909E02001
Eliminating
Mercury in Hospitals
Environmental Best Practices for Health Care Facilities I November 2002
JCAHO Environment of Care
Standards 1.3.2.3,4.0
Mercury Exposure Pathways
> In utero
• Consuming mercury-contaminated fish
• Inhaling mercury vapors in the workplace
• Handling workclothes contaminated
with mercury
Atmospheric Mercury Contributions
by Industry Sector
(1997, EPA)
How Pervasive and Harmful
is Mercury in the Environment?
Mercury is a toxic pollutant and is listed as one of 12 priority chemicals by
the EPA Persistent, Bioaccumulative, and Toxic (PBT) Chemical Program.
Consuming fish from mercury-polluted water bodies can severely affect the
central nervous system; impair hearing, speech and gait; and cause blindness,
tremors, insomnia, emotional instability, paralysis, loss of muscular control,
and even death.1 Fish consumption advisories for mercury have been issued for
thousands of water bodies nationwide, including all the Great Lakes and their
connecting waters, more than 79,000 other lakes and more than 485,000 miles
of rivers. In 2001,49 states had issued mercury advisories for lakes, rivers, and
other water bodies.2
Neonatal exposure to mercury has been linked to several serious birth defects
and recent research suggests that prenatal effects occur at mercury intake levels
5 to 10 times lower than that of adults. Additionally, a National Academies of
Science report from July 2000 showed that 60,000 children are born in the US.
each year with neurological problems because of exposure to methylmercury
in utero.3
Numerous cases of mercury poisoning, primarily through inhalation, have been
documented in the workplace. In a survey conducted by the National Institute
for Occupational Safety and Health, researchers estimated that 70,000
American workers might be exposed to mercury vapors on the job, including
nurses, lab technicians, and others working in health care facilities.4 In addition,
families of these workers were identified to be at risk of exposure from mercury-
contaminated work clothes brought home by workers.5
%
What Are The Industrial Sources Of Mercury?
Although mercury is naturally occurring in volcanoes, natural deposits, and oceanic volatilization, human activities have substantially increased the
amount of mertury cycling through the ecosystem. A1997 EPA study6 identifying industrial processes that contributed heavily to atmospheric mer-
cury found that medical waste incinerators (MWI) contribute 13% (the fourth-largest source) of the anthropogenic mercury emissions to the envi-
ronment. Additionally, hospitals contribute 4 to 5% of the total wastewater mercury load in some communities.7 Many local wastewater treatment
plants have identified hospitals as industrial pollution sources and have imposed strict wastewater limits for mercury (see Case Study 2).
Eliminating or reducing mercury use not only lowers compliance costs, but also minimizes the potential for expensive spill cleanups.
(For more information on mercury sources and health effects, see www.h2e-online.org/about/mercury.htm.)
continues
Medical Waste
Incinerators
Mimicipal
Waste Cotnbustors
24%
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page 2
Environmental Best Practices for Health Care Facilities
Eliminating Mercury in
Why Commit to Being Mercury-Free?
Public Health-
Hospitals most frequently commit to becoming mercury-free based on an ethical motivation to protect human health and the environment. This desire
often supports the hospitals' mission statements which commonly include a goal of assessing and improving community health." As significant
users of,products containing mercury, hospitals have an opportunity to play a key role in protecting public health by minimizing the use and release
of mercury into the environment.
Regulations -
Mercury waste is regulated under the Resource Conservation Recovery Act (RCRA), which requires all hazardous waste handlers to have specially
trained staff and equipment on hand in case of a spill or release. Additionally, these facilities must meet special storage, handling, disposal, waste
tracking, and reporting requirements. Failure to meet any of these requirements can result in fines up to $25,000 per day.
Voluntary Agreements—
Because of health cares contribution of mercury to the environment, EPA and the American Hospital
Association-(AHA) signed a memorandum of understanding in 1998 committing to the virtual
elimination of mercury from hospitals by 2005.8
The following sections of this fact sheet present information about mercury-containing devices and
chemicals, alternatives to mercury-containing products, vendor information, and case studies of successful
mercury elimination programs. This fact sheet also contains links to other important resources for com-
pleting a mercury inventory, setting up a mercury elimination program, and taking the steps necessary
to eliminate mercury at your hospital.
By August 2002,
over 300 health care facilities
nationwide had already taken
the "Hospitals for a Healthy
Environment Pledge."
For more information see
www.h2e-online.org
1 EPA Mercury White Paper, www.epa.gov/ttn/oarpg/t3/memoranda/whtpaper.pdf
2 EPA Listing of Fish and Wildlife Advisories. May 2002. www.epa.gov/waterscience/fish/
3 National Academies of Science, National Research Council. July 2000. "Toxicological Effects
of Methylmercury."
4 Anne Nadakavukaren. "Our Global Environment: A Health Perspective". 1995.
5 Guy Williams. "Mercury Pollution Prevention in Healthcare." National Wildlife Federation. July 1997. -
6 EPA. EPA-452/R-97- 004. "Mercury Study Report to Congress, Volume II: An Inventory of
Anthropogenic Mercury Emissions in the United States". December 1997.
7 "Making Medicine Mercury-Free: A Resource Guide for Mercury-Free Medicine." Health Care
without Harm. 2001.
8 Health Care Without Harm, in partnership with the U.S. Environmental Protection Agency, the
American Hospital Association and the American Nurses Association, has launched Hospitals for
a Healthy Environment (H2E). www.h2e-online.org
Where Is Mercury Found in Hospitals?
Although mercury is found in many places within hospitals, a mercury elimination plan
should include a prioritized list of targets. For example, the California Department of
Health Services (CA DHS)9 conducted mercury inventories at six northern California
hospitals in 1999 and found that sphygmomanometers and gastroenterology instru-
ments accounted for 89 percent of the mercury in these hospitals.
Most mercury-containing equipment have a mercury-free alternative. Although
some mercury-free alternatives may initially cost more, facilities often find that
their initial capital costs are outweighed by the total costs associated with mercury
cleanup equipment, spill costs and liabilities, and handling and disposal costs and
liabilities (see Table 1, page 5).
Mercury can be found in many commonly-used hospital devices and materials including:
Thermometers
. Contain about 0.5 gram of mercury (laboratory thermometers contain 2 to 10 grams of mercury)
« Generally account for a small percentage of total mercury at hospitals
Two recent independent studies'"'" have found
significant accuracy problems associated with
mercury thermometers:
• 25% of new mercury thermometers were
inaccurate by at least ±0.2 degrees C
•28% of mercury thermometers were inaccu-
rate by at least ±0.1 degree C
[The ASTM standard for glass/mercury medical
thermometers specifies a maximum allowable
error of ±0.1 C in the cited range.]
Mercury Thermometers:
Mercury Sphygs:
A study12 of 444 mercury sphygs found:
• 55% showed zero level between
Wand 20mmHg
• 38% had dirty columns that
obscured readings
• 20% of the columns were not vertical
• 5% had blocked air filters
• 3 units had visible mercury
droplets outside the mercury tube
continues
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Eliminating Mercury in Hospitals Environmental Best Practices for Health Care Facilities
page 3
• An important source of mercury contamination of nonhazardous waste streams because they are often disposed of improperly
• In contact with staff and patients more than any other
medical device
• Broken thermometers inappropriately disposed of in red
bags or sharps containers may be incinerated and release
mercury into the environment
• A UCLA Medical Center study found that broken mercury
thermometers were the most common sources of mercury
spills accounting for over 55% of incidents
• Alternatives are readily available (see thermometer inset that
contains detailed data on the efficacy, cost, and features
of both mercury and mercury-free fever thermometers)
Mercury Sources in Seven Northern California Hospitals
(California Department of Health Services, September, 2000)
Engineering
1.43%
Fluorescents
0.067%
Thermometers
I— 0.66%
Switches
— 0.12%
X-ray tubes
r- 0.06%
Barostats
r 0.04%
Fixatives and
stains
0.04%
Sphygmomanometers (blood pressure monitors)
• Contain 70 to 90 grams of mercury
• Typically located in heavily used areas including patient
rooms, waiting areas, triage centers, and offices where the
potential for patient or health care worker exposure to
mercury is high
• The equipment at hospitals that often contain the largest amount of mercury
• Without regular maintenance, mercury sphygs can be inaccurate
• Alternatives are readily available (see sphyg insert that contains detailed data on the efficacy, cost, and features of both mercury and
mercury-free sphygs)
Cantor and Miller Abbot tubes (also called esophageal bougies and Sengstaken-Blakemore tubes)
Used to clear gastrointestinal [Gl] restrictions
• The equipment at hospitals that often contain the second largest concentration of mercury
• A single set of bougie tubes can contain up to 454 grams of mercury
• FDA device failure database shows 58 incidents from 1991 to 2000 in which Gl tubes broke and released mercury inside patients13
• Alternatives are readily available; some substitutes are weighted with air or water while others are preweighted with tungsten; because the mercury
in Gl tubes functions as a weight, rather than a measurement device, the performance of alternatives is less questionable, and tungsten-weighted
devices are considered just as effective
• Additionally, tungsten-weighted alternatives have the advantage of being opaque in X-rays, allowing detection of the dilator as it moves
through the body
Non-Clinical Mercury Sources (sphyg repair kits, barometers, switches, etc.)
• Barometers contain about 800 grams of mercury and can be replaced with a 1-millibar precision aneroid for less than $250 or simply rely on a
local airport or weather station for data
• Eliminating mercury sphygs renders a repair kit containing mercury obsolete
Other Sources
• Batteries
Manometers on medical equipment
Esophageal dilators (also called Maloney or Hurst bougies)
• Fluorescent and high-intensity lamps
• Cleaning solutions
continues
• Staining solutions and laboratory reagents
(thimerosal, mercury chloride, immusal, and carbol-fuchin)
Check the mercury content of your chemical at
www1.netcasters.com/mercury/
• Tissue fixatives (Zenkers solution and B5)
• Thermostats
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page 4
Environmental Best Practices for Health Care Facilities Eliminating Mercury in Hospitals
UCLA Mercury Spill Frequency (1997-1999)
(average of 18 mercury spills per year)
Taking the Leap....
How do you get a mercury reduction program rolling? Heres a step-by-step plan for making mercury reduction a priority at your hospital
(also see Case Study 1, page 6):
Step 1 - Make A Commitment
Get support from the top. Talk to your hospital leadership, and get a
signed statement to be mercury-free.
Establish a mercury-free team. Designate a program leader who will
be enthusiastic and dedicated to the program and would identify a
person in each department who has the authority to make departmen-
tal changes in order to build support.
Step 2 - Conduct A Mercury Inventory
Create a baseline inventory of mercury-containing products in your
hospital against which progress can be measured.
Mercury inventory tools are widely available on the Internet. The
Mercury Assessment Toolkit produced by the CA DHS is particularly
comprehensive, easy to adapt to hospital-specific conditions, easy to
use, and tracks reductions automatically.
Seewww.dhs.ca.gov/ps/ddwem/environmental/med_waste/med-
wasteindex.htm for additional information.
Step 3 - Evaluate Alternatives
Evaluate mercury-free alternatives in the context of your hospital.
• Is the performance comparable?
• What is the purchase cost for alternatives? For accessories?
For maintenance?
• Are these costs offset by lower handling, disposal, and liability
costs?
Spill cleanup costs: Labor: approximately $ 10,000/year
Disposal: approximately S34/pound
42cr of the ha/ardous material unit incidents
involved mcrcurv
Ha/ardous material unit spent 90 hours/year
responding to mercury -related spills
in a labor cost alone of $28,()->9 for the 3-year period
Contact the vendors listed at the end of this fact sheet for more infor-
mation on mercury-free alternatives to common hospital devices, or
check out these web sites: www.sustainablehospitals.org and
abe.www.ecn.purdue.edu/~mercury/src/devicepage.htm
Step 4 - Establish Goals And Implementation Plans
Set short-term, measurable goals that match your hospitals resources. Reasonable goals, such as the elimination of mercury sphygmomanometers
within 2 years, are easily measured and proposed as part of a hospitals business plan. Once attained, the goals can provide a springboard for new
mercury reduction projects. '
continues
Matching Mercury Replacement Strategies with Budgets
Targeted Device
Financially Strapped
Capital Budgets Allocated
Snhvomomum nuclei's
Clastrointcsli
Replace at servicing intervals
Replace when expired
Replace a set percentage each quarter or year
targeting departments with high breakage first
Replace as many as possible .with available
funding, then phase out remaining devices
when broken
Replace immediately
Implement a one-time mass replacement
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Eliminating Mercury in Hospitals Environmental Best Practices for Health Care Facilities
Sphygmomanometer
Efficacy
Sphygmomanometer Efficacy
Accuracy
Calibration
Installation
Maintenance
View Window
Measurement
Technique
Other Features
Mercury
Aneroid
Vital Signs Monitor
• +/- 3 mm Hg conforms to AAMI
standards
• Operator must understand and
account for mercury meniscus
• Oxidized mercury Can make the col-
umn appear dirty and make readings
difficult
• Required every 6 months
• Adjusted only at the zero point
v
• Mercury tube must be perfectly
vertical in its unit and perpendicular
to the ground
• Requires excellent technique to read
the meniscus of a mercury column
• Without proper maintenance, accu-
racy of the device could be consider-
ably diminished
• Frequent filter replacement needed
to avoid mercury column "lag," a
delay in mercury response, that
contributes to inaccuracies
• 0 to 300 mm Hg with no stop pin
• Relies on the auscultatory technique
• +/- 3 mm Hg conforms to AAMI
standards
• Includes a self-bleeding deflation
valve for increased reading accuracy
• Required every 6 months
• Requires specialized tools and
technical skills to calibrate the
mechanism at several pressure
points, including zero
• No specific orientation required
• Easier to read than mercury column
• Easy to see if aneroid needle is off
zero when not in use
• Calibration is harder than with
mercury units
• 0 to 300 mm Hg with no stop pin
• Relies on the auscultatory technique
• +/- 3 mm Hg conforms to AAMI
standards
• Digital display removes operator
error and bias
• Automatic deflation rate improves
accuracy
• Recommended every 5 years or if the
device has been dropped
• Usually provided at no cost by the
manufacturer
• No specific orientation required
• Digital display standardize
measurements
• Automatic inflation and deflation
improves staff efficiency
• Battery replacement as necessary
(approximately every 350 uses)
NA
• Relies on oscillometric technique
pulse rate, blood pressure
J
AAMI - Association for the Advancement of Medical Instruments
mm Hg = millimeter mercury column
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Sphygmomanometer
Cost Comparison13
Environmental Best Practices for Health Care Facilities Eliminating Mercury in Hospitals
Sphygmomanometer Cost Comparison
Costs Over 5-Year Period
Mercury Unit
Aneroid Unit
Wall Unit Mobile Unit
Electronic Unit
Vital Signs Monitor
Purchase and Training
Purchase Cost14
Batteries
Training15
$129
NA
$20
' $152 $264
NA
$20
$1,250 to $3,000
$30
$80
Calibration
Biomedical Engineer
(15 minutes/calibration x $40/hour) = $ 1 0/calibration
$100"
(every 6 months)
$100"
(every 6 months)
$10
(every 5 years or if damaged)
Storage, Handling and Cleanup
Shipping, Handling and Disposal17
Mercury Spill Training and Equipment (see table below)
$34
as hazardous waste
$649
$0.03
as solid waste
$.017
as solid waste
IMA
5-Year Usage Cost Totals $932 $272 $384 $1,370 -$3120
Mercury Sphygmomanometer Spill Cleanup Costs18
Hard Floor/Early Detection
Hard Floor/Late Detection
Carpeted/Early Detection
Carpeted/Late Detection
^
Mercury Spill Kit
3 Hours of Staff Time
Disposal Of 5-gallon Bucket
Total
Mercury Spill Kit
10 Hours of Staff Time
Disposal Of 5-gallon Bucket
Total
Mercury Spill Kit
1 0 Hours Staff Time
27 Sq. Ft. Carpet Replacement
Disposal Of 5 5-gallon Drum
Total
Mercury Spill Kit
20 Hours Staff Time
90 Sq. Ft. Carpet Replacement
Disposal Of 5 5-gallon Drum
Total
Average Cost per Spill18 =
$325
$45
$620
$990
$325
$150
$620
$1,095
$325
$150
$48
$1,000
$1,523
$325
$300
$160
$1,000
$1,785
$1,539
13 Unless noted, costs are from Holly J. Barron. HealthSystem Minnesota Mercury Reduction "MnTAP Intern Project Report," 2000.
14 Purchase costs are for mercury-free sphygs: Welch Allyn wall unit, Trimline mobile unit, and Alaris/IVAC vital signs monitor (4200 or 4400 Series)
B Trainee (4 employees x 0.25 hour x $15/hour); trainer (0.25 hour x $20/hour); thour training for vital signs monitor
* Assumes one 15 minute calibration takes place every 6 months over the 5 year period (15 min/calibration x $40/hour x 2 calibrations/year x 5 years).
17 Varies by region; hazardous waste ($34 per pound or $895 - $1,200 per 55 gallon drum); solid waste (approx. $0.03 per pound, or $68 per ton);
see www.epa.gov/epaoswer/non-hw/recycle/recmeas/docs/guide_b.pdf) .
* Average for 13 mercury Sphygmomanometer spills
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Eliminating Mercury in Hospitals Environmental Best Practices for Health Care Facilities
Thermometer
Efficacy
Thermometer Efficacy
Accuracy
(see below for
ASTM standards)
Time Required For
Reading
Calibration
Temperature
Range
Other
Considerations
^~ Mercury T
Requires some skill to
account for meniscus
in reading
Oral - 3 minutes
Rectal - 3 minutes
Axillary - 4 minutes
NA
94 to 108°F
NA
r Liquid-in-Glass T
Requires some skill to
account for meniscus
in reading
Oral - 3 minutes
Rectal - 3 minutes
Axillary - 4 minutes
NA
94 to 108°F
NA
••RBi^^
Digital display stan-
dardizes measure-
ments, eliminating
user error
Oral - 4 seconds
Rectal - 1 5 seconds
Axillary - 1 0 seconds
NA
84 to 108°F
3 AA alkaline cells
good for 5,000 to
6,000 readings
Tympanic
Digital display stan-
dardizes measure-
ments, eliminating
user error
Ear - 1 second
6-12 months
Varies significantly
3 -volt lithium or
9-volt alkaline good
for 5,000 to 8,000
readings
T" Dot Matrix ^
Easier to read than a
mercury column
Oral - 1 minute
Axillary - 3 minutes
6—12 months
96 to 104.8°F
NA
• Often not left in place long enough to obtain
accurate reading
• Can be easily broken as a result of rectal
perforation, especially for neonates and
young children
1 Quick, accurate readings
1 Minimally invasive -works well with children
' Requires probe covers for hospital use
' Single use prevents
cross-contamination
' Single use increases
waste generation
' Ideal for isolation
patients
Medical thermometers are tested to voluntary standards set by the American Society for Testing and Materials (ASTM) and shown in following table.
There are non-mercury alternatives that meet these standards— ask your vendor whether the non-mercury aitemative you choose for your facility meets
the ASTM standards' for its class. ,
c
Range
Max. error allowed:
Max. error allowed:
Mercury in Glass -ASTM E667-86 ^\
Electronic -ASTM E-1112-86
< 96.4°F
±0.4°F
±0.5°F
96.4° to 98.0°F
±0.3°F
±0.3°F
98.0° to 102.0 °F
±0.2°F
±0.2°F
< 102.0° to 106.0°F
±0.3°F
±0.3°F
> 106°F
±0.4°F
±0.5°F
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1 ncmiomeler
Cost Comparison
Environmental Best Practices for Health Care Facilities Eliminating Mercury in Hospitals
Fever Thermometer Cost Comparison13
Costs Over 5-Year Useful Life (estimate 35,000 uses; approximately 20/day) '
Purchase/Training
Purchase Cost"
Probe Covers20
Batteries
($5 x replaced every 5,000 uses)
Training
Mercury
$2.00
NA
NA
NA
T" Liquid-ln-Glass 1
$13.75
NA
NA
NA
r Digital
$180
$1,960
($28 per 500)
$35
T" Tympanic
$296
$2,100
($30 per 500)
$35
$2021
"^Dot Matrix/single use"'
$3,500
NA
NA
NA
Calibration
Biomedical Engineering
( 1 5 min/calibration x $40/hour)
NA
NA
$7022
NA
NA
Storage/Handling/ Cleanup
Shipping, Handling and Disposal17
Mercury Spill Training and
Equipment (see table below)
5-Year Cost
$45.00
as hazardous waste
$649
$695
<$0.01
as solid waste
$13.76
$0.02
as solid waste
$2,265
$70.02
as solid waste
$2,511
$3.00
as solid waste
$3,503
Mercury
Hard Floor/
Early Detection
Hard Floor/
Late Detection
Carpeted/
Early Detection
Carpeted/
Late Detection
Thermometer Spill Cleanup Costs
Mercury Spill Kit
3 Hours of Staff Time
Disposal of 5-gallon Bucket
Total
Mercury Spill Kit
10 Hours of Staff Time
Disposal of 5-gallon Bucket
Total
Mercury Spill Kit
10 Hours of Staff Time
27 Sq. Ft Carpet Replacement
Disposal of 5 5 -gallon Drum
Total
Mercury Spill Kit
20 Hours of Staff Time
90 Sq. Ft Carpet Replacement
Disposal of 5 5-gallon Drum
Total
^\
$195
$45
$620
$860
$195
$150
$620
$965
$195
$150
$48
$1,000
$1,393
$195
$300
$160
$1,000
$1,655
L Average Number of Breakages/Year23 = 3.4 per 100 beds
Average Cost/SpilF= $270 ,
0 Unless noted, costs are from Holly J. Barron. HealthSystem Minnesota
Mercury Reduction "MnTAP Intern Project Report." 2000.
"Varies by region; hazardous waste ($34 per pound or $895 to $1200 per
55-gallon drum); solid waste (approx. $0.03 per pound, or $68 per ton);
seewww.epa.gov/epaoswer/non-hw/recycle/recmeas/docs/guide_b.pdf)
19 Purchase and disposal cost for mercury and liquid-in-glass thermometers
is for five thermometers (replaced once per year); digital and tympanic
thermometer is for one unit; dot matrix are single use and cost $10 per
100; liquid-in-glass thermometer purchase cost from Geratherm
20 Average taken from various medical suppliers
" Trainee (4 employees x 0.25 hour x $15/hour);
trainer (0.25 hour x $20/hour) «
22 Assumes one 15 minute calibration takes place every 9 months over the
5 year period (15 min/calibration x $40/hour x 6.66 calibrations/5 years).
23 Average breakage data for four facilities.
24 Average provided by major SF Bay Area Medical Center
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Eliminating Mercury in Hospitals Environmental Best Practices for Health Care Facilities
page 5
Step 5 - Institute Best Management Practices
• Educate staff regarding the hazards of mercury and proper handling and disposal.
• Eliminate mercury-containing equipment and products.
• Establish and monitor mercury-free purchasing policies.
Step 6 - Measure Success
Use your mercury inventory (from Step 2) to re-evaluate your facility. Identify your
successes and modify your plan as necessary. Most importantly, get the message
out to hospital staff members that they are making a difference!
Step 7 - Keep The Mercury Out
Work with your purchasing department to make sure that mercury products do
not find their way back into the hospital. Require vendors to disclose the mercury
content of products that you intend to purchase. See Tools for Change at
www.sustainablehospitals.org for an example of a vendor product mercury-content
disclosure agreement and mercury-free purchasing policy language.
(Table 1)
Mercury Spill Training and Equipment13
Training
Cost
Trainees $90
(3 employees x 2 hrs x $15/hr) + loss of productivity
Trainer (2 hrs x $20/hr) $40
+ loss of productivity
Equipment
Cost
Spill Kit and
Draeger Mercury Sniffer
$519
Total Cost: $649
Mercury Spills
Depending on the type and size of the spill and the facility, mercury cleanups at hospitals are sometimes handled by staff if they are trained and
available, or otherwise addressed by cleanup contractors. While mercury spill data from a wide variety of health care facilities including large and
small, urban and rural, emergency, research and clinical facilities are generally unavailable or incomplete, the best available data comes from a large
hospital at the University of California, Los Angeles (UCLA) between 1997 and 1999 (see summary on previous page).
What Does It Cost To Prepare For and Clean Up Mercury Spills?
Because of health and safety considerations and the environmental impact of mercury,
any hospital that stores and uses mercury-containing devjces within its facility is required
by federal regulations to be prepared to handle mercury spills. Table 1 shows costs for
mercury spill training and equipment that a hospital will incur, and Table 2 lists liability
costs that a hospital might incur. Actual cleanup costs for several spill scenarios are
itemized in the sphyg and thermometer inserts.
Human Health and Environmental Liability
Case-specific
Up to $ 75,000 +
possible jail sentence
9 California Department of Health Services. 2000. A Guide to Mercury Assessment and Elimination
in Healthcare Facilities, www.dhs.ca.gov/medicalwaste
" Leick-Rude, M.K. and Bloom, LF. 1998. A Comparison of Temperature-Taking Methods in Neonates. Neonatal Network. Volume 17. Number 5. Pages 21-37.
" Mayfield, S. R. et al. 1984. Temperature Measurements in Term and Preterm Neonates. Journal of Pediatrics. Volume 104. Number 2. Pages 271-275 as cited in Leick-Rude,
M.K. and Bloom, LF. 1998.
12 N.K. Markandu, F. Whitcher; A. Arnold and C. Carney. "The Mercury Sphygmomanometer Should Be abandoned Before it is Proscribed." Journal of Human Hypertension.
Volume 14, pages 31 through 36.2000.
13 Holly J. Barren. HealthSystem Minnesota Mercury Reduction "MnTAP Intern Project Report." 2000.
continues
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page 6
Environmental Best Practices for Health Care Facilities Eliminating Mercury in Hospitals
The following three case studies are summarized in terms of "Impetus," "Actions" and "Results" to help identify the challenges faced by hospitals and
the solutions they employed to start eliminating mercury. While each hospital is unique, these case studies may help you anticipate hurdles and
estimate costs associated with mercury elimination.
case study 01 Mercury Costs Prompt Elimination Program in Rochester, NY
Impetus: The 750-bed Strong Memorial Hospital (SMH) is the primary teaching hospital of the University of Rochester
Medical School and is a regional trauma center. Since 1997, SMH has implemented a focused mercury
reduction plan to eliminate the problems associated with spill response, disposal, and training.
Actions: Executive involvement and support:
• SMH signed a memorandum of understanding with the Monroe County Health Department
• CEO assigned program personnel and resources
Staff training and involvement:
• Trained staff in program objectives and mercury awareness
• Multidisciplinary teams identified mercury-containing devices and mercury use
• Developed a mercury training poster for newly hired nurses
• Developed and distributed a mercury use and disposal pamphlet
• Added a mercury-specific training unit to the annual Resource Conservation Recovery Act (RCRA) training,
including a "show-and-tell" for different mercury-containing items encountered during routine maintenance
• Included questions on Joint Commission on Accreditation of Healthcare Organization (JCAHO) safety ^
surveys about proper mercury disposal and a check box noting the presence of mercury-filled sphygs
• Added a hazardous materials section (including mercury) to the project manager's renovation and
construction manual
Mercury Collection:
• Developed and implemented procedures to improve staff use of mercury collection facilities including:
- Placing specially-labeled collection containers for mercury thermometers within patient care units
- Adding labels on or near sharps containers to remind staff members not to place thermometers
- in the medical waste containers
- Establishing easy-to-access battery drop-off locations
- Establishing a centralized collection point for used
fluorescent lamps
Results: • Replaced all mercury sphygs
• Reduced mercury thermometer use by over 90% — encountered difficulty replacing thermometers in the
neonatal intensive care unit due to infection control concerns
• SMH's program cited as an example of a quality improvement initiative during the 1998 JCAHO survey
• Eliminated annual disposal of 45 pounds of mercury-filled GI tubing by purchasing only tungsten-filled
GI tubing since the program began
• Histopathology and other clinical laboratories discontinued use of mercury compounds
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Eliminating Mercury in Hospitals Environmental Best Practices for Health Care Facilities page 7
case study 02 Wastevvater Violations Force Change in Boston, MA
Impetus: Beth Israel Deaconess Hospital began its mercury reduction program in 1993 when the local sewer district
lowered mercury limits in industrial wastewater to 1 part per billion (ppb) resulting in subsequent fines of
$118,000 for exceedences. Beth Israel's wastewater contained approximately 360 ppb mercury.
Actions: • Trained staff on mercury sources and proper disposal methods, posted wastewater data, and changed the
collection process for mercury-laden chemicals including the fixatives B5 and Zenker's solution
• Infrastructure upgrades: cleaned traps and pipes
• End-of-pipe treatment: installed a sand filter ($40,000) and a dewatering unit ($60,000) both requiring
minimal maintenance
• Instituted a wastewater sampling program to establish a baseline for measuring its progress
Results: (Baseline Wastewater Mercury Content: 360 ppb mercury)
• Training, awareness and lab chemical replacement reduced mercury content to 100 ppb
• Trap and pipe cleaning reduced content to 4—8 ppb
• Improved wastewater treatment reduced content to < 1 ppb
case study 02 | Spills Prompt Mercury-Free Commitment in Grand Rapids, MI
Impetus: Butterworth Hospital with 529 beds made a commitment to eliminate mercury after three separate mercury spills
cost the hospital over $6,000. In 1995, the hospital estimated that there was 1.5 pounds of mercury per bed.
Actions: • Replaced all existing sphygs and esophageal dilators containing mercury
• Instituted a policy banning the purchase of mercury-containing thermometers, sphygs,
esophageal dilators, and batteries
Results: , • Removed 300 pounds of mercury
• No longer sends mercury-containing devices overseas as part of its humanitarian efforts
Continues
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page 8
Environmental Best Practices for Health Care Facilities Eliminating Mercury in Hospitals
Resources
Mercury-Free Thermometers
Alaris/IVAC
(800) 854-7128
www.alarismed.com
Braun
(800) 327-7226
Geratherm
(888) 596-9498
www. 1 thermometer .com
Medical Indicators
(888) 930-4599
www. medicalindicators. com
Omron Healthcare*
www. omron. com/ohi
Welch Allyn
www.ivelchallyn.com
3M Healthcare
(800) 228-3957
wivw.3m.com/healthcare
Mercury-Free
Sphygmomanometers
Alco Classic*
(800) 323-4282
American Diagnostic
Corporation
(631)273-9600
www.adctoday .com/
Omron Healthcare*
www. omron. com/ohi
Tips On Procurement
www.state.ma.us/ota/pubs/epp-
march01.htm#/tips
Trimline
(800) 526-3538
www. trimlinemed. com
W.A. Baum
(888) 281-6061
(631)226-3940
Welch Allyn*
www.welchallyn.com
Mercury-Free
Gastrointestinal Devices
Miller Abbot Tubes
Anderson
(800) 523-1276, x 292
Bard Medical Services
(800) 227-3357
Rusch
(800) 553-5214
www.ruschinc.com
Bougie Tubes
Pilling
(800) 523-6507
Cantor Tubes
Anderson
(800) 523-1276, x 292
Mercury-Free
Vital Signs Monitors
Alans
(800) 854-7128
www. alarismed. com
WekhAllyn
www.welchallyn.com
Mercury-Free
Laboratory Chemicals
For alternatives see the list at
www.sustainablehosptals.org
* Companies with a mercury exchange program to help defray the cost of replacing mercury-contafning devices.
See www.state.ma.us/ota/pubs/eppmarch01.htm#tips for tips on procuring non-mercury sphygmomanometers.
This fact sheet was produced by the Environmental Protection Agency (EPA) Region 9 Pollution Prevention Program. Mention of trade names, products,
or services does not convey, and should not be interpreted as conveying, official EPA approval, endorsement, or recommendation. ^
Printed on 100% post consumer recycled paper. Processed chlorine free. Utji)
-------
Using Microfiber
Mops in Hospitals
Environmental Best Practices for Health Care Facilities I November 2002
JCAHO Environment of Care
Standards 1.3,2.3,4.0
• Large, heavy mop
• Requires frequent c,
of cleaning solution
• High chemical and water
• Labor intensive
Conventional Wet Loop|Mops
VS.
Microfiber Mops
• Light and ergonomic
• Prevents dirty mop heads from
contaminating cleaning solution
• Dense, durable fibersfeach
into surface pores
> Cost effective
Why Consider Alternative Mopping Techniques?
Using conventional loop mops for wet mopping of patient care areas has long been the standard in floor
cleaning for janitorial operations in hospitals. However, the health care industry has taken a recent interest
in evaluating hard floor maintenance techniques in terms of employee, patient, and environmental health.
Many floor cleaners used in hospitals contain harsh chemicals such as quaternary ammonium chlorides
and butoxyethanol, which can be harmful to human health and the environment. To reduce the risk of
cross-contamination for patients, conventional mopping techniques require janitors to change the clean-
ing solution after mopping every two or three rooms—meaning that cleaning solutions (including both
chemicals and several gallons of water) are constantly being disposed of and replenished.
Some facilities have begun using a new mopping technique involving microfiber materials to clean floors.
Microfibers are densely constructed, polyester and polyamide (nylon) fibers that are approximately 1/16
the thickness of a human hair. The density of the material enables it to hold six times its weight in water,
making it more absorbent than a conventional, cotton loop mop. Also, the positively charged microfibers
attract dust (which has a negative charge), and the tiny fibers are able to penetrate the microscopic surface
pores of most flooring materials. These characteristics make microfiber an effective mopping material;
the following case study provides detailed information to help your hospital evaluate the possibility of
using microfiber mops.
case study Mopping Up Savings at UC Davis
The University of California Davis Medical Center (UCDMC) in Sacramento, CA, had three
motivations for changing the way its custodial staff maintained the floors in patient care areas:
• Reduce chemical use and disposal. Conventional wet mopping practices require cleaning
solution changes after every third room to reduce patient health risks from cross-contamination.
• Reduce cleaning times for patient rooms. Conventional wet mopping practices-
including mopping the floor, preparing and changing the cleaning solution, and
wringing the mop before and after jobs—take approximately 15 minutes for a typical
patient room.
• Reduce custodial staff injuries and workers' compensation claims. Conventional wet
mopping practices can lead to custodial staff injuries through the repeated motions of
mopping and wringing.
The environmental staff at UCDMC identified MicroScrub® microfiber mops as a
potential alternative to conventional mops that might reduce costs. However, before
changing the floor maintenance techniques, the environmental staff had a few obstacles to overcome. For example, the custodial
staff was somewhat averse to change and was unconvinced that the microfiber mops would be as effective. Other hospital personnel,
such as nurses and doctors, and even patients also shared this concern.
i continues
Microfiber Mops
• are less work-intensive
than conventional
mops,
• virtually eliminate
cross-contamination
during janitorial tasks, and
1 drastically reduce chemical and water
use while cleaning more effectively.
-------
page 2
Environmental Best Practices for Health Care Facilities Using Microfiber Mops in Hospitals
Reasons for Change
Although change is never easy, the environmental staff worked
with custodial supervisors to communicate the personal bene-
fits of using microfiber mops in place of a conventional mop.
There were two characteristics that helped alleviate the con-
cerns of the custodial staff. First, the microfiber mops weigh
approximately five pounds less than conventional wet loop
mops, making them much easier to use. Second, the microfiber
mop head is changed after every room is mopped, benefiting
the custodial staff in two ways: 1) the effort of wringing a
conventional mop is eliminated, and 2) as long as the used
mop head is not put back in the cleaning solution, the custodian
does not have to change the solution between rooms. The latter
feature was particularly attractive, as a full bucket of cleaning
solution can weigh 30 pounds or more and has to be lifted an
average of seven times a day. Both characteristics have signifi-
cantly reduced labor costs. Moreover, because the same mop
water is not being shared between rooms, microfiber mopping
virtually eliminates the cross-contamination risk that floor
mopping can pose for patients.
To address concerns regarding the effectiveness of the microfiber
mops, the environmental staff performed demonstrations in
which an area would first be cleaned with a conventional mop
and then re-cleaned with a microfiber mop. In each case, the
microfiber mop would capture more dust and dirt. However,
when the same test was done in reverse order, the conventional
mop was not able to capture more dust and dirt beyond the
capabilities of the microfiber mop.
Cost comparisons between conventional wet loop mops and microfiber mops for UC Davis Medical Center
Rooms Cleaned Per Washing
$17.40each
500 to 1000'
1
$1.74 to $3.48 per 100 rooms
22 per eight hour shift
$ 12 per hour
$436 per 100 rooms
Quantityof Chemical:
Rooms Cleaned Per Day:
0.5 ounce per day
$.22 per ounce
22
$0.50 per 100 rooms
$5.00 each
55 to 2002
22
$.11 to $.41 per 100 rooms
20 per eight hour shift
$ 12 per hour
$480 per 100 rooms
10.5 ounces per day
$.22 per ounce
20
$11.55 per 100 rooms
Rooms Cleaned:
Total:
1 gallon
22
5 gallons per 100 rooms
21 gallons
20
105 gallons per 100 rooms
Electricity Usage (Washing)
Cost:
$.030per mop
CleaningFrequency:
once per room
Cost Total:
$30 per 100 rooms
$1.00 per mop
once per day
$5 per 100 rooms
1 Vendors guarantee microfiber mop heads for 500 washings;
UCDMC typically used mop heads for over 1,000 washings.
2 vendors estimate conventional wet loop mops to last 55 washings;
UCDMC replaced them after 200 washings.
» Total Costs «
$468 to $470
per 100 rooms per day
$497
per 100 rooms per day
> > Microfiber mops use 95% less water and chemicals < <
-------
Using Microfiber Mops in Hospitals Environmental Best Practices for Health Care Facilities
page 3
Program Results
UCDMC first used the microfiber mops in a pilot test beginning
in summer 1999, and within one year it completely replaced
conventional loop mops with the microfiber alternative in all
patient care areas. The program resulted in three measurable
economic benefits:
• 60% lifetime cost savings for mops
• 95% reduction in chemical costs associated
with mopping tasks
• 20% labor savings per day
The initial cost to implement the program was significant, as
a microfiber mop costs over three times more than a conven-
tional loop mop. However, the manufacturer guarantees the
microfiber mop head for 500 washings, while a conventional
mop typically withstands only 55 washings, giving the microfiber
mop a comparatively low lifetime cost. Although UCDMC uses
quaternary ammonium chloride solution for other applications,
switching to the microfiber mopping system reduced the amount
of the chemical purchased by 46 percent, from 513 gallons in
1999 to 283 gallons in 2000. Also, because the microfiber mops
are easier and faster to use, UCDMC saved 638 hours per year
for each worker, or approximately $7,665 in wages.
Three other economic benefits are less easily quantified and
will vary by location: 1) cost savings from decreased water use,
2) reduced workers' compensation claims, and 3) potential
construction savings from eliminated need for mop sinks in
janitor's closets. Because janitors no longer change cleaning
solution every third room, UCDMC cut its water use for mop-
ping by 95%. Another benefit that has become apparent is the
cost savings from reduced workers' compensation claims.
UCDMC management has determined that the microfiber mops
are easy enough to use that janitors placed on "light duty"
because of an injury are tasked with mopping floors. However,
because of the variety of claims made and the inconsistent
associated costs, UCDMC has been unable to quantify the cost
savings from reduced claims. Lastly, since microfiber mops
eliminate the need to frequently change cleaning solution and
rinse mop heads, the need for a mop sink in janitor's closets is
The secret of microfiber
Microfiber cleaning materials are a blend
of microscopic polyester and. polyamide
fibers which are split in such a way as to
create microscopic "hooks" which act as
claws that scrape up and hold dust, dirt,
and grime. They are 1/16 the thickness of
a human hair and can hold six times their
weight in water.
eliminated. This should be taken into consideration when new
facilities are built or existing facilities are remodeled.
Limitations
UCDMC does not use the microfiber mops in areas contaminated
with an extraordinary amount of blood or other body fluid,
including certain areas of the emergency and operating rooms.
In these cases, UCDMC personnel use conventional loop mops.
The microfiber mops are also not used in greasy, high-traffic
kitchen areas; rather, UCDMC continues to use mechanical
floor cleaning machines in these areas.
The microfiber mop heads cannot be laundered in industrial
washers and dryers, as the heat settings are often too high and
can damage the material. To address this issue, UCDMC estab-
lished a cooperative agreement with Mercy General Hospital
(which also uses microfiber mops), to launder the mop heads
in house. Mercy General Hospital uses a standard commercial
washer and dryer .with controlled heat settings and standard
laundry detergent. The vendor advises against using chlorine
continues
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page 4
Environmental Best Practices for Health Care Facilities Using Microfiber Mops in Hospitals
bleach, which can degrade-the material, and discourages washing
microfiber mops with other non-microfiber materials.
How many mops do you need?
Because a clean microfiber mop head must be used in each
patient room, UCDMC learned that it is important to consider
the amount of time required to launder the mop heads when
determining how many to purchase. If this factor is not properly
evaluated, instances could occur where not enough clean micro-
fiber mop heads are available for the day's cleaning routine.
Simply put, the longer the turnaround time for laundering the
mop heads, the more mop heads needed. UCDMC learned that
room size affects the number of mop heads needed. Because a
microfiber mop is not dipped back in the cleaning solution
once the mop has been used, larger rooms may require more
than one mop head. Mercy General Hospital has implemented
another way to add more moisture and cleaning solution with-
out causing cross-contamination concerns: their janitorial staff
carries a spray bottle of cleaning solution to use on stubborn
spots or to provide additional moisture.
Resources
UCDMC Case Study:
Environmental
Service Department
(916)734-3425
Vendors:
Clean System
(415)939-0301
www. cleansystem. com
Edge Tech Industries
(858) 627-9260
www.edgetk.com
Redco
(714) 418-2960
www.dustneversleeps.com
The-Cloth.com
(877) 837-3045
www.amazingcloth.com
The Rag Company
(208) 322-4703
www.theragcompany.com
Ml
This fact sheet was produced by the Environmental Protection Agency (EPA) Region 9 Pollution Prevention Program. Mention of trade names, products,
or services does not c6nvey, and should not be interpreted as conveying, off icial EPA approval, endorsement,or recommendation.
Printed on 100% post consumer recycled paper. Processed chlorine free. (.f\)
-------
Reducing Ethylene Oxide
and Glutaraldehyde Use
Environmental Best Practices for Health Care Facilities I November 2002
JCAHO Environment of Care
Standards 1,3,2.3,4.0
Where are Ethylene Oxide and Glutaraldehyde Used?
Although many environmentally preferable technologies exist for sterilizing equipment and surfaces within hospitals, these technologies
can damage some medical instruments that are susceptible to moisture and heat. In such cases, hospitals typically use ethylene oxide (EtO)
to sterilize moisture- and heat-sensitive Instruments and glutaraldehyde as a high-level disinfectant. Health care employees who commonly
use glutaraldehyde-based products work in many departments, from gastroenterology, urology, and cardiology to x-ray, laboratory, and
pharmacy. This fact sheet provides.background information on the uses and hazards of both chemicals, describes environmentally preferable
alternatives, and provides detailed case study and cost information to help your hospital evaluate alternatives to EtO and glutaraldehyde.
The first step in assessing the impacts of ttO and glutaraldehyde is to conduct an inventory of who, how, and where the chemicals are used in
your hospital. Completing the usage inventory will enable you to prioritize your actions, monitor progress in eliminating the use of the chemicals,
and ensure that affected employees are included in training and monitoring programs. In addition, an inventory may create opportunities for
gathering feedback from hospital personnel on EtO, glutaraldehyde, and which alternatives might be best. Common locations to look for EtO
and glutaraldehyde are mentioned in the following sections. ,
Why Eliminate EtO?
Ethylene oxide (EtO) poses several health hazards requiring special
handling and disposal of the chemical and training in its use. It is identified
by the National Toxicology Program as a known human carcinogen (see
http://ntp-server.niehs.nih.gov/) and has several other acute and chronic
health effects:
• Inhaling EtO can cause nausea, vomiting, and neurological disorders.
• In solution, EtO can severely irritate and burn the skin, eyes, and lungs.
• EtO is a probable teratOgen and may pose reproductive hazards.
• EtO may damage the central nervous system, liver, and kidneys,
or cause cataracts.
MHMH s 3-Step Approach to Eliminating EtO
1-2-3
Determine
which medical
instruments are
sterilized using
EtO.
Evaluate
methods of
eliminating
EtO steriliza-
tion for each
instrument*
'Usually achieved by alternative technologiesor a
new or alternative device approved for sterilization
with non-EtO technologies
Establish a "work-
ing group" to facil'
itate the decision
making process
and ensure that
sterilization
standards are not
compromised.
EtO is also extremely reactive and flammable, increasing the risk of chemical
accidents that could injure hospital employees and patients. For example,
even static electricity can cause EtO to ignite; therefore, employees using it should be well trained and aware of its potential dangers. A small selec-
tion of hydrogen peroxide- and peracetic acid-based sterilants can be used to replace EtO for many applications throughout your hospital. The fol-
lowing case study discusses the costs and benefits of switching to non-EtO alternatives.
case study Finding Alternatives to EtO at Mary Hitchcock Memorial Hospital'
Facing increasing regulatory pressure and a growing awareness of the occupational exposure hazard of using EtO, Mary
Hitchcock Memorial Hospital (MHMH) in Lebanon, New Hampshire began evaluating non-EtO sterilization unit alternatives.
MHMH adopted two alternative technologies: Sterrad, a plasma phase hydrogen peroxide-based sterilizing agent and Steris, a
peracetic acid-based technology. The primary difference between the two alternatives is that Steris is a "just-in-time" technology
that requires sterilized items to be immediately used after being removed from the unit. This aspect makes it impractical in some
applications, specifically for trauma cases where the need for a specific instrument cannot be predetermined. In most cases,
continues
-------
page 2
Environmental Best Practices for Health Care Facilities
Reducing Ethylene Oxide and Glutaraldehyde Use
MHMH Sterilization Cost Comparison
Ethylene Oxide (EtO)
Non-EtO Alternatives
Capital Costs
New emissions control equipment for existing
Renovation and construction
"Lost time" from construction disruption
2 Sterrad units2
EtO unit $25,000
:.. $20,000
$20,000
$212,000
Cost Total: $277,000
2 Steris units
New and/or replacement of instruments over 2 yrs
Cost Total
$212000
$35,000
.$50,000-$75,000
$297,000-$322,000
Annual Operating Costs3 • . • *
Alarm system maintenance, testing, EtO monit
Sterrad operating costs
V
$10,000
$5,000
3ring $5 000
$2,000
Cost Total: $22,000
Sterrad operating costs -.
Steris operating costs
EtO outsourcing ($80/Ioad approx. 60 loads/year)...
$2,000
$1,000
$4 800
Cost Total: $7,800
J
1 Background information adopted fromTelluslnstitutes"Healthy Hospitals: Environmental ImprovementsThrough Environmental Accounting—Appendix B"
2 BecauseEtooperations are limited to one load perdayunderMHMHs Title V permit, the addition of two non-EtO units were needed to meet the sterilization needs of the hospital.
3 Contingent costsof an EtO incident or related fines are not included
Advanced Sterilization Products
provided the following costs
per sterilized square foot:
Sterrad has proved to be an acceptable alternative to EtO; how-
ever, in some instances, manufacturers have not yet approved
the use of EtO alternatives for sterilization of their -products.
Such limitations vary by vendor and are not specific to one
instrument or medical device product type. For example,
MHMH must still sterilize the following five instruments using
EtO: angioscopes, choledocoscopes, surgiscopes, bone flaps, and
hysterectoscopes.
Devices that have not been approved for sterilization using EtO
alternatives are often constructed of complex mixed-media mate-
rials. To completely eliminate
the need for EtO, MHMH is
collecting data from other
healthcare facilities to find
alternative instruments (or in
some cases, the same prod-
uct by a different vendor)
that have been approved for non-EtO sterilization alternatives.
MHMH conducted a detailed cost analysis to evaluate the difference
between using EtO and non-EtO sterilization technologies (see
"MHMH Sterilization Cost Comparison"); however, several costs
and benefits of eliminating EtO were not quantified, including:
• Transaction cost of reduction effort
• Value of quicker average sterilization time
. Benefit of increased availability of instruments and
sterilization process control, which ultimately translates
to better infection control
• Instrument upgrade/replacement costs; some of which would
have been necessary regardless of the EtO elimination effort
« Benefit of avoided EtO exposure incidents
Overall, MHMH staff are pleased with both Steris and Sterrad
technologies. In addition, because the new technologies have
shorter processing times and therefore higher productivity,
MHMH is able to sterilize instruments that were previously
being high-level disinfected. Also, the labor required to operate
the technologies has proven to be less than expected, despite
increased productivity.
Why Eliminate Glutaraldehyde?
Glutaraldehyde is most frequently used as a cold liquid high-level disin-
fectant for heat-sensitive equipment such as dialysis instruments; surgi-
cal instruments; suction bottles; bronchoscopes; endoscopes; and ear,
nose, and throat instruments. There are other, less obvious areas where
glutaraldehyde is used as well. For example, it is used as a tissue fixative
in histology and pathology laboratories and as a hardening agent in the
development of x-rays. Unlike EtO, glutaraldehyde is not a human carcino-
gen; however, several health effects have been reported among hospital
workers exposed to glutaraldehyde:
• Asthma, and breathing difficulties
• Burning eyes and conjunctivitis
• Headaches
• Nosebleed, irritation, sneezing,
and wheezing.
Several hydrogen peroxide-, peracetic acid-, and orthopalahaldehyde-
based high-level disinfectant solutions can be used to replace glutaralde-
hyde throughout your hospital. The following case study discusses the
costs and benefits of switching to glutaraldehyde alternatives.
case study Kaiser Woodland Hills Medical
Center Eliminates Glutaraldehyde
Prompted by increasing health concerns related to the use of
glutaraldehyde, Kaiser Woodland Hills Medical Center
Hives
Nausea
Rashes and allergic dermatitis
Staining of the hands ,
Throat and lung irritation
-------
Reducing Ethylene Oxide and Glutaraldehyde Use
Environmental Best Practices for Health Care Facilities
page 3
(Woodland Hills) in Woodland Hills, CA eliminated it from its
highest use area: the Gastroenterology Department. This
department accounts for over 50% of the hospital's glutaralde-
hyde use. The department relies on eight automated endo-
scope reprocessors for high-level disinfection of endoscopes,
which are in use about eight hours each day. The Environ-
mental Health and Safety Director at Woodland Hills identified -
Cidex OPA (ortho-phthalaldehyde) as a possible glutaraldehyde
alternative because of 1) its lower inhalation exposure risk, 2)
reduced disinfecting time (12 minutes vs. APIC-approved 20
minute disinfection time and FDA-approved 45 minute disin-
fecting time for Cidex), 3) the solution is approved for use in
almost all of their equipment without negating the warranty
and 4) the cost of using Cidex OPA was significantly less than
installing a more substantial ventilation system to minimize
respiratory irritation from using glutaraldehyde. Cidex OPA,
however, cost approximately $25 per gallon—three times more
than glutaraldehyde.
Due to its toxicity, California legislation deemed Cidex OPA a
hazardous waste'beginning January 1, 2001. However, this
legislation exempts healthcare facilities from tiered permitting
regulatory requirements when treating Cidex OPA with glycine
on site to render it a non hazardous waste. (If local publicly
owned treatment works (POTWs) or sewer agencies have other
prohibitions against sewerage of aldehydes, facilities must seek
approval for this process as well.) To comply with California
Top Reasons to Eliminate Glutaraldehyde
Adapted from the Sustainable Hospitals Project
Glutaraldehyde is a potent occupational skin irritant
and sensitizer.
' Glutaraldehyde is a recognized cause of occupational asthma.
' Patients, visitors, and hospital employees may be needlessly
exposed to glutaraldehyde vapors in patient rooms and clinic
areas where open bins or poorly ventilated reprocessing units
are in use.
• Cost-competitive alternatives exist that meet infection
control standards and reduce risks to patient, visitor, and
employee health.
• Several regulatory organizations, including OSHA, NIOSH,
andACGIH, are re-evaluating their exposure limits for
glutaraldehyde.
The Sustainable Hospitals Project website includes a 4-step
glutaraldehyde use survey that can help 1) identify where glutaralde-
hydeis used, 2)prioritize areas for improvement, 3) monitor progress,
and 4) ensure affected employees are included in training and
monitoring programs.
legislation, Woodland Hills treats Cidex OPA with 25 grams of
glycine per gallon for 1-hour, which renders it a non-hazardous
waste. Woodland Hills must utilize an external treatment tank
for this process, since manufacturer warranties would be voided
if the Cidex OPA were treated within the reprocessor. It spent
continues
Overview of EtO and Glutaraldehyde Alternatives-
Sterrad
(Advanced Sterilization
Products)
Enclosed sterilization processor
with 45-minutecycle time
Processor $65,000 to $130,000
Hydrogenperoxide cassettes $216
to $265 per case ($43 to $53 per
cassette, or $9 to $10 per cycle)
Generates hydrogen peroxide gas
plasma from 58% hydrogen
peroxide solution
Steris 20
(Steris Corporation)
Cidex OPA"
(Advanced Sterilization Products)
Sterilizationin 12 minutes at 50 to
55°C; instruments "patientready"
in less than 30 minutes
Processor $18,200
Peracetic acid cups $ 128 per case
($7 per cup)
Glutaraldehyde Alternatives
High-level disinfection in
12 minutes at 20 °C
$25 per gallon
0.2% peracetic acid
(diluted from 35%)
0.5 5% OPA solution: exposure limits
not yet determined
Sporox H
(Sultan Chemists)
High-level disinfection in
30 minutes at 20 °C
$2 5 per gallon
7.5% hydrogen peroxide
Sterilox
(Sterflox Technologies Inc.)
Cycle time is 10 minutes for high-
level disinfection
Rental of generator $ 15,000 year
costing approximately $ 1 — $3 per
cycle, depending on use
System generates hypo-chlorus acid
Currently used in Europe as liquid
chemical sterilant; FDA pre-market
clearance pending
Table adapted from Sustainable Hospitals Project website. Costs provided are vendor list prices; actual costs may vary significantly under contract agreements.
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page 4
Environmental Best Practices for Health Care Facilities
Reducing Ethylene Oxide and Glutaraldehyde Use
$700 to purchase the external treatment tank, which includes
a mobile cart, treatment tank, pump, and tubing. Glycine costs
approximately $5 per gallon, including the cost of the product and
labor. This is more effort than what is required for glutaraldehyde;
vendors often provide test strips that when dipped in solution,
will change color to show whether it has fully degraded.
Despite the added treatment steps, Woodland Hills employees
are very satisfied with the OPA-based product. Symptoms asso-
ciated with using Cidex OPA are described as being very mild,
with select staff indicating slight eyelid irritation and a "chalky"
taste after prolonged use. However, Woodland Hills staff noted
that the complaints received for OPA are much less frequent
and significantly less severe than comments made regarding
glutaraldehyde. Also, because Cidex OPA has a quicker cycle
time than glutaraldehyde, Woodland Hills saves approximately 8
minutes with each disinfection cycle, or a savings of 1 hour for
each 8-hour automated endoscope reprocesspr shift. This
allows greater turn-over of endoscopes, while requiring fewer
reprocessors to disinfect them. This is especially important to
consider for new facilities, since the cost of endoscopes is
approximately $30,000 and reprocessors are often near $15,000.
In addition, Woodland Hills has found that Cidex OPA does not
lose efficacy.as fast as the glutaraldehyde-based product. In their
high-volume department, they are now able to disinfect approx-
imately 60% more endoscopes during the life of the solution;
Accounting for Time
Perhaps the most significant savings when switching to a non-
EtO or non-glutaraldehyde alternative is the value of time
saved in sterilizing or disinfecting equipment. This value is diffi-
cult to quantify however, because the direct impact of shorter
process times is dependent on several factors, including such
things as. on-hand inventory of equipment and cost of labor..
A Look at Orfho-Phthalaldehyde
(Adapted from the Michigan Health and Hospital Association Employee
Safety and Disability Service Newsletter)
Also an aldehyde, ortho-phthalaldehyde (OPA) is chemically related
to glutaraldehyde. According to the Michigan Health and Hospital
Association (MHA), the disinfecting mechanism of OPA is thought
to be similar to glutaraldehyde and is based on the powerful binding
of the aldehyde to the outer cell wall of contaminant organisms.
A notable difference between the two commercial disinfectants is the
percent of active ingredient in each product. Commercial OPA-based
disinfecting products contain only 0.55% of the active ingredient,
while most glutaraldehyde-based disinfecting products contain 2.4
to 3.2% active ingredient — 5 to 7 times that of OPA products.
Although OPA may pose similar occupational hazards to glutaralde-
hyde — including mild eye, skin, and respiratory tract irritation and
skin and respiratory sensitization — the risk is significantly reduced
due to the low percentage of OPA and relatively low vapor pressure
of OPA-based commercial products. OPA does not currently have a
recommended exposure limit; however, vendors recommend that
similar protective equipment be used, including gloves and goggles.
For example, consider the Kaiser Woodland Hills glutaraldehyde
case study: using Cidex OPA saved 1 hour of endoscope pro-
cessing time each day. This can result in a significant increase
in productivity by allowing equipment to be available for
patient care sooner. A shorter process time also saves labor, as
technicians do not have to wait as long for equipment to
process, allowing them to do more with their time. Ultimately,
quicker process times can mean that more patients get treated
sooner. A careful analysis of how time affects your facility
should be performed when considering non-EtO or non-glu-
taraldehyde alternatives. While difficult to calculate, these
savings can easily make up for the higher cost of non-EtO and
non-glutaraldehyde alternatives.
Resources
Cidex OPA Material Safety Data Sheet, Advanced Sterilization
Products. http://www.cidex.com/ASPnew.htm
Massachusetts Toxics Use Reduction Institute. "Massachusetts
Chemical Fact Sheet: Ethylene Oxide." www.turi.org/PDF/eo.pdf
Michigan Health and Hospital Association. "Glutaraldehyde Free
High Level Disinfectant Introduced," March 2000. \vww.mhaser-
vicecorp.com/esdm/newsletter_archive/pages_archive/
Years_past/March2000nv.html
National Institute for Occupational Safety and Health.
"Glutaraldehyde: Occupational Hazards in Hospitals." May 2001,
National Safety Council."Ethylene Oxide Chemical Backgrounder."
July 1997. www.nsc.org/library/chemical/EthylenO.htm
Occupational Safety and Health Administration.
www. osha-slc .gov/SL TC/ethyleneoxide/index. html
Sustainable Hospitals Project, www.sustainablehospitals.org
Tellus Institute. "Healthy Hospitals: Environmental Improvements
Through Environmental Accounting." July 2000.
www.tellus.org/b&s/publicaticns/R2-213-Nb.pdf
This fact sheet was produced by the Environmental Protection Agency (EPA) Region 9 Pollution Prevention Program. Mention of trade names, products,
or services does not convey, and should not be interpreted as conveying, official EPA approval, endorsement, or recommendation.
(&\
Printed on 100% post consumer recycled paper. Processed chlorine free. \J*4?/
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Reusable Totes,
Blue Wrap Recycling
and Composting
Environmental Best Practices for Health Care Facilities I November 2002
JCAHO Environment of Care
Standards 1.3,2.3,4.0
How Much Waste is Wasteful?
Although medical and infectious wastes are often highlighted in evaluations of
a hospital s waste stream, these hazardous wastes constitute only 15% of a hos-
pitals total waste generation. The remaining 85% of a hospital s waste, which is
considered to be nonhazardous solid waste, is similar to a combination of
wastes from hotels, restaurants, and other institutions providing lodging, food
services, data processing and administration, and facility operations. In fact,
disposal costs for hospital solid waste in 2000 ranged from $44 to $68 per ton,
depending on local conditions, disposal method (landfilling versus incinera-
tion), and proximity to the disposal facility. Often, solid waste is mistakenly
placed in red bag or medical waste containers, thus increasing the cost of
disposal and unnecessarily raising the level of treatment needed for the waste.
By implementing effective solid waste reduction and recycling programs, hospi-
tals can significantly reduce their solid waste streams.
This fact sheet highlights case studies for three of the largest components of
an average hospitals solid waste stream: paper material (including cardboard),
plastics, and food waste. The casa studies provide detailed information on
costs, savings, and implementation issues to he.lp your facility evaluate these
waste reduction and recycling techniques.
Hospital Solid Waste Composition
Other Wood Glass Plastics Food Metals Paper
10% 3% 7% 15% 10% 10% 45%
From Bisson, McRae, and Shaner,1993
Reusable Totes: Cardboard Pollution Solution
Cardboard and other paper materials represent almost half of a typical hospitals solid waste stream. The following case study describes how one
large healthcare system decreased cardboard and packing material use by implementing reusable totes for internal distribution of supplies. The
cost-effectiveness of using reusable totes varies among hospitals and greatly depends on the structure of the health care organization. The reusable
totes are most cost-effective when they replace a constant cardboard need, such as when a health care system has a central distribution center and
uses new cardboard boxes to distribute materials to satellite locations. However, the scale of a reusable tote program can be tailored to meet the
needs of the organization —even on a small scale, reusable totes may be a cost-effective alternative for replacing a constant cardboard need.
case study Cutting Cardboard with Kaiser Permanente
Kaiser Permanente (Kaiser) operates three distribution facilities that serve as central supply warehouses for all its hospitals and
clinics throughout the United States. Kaiser sorts and repackages the medical supplies delivered to the central supply facilities
(most often on pallets) based on the needs of each hospital and clinic. In 1990, Kaiser implemented a pilot program that has since
changed the way it manages inventory: Kaiser began using reusable totes in place of disposable cardboard boxes for distribution.
The program began in Kaiser's Livermore, California, supply warehouse, which serves 12 northern California hospitals. Initially,
Kaiser purchased a total of 11,000 totes in four sizes: large, medium, small, and tiny. This enabled warehouse employees to
select totes based on the volume of material to be distributed, nearly eliminating the packing material needed to fill partially full
containers. Since implementing the program in 1990, Kaiser has saved approximately $40,000 a year by dramatically reducing
the cardboard boxes, tape, and filler purchased. Because Kaiser had previously recycled the cardboard at no cost, most of it was
continues
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page 2 Environmental Best Practices for Health Care Facilities Reusable Totes, Blue Wrap Recycling and Composting
already being diverted from the landfill and does not represent a
significant savings in avoided disposal costs. Unlike cardboard
boxes, the totes do not require assembly for use and resulted in
a significant increase in productivity, saving approximately 500
labor hours or $12,100 in wages annually.1
Kaiser also reduced the amount of labor required for delivery
of supplies to end-users" by color-coding the totes according to
their content. Kaiser employees can identify the contents—and
general destination — simply by noting the color of the tote.
Because the large, medium, and small totes each have the
same footprint, they are easily stackable ("nestable") and do
not require much storage space — the medium and large totes
have an average footprint of 15 by 21 inches, varying in height
be/ween 6 and 9 inches. The smaller totes are 6 inches high
and have a footprint of 10 by 10 inches.
In addition, the totes have proven to be very durable. Since the
initial purchase, Kaiser has bought an additional 500 to 700 totes
per year (5 to 7% of total inventory) to replace totes that were
damaged, "lost" in the system (used for storage), or stolen.
Kaisers color coded totes helped reduce labor cost
and simplify routing
For non-perish- For pharmacy For initial pre- For refrigerated
able consum-
able goods such
as intravenous
bags, tubing,
and bandages
refills that
are less time-
critical
scriptions that
are urgently
needed
medication that
must be kept
cold
Lastly, the totes have not posed a significant maintenance issue.
Because the contents of the totes are new, sealed products, the
interiors of the totes stay clean. About every other year, Kaiser
sends 2 5 percent of the inventory to be steam-cleaned, which
costs $0.50 per tote or $687.50 annually.
The program has since been expanded from the Liverrrtore facil-
ity to the other two central supply warehouses.
Kaiser Permanente Reusable Tote Program
Cardboard Boxes (360,000), Tape, and Packing Material $40,000
500 Hours for BoxAssembly2 $12,100
Disposal of Cardboard Boxes Not quantified5
Purchase of 11,000 Totes at $14.50 each3
Steam-Cleaning 25% of Tote Inventory4
Replacing 500 to 700 Totes
$159,500
$688
$8,700
Payback Period:. Less Than 4 Years
1 While not quantified for this case study, additional labor may have been saved since Kaiser did not have to breakdown the cardboard boxes for recycling.
2 Exadt numbers were not available at the time of this fact sheet publication. Kaiser estimates that a cardboard could be assembled in 5 seconds or 720 cardboard boxes per hour.
3 The average retail cost for a 12-gallon tote sold by vendors listed on the back page of this fact sheets; considerable discounts are typically offered to organizations purchasing in bulk.
« Totes are steam-cleaned every other year costing Kaiser $687.50 annually
5 Since the cardboard was recycled at the facility where the supllies were delivered, cumulative disposal costs were not available.
Blue Sterile Wrap and Plastic Film Recycling
Recently, blue sterile wrap recycling has attracted interest as a way to significantly reduce the amount of plastic disposed as solid waste. For example,
the Nightingale Institute estimated that approximately 19% of the waste stream generated by surgical services is blue sterile wrap. Made of polypropylene
(plastic #5), a polymer with good resistance to chemicals and wear, blue sterile wrap is used in all hospitals to protect patient gowns and toiletries,
medical devices, and surgical instruments from contamination. Blue sterile wrap waste is most often generated in just a few areas of a hospital,
simplifying the collection process. Blue sterile wrap is no"t reusable, as the material does not withstand the sterilization process between uses. Less
bulky material has been considered; however, the alternatives have not matched polypropylenes ability to 1) resist tearing when holding sharp surgical
instruments and 2) provide a protective moisture barrier to prevent contamination after sterilization. Recently, several manufacturers have begun
using polypropylene as feedstock for other retail products, making it easier to recycle blue sterile wrap and other plastic films (including plastics #2,
#4 and #5). Nonetheless, a few key requirements must be met to make a recycling program practical:
• Identify a local market for polypropylene or #5 plastics. Without a regional recycler, it is unlikely that a program will be economically feasible.
It is inefficient to ship the material significant distances for recycling because of the relatively low market value of #5 plastics and the high volume
and low weight of the material.
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Reusable Totes, Blue Wrap Recycling and Composting Environmental Best Practices for Health Care Facilities page 3
Dominicans Blue
Sterile Wrap Program Performance
• Establish a low-cost collection and transport system. Because the market value of polypropylene is relatively low, collection and transportation
costs must be minimized. Essentially, the cost of collection and transport cannot exceed the recycling income (approximately $0.04 per pound)
and avoided disposal fees (approximately $0.03 per pound, or $56 per ton).
• Generate a significant quantity to warrant vendor cooperation. Although arrangements
can be made with local recyclers to supply blue sterile wrap and plastic film collection '
containers at little or no cost to a hospital, the facility must generate enough used
' polypropylene to make the program worthwhile. However, the quantity required varies
directly with regard to the points above. For example, the further the distance from a
regional recycler, the greater the quantity required to support a program.
These requirements are dependent on other factors as well, such as distance to a regional
recycler and proximity to other healthcare facilities that are also recycling blue wrap and
other plastic films. The following case studies provide details of how two organizations have
implemented successful blue sterile wrap recycling programs and highlight the potential
environmental and economic benefits. The first case study highlights a new program, while
the second features a program that has been operating for over 10 years.
8 tons in 12 months
2 Average: 1,MH) Ibs per month
Total Diversion Savings: $544
case study Easy Transition to Recycle Blue
Sterile Wrap and Plastic Film
Dominican Hospital (Catholic Healthcare West) in Santa Cruz,
California, implemented a blue sterile wrap and plastic film
recycling program in May 2001. Dominican's initial objective
was to divert only the blue sterile wrap from the waste stream;
however, the hospital learned that their plastic film often used
to package materials and wrap pallets can also be recycled with
the blue sterile wrap. Clearly labeled collection containers
were placed in the six departments that generated the highest
quantities of blue sterile wrap and plastic film waste: central
distribution, purchasing, the pharmacy; the operating rooms,
outpatient oncology, and labor and delivery. Before implement-
ing the program, the environmental staff discussed program
Dominican Hospital
Cumulative Blue Sterile Wrap and Plastic Film Recycling
May, 2001 through June, 2002
Tons -
Blue sterile
wrap represents
about 19% of
all surgical
service waste'
May'01 | July \ Sept
June Aug Oct
Dec
April June
objectives and logistics with department staff members —
including nurses, administrative personnel, and custodial
employees — to address their concerns and convey the benefits
of the program. In total, Dominican's environmental staff spent
about 3 days setting up the program, including gaining buy-in
from hospital staff, working with vendors, and setting up collec-
tion containers and schedules.
Collection Containers and Disinfection
One concern that emerged from the meetings with department
staff was how to disinfect the containers used to collect the
blue sterile wrap and plastic film. Although administrative
departments such as central distribution and purchasing were
satisfied with the standard cardboard containers, the operating
room wanted containers that could easily be routinely disinfected.
Therefore, a stainless-steel frame that could be easily wiped
down was used to collect blue wrap in individual operating rooms.
Material Management
The custodial staff spends less than 30
minutes each week emptying all the
collection containers in the hospital as
they are filled. Full bags, weighing
about 17 pounds each, are transferred
to a 3-cubic-foot dumpster on the
building's loading dock. Dominican
donates the sorted blue sterile wrap
and plastic film to a local nonprofit
recycling organization, Grey Bears, that
uses the proceeds from the sale of recy-
clable commodities to buy and prepare
hot meals for disadvantaged senior citi-
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page 4 Environmental Best Practices for Health Care Facilities Reusable Totes, Blue Wrap Recycling and Composting
zens in the community. Grey Bears picks up the dumpster each
Friday and bales the blue sterile wrap- and plastic film until a
full-enough load has accumulated to warrant a pickup by Marathon
Recovery of Oakland, California, which purchases the material
to be used as a binding agent in making siding materials.
A similar program was established throughout the Legacy Health
System (LHS) in Portland, Oregon. Since summer 1991, house-
keeping employees collect sorted recyclable commodities, including'
blue sterile wrap and other polypropylene plastics, at four LHS
hospitals in the greater Portland area. The material is col-
lected in either clear or
blue plastic bags and is
delivered to the recy-
cling depot in each
building.
LHS owns and operates
its own recycling center
just two blocks from
Good Samaritan
Hospital, one of LHS's
facilities. LHS has established a cooperative relationship with
several of its vendors, including Kimberly-Clark, Owens and
Minor, and BioMed, to transport the recyclable commodities to
Blue sterile wrap recycling at
Dominican Hospital
Legacy Health System Blue Sterile
Wrap Recycling Program
Monthly Diversion Savings:
S400
the LHS recycling center.
The commodities are
hauled as "backfill" mate-
rial, meaning that they
are collected on return
trips when the vendors'
trucks are empty. In addi-
tion to die four LHS hos-
pitals, LHS has begun
accepting blue sterile
wrap waste from other
Portland-area hospitals
that can make similar transport arrangements with dieir vendors.
Once die recyclable commodities are dropped off at die recycling
center, employees of die Susan Christiance Vocational Program
(SCVP), a non-profit organization mat employs challenged indi-
viduals, sort die material. The blue sterile wrap is placed in a
40 cubic-yard roll-off container provided at no cost by Waste
Management Incorporated. The container is hauled three to
four times per month, diverting 3.5 tons of blue sterile wrap
from die solid waste stream and saving $400 in disposal costs.
Waste Management bales die blue sterile wrap and, once enough
has accumulated, transports die material to Marathon Recovery.
Getting Green in the Kitchen
The kitchen and food service operations of a hospital leave a unique mark in the hospitals environmental footprint. Although food waste itself can
represent 10% of the hospitals waste stream, for every patient tray, another 15 pounds of waste is generated (including glass, cans, and cardboard
fromfood and washing solution packaging).2 Although the kitchen and food service operations of a hospital
generate a variety of solid wastes, source reduction and recycling programs often overlook this area of the
facility—especially the opportunity to divert organic matter through composting food waste. How ever, there
are several obstacles to consider when implementing a food waste composting program:
Space limitations. In many cases, space constraints are the primary factor dictating which composting
method a hospital can adopt. Because hospitals are often located in urban areas where space is limited,
they must either make arrangements to haul the food waste to an off-site composting facility or pur-
chase a compact, in-vessel composting unit.
Beating the stigma. The benefits of composting are often misunder stood and overshadowed by miscon-
ceptions. For example, many people fear that composting will produce a strong odor and attract pests
such as insects or rats. Consequently, a composting program should feature (1) management buy-in to
ensure that employees participate in the program and (2)well-run operations to prevent odor and the
presence of pests.
Program participation. For composting to be cost-effective, a hospital must tailor the scale of the pro-
gram to the quantity of food waste generated and must ensure that employees participate in the pro-
gram. Both points are especially important for facilities that make a significant capital investment in
purchasing on-site composting technologies.
Vermitech system
(worms, digester and shredder):
$25,000
Building and supplies:
$31,000
Labor:
$62 per week
Composting Program
Costs
VS.
Savings
Diversion savings:
$59.50 per ton
Worm castings:
$ 1 per pound
Medcycle Offers Opportunities for Nurses as Front-Line Recyclers, Nightengale Institute, www.nihe.org/medcyc.html
Saving Disposal Dollars: Hospital Finds Winning Waste Reduction Formula BioCycle, January 1999
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Reusable Totes, Blue Wrap Recycling and Composting Environmental Best Practices for Health Care Facilities page 5
The following case study provides details of how one facility has begun
to divert food waste from their cafeteria and discusses some of the
obstacles to implementing a successful program.
case study Putting Worms to Work at the
Medical University of South Carolina
In a continuing effort to cut material from its waste stream and
noting the success of other universities' composting programs,
the Medical University of South Carolina (MUSC) in
Charleston, South Carolina, implemented a food waste com-
posting program in July 1999. Three state and national organi-
zations provided approximately 70 percent of the startup costs:
the Department of Health and Environmental Control
(DHEC),Hhe DHEC Energy Office, and the Sustainable
Universities Initiative. Because of its urban location and signifi-
cant space contraints, MUSC chose to install the Vermitech
Systems Incorporated in-vessel vermi-organic digester.
MUSC built a simple, 18 by 24-foot building to house the
digester; building features include a sloped floor coated with
acrylic for easy cleanup, a ventilation fan, and a 10-gallon water
heater. (The digester can also be placed in an existing structure
or in a secure 9utdoor location.) Necessary supplies include
four 45-gallon, wheeled containers; a scale; a long-handled
squeegee; gloves; a long-handled plastic broom; a flat headed-
shovel; a hose with multi-option spray nozzle; a dustpan; and
pH and moisture meters.
Contracted kitchen staff collect preconsumer food waste from
the hospital's cafeteria kitchen in a 45-gallon container. Once
a day the recyling staff collects the container, which varies in
weight according to its contents. The contents are fed into a
Medical University of South Carolina
Composting Food Waste Diversion Amounts
1999 through 2001
Ql Q2
FT '99-00
Ql Q2
FY'00-01
Thousands of worms live in the Vermitech Systems composting digester
at MUSC, turning food waste into a valuable soil amendment.
shredder, where the food waste is mixed with cardboard until
the appropriate moisture level is obtained. The mixture is then
fed into the in-vessel digester by a conveyer belt. The worms in
the digester can eat 250 pounds per day, reducing the volume
of the food waste and cardboard mixture by 80 percent
overnight. The worms produce castings that are used as a soil
amendment and have a value of about $ 1 per pound. The cast-
ings also slightly reduced the hospital's need for commercial fer-
tilizers and actually improved the condition of the soil. Because
the worms tend to stay near the top of the in-vessel digester
(near the fresh food), the castings are mechanically harvested
from the bottom of the container. The castings fall to the floor,
where they are swept up using a broom and squeegee. The cast-
ings are then given to MUSC's grounds department. It typically
takes no more than 1 hour each day to collect the food from
the cafeteria and transport it to the composting building,
process the food through the digester, and clean up after pro-
cessing a batch of food waste. The recycling coordinator also
spends 30 minutes per week checking the depth of the digester
bedding and the health of the worms and their environment.
MUSC composts 115 pounds of food waste each day, repre-
senting 50 percent of the digester's operating capacity. At this
rate, the program can sustain itself, but is not paying back the
capital costs required to set up the program. MUSC believes
that the low participation rate is due to ongoing employee resis-
tance and skepticism. Although the MUSC recycling staff
makes constant efforts to convey the benefits of the program
and encourages MUSC kitchen staff to participate in the pro-
gram, staff participation level ranges result in using only 30 to
70 percent of the digester capacity. If the program operated at
100 percent capacity, processing 250 pounds of food waste per
day and harvesting 3,000 pounds of castings per month, the
payback time would be approximately 6 years (which is compa-
rable to other in-vessel unit payback periods).
v continues
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page 6 Environmental Best Practices for Health Care Facilities Reusable Totes, Blue Wrap Recycling and Composting
Resources
Reusable Totes
Kaiser Permanent e
(818) 321-2276
Akro-Mih
(800) 253-2467
Retncon Plastics Inc.
(800) 253-2467
Blue Sterile Wrap and
Plastic Film Recycling
Dominican Hospita I
(831)462-7674
Legacy Health System
(503)413-6066
Conigliaro Recycling
(888) 266-4425
Marathon Recovery
(510)636-4191
Composting
Medical University of South Carolina
(843) 792-4066
Green MountainTechnologies
(802) 368-7291
Vermitech Systems Inc.
(416)693-1027
This fact sheet was produced by the Environmental Protection Agency (EPA) Region9 Pollution Prevention Program. Mention of trade names, products,
or services does not convey, and should not be interpreted as conveying, official EPA approval, endorsement,or recommendation.
Printed on 100% post consumer recycled paper. Processed chlorine free.
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