Sasha Laferte: Hi everyone! Welcome to today’s Webinar on In-Depth Waste Stream Analysis. My name is Sasha and I'll be your moderator for today. Before we get started I just want to give you a brief of overview on what today's Webinar is going to entail as well as a short introduction for our speaker today.
Today's Webinar will start with a slideshow presentation by our in-house expert Steve Todisco. He'll be discussing a variety of topics with you that are related to Waste Streams in Healthcare Institutions. The Webinar will show you how to thoroughly and expediently analyze your own waste streams as well as provide you with real life tactics for cost-efficient waste stream management.
At the end of this presentation, there will be an open Q&A. We will be accepting questions in two ways. You can tweet us questions @triumvirate by using the hash tag #wastestream. If you don't have a Twitter, you can ask questions by typing them in the chat pane on your right where it says Questions. All unanswered questions will be answered and sent out in an e-mail after the presentation. In addition to the questions, all attendees will receive a recording of the presentation and a copy of the documents.
Today's speaker, Steve Todisco, is the Corporate Director of Healthcare at Triumvirate Environmental. He has 12 years of experience in the environmental services field and specializes in solutions for healthcare organizations. Steve is responsible for the design and oversight of Triumvirate's Pharmaceutical Sustainability and Regulated Medical Waste Initiates, developed to identify and resolve compliance management and efficiencies.
Steve has spoken on many topics including Healthcare Facility Inspections and Hazardous Waste Compliance. He’s a certified Healthcare Environmental Manager and certified Hazardous Material Manager. With that, I’m going to turn it over to you Steve.
Steven Todisco: Hello everybody! Good afternoon! Like what Sasha said, my name is Steve Todisco. I spent the last 12 years here at Triumvirate Environmental. I spent a lot of time in healthcare. Its part of what I love to do. Sometimes it makes me feel a little bit crazy being awhile in the healthcare environment but it’s really a great environment to be the one talking about waste management.
What I'd like to do today is spend some time on a couple of different topics, all with sort of a key message in mind. I'd really to make sure that we portray this as a common theme throughout the entire presentation. That is being with the key and right methodology, education and resources. Any hospital can really improve its Waste Management Plan where the annual savings really can pay for one of itself out of every four years.
If you think about that in real terms, that data is based on several vesting class organizations and their quest to drive down costs through sustainable practices and development of their right resources. Building a plan and developing a strategy is the key message today. If I could have everybody to keep that in mind, that will be fantastic.
As we go through, just as an overview, we're going to be spending some time on four of the major regulated Waste Streams. These are Hazardous, Universal, Pharmaceutical and Medical Wastes. Things we won't be including today that you'll see on your pie chart are Municipal Solid Waste and Recycling. These are two of the other components that make up the vast majority of the waste that healthcare generates.
You might be asking yourself why spend all this time to the smaller percentages of waste generate. All these waste streams combined that we're going to be talking today make up roughly a third of waste volume that leaves healthcare. But the reality is this; they make the largest percentage of healthcare violations, fines and total dollar spent. The bigger the headache to you guys the more the safety violation. That's why spending some time on these specific waste streams today.
We'll also spend some time discussing the regulators, who they are, what their focus has been and some of the key components to make sure that we can all pass with flying colours in any of those inspections that they've come and inspect your facilities for. So, just generally, who is this education component for? It can be valuable on all levels for different reasons. Several of which, we believe, are critical to developing best class institutions.
But when you think about who this training and education might be for, it really is focusing on simple safe and compliant programs, which we see in all levels of healthcare waste generation whether that be laboratory staff, facilities personnel, pharmacy, nursing, senior leadership directors or all of them. They thrill over into building cost-effective programs that are pretty reliable on sustainable practices and programs so that we can afford citations and public relation nightmares when it comes to development of our programs throughout the healthcare sector.
Before we begin, you should now be seeing on the screen in front of you just a quick one to five scale of a question. That question is being, "How confident are you with the compliance with your waste programs?" Sasha is going to go ahead and put up a survey. You guys can go ahead and fill out this one to five scale for us to get an idea of where the audience feels in relationship to their confidence levels for their waste programs.
While we're waiting for the pole to commence and get to the results, we typically find that a lot of answers to this are that most people feel that they're fairly confident. As comparison, some of the confusion related to simply what folks may not know is on any of the scale depends where they don't feel confident on some of their programs specifically related to some of the things that they don't know.
As we get close to finishing up the polling, let's give another couple of seconds here for people to answer. Are we okay? Sasha, if you can see those results, would you share them with us?
Sasha: Sure! It looks like more people were somewhere between three and four.
Steven Todisco: That's not all that uncommon. We spent a lot of time on that area. Thank you very much for your feedback. It gives me a great heads up as to where people are as a result of their programs.
A little bit more of what you'll learn today is about who are the regulators that are focusing on you? Healthcare is really one of the most regulated agencies of the country, if not the world. We believe that few of the things you'll learn today are very specific to the waste stream that we're going to cover.
We're going to cover the Hazardous Waste, Pharmaceutical Waste, Universal Waste and Medical Waste Streams. And that ultimately where your opportunities can be within one of those four streams to increase compliance, build simplicity into your programs and drive cost down as a part of building the best of class program.
Some of the 30,000-feet organizations that we were interested in paying attention fall into three specific levels. These are the Federal, State and Local levels. A good example here in Massachusetts of a Local institution is the Massachusetts Water Resources Authority. It directly compares to both the State Mass Department of Environmental Protection and the Federal EPA. They have three different requirements for the same standards. The MWRA, being the most astringent, is what you're required to follow here in Massachusetts if you fall in the Massachusetts Water Resources Authority District.
With all those four waste streams that we're focusing on today, they are all, both local and state institutions as well as federal, making sure that federal regulations are in place in the event that the state or local authority doesn't have those. In healthcare, sometimes we think of this as the authority having jurisdiction. That will be AHJ.
One of those 43 agencies could be the Fire Department or could be the State Emergency Response Committee. Here are a few and some of them we'll spend most of our time on today, focus on the Environmental Protection Agency, OSHA, the Joint Commission and your state agencies. There are several states’ representatives here today so we'll probably cover some of them for everybody. On the Medical Waste side, because that's primarily a state-by-state driven program, the Department of Health of the Health Community Services Department for each state.
We'll see a lot of questions come to us, from clients and prospects alike, asking questions like, "Where are the regulators focusing their time?" We worked with over 400 institutions within our geographic reach and what we hear is up on the slide now. Pharmaceutical Waste Management is still huge after almost ten years of managing pharmaceutical wastes. It's still a huge focus and it falls in line with some of these other focus requirements.
It is in line with the Improper Drain Disposal, Pharmaceutical Waste and Laboratory Chemicals as well or not collecting that material at all. They’re missing them both, when it comes to specific items that need to be collected. Another huge piece of the pie, nowadays, that the regulators are spending their time on is increasing the focus of recycling, reducing waste across the board and with some recent narcotics update to the DEA. There are some additional components that you can or cannot do with your narcotics collection.
Regulator focus has been specific in healthcare over the last several years and Pharmaceutical Waste management being of the ones right up to the top. In particular, specific to increasing recycling rates and waste reduction, the United States just signed a new agreement in China to reduce carbon pollution faster. This falls right in line with our waste reduction process. The less waste we generate, the less pollutions, the less the emissions that we end up generating as well. In the US, goal is a reduction 0f 26-28% below 2005 levels by 2025.
Now, I've been in this industry for 12 years and 2025 seems like a long way but we're only ten years from that. It's pretty exciting that all this stuff is happening very quickly. China's goal is to obtain result by 2030. It's a little bit farther out. These are two of the largest producers of waste in the world and they make up about a third of the world's carbon pollution.
As we talk about some of these opportunities related to these waste streams, I want you to think about something very specific. Most of the top institutions that we see track at 25% below what other hospitals generate for waste. Where do all of these lead us? It leads us to say that best in class hospitals combine their regulatory knowledge with best practices to achieve significant savings to three things.
These three things are things that I believe wholeheartedly. One is the commitment. When I say commitment, I mean the commitment from senior or institutional leadership to a plan. It is a plan that incorporates a very specific strategy whether that's a waste stream specific strategy or something that crosses all waste streams. Having a plan is critical to making sure your opportunity is the most successful.
Then ultimately is having a long range target. It's something that's measurable and something that's attainable. Throughout the presentation, you'll hear all the mechanisms related to tracking and trending, which is becoming more and more prevalent every day. Basically, we believe that most healthcare institutions can pay for about one out of every four years by building a more efficient program.
Let us get into the waste stream spot light. First waste stream that we're going to talk about is Hazardous Waste. We talked a little bit about it in the beginning where one of the smallest but major waste streams is Hazardous Waste by volume but the largest in cost by waste stream in percentage. It's also the largest in citations and fines and the largest of headache largest waste players s in which we rather spend less of our time.
There are several areas we should focus on and spend our valuable time. One of those areas is the Laboratory, which is one of the major waste players and part of the largest waste generators that they have are solvents. There are several departments listed in front of you. Histology is one of those departments that if you have a laboratory, will generate quite a bit of waste.
Several key streams that folks tend to miss in this area include the waste from hand staining procedures, in which you'll see a lot of methanol-based items or ignitable items as a part if the hand-staining process. Regulators look for the purple safe. I'm sure most of you know exactly what I'm talking about. The key is to collect those items if and when they meet the definition of ignitability.
When we see a lot of thin prep vials or sure path vials, these are trade name items that are developed specifically from cytology and they have a human component to them inside of them. A lot of people believe that they are medical waste. They're actually not. The tissue is fixed for its intended purpose and ultimately it’s no longer infectious. But the liquid where that material is in is methanol.
Methanol, being an ignitable and hazardous component, when decided to throw away becomes a hazardous waste. It has a D001 code for ignitability. It should be disposed of as a hazardous waste and not as medical waste.
We see specifically a lot of decalcifying solutions. Things that are acids are both organic and inorganic acids. A lot of that material is specifically used to decalcify bones. That material is corrosive. The corrosive components are on a very specific scale, the pH scale. Anything less than two or greater than 12.5, you'd get a corrosive hazardous waste stream. Ultimately, if it falls in between that material could be none hazardous and avoid collection.
We talk a lot about alcohols in the laboratory environment. There are some folks that collect all of their alcohol and some, for one reason or another, believe that it's okay to dump their alcohols down the drain. Some of them even have very specific letters from their local Publicly Owned Treatment Works (POTW). It's because the POTW enjoys the solvents for the good bacteria kills off the bad bacteria and provides nutrient source for the good bacteria. This is in stark contrast with what the EPA believes.
If you have an ignitable solution, whatever it is, if it meets the definition of ignitability being a flash-point of less than 140˚F, that material is supposed to be collected and not drain disposed. You're actually chemically treating a waste without a permit, in the event that the material makes its way down the drain.
In Chemistry, you'll see a lot less waste generated. For those of you who have Chemistry departments, what your concern within these Chemistry departments are the chemical-analyzing machines. A lot of them will have a very high concentration of water as a drain discharge directly to your drain disposal. In 99% of the time that's completely fine.
What the regulators are most concern with is making sure that you've done your diligence to understand that waste characterization has been made on that particular material and that you've updated that either when things changed or on a yearly basis. So that when the regulators come in, you'll have all the proof in the world to say, "We've done our due diligence. Here is our waste characterization. This waste stream is allowed to go down the drain."
As we move from the laboratory into facilities, engineering or buildings and grounds depending on what your organizations would call them, we'll key in all the shops. These are the Paint Shop, the Carpentry Shop, Plumbing, and Electrical and so on and so forth. Everyone has these departments and every one of them generates hazardous wastes where some are larger than others.
The easy area for regulators to find issues is Facilities and Engineering. It's usually down in the bowels of our institutions. The section of the buildings where there are no windows. Some of the waste streams that are most often sighted are in the Paint Department.
Most of your Paint Shop actual material is either latex or enamel at this point and no longer an ignitable-based paint or oil-based paint. But the reality is painters wash their brushes in ignitable solvents whether that is a turpentine, paint thinner type material or acetone. A lot of this stuff gets washed in the sink. They end up drain-disposing a material that they're washing their brushes in. It’s a crime in real estate for regulators to come and identify material that's being drain-disposed that shouldn't be.
That's a big one, Lead-Based Solders found in some older piping in older buildings. We still see a lot of lead-based solder. If you're getting rid of any material piping, then you ought to make sure that you either have or don't have lead-based solder so that you can dispose of it appropriately.
We see a lot of inherently waste-like chemicals in facilities and engineering in oil plants. These are chemicals that are out of date, old containers in the dark corner or dark humid spaces. Regulators have the ability to say that's inherently waste-like. It shouldn't be there. It's not labelled appropriately and ultimately cites you for it. This is something to think about when you purchase materials. It's an opportunity to spend a little less money on the purchasing side of the house.
We see a lot of OSHA violations coming from this area. We see some machine guarding, lock out tag out and exposure risks. The customaries of the institutions that are visited a little less frequently have the opportunity to have areas where very few people are involved 24 hours a day.
Moving on from Facilities and Engineering into Research. Typically we see two types of research. We see both Clinical and Non-Clinical. Here is where you'll generate a whole slew of different waste streams such as individual bottles or old outdated chemicals. Your satellite accumulation areas can look a little bit different in your research areas. These are typically bins that collect waste bottles with labels on them.
Some of the things to think about are very specific. Does my waste meet a particular characteristic? Is it ignitable or corrosive? Is it toxic? Is it reactive? And again, from the ignitability standpoint, we're focusing on things that have a flash point less than 140˚F under RCRA. Corrosive will spend a minute on less than two or greater than 12.5 on pH scale.
From the toxicity component, there are quite a few. We have arsenic, barium, cadmium, chromium, lead, mercury, selenium and silver. Those are the recreate metals and there are 43 total D-listed toxics. They are regulated under RCRA.
Last but not the least, is reactive. Believe it or not, this isn't always the things that boom and explode. These can be things that generate heat when they come in contact with water, air or when friction is composed. Very specifically, it doesn’t have to explode to be considered reactive. You can end up with something that is a reactive material on your list.
Then we see the Listed Items, which are the U-Listed and P-Listed Items. These are more commonly known of those related to pharmaceutical wastes in healthcare. We see quite a bit of virgin products that could meet the U- and P-Listing in research.
Just quickly and very specifically, you don't have a U-Listed Waste of P-Listed Waste and alas you have a virgin product and it’s not reactive ingredient. If it's not one of those two things then it might not be regulated at the federal level. Check your state and local listings, depending on what state you’re in; if that material has a state-specific regulation like oil may have in Massachusetts.
Another department that frequently gets missed is Bio-Medical Engineering. These are the folks that generate quite a bit of batteries and some of the Universal Waste generated in most healthcare institutions. These are very specific waste streams and there's a huge opportunity for recycling here and potentially some profits. There are some electronic scrap materials and scrap metal components here that can generate profits from some of the materials that Bio-Medical Engineering generates.
One of the issues in collecting waste from Bio-Medical Engineering is the improper collection and storage of waste batteries. These batteries all have terminals. If you've seen them before, some of that lead acid-battery terminals are more specific to see. Lead acid batteries will be all throughout the facility, in pieces of machinery, in equipment, in back-up lighting in the hallways. When you touch those terminals together, there is the risk for sparks and for fires to collect in waste containers, in drums or in departments.
It’s important to tape those terminals, one from a safety perspective, but two, you can't ship them offsite without taping those terminals for the Department of Transportation. Bio-Medical Engineering is a large generator of Universal Waste. It is very important to the RCRA environment as in your facility.
Now, we'll see these opportunity slides as we roll through and this going to come to the end of our mini-RCRA session. Just a couple of opportunities for you that is right in front of your face and in disguise. We call them managing the 90 or 180 Day Clock depending of what size of generator you are, whether you're a small or large quantity generator.
When we talk of Lab Pack in Process, you think about when you have an oldest bottle in your waste stream, you ship wastes every 90 days and you're a large quantity generator. You don't necessarily have to do that because each bottle is regulated by itself. It's about what the oldest chemical is. You don't necessarily have to remove all the items in your main accumulation area if there are only one or two old bottles. Just get rid of all those old bottles. You can save quite a bit of money for the life cycle of the year and in your budget cycles by bingeing on those waste streams on container by container basis.
If you have one bottle of waste Sodium Hydroxide, you have 90 days as allowed for a large quantity generator to generate more than one bottle of Sodium Hydroxide. For those of you who are shipping smaller waste streams like five-gallon pail instead of shipping multiple five-gallon pails after a course of the year, it might be an opportunity for you to generate one five-gallon pail over the course of your life cycle depending on what size generator you are.
Some of those things have to go out by themselves is unfortunate but it's a requirement from the DOT. Maintain your oldest dates and ship in the most appropriate sized containers. In a lot of cases we see a 15% to 20% cost reduction just by managing their clock so that they don't have to necessarily send out everything and have large bills as soon as you enter your waste shipments two or four times a year. Use your generator size to your advantage.
As we move into a subset of Hazardous Waste, being Universal Waste, I just like to take a second and explain how something is considered a Universal Waste. In stark contrast to some other things, you have to have once been a Hazardous Waste to technically be considered a Universal Waste. We'll talk about things that have been deregulated as we get into the Universal Waste components. We'll see a lot of batteries that we talked about. We'll also see pesticides.
Pesticides will not only fall under the Universal Waste standard under RCRA but they will also fall under the Federal Insecticide Fungicide and Rodenticide Act (FIFRA). These are all the things that come out of your buildings and grounds components that have to do with lawn care and maintenance. Some of you may do that in-house and some of you may outsource that to a vendor. If you have any of these materials onsite, they'll be regulated both under the Universal Waste Act and FIFRA component.
As much as we'd like to believe that we're Mercury-free, healthcare is still not Mercury-free. We see a lot of sphygmomanometers and switches from the oil plants still left. Of course we see different light bulbs with different components. We see a lot of straight bulbs, U-tubes and circulars.
What people tend to forget about the most are their parking lots and the HID bulbs with high intensity discharge. These are typically very large, sometimes a foot or two in length, 68 inches in diameter and take up a lot of room. When they break, they're no longer Universal Waste. They're Hazardous Waste. It's very easy to break this large light bulbs because they’re bulky items and proper storage of these items will save quite a bit money when it comes to managing your Universal Waste over the life cycle of the year versus your Hazardous waste, which is either a 90 or 180 day mixed depending on your generator size.
As we see this opportunity slides, most people get build either by the pound or by the drum. If you get build by the drum, obviously one of the opportunities is to maximize what's going into that drum. We don't want to overfill some of these containers because they all have weight limits and batteries can be heavy. But an opportunity to save some dollars comes by managing waste streams by the drum. There are advantages on some levels to have some of your waste streams specifically the batteries managed by the pound because you don't want to pay an entire drum worth of storage for just a few pounds of lithium batteries. Let's say those little tiny button cell batteries that use lithium metals as the energy source.
Your smaller waste streams in relationship to batteries can be managed by the pound. Specifically what containers have you been shipping yet? There are requirements for certain things, will it be metal, steel, poly or a fibre container. There are some opportunities to reduce some of those costs and utilize reconditioned containers. They usually cost a little bit less.
Ultimately there would be stream lining of your disposal or your recycling vendors with folks that also ship your hazardous wastes. We see a lot of this. We see a lot of separate universal waste vendors. Avoiding some of those additional initial pick-up fees or scheduled delivery fees might be an opportunity for you to consolidate and spend less time with multiple vendors and ultimately drive some efficiency in your universal waste program.
In opportunity, we see a lot as one of the most cited things in the universal waste world is not storing your light bulbs appropriately and they ultimately break. One of the most specific fines that we see is related to light bulbs and light bulb storage so that they are intact and can be managed as universal waste. Once they break, they become hazardous wastes. Maximizing that light bulb storage either in the existing containers that they've come in, if you can maintain those, or buying a bulb drum with the correct lids and labelling, you'll save money over time.
A topic near to my heart, fortunately or unfortunately, I'm also a Pharmaceutical Waste Management Director. This is something that has gone on for almost as long as I've been working here in the industry. It's still a very hot topic depending on what state you live in. In the North East, it's still a very hot track on pharmaceutical waste programs.
Usually today we see folks revisiting existing programs and we see very few that still don't have a program. I just want to remind everybody that pharmaceutical waste is regulated under RCRA, which is a hazardous waste standard. It's not regulated under your medical waste component. It's not regulated any other way. Pharmaceutical waste falls under RCRA, unless your state also manages it in the state level. States like New Jersey and Florida do things a little differently and require some additional waste collections.
How this section of the program is going to go is that it's broken down to eight-course steps that we believed are key and critical to building any pharmaceutical waste management program. We think that those eight steps are driven by key compartments. The first is being the fact finding mission. It's your advantage to use the rules to your advantage so that you can identify some of those states and local differences.
Part of the fact finding mission is really understanding how big you are, what state you're in and what are the exemptions that you can take advantage of. If you're a small quantity generator and you have a lot of P-listed wastes or acutely toxic wastes, you are only allowed to generate 2.2 pounds of that particular P-listed waste per calendar month.
If you're on the border and you think by building a pharmaceutical program is going to force you into that large quantity generator status, it might make a whole lot of sense to build your program as an LQG right from the start. You can generate less waste containers. You can purchase less supply.
There are some additional responsibilities by being a large quantity generator. What you'll find is you can basically have a virtual one-bucket program nowadays. There are some specific materials that are chemically incompatible and they can't go together but they're very few and very far between.
The major component to any fact finding mission in the pharmaceutical waste world is performing what the industry has come to call a Formulary Characterization. It is specific to the Pharmacy Department and it's really like an inventory. Think of what a pharmacy has the ability to purchase on any given day. It's something that's on their formulary.
Spend time doing a waste characterization on those items in formulary and don't forget some things that can be considered off the formulary or none formulary items. These things will be things that ultimately are purchased by some other department in the hospital. Sometimes radiology will buy their barium sulphate solutions themselves or materials management will buy specific items for wound care for other department. Performing this waste characterization just like every other waste characterization you're required to do on your waste program is not only required but helps you get to the next steps in the operational component of how I'm actually going to collect this material.
The last component to the fact finding mission is really related to reverse distribution. I haven't come across of a pharmacy yet that haven't use the reverse distribution. For those folks that don't understand what a reverse distribution is, it's basically receiving a monetary credit for something that you'll no longer be using at your facility. Some of those are non-expiring items. Some of those actually can be expired items but and they go back to the manufacturer through a middle man and the hospital will receive financial credits for them.
The EPA is very clear on where you can and can't use reverse distribution for. What you're not allowed to do is to use the reverse distributor as a form of hazardous waste disposal. There's no paper work, no manifest and no land disposal restriction notification. But ultimately using a reverse distributor for what it's required for, from which clearly you're getting credit for. That's the difference, what you're getting credit for versus what you're not getting credit for.
If you've received credit, the waste doesn't fall under RCRA and it doesn't fall into the hazardous waste category then you can continue to send it back and get credit. If it's something that is disposed of and something that you're not getting credit for, that's the material. If it meets the definition of hazardous waste, then you want to consider collecting for hazardous waste disposal. You'll actually find some savings on the reverse distribution side of the house because most folks bill you the cost of disposal of medications not necessarily what traditional disposal cost will be. We all know medications can be very expensive.
The operational component, as we walk through this pharmaceutical waste program, is identifying where you're going to collect wastes. We call those satellite accumulation areas. These can be located in nursing units on the floors, so did utility rooms or medication rooms. You want to walk the facility and understand not only where these can be located but where they should be located from a security standpoint. You want ease of access for all those involved in collecting wastes and there are some regulatory requirements that fall under these worlds like labelling, signage and keeping container lid shut when they're not being added to.
One of the differences here is finalizing your weight streams. This will be different for large quantity generators versus small quantity generators. We talked a little bit about P-listed wastes, which is 2.2 pounds per calendar month, is not a whole lot. If you're a small quantity generator, you're required to prove that you're actually generating either that or less. The only way to do that is really to collect them separately.
Some states, Massachusetts included, have unwritten rules related to how they portray how they generate that P-listed wastes. There are some components of lee way there. In finalizing those waste streams into either a one-bucket program, if you're a large quantity generator, you have to make sure that any incompatible items are stored separately. Things like virgin and unused silver nitrate sticks are oxidizers and they react with things that are organic so you can't put them together.
Everybody has to assign an antidote kit if any pharmacist is listening. We don't use this whole lot and they expire usually every four years. These are both organic and inorganic oxidizers and they have to be separated as a program.
Finalizing your waste stream is important to understand what you're total waste program is going to look like. Then, what are very important are the containers that you choose. Make sure you choose a DOT shippable container. What you want to avoid is shipping containers inside of other containers just to get them off your site because they're not DOT shippable. You spent quite a bit of money on over packing containers, when all you really need to do its ship this out either individually or palletized because they are DOT shippable containers.
There are many types of them in the industry. There's a picture here of one of them made by the committee. They're great products. Some people have the ability to store more than others. Choosing a container is very important when you're building at you're program.
As we wrap up pharmaceutical waste, the most important program component, in my eyes, of pharmaceutical waste management is the education and training of your staff. Most folks spend a lot of their time in nursing, environment services and pharmacy. That's cover about 90% of materials in focus that you need to have trainings. This is where I would spend my money personally on the education because it's going to come back ten-fold when these folks are actually collecting wastes. We want to make sure they're collecting the right material. We want to make sure they have proper collection techniques. We want to make sure that they avoid collecting things that are not required or things that shouldn't be collected for one reason or another.
This is what we're recommending to spend most of your time and anything that you can do as a bonus education component. A lot of pharmacy has the ability to program Pyxis machines, Omnicell machines and many tech units that help flag items that need to be disposed of as hazardous wastes when they get pulled out of those units up on the floor. It's something more extreme like that or something very simple like colour-coded systems that come from pharmacy or from other departments, can help follow that particular item through its life cycle and be collected in the correct container.
This is an opportunity slide again specific to pharmaceutical wastes. We want to make sure that this DOT shippable component sticks. People save quite a bit of money on not spending money on those supplies or over packed containers for those DOT things. We really want to hammer down the education means generating the correct waste for your facility and your institution regardless of what your generation is.
Automate what you can and take the human factor out of it. Make pre-printed labels, custom signage and things like that. And ultimately, where you can, make sure you understand what size generator you will be when rolling out this program in its entirety. If you think that you're going to be a large quantity generator at all, it might make sense to build that program as an LQG as opposed to small quantity generator.
Nursing education is going to be your best friend when it comes to rolling out your program because they know their stuff, which is typically the largest in any institution. In regard to training and education, they need to receive. That training is a yearly requirement under RCRA General Awareness Level. New hires have to have that training within six months of employment.
As we finish up pharmaceutical waste and RCRA in general, the Resource Conservation and Recovery Act is a gravity-based matrix for civil penalties. It's a grid. On the left-hand side, we see the potential for harm. The more harm it could do the more the fine. To the extent of the deviation from the requirement, moving from right to left is where the fine increase also. A labelling issue might be something that we see in the bottom right-hand side of this. Something that's very habitual and consistent throughout an entire program or not having a program makes its way into the upper left-hand side. That's just a component from an example stand point.
Most fines are negotiated so you typically don't see what you start with or what you end with. Sometimes there are what we call supplemental environmental programs that you can substitute in conjunction with a monetary fine to build programs that best support your institutions, your communities and your networks. I find that a lot of regulators this time and a colleague of mine used to say "Follow the buck. Where the money is, they will go."
As we get into the last waste stream spotlight that we're talking about, medical waste, this is an ever growing opportunity for waste reduction and reversion. Believe it or not, about 90% of all wastes in medical waste world is actually not Regulated Medical Waste (RMW). Imagine if you could generate 50% less RMW because people will put the right waste streams in the right containers, you'll see you could save quite a bit on your overall budget. Medical waste is one of the largest volumes as compared to hazardous, universal and pharmaceutical wastes. It ultimately has a huge opportunity for upsize.
Depending on what state you're in, there will be different names. If you’re in New York, listening today, we call it Regulated Medical Waste. I've spent five years in our New York office and its very different than some of these other states. They title it Infectious Waste or even Biomedical Waste. If there are any Maine folks, biomedical waste is very particular in their language.
There are several treatment standards for medical wastes. We think of these treatment standards for the most part for major waste streams like red bag or just infectious waste, sharps, trace chemotherapy items and pathological waste. When we think of trace chemotherapy waste, there's an opportunity for people to have a discrepancy here. A lot of times, trace chemotherapy waste is managed under the medical waste program, which technically it falls under but this is a little bit a grey area between RCRA and trace chemotherapy. You actually have the ability to do both. You could manage your trace chemotherapy waste under RCRA and the pharmaceutical waste program if it made more sense to you and your institution or keep it under the medical waste treatment.
Some of the mechanisms here that we see in the treatment standards fall under the following categories. There's incineration, which is a choice for a lot of trace chemotherapy and pathological materials. Autoclave is the largest by treatment standard used by many states. A lot of the sharp wastes make their way to the autoclave and to landfill.
Most recently, triumvirate has implemented a new recycling program for medical waste. We actually take both red bag waste and the sharps waste and turn it into usable form of plastic, which people can get recycling credits for and reduce the budget significantly from a waste diversion stand point. Check that out, if recycling is at the top of your radar stream with medical waste being the largest waste stream that your institution generates.
Here are some general terms. Just as a copy out here, each state for the most part, manages their own medical waste program and some of these terms are different state by state just like names were. There's biomedical waste versus infectious waste or regulated medical waste. There are two slides here. These are not state-specific slides. I'm going to spend some time talking about the different departments that generate these.
Specific to pathological waste, we see a lot of these, as the name says, come from gross pathology. These tissues are usually fixed and many states require the incineration of these. Massachusetts is one of them New York doesn’t necessarily require it. They use it as a best manager practice. It's about 75% or 45% split between the states all across the country as to who require incineration versus those that don't.
Human blood and blood products, a lot of these materials end up going down the drain, which in many states is allowed. Cultures and stocks, we see a lot of this stuff come from not only haematology and microbiology but also in research laboratories. A lot of medical waste are in research laboratories in, not only healthcare, but also in folks that are in allied sciences arena and those that work in biotech. We see a lot of cultures and stocks from those waste streams.
We're no stranger to sharps. We get to the point where these are folks that are due to pick up almost on a daily basis. There's quite a bit of waste stream that is generated from here. We see both reusable and disposable containers. There are arguments for either. This is a very high-tech waste stream for needle-stick increase and not specifically needle sticks but also in laboratory sessions within research areas. It's not just specifically syringes and needles but also plastic pointy objects like plastic pipettes and broken glass are considered as sharps under the medical waste standards.
I'm not going to mention a whole lot of isolation waste but it's something we forgot a lot about recently with the Ebola scare. This is a prime example of waste generated at isolation. There are plenty of others. This is being the most recent and upfront in our face. Last but not the least, we see animal carcasses, body parts and bedding related to a lot of these animal facilities that we may or may not have in our institutions if we do any animal research.
As we finish up the medical waste, some the opportunities that derived themselves there are making sure the containers have minimal amount of touches as possible. If there's an opportunity to ship the waste in the same container that you generated in, infection control I’m sure would love you very much. Multi-touch containers are reality and we have to utilize them but there are opportunities there for reduction.
Storage space is key. The more you can ship at any given time will streamline your waste shipments. There's an argument that we talked about between reusable and disposable containers. In a lot of cases, it might be washed depending on how much disposable containers you go through but the reusable market id great from the sustainability component.
Lastly, we have recycling. We here at Triumvirate are very forthcoming with building recycling programs and building best-in-Class world renown institutions. If anybody is interested in medical waste recycling components, please feel free to reach out to any of us after the webinar. We'll be happy to answer any questions.
In summary, we talked a little bit about the regulators. We talked a little bit about what their focus was. We spent some time in these four arenas. This is a lot of the waste that gets generated in healthcare and all of it gets regulated. The biggest difference is with opportunities come a lot of challenges. Not having a plan is the biggest one. We see a lot of people with the inability to assess the complete data for their total spend. They don't have any idea on what they actually spend. Getting a really good understanding of where the money is spent and what you've spent on is part of the plan. It’s part of the development of your program.
They don't know where programs begin or end. That's extremely important too to understand where your budget begin and end. Not only just from a physical component and when they started on the calendar but whose department is in charge of what waste streams and if there's an opportunity there.
Most folks don't link waste management tasks to what we call key performance indicators or key performance matrix. These are things like adjusted patient days. Why not measure waste generation the way that hospital understands. It’s not just some of the folks in our environmental health and safety departments or environmental services departments.
If you generated x amount of waste per patient day or if you generated x amount of waste per your adjusted patient day, it might make a little bit more sense to those folks all throughout the institution so that it's a relevant internal matrix. Service providers are typically motivated to increase waste and not decrease it. We tend to spend a lot of time on the recycling components. Align your goals with your waste management providers and you'll have a little bit less challenges on this side of the house.
Just to recap, with the right methodology, education and resources, healthcare can improve its waste management plan where the annual savings really could pay for what out of every four years. We've seen this time and time again, in some of these institutions. We spent a lot of time in their plan and their programs. This is the goal of the presentation. It's to make sure that folks can dive into their waste streams and then zoom back out to the larger picture and ultimately develop an action plan.
This is an action plan which in my mind should include these three major components. These are perform that gap analysis, understand where you are and where you need to be of your program, and point out the weak points. It's okay to have weak points in the program. There are a lot of great resources out there, Triumvirate included. Please feel free to reach out to us if you need help with building your action plan.
It's all about data. Being able to provide accurate and real-time data helps everybody make decisions much fast. Wouldn't it be nice, if instead of waiting on the end of every month to determine how you did, you’ll know where you are every single day? Utilizing that plan and gap analysis to track the data that you want to track is a key component of this action plan. One that I would highly recommend using the key performance into cater as often as possible.
With that, I sort of said a lot in relationship to very much of the regulated waste streams so I will turn it back over to our moderator, Sasha, and fill every question that everybody ask. If we don't get to some of them, we'll make sure that we follow up with everybody individually. Thank you very much for your time and I look forward to your questions.
Sasha Laferte: Okay, if everybody would look to your sides, we're opening it up for questions. If anybody wants to ask some questions, you can type them into the questions' pane on the right side of their screen. Please feel free to do that.
Our first question is about pharmaceutical waste. Someone said that they saw the pie chart that you included and they said that pharmaceutical waste only represents one per cent. Why should they even really care about it? What's the point of focusing on pharmaceutical waste?
Steven Todisco: Yes, that's a great question. Pharmaceutical waste does represent a very small percentage of the total waste volume. Now, you really have to understand that most of the fines in the last three to five years has been on pharmaceutical waste. It's a huge opportunity in disguise. You can take that tiny little waste stream and make sure that you're managing it as officially as possible so that your waste budgets come down. Being a regulator focus and being specifically one of the drivers of fine and citations over the last half decade, it's probably one of the biggest driving components of making sure that small waste stream is managed appropriately.
The other reason is it touches more people in your institution than a lot of the other programs too. Most of these other programs are focused department by department while pharmaceutical waste is across all the clinical and non-clinical practices such as nursing, pharmacy, the doctors and all the different departments whether it will be high risk areas like the OR, the ED or the PACU. It's very important to maintain that level of compliance in a program that such high priority throughout the institution.
I hope that answers your question. There are million and one reasons to build a great pharmaceutical program. Those are just a couple.
Sasha Laferte: Next question says, "I was under the impression that alcohol was not required to collect as a hazardous waste. My local POTW has even given me a letter stating that it's okay to drain this disposal alcohol waste. Is the alcohol waste that is generated from my laboratory regulated as a hazardous waste? Are we required to collect that material?
Steven Todisco: That's definitely a great question. We get this a lot and typically from small to midsized healthcare outside of big cities, within a pretty good radius of a major city like outside of Boston or New York. Specifically the answer to the question do you have to collect your alcohols is yes. The EPA under Federal Law under RCRA regulates that all ignitable material, and they define ignitable being having a flash point of less than a 140F, be collected for hazardous waste disposal.
There are some exceptions like the 24% alcohol exception. If you have an alcohol that's less than 24%, then you might be exempted from that material. The alcohols that we see in laboratories is the primary driver alcohols for waste collection throughout an institution and healthcare, is nowhere near the 24% exception. They're all on the 95% to 100% range and will obviously not apply to things that are not specifically alcohols.
When we talk about alcohols and alcohol exemptions in opportunities allowed to collect, we're thinking of things like isopropanol or ethanol. There's not very many of them. Healthcare will generate xylene and other ignitable solvents as a component with their ignitable alcohols. Make sure you definitely collect those alcohols even if you have a letter from your local's or POTW. They like those alcohols for different reasons. Ultimately, you have to always comply with the more strict regulation. In this case, the more strict regulation falls under the federal RCRA regulations related to ignitability.
Sasha Laferte: Okay. Thanks. That's very helpful. It looks like a few of you have raised your hands in the attendees bar. Just so you know there's no need to raise your hand while I'm fielding other questions. If you just want to directly ask in the questions' pane that would be great. I have one more question lined up. We will have a little bit more time to answer any other extra questions. If anybody would like to ask another question, I'd be happy to get it answered.
The next question says, "In my hospital, we used only green tip light bulbs. We have been told that these bulbs are not considered universal waste and they can go into the trash. Is this correct?"
Steven Todisco: That's a great question. Again, that's another one that we get a lot. The industry is shifting. If we see a lot of green tip bulbs, depending on your institution and your abilities to purchase, you may or may not have some of those. All the green tip bulbs mean there is less mercury vapour inside that light bulb.
There are a million and one studies out there that show that not all the time this fall below the regulated levels. If you were to run a split, it’s about 75% of the material. All light bulbs are not created equal. If you have a hundred of those light bulbs with all the same make, model and manufacturer, 75% of them, according to the studies, will actually still trip. It's called the TCLP value or TCLP for mercury.
All the RCRA metals are regulated and mercury is one of them. In this particular case, it's the mercury vapour inside the light bulb. There are very few that analytical has been run that come out of the hazardous waste category. The trick is knowing which ones are which because you're not really going to do analytical in every single light bulb before you dispose them.
So, yes, you are required to collect light bulbs as universal waste to the environment. If you have green tip light bulbs, you have a couple of options. You can both comply with the stricter standard and collect that material for waste disposal, which in this case recycling. Or, you can perform analytical and perform that within a reasonable time frame. You have to continue doing that so that the regulators have a proof that you've done some due diligence to understand what you're required to collect and what you're not required to collect.
I hope that answers your question. It's a tricky subject because a lot of the manufacturers will push that these light bulbs have less mercury in them and that they may not be regulated in the same way. They're absolutely true but there are some sticky points related to the levels that you'll see in those light bulbs of mercury vapour.
Sasha Laferte: Okay. There are few more questions on the queue. Someone wants to know if you could tell us a little bit more about collecting controlled substances under the pharmaceutical waste arena?
Steven Todisco: Yes, sure! Narcotics are very hot topic again for a couple of different reasons. One of them is the diversion of those narcotics. When you think about hazardous waste and hazardous waste in pharmaceutical programs, it's a very small window of what you're required to do.
There are a couple of narcotics that we think about when we're looking at RCRA regulated narcotics. Probably one of the most common ones that we see is chlorohydrate. It is a U-listed hazardous pharmaceutical waste that also meets the definition of narcotics. In the event that you have something that was both a RCRA regulated narcotic and something that fell under one of the spectacles of narcotics, you will be required to collect that if and when you had any material leftover that still met the definition of that particular hazardous waste.
Just to follow up on the example of chlorohydrate, if it has been spent for its intended purpose and RCRA empty, which is less than three per cent of the total liquid volume of the container, falls out of that category. We see people collect very little hazardous narcotic waste because one is that chlorohydrate is none by the way side. Not everybody generates it. And ultimately because this material get to be used and spent for its intended purpose and doesn't fall into the hazardous waste characteristic of U34 code for chlorohydrate.
There have been some recent additions by the DEA to help hospitals in particular become generators of waste narcotics from patients so that their community can bring narcotics to them. There is some registration requirements and definitely maybe another webinar where this is a great big topic to get some narcotics off the streets and get them into a place where they could be managed appropriately.
Sasha Laferte: Okay. I think we still have time for another question. If anybody has more questions, feel free to type them into your questions' pane and we'll answer them after the webinar.
This is the last question. Someone asked if you could tell a little bit more about how RMW can be converted to a plastic.
Steven Todisco: It's an exciting process. Just to back up for two seconds, we've been looking over the last six years on how to better handle some of the largest streams in healthcare. One of that being solid wastes. Solid wastes recycling has absolutely taken off another being medical waste. As part of medical waste, believe it or not, based on our studies about 78% of all the materials that goes in red bag waste and as sharps waste, it's actually plastic already.
We have a unique process at one of our facilities where there's a source separation component where we take the hard part of things that end up in those waste containers, which as you understand is quite a lot. We separate them and think of it like a brew master. You want to pull all that stuff apart and its component pieces and put it together with the right components so that we can make what's called a low grade industrial plastic that could be used for industrial forms and things like that.
When I say that we make a plastic, we make a real live plastic product that gets sold on the back so we can offset some of the disposal cost and share those cost savings with the customers. We ultimately get to help in their medical waste programs as for materials for recycling. There are a lot of specifics and new ones in the actual plasticization process and the source separation process. It can take a lot of grinders, shakers, magnetics and things like that to use source separation. It's about taking all the components apart and putting them back together again in the right form so that we can produce what is ultimately a low-grade plastic product for use.
Sasha Laferte: Okay.
Steven Todisco: If you have any further question, I'd be more than happy to follow up with you individually. There's just a lot to it.
Sasha: Awesome! It looks like we're out of time. I just want to thank everybody for their questions. I would like to let you know that we'll send you an e-mail with the copy of the presentation along with the recording later today. The e-mail will also have a link to a survey asking you to rate this webinar. If you could please fill it out, that would be very helpful to our team here at triumvirate in working to improve future webinars.
We have several upcoming webinars including one on the Best Preventive Maintenance practices at your Facility. You can find these events on our event's page at the link www.triumvirate.com/training/events. I will also send you that link. There's no need to memorize it.
Also, we recently came out with the Waste Minimization Blue Print, specifically for the healthcare industry. This is a custom checklist designed to help you save money and meet sustainability quality through waste minimization. The link is http://info.triumvirate.com/waste-minimization-in-the-healthcare-industry, which is the one at the end of the page. I'll also send this link with the e-mail.
Also, keep an eye out for special offer from us at Triumvirate for attending this webinar. Thank you guys for your time! It was fun! Bye!
Steven Todisco: Thank you everybody! We appreciate your time.