VETERANS AFFAIRS HOSPITAL
AND HOSPITAL WASTE MINIMIZATION CASE STUDIES
by
Kenneth R. Stone
Pollution Prevention Research Branch
Waste Minimization, Destruction and
Disposal Research Division
Risk Reduction Engineering Laboratory
Cincinnati, Ohio 45268
RISK REDUCTION ENGINEERING LABORATORY
OFFICE OF RESEARCH AND DEVELOPMENT
U.S. ENVIRONMENTAL PROTECTION AGENCY
CINCINNATI, OHIO 45268
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VETERANS AFFAIRS HOSPITAL AND HOSPITAL WASTE MINIMIZATION CASE STUDIES
by: Kenneth R. Stone
Risk Reduction Engineering Laboratory
U.S. Environmental Protection Agency
Cincinnati, Ohio 45268
ABSTRACT
The U.S. Environmental Protection Agency has instituted a broad pollution
prevention research program through the Office of Research and Development to
support continued environmental improvements throughout the nation. The
Agency is also responding to the national concern in regards to the generation
and disposal of medical wastes. Recently, EPA's Risk Reduction Engineering
Laboratory (RREL) produced the "Guide to Waste Minimization in Selected
Hospital Waste Streams" (1) with the cooperation of the California Department
of Health Services (hereafter referred to as the "California Study"). The
California Study serves as a manual for conducting waste minimization
assessments at surgical and general medical hospitals to reduce the generation
of hazardous wastes from chemotherapy and antineoplastic chemicals,
formaldehyde, photographic chemicals, radionuclides, solvents, mercury,
anesthetic gases and other waste chemicals.
In order to effectively implement its pollution prevention programs, the
EPA is also investigating how the departments and agencies within the Federal
community can help each other reduce their generation of wastes. As a part of
these efforts, RREL provides staff and support to conduct waste minimization
assessments under the Waste Reduction Evaluations and Assessments at Federal
Sites (WREAFS) Program. Under the WREAFS program, the U.S. Department of
Veterans Affairs Cincinnati - Fort Thomas Medical Center (DVA-Cin) offered to
host an assessment of pollution prevention opportunities at their facility
(2). With the California study having researched the generation of hazardous
wastes in hospital settings, the DVA-Cin study investigated the use of
disposables in patient care in order to identify research opportunities for
future solid waste minimization.
During the assessment it became clear that DVA-Cin, driven by its
sensitivity to health care costs,, has in place some very effective waste
minimization practices. Unlike most hospitals, DVA-Cin does not have access
to private insurance and therefore cannot assign costs on a per bed basis. As
a result, the generation of medical waste is well below the average level for
a hospital of this size.
This paper has been reviewed in accordance with the U.S. Environmental
Protection Agency's peer and administrative review policies and approved for
presentation and publication.
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on how such waste is to be disposed. What is allowed in one State may be a
violation in another. Therefore, the waste minimization recommendations that
are made in this paper have to be taken in light of the medical waste
regulations of the State in which the hospital is located.
Formaldehyde - Formaldehyde is used in pathology, autopsy, dialysis,
embalming, and nursing units. For use in dialysis, formaldehyde is generally
purchased as a 37 percent solution (formalin) that will be diluted with
filtered, de-ionized water to a final formaldehyde concentration of 2-4
percent. Formaldehyde is used to disinfect membranes in dialysis machinery
and, in other departments, to preserve specimens. Effluent is commonly
discharged to a sewer, although in some States this may be considered an
illegal practice.
Photographic Chemicals - Photographic developing solutions consist of
three parts: developer, stop bath, and fixer. The developer normally contains
approximately 45 percent glutaraldehyde. Acetic acid is a component of stop
baths and fixer solutions. The fixer will contain 5-10 percent hydroquinone,
1-5 percent potassium hydroxide, and less than 1 percent silver. Silver-
containing effluent is typically passed through a steel wool filter or
electrowinning unit to recover the metal. The remaining aqueous waste,
containing approximately 1.4 percent glutaraldehyde, 0.3 percent hydroquinone,
and 0.2 percent potassium hydroxide, is typically discharged to the sewer.
Radionuclides - Radioactive wastes are generated in nuclear medicine and
clinical testing departments. At the hospitals surveyed, radioactive
materials in nuclear medicine were held on-site until they decayed to non-
hazardous levels. In clinical testing laboratories, solvents were used for
radioactive tagging. Wastes at the hospitals were generated at the rate of
800 cubic centimeters per week. Radioactive wastes were transported off-site
to a landfill.
Solvents - Solvent wastes are generated in small amounts in various
departments: pathology, histology, engineering, embalming, and laboratories.
A variety of halogenated and non-halogenated compounds are used, but, in the
hospitals surveyed, the most frequently used solvents were non-halogenated:
xylene, methanol, and acetone. While acetone and methanol wastes are usually
evaporated and/or discharged to a sewer, xylene is handled as a hazardous
waste. Solvent wastes are typically recycled or transported off-site for
incineration. However, some solvent wastes become absorbed into the specimen
and then must be treated as infectious wastes. In the past, small quantities
of solvent waste would be routinely disposed via lab packs to landfills.
However, high disposal costs, long term liability and regulatory
limitations make this an undesirable disposal alternative.
Mercury - Mercury wastes are primarily generated by broken or obsolete
equipment. Spilled mercury can be recovered and reused if uncontaminated,
however, spillage is not frequently recovered and no mercury spill kits were
present in any of the surveyed hospitals.
Anesthetic Gases - Nitrous oxide and the halogenated agents halothane
(Fluothane), enflurane (Ethrane), isoflurane (Forane), and other substances
are used as inhalation anesthetics. Nitrous oxide is supplied as a gas in
cylinders and used containers are returned to the supplier for refill. The
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TABLE 1. WASTE MINIMIZATION METHODS
FOR GENERAL AND SURGICAL HOSPITALS
WASTE CATEGORY
WASTE MINIMIZATION METHOD
Chemotherapy and
Antineoplastics
Formaldehyde
Photographic Chemicals
Radionuclides
Solvents
Mercury
Waste Anesthetic
> Optimize drug container sizes in purchasing.
> Return outdated drugs to manufacturer.
> Centralize chemotherapy compounding location.
> Minimize waste from compounding hood cleaning.
> Provide spill cleanup kits.
> Segregate wastes.
> Minimize strength of formaldehyde solutions.
> Minimize wastes from cleaning dialysis machinery.
> Use reverse osmosis water treatment to reduce
dialysis cleaning demands.
> Capture waste formaldehyde.
> Investigate reuse in pathology, autopsy labs.
> Return off-spec developer to manufacturer.
> Cover chemical tanks to reduce evaporation.
> Recover silver efficiently.
> Use squeegees to reduce bath losses.
> Use counter-current washing.
> Use less hazardous isotopes whenever possible.
> Segregate and label radioactive wastes, and store
short-lived radioactive wastes on-site until decay
permits disposal as general trash.
> Substitute less hazardous cleaning agents.
> Reduce analyte volume requirements.
> Use pre-mixed kits for tests involving solvent
fixation.
> Use calibrated solvent dispensers for routine tests.
> Substitute electronic devices for mercury-containing
devices.
> Provide spill cleanup kits and personnel training.
> Recycle uncontaminated mercury wastes.
> Employ low-leakage work practices.
> Purchase low-leakage equipment.
> Maintain equipment to prevent leaks.
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Convenience - Such things as disposable operating room (OR) packs provide
all the sterile materials needed for a specific operation, reducing OR prep
time.
Space Constraints - Only needed materials are kept in stock, and there is
no need to review inventory for aging and obsolete items.
DISPOSABLE WASTE PROFILE
The majority of waste generated by a hospital consists of disposable
products. According to DVA-Cin personnel, approximately 80 percent of the
hospital's supplies are disposed after a single use. The DVA-Cin saw a change
from reusables to disposables 10-15 years ago and an additional increase in
the use of disposables in the last 2-3 years due to concern by hospitals over
both patient safety and staff occupational exposure to the AIDS virus.
Therefore, the increase results from greater usage of existing disposable
supplies (i.e., single-use sponges for patient surgery, and disposable gloves
and masks worn to protect hospital staff) rather than from the use of newly
developed disposable items.
This section will profile the major disposable items ordered by these
DVA-Cin departments: Laboratory Services; Surgery; Surgical Intensive Care
Unit (SICU); 5 South (a patient floor); Medical Intensive Care Unit (MICU);
Hemodialysis; and the Outpatient Clinic.
Laboratory Services - This department performs analyses on specimens
taken from patients. In a 9 month period ending June 30, 1989, the laboratory
had conducted 41,097 venipunctures, 9,935 bacterial cultures, 4,730 blood
cultures, 854 fungal cultures, and 815 tuberculosis cultures. The Laboratory
consists of 4 areas: (1) Hematology, (2) Clinical chemistry, (3) Microbiology,
and (4) Histopathology.
11 Hematology Laboratory - Hematology draws and analyzes blood
samples from 50-60 patients daily. The technicians visit the patients to
draw samples and then return to the laboratory to conduct the analyses.
Cloth gowns are worn while blood is drawn and then replaced with a second
cloth gown for lab work. All gowns are laundered for reuse.
Hematology generates two 30-gallon bags of infectious waste each
day. It is rendered non-infectious via autoclaving and disposed of as
general trash. Sharps (needles, broken glass) are placed in sharps
containers and those containers are collected by housekeeping staff for
weekly incineration.
2J. Clinical Chemistry Laboratory - Clinical Chemstry conducts blood
serum and urine analyses on samples drawn by the hematology technicians.
Approximate waste generation rates for the principle disposables are:
> Glass test tubes - 2,100 per week
> Glass sample cups - 2,000 per week
> Dry reagent slides - 21,000 per week
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Surgical Intensive Care Unit (SICU) - Almost all of SICU's eight beds are
occupied on a regular basis. Cloth gowns are worn by patients and staff and
are laundered for reuse. Procedure trays are re-sterilized on-site and
reused, but SICU staff would like to go to the disposable packs like those
used in surgery.
Blood and body fluid waste generated by SICU consists mainly of suction
liners and tubes. Foley bags and chest tubes are flushed of their fluids and
placed in general trash. I-V bags go directly into general trash. Sharps are
boxed and incinerated on-site.
Waste is segregated into three categories: (1) sharps; (2) blood and body
fluids, and; (3) general trash. Blood and body fluid wastes are strictly
segregated into one-to-two 30-gallon bags per day. However, for those
patients requiring isolation, SICU may generate as much as ten 5-gallon bags
of medical waste per day for each patient. The number of patients in
isolation varies.
5_ South: Patient Floors - 5 South has 36 beds, of which 29-32 are
occupied at any given time. 5 South provides pre- and post-operative care,
including administration of medications and changing dressings. In total, the
medical and surgical patient floors have 106 beds, of which 78 are occupied at
any given time. Cloth gowns are generally worn on patient care floors,
although disposable gowns are used whenever cloth is unavailable.
Waste is segregated into three categories: (1) sharps; (2) blood and body
fluids, and; (3) general trash. 5 South generates one-to-two 30-gallon bags
of blood and body fluid waste per day. In practice, nurses often dispose of
non-blood and body fluid waste in the blood and body fluid waste container as
a matter of convenience.
Medical Intensive Care Unit/Cardiac Care Unit (MICU/CCU) - the MICU/CCU
has eight beds, all of which are constantly occupied. MICU/CCU reuses woven
gowns and pressure bags. Pressure bags are used to introduce blood to a
patient, and will be cleansed out for reuse.
Waste is segregated into three categories: (1) sharps; (2) blood and body
fluids, and; (3) general trash. The assessment team again observed waste
being dropped in blood and body fluid containers that did not need to be
there; empty disposable urinals were observed in the blood and body fluid
containers.
Hemodialysis - This unit has 9 treatment stations. Treatment occurs in
shifts with a capacity to treat 55 patients each week. Treatment takes about
5 hours. Nearly all products are disposable, including aprons and masks. As
is common practice in many hospitals, disposable dialyzers are re-sterilized
and reused approximately 20 times before disposal. The practice of reusing
disposables in health care is controversial and will be discussed further in
this paper.
At least four 30-gallon bags of blood and body fluid waste are generated
each day. Most of the disposable items are discarded in the blood and body
fluid containers. Sharps are handled as previously indicated.
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CHOOSING BETWEEN DISPOSABLE AND REUSABLE PRODUCTS
As stated earlier in this paper, there are four major factors supporting
the medical professions preference for disposables: health and safety; cost;
convenience; and space constraints. With the advance of technology, intricate
devices are mass-produced and sold as single-use items, prepackaged and
sterilized to relieve the hospitals of such quality assurance concerns. Labor
and reprocessing costs are relieved, being replaced by the apparently lower
costs of treatment, destruction, or disposal. Packs of disposable goods are
custom-fitted, used and discarded, alleviating OR prep time and simplifying
inventory control.
An excellent example of this decision-making process is found in the
demise of hospital laundries. Reimbursement of medical services on a cost-
plus basis provided the incentive to introduce new products and services to
ease hospital workloads. This created a situation wherein funds were not
allocated to upgrade traditional services, because there was little incentive
to modernize operations and streamline procedures. In the case of hospital
laundries, they were experiencing a rising demand for all linen products as
inpatient services increased during this period. Antiquated laundry
operations were incapable of meeting the new demand, becoming unable to
efficiently process and sterilize the soiled linens. Acquiring disposable
linens ensured an adequate supply of products, relieved an overburdened
laundry, and provided cost savings by allowing hospitals to abandon or further
downgrade this service, rather than invest in capital improvements. The cost-
plus reimbursement method for medical services had led the hospitals into
allowing formerly efficient laundries to lapse into a condition in which the
most cost effective solution resulted in the greatest generation of solid
waste (4). The assessment team for the VA-Cin study suggested that the
medical center's extraordinary use of linens and access to the Dayton laundry
was a significant factor in explaining DVA-Cin's very low waste generation
rate.
REUSING SINGLE-USE DEVICES
Hospitals and other health care facilities have attempted to reduce costs
by reprocessing disposable, single-use devices/products (see Table 2 for a
listing of the most commonly reused disposable products). Although the issue
of reusing disposable devices is highly debated, health care professionals
agree that if a product is to be reused it must be as functional, sterile, and
safe as when new. In making this decision, health care professionals must
consider the possibility of disease transmission or infection, assumption of
product liability, decreased reliability, and cost.
These concerns impact the decision on what may be reused. The less
critical an item, the more likely it can be reused (5). For example, because
a bedpan is considered to be a non-critical item by the Center for Disease
Control (CDC) and the risk of infection or disease transmission is minimal,
reuse would be considered. However, an arterial embolectomy catheter would be
considered critical and the potential risks from reuse great. The hospital
will always opt for health and safety over any issue of economics or ecology.
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FACTORS AFFECTING CONTINUED RELIANCE ON DISPOSABLES
When considering reusable, or durable, products and reuse of disposable
products as a means for reducing the rate of waste generation and its
associate costs, infection control is the primary limiting factor. This paper
has noted the increased attention that medical professionals are paying to
this issue in the wake of public concern over the AIDS virus and other blood-
borne pathogens. The CDC's Universal Precautions state that all blood and
body substances must be treated as potentially infectious. As the first lina
of defense against pathogen transmissions, the medical community employs
physical barriers to prevent contact with body substances: gloves, protective
clothing, masks and eye protection. Single-use items intended for personnel
protection provide hospitals with added assurance against accidental
transmissions because they are used once, rendered non-infectious through
autoclaving and either hauled off-site as general trash, or incinerated on-
site. This eases the quality control burden for the hospital.
In any case, the barriers are employed but once, and that is what counts
to the peace of mind of both doctor and patient. And, from a more pragmatic
viewpoint, it is clear that, when considering the increasing frequency of AIDS
in urban areas and the seriousness of all infectious diseases, health
facilities must first ensure the sterility of a product or device first, and
then consider the opportunity for pollution prevention.
Another obstacle to converting from a single-use back to a durable
product or device is that it may simply no longer exist in that form, or be
too expensive to employ. The DVA-Cin procurement office indicated that
disposable products had, in many instances, completely eliminated the market
for the durable good. As a result, the durable version is either no longer
available, or can be acquired through special-order supply companies that may
be unable to guarantee long term availability and unable to provide
sufficiently large quantities. This situation in turn drives up the cost of
the durable version, potentially making it cost prohibitive.
POLLUTION PREVENTION OPPORTUNITIES AT DVA HOSPITAL
A variety of disposable devices ranging from syringes to hemodialyzers,
from Petri dishes to bedpans, contribute to the growing waste streams
generated by health care facilities. In order to successfully reduce waste,
it is important for hospitals to reconsider the situations in which single-use
devices/products are used and evaluate whether the disposable is still the
best option. If a reusable good provides comparable reliability, sterility
and safety, it would be reasonable to consider going back to the reusable. In
those instances wherein the hospital is reprocessing single-use devices, it
would appear that the durable version is an even more attractive substitute
because the disposable has not relieved the hospital of the burden of re-
sterilization, quality assurance, or labor costs.
Because of the diversity of the areas toured at DVA-Cin, it would be best
to discuss pollution prevention opportunities by ward. The major disposable
items in each ward will be reviewed.
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bags never come into contact with body fluids and remain uncontaminated during
use. Therefore, plastic I-V bottles could be safely reused for a single
patient, and should be considered as a substitute for the I-V bags.
5. South - Patient Floors - Outpatient Clinic - The disposable products
regularly used on the patient floors include suctioning equipment, tubing,
catheters, blood transfusion equipment, chucks, and dressing supplies.
Because of the inherent contact with blood and body fluids, these products are
assumed to have a high risk of disease transmission. The only pollution
prevention option recognized is in the use of chucks. Chucks act as linen and
surface protectors, absorbing blood and body fluids in order that the reusable
linens will not become grossly soiled and that surfaces will be easier and
safer to clean. (Chucks are used in the laboratories as well to contain small
spills at ork stations.) Chucks are present throughout the hospital, and
DVA-Cin may want to review the use of chucks to determine whether their
availability has led to use in situations where they are not needed.
Hemodialysis - The major disposable products in this ward are I-V bags,
tubing, gloves and dialyzers. Most of these items have been discussed, and it
has been noted that the dialyzers are reused approximately 20 times before
their disposal. The reuse of dialyzers has been found to be a common practice
in health care institutions. An informal survey on the reuse of disposables,
conducted at the 1984 Georgetown University International Conference, showed
46 percent of the respondents reporting the reuse of this item in their
institutions (6).
With respect to high-tech items, it is believed that hemodialyzers are
the only devices which have been studied in sufficient depth to show that
function is not impaired through reuse (7). Hith this technical knowledge as
evidence of safety and reliability, hospitals are able to write policies
allowing dialyzer reuse as a waste reduction option.
ADDITIONAL OBSERVATIONS ON DVA-CIN'S POLLUTION PREVENTION EFFORTS
The DVA Hospital has already realized many of the waste reduction
opportunities arising from product substitution and waste segregation
practices. The hospital's standard use of wovens is a significant part of the
reason DVA-Cin's waste generation rates are so low in comparison to industry
average. The use of wovens in surgery accounts for the fact that DVA-Cin
produces 50% to 65% of the waste normally produced during operations in
Cincinnati area hospitals.
There has been some discussion on the reprocessing of glassware. The
recycling of glassware from sodalime (e.g., pasteur pipettes) may greatly
reduce the volume and weight of a hospital's current wastes. However, a large
percentage of the glassware used in laboratories is made of borosilicate which
cannot be recycled wit,ji general consumer waste glass. Also, despite the
reliability of disinfection from autoclaving there is a stigma ascribed to
medical waste that may restrict or eliminate recycling as a pollution
prevention option. Community recycling centers should be contacted regarding
their policies for accepting waste glass from health care facilities.
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Development of. Reprocessing Capacity - Two pollution prevention
alternatives cited by this paper involved reprocessing services that have been
diminished by the disposable revolution. Space and labor constraints, coupled
with the general availability and convenience of disposables, appear to be the
major obstacles to on-site reprocessing of durable materials. However, as
health care cost containment gains increasing importance, reprocessing may
become cost effective for some items. The potential for promoting some
reprocessing capability should be explored, particularly in those areas
exhibiting a high density of medical facilities.
Developing a Reusable Market - Certain bills in Congress to amend the
Resource Conservation and Recovery Act (RCRA) will require that Federal
agencies meet certain objectives for use of recyclable products. The EPA and
DVA should consider working together in developing procurement guidelines for
the DVA which will stimulate the production and distribution of reusable and
recyclable products.
CONCLUSION
In the case of the DVA study, the Assessment Team was impressed by the
difficult challenges undertaken by the hospital professionals to perform their
duties of human care while attempting to minimize the impact of those
activities on the environment. F.ollow-on discussions indicate that this is a
dynamic process for DVA-Cin, as they develop initiatives in training,
information sharing and cooperation with other Federal agencies.
For its part, the EPA hopes to learn from future cooperation with DVA,
seeking the health care professionals advice and guidance in planning and
implementing research programs to respond to the needs of the medical
community in the areas of hazardous waste, infectious waste, and other waste-
streams. Opportunities to reduce these wastes do exist, and additional
opportunities will be uncovered through research. Research will also provide
the data on which to make operational decisions of benefit to health care
facilities, while favoring environmental considerations.
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