Healthcare Best Practices Blog

The Myths and Truths About Waste Recycling

by Shane Zuffante and Brian Ryerson

There are many myths surrounding recycling programs out there today.  First and foremost, the notion that recycling costs money and is not vehicle for savings.  However, as recycled material is a renewable resource often times this is the least expensive material leaving your institution.  By implementing a proper waste diversion program you can instantly realize savings.

Myths of Recycling:

• Recycling costs money
• People are opposed to change
•  “material” doesn’t actually get recovered
• I don’t believe I can make a difference
• It’s too hard to implement a program

Truths of Recycling

• Recycling provides savings as it is a renewable resource
• People are desirous of doing the right thing
• More than 56% of paper consumed in 2007 was recovered for recycling
• Recycling works because of you
• There are several companies who can help guide your efforts

Proper programs should be working together with existing culture in your institution.  Rather than forcing a change, adapt your program to ensure a successful path to recycling.

As these “materials” are considered commodities in today’s marketplace there is a strong desire to divert them from the waste and realize the value of the material.

At the end of the day, all recycling programs start and end with you.  A successful program will be flexible and simple enough for all employees to make diversion choices.

In today’s climate of greening and sustainability there are many firms who have the experience and expertise to develop and implement a unique strategy for you and your institution that has minimal impacts on your existing culture.

Blue (Wrap) is the new Green for Hospitals

by Shane Zuffante, Healthcare Account Manager

2011 will prove to be the year most businesses strive to achieve new levels of sustainability (or ‘greening’) and at the same time reducing their overall cost of operations.  Hospitals and Healthcare facilities are at the top of the list for ‘green strivers’, adding patient safety into the mix as a priority.  Many clients I talk to are sidelined with the same issue: WHERE DO WE START?

Greening may be a challenge, but the benefits truly outweigh the obstacles.  I suggest beginning departmentally; take an audit of each department and see where and with what you can make little changes that will greatly impact the whole.  One department I always suggest starting with is the OR.  Aside from the obvious bio waste, another element that can make a huge impact on cost and the environment is BLUE WRAP.

What is BLUE WRAP?

• Blue wrap is made from polypropylene (# 5 plastic) – one of the cleanest, purest waste streams.
• Blue wrap is used for wrapping surgical instruments for sterilization.
• Blue wrap is generated and used in only a few areas (i.e. surgical rooms).
• Sterile, uncontaminated blue wrap can be collected for recycling. 

Why should hospitals recycle BLUE WRAP?

Blue Wrap is limited to one area: the Operating Room.  9 times out of 10, the Blue Wrap is disposed of in the Red Bag; the issue here is that Red Bag waste is much more costly than regular trash, and Blue Wrap is clean waste.  Buy setting up a recycle bin for Blue Wrap, you reduce the amount of Red Bag (or expensive) waste.  Plus, the Blue Wrap can be recycled and reused as ER curtains, tote bags, pelletized for raw materials, etc. 

Any time you can reduce waste and cost while not compromising patient safety is a win for the hospital.  If you have a green team, suggest setting up recycle bins in the OR on a trial basis to start a new habit or routine for surgeons and their staff. 

What are you doing personally to impact your hospital?

Healthcare Drain Disposal: A cost-savings, but at what cost?

by Tom Goss, Recycling Strategist

“My formalin, buffer and reagents can get dumped down the drain, right?”

Lab technicians at hospitals ask me this question all the time. I’m always reluctant to answer the question immediately, because the answer isn’t usually a simple “yes” or “no” question. It’s not just a question of “what’s legal?”. Sometimes it’s a question of “what’s safe?” or “what’s ethical?”. What follows in an anecdote that illustrates my point.

The other day I was taking an inventory of healthcare client’s stock chemicals and I came across a peculiar product. The product was inconspicuously labeled by the manufacturer as a “concentrated wash buffer”, and in speaking with my client’s lab staff I discovered that this liquid material is processed in large quantities on a daily basis in an immunoassay and clinical chemistry testing procedure. The lab analyzers which process this material are plumbed to discharge this wash buffer into the municipal sewer.

When I saw that the analyzers were piped directly into a floor drain I took it upon myself to investigate further. I asked technicians in the area about the analyzers and why they were piped directly to the drain. I could have predicted the response:

“It’s just buffers and reagents. That can go down the drain, right?”

I suppressed a response and asked for permission to use a computer with an internet browser. I used the product label to locate a copy of the MSDS for this material online. When I reviewed the MSDS I noted that the product listed the following materials as constituents:

98.91% - Mixture of chemical and/or biological substances for in vitro diagnostic use.

00.90% - Sodium azide

00.19% - 1,2-propylene glycol

Okay, so this material isn’t considered an EPA hazardous waste based on these constituents. So you can dump it down the drain, right? Not so fast! Consider this language which was pulled from multiple sections of the same document:

• “Prevent liquid and vapor from entering sewage system, storm drains, surface waters, and soil.”
• “Do not discharge to storm drains or sewage system.”
• “Harmful to aquatic organisms, may cause long-term adverse effects in the aquatic environment”
• “Do not allow product to reach ground water, water course, or sewage system.”
• “Flush drains thoroughly with water to prevent the formation of potentially explosive metal azides in plumbing, if product and/or instrument waste is released to a drain.”

I have visited clinical laboratories at many hospitals and I have spoken with many laboratory technicians who work with analyzers that are piped directly to drains. Often times I will hear lab staff defend their drain disposal practices after they have read only a portion of the MSDS. Consider the example I have described above. Does the last bullet point above provide justification for sewer disposal? If you read carefully, you will discover that the sentence is carefully worded by the manufacturer. The key word is “if”. This manufacturer does not endorse drain disposal in this document, and in fact, they have gone to great lengths in other sections of the document to discourage drain disposal.

You don’t have to be an environmentalist to appreciate the serious consequence associated with discharging harmful materials into sewer systems. Our society thinks of its hospitals as stewards of public health. Public health and the health of the environment are fundamentally and directly linked. A hospital that makes unwise decisions about its sewer discharge policies is at risk of violating the public’s trust and contradicting its very purpose: to ensure that people are healthy.

Bottom line: if you are a lab technician or EH&S administrator at a hospital I encourage you to carefully evaluate and periodically reevaluate decisions to discharge lab waste into your community’s sewer system.

Flushing Trace Sodium Azide Solutions: A Healthcare Caution

By Tom Goss, Recycling Strategist

Sodium azide (NaN3) is extremely toxic and potentially explosive under certain conditions. This azide compound is frequently used as a preservative in many reagents and stock solutions that are utilized in healthcare facilities. Some manufacturers of these solutions recommend that users discharge these reagents and stock solutions into sewer drains provided that copious amounts of water are added to flush the material down the drains lines. Many institutions and safety experts discourage this practice because it can constitute a safety hazard if performed improperly and because sodium azide is a known environmental pollutant. Accumulation of azide salts in plumbing has resulted in explosions.

Laboratory technicians who opt to flush solutions with sodium azide preservative into sewer lines will sometimes deposit the material into a sink or floor drain where water is deliberately left running 24 hours a day. This practice is intended to lessen the risk of explosions, but it presents an added cost to the laboratory in the form of high water/sewer bills. You should also consider the affect that this disposal method has on the environment. It represents an enormous waste of water and it results in a release of a known environmental pollutant directly into your community’s water ways.

If you are a lab technician or administrator at an institution where stock solutions with sodium azide preservative are used, you should consider containerizing these waste liquids in plastic drums and having your waste vendor ship and dispose of your waste as non-hazardous rinse water. Your waste will be disposed at a licensed, permitted disposal facility equipped to handle the material. You will have mitigated your institution’s safety risks, helped to keep your community’s water pristine and you may have saved a few bucks.

Chemotherapy – What you don’t know might hurt you

Written By Matt Bauer, Marketing Intern

Chemotherapy treatment has been responsible for saving the lives of millions of cancer patients, but this same treatment may be killing those that administer it.  By design, chemo drugs are deadly.  Chemotherapy drugs are used to exterminate fast-dividing cancer cells in the body, in order to return the body to its normal state.  Also, chemicals similar to chemo drugs were used in World War I as deadly mustard gas against soldiers. 

Studies from as far back as the 1970’s linked chemo agent exposure with increased rates of cancer, but it wasn’t until the mid-1980’s that Occupational Safety and Health Specialists (OSHA) deemed chemotherapy agents “hazardous.” Thousands of healthcare workers were chronically exposed to these agents on the job before voluntary regulations were put into place. 

Although the drugs and byproducts of chemotherapy are considered toxic, recent findings from the Pacific Northwest based investigative journal, InvestigateWest, show that OSHA does not regulate exposure in the workplace.  A new study done by the U.S. Centers for Disease Control (CDC) confirms that chemo continues to contaminate these facilities, despite knowledge of the dangers and the safety precautions necessary to avoid them.

 In regards to these findings, OSHA claims to have no regulatory authority over the matter other than under their “General Duty” clause – a clause that allows inspectors to warn institutions if they see a concern.  InvestigateWest documents that OSHA has only used the General Duty clause once in the last 10 years to warn a healthcare facility of their handling of hazardous material. 

There are several chemotherapy drugs that are regulated under RCRA hazardous wastes standards, but many others are not.  Due to this disconnect in the OSHA and RCRA regulation, most hospitals and other healthcare facilities have customized procedures for employee handling of chemo agents.  This confusion about regulation and hazardous material determination is a common problem in the healthcare industry. 

Workers in the Healthcare field come into more contact with known human carcinogens than workers from any other occupation.  For this reason, most occupational health specialists advocate for stricter regulation of chemotherapy drugs and chemo waste.  In order to reduce confusion, changes must be made on a federal level.  More needs to be done to protect the people that help save so many lives.

If you have any questions please contact Steve Todisco, Senior Healthcare Account Manager Triumvirate Environmental Cell: 339-226-0524, stodisco@triumvirate.com

Keeping costs down in the Healthcare EH&S Arena

Steve Todisco, Senior Healthcare Account Manager

When it’s time to get something done what is your typical method of making it happen if you can’t get it done internally? Whether you work for a living, purchase goods and services as a private consumer, own your own business, work for yourself, or work for someone else, when you need something you go out and research your best overall value; right? Maybe you go out and get a few “bids” so that you can accurately compare costs from multiple organizations. People do it when they buy homes, shoes, and when they purchase professional services.

There is a commercial floating around right now that speaks to cutting costs and there is a group of office folks sitting around a conference room table trying to figure what else to “cut” from their budgets. I know you have seen it. One of them has an epiphany and says to everyone. “What about all of this stuff?” Referring to paper, pens, folders, supplies, software, people, time, effort, etc. Then the finance guy says it could cost us millions. Millions?

The point that I am trying to make is when purchasing anything there are certain costs that we usually don’t track. These costs are typically referred to as soft costs. Soft costs can include:

• Your time spent: (Your time is valuable right? How much have you wasted so far?)
• The cost of doing your due diligence
• Hiring a consultant to help you make a decision
• Wasted office supplies
• Insurance on existing
• Benefits for existing employees
• Pulling existing resources away to make them do something else, at a lower quality
• Many, Many more

I recently was involved in bidding on a hazardous waste pharmaceutical program and then won the contract, and some of the individuals involved kept telling me that they were going to “do that internally”. They were referring to completing their own waste pickups, doing their own training, inspections, purchasing their own containers, etc. In the midst of the whole process I kept trying to inform them that the individuals who you will be tasking to complete these new jobs already have many tasks to do day to day, and I kept asking them - have you considered the cost (internally) to having these folks work the extra hours, etc. Of course they thought that they didn’t have to worry about those things because it wasn’t their job to. The largest cost to this particular institution was to complete their own training of about 1200 nurses. Now I don’t know about you but I’ve trained a lot of nursing staff over the past 5 years; and I don’t care what anyone says, it takes some time to get that done. If you plan on doing it yourself plan on making sure that you consider the internal “cost “ to your organization of about 150 hours of actual training time. That’s no small cost. And when you add in the fact that they have to be trained also it adds even further soft costs to the overall concept.

What is the kicker is that this person making the decisions wasn’t aware that an independent consultant was hired by senior management and was in the process to “dig in” to where the spending was occurring in their department. When they uncovered the internal costs to the organization for all the wasted time, untrained resources, lack of knowledge on the topic, and many other factors they came up with the department had actually costed internally $146,000 (These are actual numbers folks) dollars to this specific program in soft, internal costs. In my world that is a lot of money, and lo and behold guess what happened next? Yup – you guessed it. The individual that was responsible for this department was let go due to overspending, and not truly understanding what it was really costing them. (Now I guess getting rid of a position is a cost savings).

Senior management then asked me to provide what would have been the cost if we had completed all of the items that they wanted to do “internally”, and I was sad to say that the number came up to a measly $38,000 dollars when all was said and done. This means I am probably not charging enough. That’s a story for another day.

The overall and underlying point I am trying to get across is that there are many costs that we don’t think of as “hard costs”. The costs that don’t show up on the budget sheets in those senior management meetings, the ones that come up to organizations each and every day.  The really great organizations, which balance the budget sheets well, and can, stay in the black, are those that have all the facts, and make decisions that best fit their particular organizations. These need to be considered all the time, and especially when you hire a vendor, contractor, company who provides supplies, etc. We can usually provide a better, more customer intimate service that gets the job done for an overall less cost (both hard and soft) to an organization.

If you have any questions on how to manage and or define your soft costs please don’t hesitate to contact me.

Steve Todisco, HEM, CHMM Senior Healthcare Account Manager Triumvirate Environmental Inc. stodisco@triumvirate.com

Similarities and differences between Pharmaceutical and Chemotherapy waste

By Steve Todisco, Senior Healthcare Account Manager

Some of you out there have been asking questions about the differences and similarities between chemotherapy waste and the newly coined term, "pharmaceutical" waste. By definition, pharmaceutical waste includes all expired, unused, contaminated or discontinued drugs (also known as medicines or chemicals) that can no longer be used for humans or animals. Chemotherapy waste, once no longer intended for human or animal use, is really just a sub-set of pharmaceutical waste.

In the broader scale, Pharmacy waste falls in to one of several categories; it is either hazardous or non-hazardous (as defined by the EPA). Thus, it stands to reason that chemotherapy waste, also, may be either hazardous or non-hazardous. There are currently nine (9) chemotherapy drugs whose waste is listed by the EPA as hazardous since 1976. Ironically, this list has not been updated and there are today many more chemotherapy drugs whose waste is much more dangerous to the environment than the original list of nine (9)...more to follow on this issue.

Typically, chemotherapy waste no longer intended for human or animal use comes in three flavors for those who are managing, collecting and disposing of it; namely, "product", "trace" or "bulk". The following rules apply: 1) If the chemotherapy waste is a packaged drug and eligible for reverse distribution (a topic for another day), then it may be managed as a "product" and returned for credit. 2) If the chemotherapy waste is EPA "listed" or "characteristic" within a container and less than 3% of its therapeutic dose remains intact (including gowns, glove, masks used in the administration of the chemotherapy waste for which there are no spills or leaks on them), then it may be managed as non-hazardous "trace" chemotherapy waste. It is usually collected in a "yellow bucket" and may be disposed of by a medical waste incinerator. 3) If the chemotherapy waste is EPA "listed" or "characteristic" within a container and more than 3% of its therapeutic dose remains intact (including contaminated gowns, gloves or other disposable items upon which chemotherapy has spilled or leaked-out upon them), then it must be managed as hazardous waste. It is then typically placed in the "black bucket" and disposed of by a hazardous waste incinerator. And finally, 4) if the chemotherapy waste is not identified as either "listed" or "characteristic", it may be managed as non-hazardous waste and disposed of as trace chemotherapy per above.

Which, of course, leaves us some final, parting thoughts; such as:

1. Given that the chemotherapy drugs developed and manufactured after 1976 are far often more dangerous to ourselves and to our environment than those identified in 1976 (albeit currently not regulated), should we, as good and responsible stewards of the earth, collect all chemotherapy waste, regardless of their properties, and,

2.  If we do, should all chemotherapy waste then be disposed of only by hazardous waste incineration?

Where does the line blur between "cost" and "conscience"?

For your opinions, or for a free consultation for building an EPA compliant pharmaceutical program, please contact per the information below.

Steve Todisco, Senior Healthcare Practice Manager, HEM, CHEM
Triumvirate Environmental, Inc.
Cell Phone: 339-226-0524 or Email: stodisco@triumvirate.com

An Intro to Rad Waste for New York State Hospitals

By Courtney Drayer, Technical Services Representative

Radioactive waste is divided into 3 categories; high level, mill tailings, and low level. High level radioactive waste is spent nuclear reactor fuel. Mill tailings are contaminated soils and debris remaining after an area has been mined for Uranium Ores. Commercial waste that is neither high level nor mill tailings is low level radioactive waste. Low level radioactive waste (LLRW) can consist of any material that has become contaminated with radioactive material or has become radioactive via exposure to neutron radiation.

LLRW are generated at commercial facilities such as hospitals, universities, and some industrial facilities. Some common examples of LLRW include PPE used in areas where radioactive material is present, animal carcasses containing radioactive pharmaceuticals, scintillation fluids, and equipment used to process radioactive materials. Low level radioactive waste is then further divided into 4 subcategories in 10 CFR 61.55-56 (http://www.nrc.gov/reading-rm/doc-collections/cfr/part061/part061-0055.html). These subdivisions are, in order of increasing radioactivity; Class A, Class B, Class C, and Greater than Class C. Class A-C is regulated by the Nuclear Regulatory Commission while the "Greater than Class C" group is generally regulated by the Department of Energy. Most radioactive materials used in Hospitals can be stored on site until the material has decayed to a point where the radiation level of the waste matches that of the background level. At that point, the waste can either be disposed of as regulated medical waste or hazardous waste, as appropriate. When decay does not occur within a reasonable time frame (half lives > 90 days), this waste must be sent to a low level radioactive waste disposal facility for proper disposal.

In order to obtain any radioactive material or engage in research or clinical activities with radioactive materials in NYS a license must be obtained. The licenses for radioactive waste generators in New York State fall under the jurisdictions of the New York State Department of Health (NYS DOH), the New York City Department of Health (NYC DOH), or the Federal Nuclear Regulatory Commission (NRC). Most sites will fall under the NYS DOH jurisdiction. Institutions in NYC will fall under NYC DOH while Nuclear power plants will fall under NRC. All licensees that generate or plan to generate LLRW within the next 5 years, regardless of jurisdiction, are required by 21 NYCRR Part 502 (http://www.nyserda.org/about/nyserda.regulations.pdf) to file an annual low-level radioactive waste report with the New York State Energy Research and Development Authority. If any of the waste disposed of is mixed radioactive and hazardous waste, that waste will also need to be included on the annual report for hazardous waste for NYS and included in waste weights for the NYS TP550 quarterly hazardous waste tax.

DAB Disposal in NYC

By Courtney Drayer, Technical Services Representative

3,3'-Daminobenzadine tetrahydrochloride (DAB) is an organic molecule that is oxidized by hydrogen peroxide in the presence of hemoglobin to produce a dark brown color that histologists can used to stain nucleic acids and proteins. Although DAB waste is not specifically regulated by the Environmental Protection Agency (EPA) or the New York State Department of Environmental Conservation (NYS DEC), DAB comes from a class of molecules (benzadines) which are known carcinogens. In fact, all benzadines that have been studied have been determined to have mutagenic properties by the US National Toxicology Program. Since DAB is not regulated, specifically, by EPA or NYS DEC, lab personnel may be tempted to "detoxify" and/or dispose of DAB through the sewers. It should be noted, however, that most methods of treatment result in either a hazardous solid or chlorinated byproducts that are also mutagenic. So what's an EH&S manager to do?

There is at least one more regulatory agency in New York City to consider while deciding how to handle your DAB waste; The Department of Environmental Protection. The DEP governs and enforces the RCNY (Rules of the City of New York) regulatory body which covers "Materials and Substances Excluded from Public Sewers" in Title 15, Chapter 19-03. This chapter describes materials that not permitted to be discharged down the drain and Line 10 (iii) states that:

Toxic substances in such quantities, which the person knows or has reason to know, may when discharged from a single source or in combination with other sources; (iii) be detrimental to the health of human beings, animals, or aquatic life.

Since benzadines are known carcinogens, they are detrimental the health of humans and animals. Within NYC, the RCNY is the regulatory basis for the collection, treatment, and ultimate disposal of DAB as a non regulated but toxic material. Outside of NYC, line 10 (iii) is still regulation with a lot of common sense. If you wouldn't want to drink it and it causes harm to people and the environment, please don't put it down the drain.

EPA INSPECTIONS: Preparing for, and responding to a surprise inspection

By Lawrence Hren, Onsite Support Services Coordinator

In my recent experience with EPA inspections focused toward laboratory and hazardous waste management, it has become apparent that preparation for a surprise inspection is every bit as important as properly responding to an inspection. While this is by no means an all-inclusive guide to successfully handling an EPA inspection, the following should serve as an outline of key points to consider prior to and during an inspection:

• Is your emergency contact information accurate and up to date?
• This may be one of the first things an inspector delves into upon arrival at your facility. Additionally, it is important to test your primary and secondary methods of acquiring an MSDS in the event of an emergency. For example: if you have identified that MSDS's will be obtained via the internet in the event of an emergency, you should also be sure that you are familiar with an alternative method such as calling an emergency MSDS hotline and that an MSDS can be faxed to your facility on short order.
  

• Is your Main Accumulation Area (MAA) well maintained, in compliance, and is your weekly MAA inspection log complete and up to date?
• Proper MAA maintenance is intrinsically linked to running a top notch Haz-Waste management program at your facility. Deficiencies during this portion of an EPA inspection will most likely lead to a higher level of scrutiny during the remainder of the inspection. Be sure that you are completely in compliance with MAA regulations and that the space is as clean and organized as possible. Don't forget to make sure all emergency contact info is conspicuously posted and a phone is located inside of or very close by the MAA
• Weekly MAA inspection logs are to be kept on file for 3 years. It is crucial that there are no gaps in the records. Be sure to take into account long weekends and holiday schedules. If you can present a simple SOP geared towards accommodating for such circumstances, all the better!
  

• How well are your laboratories maintained? Are training records kept on file and readily available?
• Once inside the lab, an inspector will most likely ‘interview' lab staff. Questions will focus on waste management, safety procedures, and chemical compatibility issues in your chemical storage cabinets. 
• RCRA is all about records. Be sure that all laboratory training records and lab SOPs are available. 
• Out of date, unusable, or excessive amounts of chemicals should not be stored in the lab. Chemical storage/labeling issues raise a red flag, and are viewed as an indicator of poor lab practices

The main thing to keep in mind during an inspection is to remain calm and answer all questions honestly and to the best of your ability. Never try to down-play compliance issues as a means to dissuade the inspector from looking into them. Dedication to running an exemplary program goes a long way.