as Clostridium difficilepose a risk, especially during warm months, and that health care providers should consider prohibiting scrubs outside the hospital, whether on lunch breaks or into the home, to keep from spreading infection. The best practice would be for hospitals to have on-site laundries, it says.

The scrubs a doctor or nurse wears outside of work are not necessarily dirty, as some may never have come into contact with a patient. And some hospitals do require medical practitioners to come to work in street clothes and change back after work, never wearing the scrubs off hospital property.

But some staff members can and do buy and launder their own scrubs and wear them to and from work. Lab coats are another item of concern: it is often the case that physicians launder their own coats.

Dr. Michael Bell of the Centers for Disease Control and Prevention in Atlanta warns that “Gowns and hand hygiene used as part of standard precautions should be implemented regardless of attire,” he said.

10 Medical Waste Management jan-mar 2011

AJIC Study Sees Positive Roll for MRSA Screens on ICU Patients

S

ciencedaily.com reports that a study published in the American Journal of Infection Control says that screening ICU patients for MRSA saves costs for the whole hospital. The Minneapolis Veterans Affairs Medical Center study used a statistical simulation model to determine the costs per hospital admission of screening ICU patients for MRSA and isolating patients who tested positive. The screening would be cost-neutral even under the most conservative assumptions, and under optimal assumptions, screening could result in savings of almost $500 per admission.

The program can be fit into an overall institution-wide infectionprevention program to complement other strategies. Some policy-makers have recommended universal screening to reduce hospital-acquired MRSA infection, but a more targeted, evidence-based approach would let hospitals customized screening efforts based on their unique situation.

First Recorded Flu Pandemic Began 500 Years Ago

­T

he first worldwide influenza pandemic in recorded history began in Asia in the summer of 1510 and quickly spread to Africa and Europe 500 years ago, say researchers at the National Institute of Allergy and Infectious Diseases, reports sciencedaily.com. Spreading along trade route lines, the disease was highly infectious, though it caused relatively few deaths and ended quickly. Since then, advances in microbiology, preventive vaccines and better treatment methods mean that we can better plan and prepare for seasonal and pandemic flu, and a new universal influenza vaccine is under study.

France Uses Mandatory Reporting and Audits to Reduce Hospital Infection

F

rance’s national infection control program for healthcare facilities has seen advances in lowering the rates of healthcare-associated infections, including MRSA and surgical site infections, since 2004, showing the value of a national standard reporting system, according to sciencedaily.com. The nation’s national, regional and local coordinating centers have undergone reorganization so facilities could better comply with mandatory public reporting requirements and conform to program goals. Researchers in the U.S. think a similar system there can reduce HAIs through public reporting.

A team of infection control experts evaluated the impact of the French national program to reduce HAIs using aggregated data compiled from mandatory reports from 2,800 facilities between 2005 through 2008, verified by audits. Most target objectives were achieved, with 89% of healthcare facilities in the best performance class. Among the results: MRSA cases have decreased by 40%, local and regional infection control teams have been appointed in 94% of facilities. 96% have implemented an evaluation program and a system for quickly disseminating infection alerts, 89% have an anti-infective drug committee, and 97% have guidelines for preventing surgical site infections.

The French media publish a list of best and worst performing hospitals.

news briefs

Johns Hopkins Study Sees Infection Control Reducing ICU Deaths by 10%

A

ccording to a study in the British Medical Journal, Johns Hopkins University School of Medicine has created an infection control program that has helped lower death rates in ICUs by 10%, reports mcknights.com. The program uses checklists to prevent errors and reduce costs, as well as thorough hand washing, questioning catheter use, using coverings on the patient when a catheter is inserted, and seeking alternatives to central lines in the groin.

The Johns Hopkins study reviewed 22 months worth of records for 1.3 million ICU patients over the age of 65 in 95 Michigan hospitals, 77% of which used a checklist of infection-prevention steps as part of a “Keystone: ICU” quality improvement project. The data were compared with outcomes from hospitals in 11 other Midwestern states from 2001 to 2006. The median central line infection rate fell to virtually zero per 1,000 catheter days, vs. a national average of 5.2.

The Michigan safety effort saved thousands of lives, said Dr Peter J. Pronovost, MD, PhD, a study co-author and leader of the Keystone project and director of the Quality and Safety Research Group at the Johns Hopkins University School of Medicine in Baltimore. The project was based on work pioneered at Johns Hopkins Hospital. Thompson/ Reuters says these practices could save $3.6 trillion in waste over 10 years if adopted, and that they can be adapted for other healthcare settings, and the Agency for Healthcare Research and Quality hopes to duplicate Michigan’s success in 40 other states.

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news briefs

NC Medical Waste Incinerator Jumps Up Regulatory Limit Compliance by a Year

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hetimesnews.com reports that USEPA rules will require Stericycle Inc. to follow federal requirements for stricter limits on emissions in 2013, a year earlier than expected. This was due to a NC Division of Air Quality renewal of an air permit that would let the Stericycle incineration facility keep operating pollution-control devices in two dualchamber medical waste incinerators. The NC Environmental Management Commission had adopted rules in November that make the new federal clean air requirements enforceable beginning July, 2013.

Under the permit, Stericycle Inc. must show it can comply with state and federal rules for controlling pollutants, using scrubbers as its primary air pollution control devices. This permit does not change the plant’s capacity. Selin Hoboy, Stericycle’s vice president of legislative and regulatory affairs, said the company had met its regulatory obligations for the last 11 years, except for one year with exceeded mercury limits.

Several Burlington and Alamance County residents had been asking the government to force the firm to adopt federal clean air standards in 2012 rather than the 2014 federal deadline, citing statistics about the effects of mercury, dioxins and other chemicals emitted by medical waste incinerators from the EPA, CDCP and North Carolina officials and the effectiveness of non-incinerator waste disposal. However, the Burlington City Council rejected the move, as did the Alamance County Board of Commissioners when presented with a citizen petition for resolution.

The Graham City Council also refused to support a 2012 deadline, but Green Level, Mebane, Haw River, Gibsonville and Swepsonville backed the citizen-led resolution.

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Maryland Hospitals Recognized for Medical Waste Recycling and Other Green Initiatives

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aryland Hospitals for a Healthy Environment has announced its 2010 Trailblazer Awards for leadership in advancing sustainability, with honors going to Anne Arundel Medical Center, Annapolis, and Franklin Square Hospital Center, LifeBridge Health and the University of Maryland Medical Center, all in Baltimore, reports news.nurse.com.

Franklin Square was noted for being the first hospital in the state to develop and implement an Environmental Management System to reduce environmental impacts, including a hazardous pharmaceutical waste management program in the MedStar Health system that became fully operational in three years, as well as introducing LEEDcompliant features in a new patient care tower and ED. UMMC also developed a hazardous pharmaceutical waste management program, “The Safe Handling and Disposal of Hazardous Medication.”

The program, which began a year ago, collected more than 3,500 pounds of hazardous pharmaceutical waste in less than that time.

LifeBridge Health began a system-wide regulated medical waste separation and reduction program that reduced red bag waste by more than 50% since 2002, including a fluid waste management system at one operating suite, as well as replacing fluorescents with LED lamps and composting to meet landscaping needs. Anne Arundel designed and built an eight-story tower that will be the first acute care facility in Maryland to achieve the U.S. Green Building Council’s Leadership in Engineering and Environmental Design–Silver certification.

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medical waste management

Eliminating Mercury from Healthcare Continued from page 7

handling the material have been properly trained. Spill kits are commercially available through such companies as Absolute Sorbent Technologies, Inc. You can also make your own if you have the proper supplies.

Here are some basic steps to consider for a safe cleanup process: • Assemble the following materials: rubber gloves, an eyedropper, two stiff pieces of cardboard, two plastic bags, a large tray, duct tape, a flashlight and a wide mouth container.

• Ventilate the area and have all people not involved in the clean up stay away. Do not use a vacuum. Do not touch the mercury. Remove all jewelry from your hands as mercury will bond with the metal. Wear rubber gloves. Use a flashlight to locate the mercury. The light will reflect off the mercury beads and make them easier to find.

• On a hard or tightly woven fabric floor use the stiff paper to push beads of mercury together. Use the eyedropper to suction the beads of mercury, or working over the tray to catch any spills, lift the beads of mercury with the stiff paper. Dispose of all items used in the clean up as hazardous waste.

• On a carpet or rug, the mercury contaminated section should be cut out and disposed of as hazardous waste.

Above and Beyond

L

ast but not least, mercury elimination is an opportunity to help your community, your customers, your employees and the environment.

Many healthcare facilities offer mercury thermometer exchanges, where employees and the public can trade in a mercury thermometer for a digital thermometer. This kind of event helps everyone and can also be paired or held separately from events where used CFLs and fluorescent light bulbs are collected as well.

For years, mercury has been a consistent part of healthcare, but in recent years alternatives have been developed that provide equal or better care for patients and a lower risk to humans and the environment.

It is a tangible project that can be implemented in a healthcare facility to demonstrate a commitment to sustainability. It’s also a great project to engage employees as anyone and everyone can be involved in finding mercury devices in a facility.

Where to Go for More Information http://cms.h2e-online.org/ee/hazmat/hazmatconcern/mercury/10step/ http://www.epa.gov/hg/ http://www.sustainablehospitals.org/HTMLSrc/IP_factsheet_contents. html#mercury Tom Badrick is President of Badrick Consulting specializing in healthcare sustainability program design and implementation. Tom is a recognized speaker in the healthcare sustainability field. He successfully crafted and directed the nationally recognized and award winning sustainability program for a large health system and has guided and assisted many other organizations to create or expand successful programs as well as partnering with suppliers.

Tom has a background in Environmental, Health and Safety management in biotech/chemical manufacturing and the electronics industry. Badrick Consulting offers a wide range of services from program creation/development to partnering in management of specific components of a sustainability program ranging from waste management to climate change initiatives. The Badrick Consulting website can be found at www.badricksustainability.com and Tom can be reached via email at tbadrick@aol.com.

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TOP STORIES Drug War: Responsibility for Take-Back Programs at Issue

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HWI Reviews Critical Issues Facing the Healthcare Waste Industry

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Eliminating Mercury from Healthcare

PAGE 7

Going Green in the Operating Room

PAGE 9

Johns Hopkins Study Sees Infection Control Reducing ICU Deaths by 10%

PAGE 11

NC Medical Waste Incinerator Jumps Up Regulatory Limit Compliance by a Year

PAGE 12

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